Type 2 Diabetes in Children and Adolescents

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Constadina Panagiotopoulos MD, FRCPC Michael C. Riddell PhD Elizabeth A.C. Sellers MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Anticipatory guidance regarding healthy eating and active lifestyle is recommended to prevent obesity.
  • Regular targeted screening for type 2 diabetes is recommended in children at risk.
  • Children with type 2 diabetes should receive care in consultation with an interdisciplinary pediatric diabetes healthcare team.
  • Early screening, intervention and optimization of glycemic control are essential, as the onset of type 2 diabetes during childhood is associated with severe and early onset of microvascular complications.

Note: Unless otherwise specified, the term “child” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age.

Highlights of Revisions

  • The recommendation regarding pharmacological agents in children with type 2 diabetes has been expanded and strengthened.
  • The recommendation regarding screening for microalbuminuria has been expanded and strengthened.
  • A new recommendation has been added about the need to screen for other comorbid conditions at the diagnosis of type 2 diabetes.

Recommendations

  1. 1.Anticipatory guidance promoting healthy eating, maintenance of a healthy weight and regular physical activity is recommended as part of routine pediatric care [Grade D, Consensus].
  2. 2.Intensive lifestyle intervention, including dietary and exercise interventions, family counselling and family-oriented behaviour therapy, should be undertaken for obese children in order to achieve and maintain a healthy body weight [Grade D, Consensus].
  3. 3.Screening for type 2 diabetes should be performed every 2 years using an FPG test in children with any of the following:
    1. I.≥3 risk factors in nonpubertal or ≥2 risk factors in pubertal children [Grade D, Consensus]
      1. a.Obesity (BMI ≥95th percentile for age and gender) [Grade D, Level 4 (1)]
      2. b.Member of a high-risk ethnic group (e.g. Aboriginal, African, Asian, Hispanic or South Asian descent) [Grade D, Level 4 (1)]
      3. c.Family history of type 2 diabetes and/or exposure to hyperglycemia in utero [Grade D, Level 4 (1)]
      4. d.Signs or symptoms of insulin resistance (including acanthosis nigricans, hypertension, dyslipidemia, NAFLD [ALT >3X upper limit of normal or fatty liver on ultrasound], PCOS) [Grade D, Level 4 (1)]
    2. II.Impaired fasting glucose or impaired glucose tolerance [Grade D, Consensus]
    3. III.Use of atypical antipsychotic medications [Grade D, Consensus]
  4. 4.An oral glucose tolerance test (1.75 g/kg; maximum 75 g) may be used as a screening test in very obese children (BMI ≥99th percentile for age and gender) or those with multiple risk factors who meet the criteria in recommendation 3 [Grade D, Consensus].
  5. 5.Commencing at the time of diagnosis of type 2 diabetes, all children should receive ongoing intensive counselling, including lifestyle modification, from an interdisciplinary pediatric healthcare team [Grade D, Level 4 (2)].
  6. 6.The target A1C for most children with type 2 diabetes should be ≤7.0% [Grade D, Consensus].
  7. 7.In children with type 2 diabetes and A1C ≥9.0% and in those with severe metabolic decompensation (e.g. DKA), insulin therapy should be initiated but may be successfully weaned once glycemic targets are achieved, particularly if lifestyle changes are effectively adopted [Grade D, Level 4 (3)].
  8. 8.In children with type 2 diabetes, if glycemic targets are not achieved within 3–6 months using lifestyle modifications alone, one of the following should be initiated:
    • Metformin [Grade B, Level 2 (4)] OR
    • Glimepiride [Grade B, Level 2 (5)] OR
    • Insulin [Grade D, Consensus]
  9. If the decision is made to use an oral antihyperglycemic agent, metformin should be used over glimepiride [Grade D, Consensus]. Metformin may be used at diagnosis in those children presenting with A1C >7.0% [Grade B, Level 2 (4)].
  10. 9.Children with type 2 diabetes should be screened annually for microvascular complications (nephropathy, neuropathy, retinopathy) beginning at diagnosis of diabetes [Grade D, Level 4 (6)].
  11. 10.Children with type 2 diabetes should be screened for microalbuminuria with a first morning urine ACR (preferred) [Grade B, Level 2 (7)] or a random ACR [Grade D, Consensus]. Abnormal results should be confirmed [Grade B, Level 2 (8)] at least 1 month later with a first morning ACR and, if abnormal, followed by timed, overnight urine collection for albumin excretion rate [Grade D, Consensus]. Microalbuminuria [ACR > 2.5 mg/mmol (9)] should not be diagnosed in adolescents unless it is persistent as demonstrated by 2 consecutive first morning ACR or timed collections obtained at 3- to 4-month intervals over a 6- to 12-month period [Grade D, Consensus]. Those with persistent albuminuria should be referred to a pediatric nephrologist for assessment of etiology and treatment [Grade D, Level 4 (10)].
  12. 11.Children with type 2 diabetes should have a fasting lipid profile measured at diagnosis of diabetes and every 1–3 years thereafter, as clinically indicated [Grade D, Consensus].
  13. 12.Children with type 2 diabetes should be screened for hypertension beginning at diagnosis of diabetes and at every diabetes-related clinical encounter thereafter (at least biannually) [Grade D, Consensus].
  14. 13.Children with type 2 diabetes should be screened at diagnosis for comorbid conditions associated with insulin resistance, including NAFLD [Grade D, Level 4 (1,11)] and PCOS in pubertal females [Grade D, Level 4 (1)], and yearly thereafter as clinically indicated [Grade D, Consensus].

