New Guidelines Address Type 2 Diabetes in Youth

Miriam E. Tucker

January 28, 2013

New clinical practice guidelines from the American Academy of Pediatrics address the management of type 2 diabetes in children and adolescents.

Type 2 diabetes, formerly thought to occur only in adults, is now developing in children and adolescents as childhood obesity rates have soared. Seen disproportionately in ethnic-minority youth, type 2 diabetes accounts for up to 1 in 3 new cases of diabetes in those younger than 18 years of age.

"Few providers have been trained in managing type 2 diabetes in children and, to date, few medications have been evaluated for safety and efficacy in children," coauthor Janet Silverstein, MD, professor of pediatrics at the University of Florida and chief of endocrinology at Shands Hospital, Gainesville, told Medscape Medical News.

"This is a real issue in the pediatric population. It's something that many of us as pediatricians didn't grow up with because we just didn't see it very often," said Dr. Silverstein. The clinical practice guidelines, along with a separate technical document on screening for comorbidities, were published in the February issue of Pediatrics, which was published online January 28.

The 10-member panel that developed the evidence-based guidelines included 2 pediatric endocrinologists — Dr. Silverstein and the other cochair, Kenneth C. Copeland, MD, from the Department of Pediatrics, University of Oklahoma, Oklahoma City — along with 4 general pediatricians, 2 family physicians, an epidemiologist, and a nutritionist.

In addition to the American Academy of Pediatrics, the documents were developed with support from the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association).

"This guideline was designed to provide a framework for management of type 2 diabetes in youth and is geared to general pediatricians, family physicians, pediatric endocrinologists, and other healthcare providers who deal with children," Dr. Silverstein told Medscape Medical News.

Recommendations

The first of the 2 documents provides "Key Action Statements" pertaining to glycemic management in newly diagnosed children and adolescents and also addresses ongoing management.

First is a recommendation for insulin treatment in all patients who present with ketosis or extremely high blood sugar, in whom it may not be clear initially whether they have type 2 or type 1 diabetes. This is important because overweight or obese children are frequently misdiagnosed as having type 2 when in fact they are positive for antibodies associated with type 1, Dr. Silverstein said.

Once type 2 diabetes is confirmed, lifestyle modification along with metformin as first-line therapy is recommended. Metformin and insulin are the only 2 glucose-lowering medications currently approved in youth less than 18 years, but others are being studied, Dr. Silverstein said.

As with adult patients, hemoglobin A1c levels should be measured every 3 months and therapy intensified if goals for both A1c and blood glucose aren't met. Citing several papers, the panel endorsed a general target A1c of less than 7% for youth with type 2 diabetes but noted that individual needs may require adjustment of that goal up or down.

Finger-stick self-glucose monitoring is advised for all patients taking insulin or sulfonylureas, those initiating or changing therapy, and those who haven't met treatment goals or who have intercurrent illness.

Recommendations on frequency of monitoring vary, but generally the panel endorsed the ADA's guidelines, which include 3 or more times daily for those on insulin and less frequent measurement, including postprandial checks, as a guide to therapy for those not on insulin.

The panel cited fasting blood glucose value of 70 to 130 mg/dL as "a reasonable target for most."

Nutrition counseling based on Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines by the Academy of Nutrition and Dietetics was endorsed for children and adolescents with type 2 diabetes, both at the time of diagnosis and for ongoing management.

The panel also advised moderate to vigorous exercise for at least 60 minutes daily and the limitation of nonacademic screen time to less than 2 hours per day.

In the separate technical report, the panel addresses screening for common diabetes comorbidities, including hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression.

Primary Care Role

Dr. Silverstein told Medscape Medical News that primary care physicians should be on the alert for type 2 diabetes, since the diagnosis may not be obvious. "We need to think about it in all children who are overweight or obese. The symptoms aren't as obvious as in type 1 diabetes…. Type 2 is insidious. It occurs much more gradually."

In fact, she said, many children with type 2 diabetes don't exhibit the classic acute polyuria, polydipsia seen with type 1. Rather, those with type 2 may have no symptoms and are found to have diabetes only on a school screening exam or when they present with candidiasis or a urinary tract infection.

"They may not have the typical symptoms associated with diabetes, so [physicians] need to be thinking about it," she said.

Once a patient is diagnosed, management of children and adolescents with type 2 diabetes requires team care, with coordination between the primary care physician and endocrinologist specialist, along with a nutritionist, diabetes educator, and importantly, psychologist or social worker to address behavioral issues.

In areas where pediatric endocrinologists aren't available, the primary care physician could communicate with an endocrinologist by phone or via teleconferencing, she said.

Dr. Silverstein provided Medscape Medical News with one more important piece of advice that is not included in the guidelines: Prediabetes is even more common in overweight youth than is frank diabetes, so the time to intervene is when the child is first noted to be gaining excess weight. "It's important to advise parents that it's much easier to prevent type 2 diabetes than to treat it."

Expert Opinion

Pediatric endocrinologist Dennis M. Styne, MD, the Yocha Dehe Chair of Pediatric Endocrinology and professor of pediatrics at the University of California, Sacramento, who was not involved with the guidelines, had high praise for them.

"This clinical-practice guideline and technical report concerning type 2 diabetes in children and adolescents is timely and exceptionally useful," Dr. Styne told Medscape Medical News.

"As so often is the case in pediatrics, expert opinion replaces evidence-based conclusions that should be the results of large, long-term clinical trials," he said, adding that in contrast, most studies of type 2 diabetes in youth are "small, short-term, imperfect, or nonexistent."

However, Dr. Styne said, "The team that wrote these publications is at the forefront of clinical care for children and adolescents with type 2 diabetes, and their expert opinion and detailed review of existing studies is quite valuable."

Dr. Silverstein has received small grants from Pfizer, Novo Nordisk, and Lilly and was on a grant review committee for Genentech and on an advisory committee for sanofi and Abbott Laboratories for a 1-time meeting. Dr. Copeland served on the Endocrinology and Pediatric Endocrine Society liaison for Novo Nordisk, Genentech, and Endo. Disclosures for the other coauthors are listed in the article. Dr. Styne has disclosed no relevant financial relationships.

Pediatrics. Published online January 28, 2012. Guidelines full text, Technical report full text

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