Management of Type 2 Diabetes in Children
Type 2 diabetes was previously considered a disease of older adults often tied to genetics. However, over the last 30 years, concurrent with the increase in obesity, availability of fast food, and decreased recreational activity outdoors, Type 2 diabetes has been become more prevalent in children and adolescents. The American Academy of Pediatrics recently published “Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents” as guidelines for practicing physicians. According to Copeland, Silverstein, and Moore, et. al, in the United States up to 1 in 3 new cases of Diabetes mellitus diagnosed in youth younger than 18 is Type 2 Diabetes. The increased frequency of type 2 diabetes is very much dependent on the ethnicity of the patient population and therefore is variable in different parts of the country. Type 2 diabetes is more prevalent in ethnic minorities and occurs most commonly between 10-19 years, although, rarely, there have been children diagnosed with T2DM even at a younger age. The T2DM epidemic also is present worldwide. Familial history as a well as a western diet are predisposing factors in other parts of the world.
The American Academy of Pediatrics developed a subcommittee on T2DM in children and adolescents with consultation from the American Diabetes Association, Pediatric Endocrine Society, American Academy of Family Physicians, and the Academy of Nutrition and Dietetics. Based on this collaboration, practice guidelines were developed for pediatricians. The resulting guidelines were developed from evidenced-based literature: some of the guidelines result from very strong evidence; others are more informational and require the judgment of the pediatrician. Treatment options were either “strongly recommended (clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present),” “recommended (clinicians would be prudent to follow a recommendation but should remain alert to new information and sensitive to patient preferences),” “optional (Clinicians should consider the option in their decision making and patient preference may have a substantial role ),” or “no recommendation (clinicians should be alert to new published evidence that clarifies the balance of benefit versus harm).”
The following are the key action statements based on the subcommittee:
Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2DM who present with ketones or Diabetic ketoacidosis, or if they are unable to differentiate between type 1 or type 2 diabetes. Insulin should be initiated for those children/adolescents with:
- A random venous or plasma Blood glucose level greater than 250 mg/dl, OR
- Hb A1c greater than 9 percent (STRONG RECOMMENDATION)
- 2. In other cases, the clinician should initiate a lifestyle modification program (with nutrition and exercise AND start metformin (insulin sensitizer) as first line therapy at the time of diagnosis. (STRONG RECOMMENDATION)
- 3. Clinicians should monitor Hb A1c every 3 months and intensify treatment goals for blood glucose levels and if Hb A1c goals are not being met. (OPTION)
4. Clinicians should have patients monitor blood sugars in those who are:
- a. Taking insulin or other medications with hypoglycemia risk.
- b. Starting or changing insulin regimen.
- c. Have not met treatment goals.
- d. Have intercurrent illnesses.
- e. Note: blood glucose monitoring should be more than 3 times per day for patients employing multiple daily injections or insulin pump therapy. For patients with less frequent insulin injections or no insulin, blood glucose monitoring is helpful to guide therapy. In Type 2 DM, blood glucose monitoring post-prandially will be helpful to achieve appropriate targets. (OPTION)
- 5. Clinicians should incorporate the Academy of Nutrition and Dietetics Pediatric Weight Management Evidence Based Nutrition Practice Guidelines as guides for nutrition management (OPTION).
- 6. Clinicians should encourage children and adolescents with T2DM to engage in moderate to vigorous exercise for at least 60 minutes daily and limit recreational TV/video time to less than 2 hours per day (OPTION)
- Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2DM who present with ketones or Diabetic ketoacidosis, or if they are unable to differentiate between type 1 or type 2 diabetes. Insulin should be initiated for those children/adolescents with:
These guidelines are meant for practicing pediatricians who should feel comfortable referring to a pediatric diabetes team at any time. The key is that much of the care may be done by the pediatrician and consultation with pediatric endocrinology would be appropriate when new issues arise or treatment goals are not met. It should be noted that these guidelines are meant to be just that--guidelines and each healthcare provider has the option with the cooperation of the patient and family to follow closely or choose different options.