Abbreviations:
A1C, glycated hemoglobin; ACR, albumin to creatinine ratio; ALT, alanine aminotransferase; BMI, body mass index; DKA, diabetic ketoacidosis; FPG, fasting plasma glucose; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome.

References

  1. Amed S, Dean HJ, Panagiotopoulos C, et al. Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: as prospective national surveillance study. Diabetes Care 2010;33:786-91.
  2. Wittmeier KDM, Wicklow BA, Sellers EAC, et al. Success with lifestyle monotherapy in youth with new-onset type 2 diabetes. Paediatr Child Heath 2012; 17:129-32.
  3. Sellers EA, Dean HJ. Short-term insulin therapy in adolescents with type 2 diabetes mellitus. J Pediatr Endocrinol Metab 2004;17:1561-4.
  4. Jones KL, Arslanian S, Peterokova VA, et al. Effect of metformin in pediatric patients with type 2 diabetes: a randomized controlled trial. Diabetes Care 2002;25:89-94.
  5. Gottschalk M, Danne T, Vlajnic A, Cara JF. Glimepiride versus metformin as monotherapy in pediatric patients with type 2 diabetes: a randomized, singleblind comparative study. Diabetes Care 2007;30:790-4.
  6. Eppens MC, Craig ME, Cusumano J, et al. Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes. Diabetes Care 2006; 29:1300-6.
  7. Shield JP, Hunt LP, Baum JD, et al. Screening for diabetic microalbuminuria in routine clinical care: which method? Arch Dis Child 1995;72:524-5.
  8. Houlihan CA, Tsalamandris C, Akdeniz A, et al. Albumin to creatinine ratio: a screening test with limitations. Am J Kidney Dis 2002;39:1183-9.
  9. Hogg RI, Furth S, Lemley KV, et al, National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease in Children and Adolescents: Evaluation, Classification, and Stratification. Pediatrics 2003;111:1416-21.
  10. SellersEA, Blydt-HansenTD, Dean HJ, et al.Macroalbuminuria and renal pathology in first nation youth with type 2 diabetes. Diabetes Care 2009;32:786-90.
  11. Nadeau KJ, Klingensmith G, Zeitler P. Type 2 diabetes in children is frequently associated with elevated alanine aminotransferase. J Pediatr Gastroenterol Nutr 2005;41:94-8.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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