Miriam E Tucker

September 17, 2015

STOCKHOLM — A Texas toddler is believed to be the youngest person ever diagnosed with type 2 diabetes.

The case report was presented September 16 in a poster discussion session here at the European Association for the Study of Diabetes (EASD) 2015 Meeting by Michael Yafi, MD, director of pediatric endocrinology at the University of Texas Health Science Center at Houston.

But during the question-and-answer period, session moderator Tiinamaija Tuomi, MD, PhD, head of the department of endocrinology at the University of Helsinki, Finland, raised the possibility of an alternative diagnosis: maturity-onset diabetes of the young (MODY).

Liquid Metformin for Kids?

The child, a 3-year-old Hispanic girl weighing 35 kg (77 pounds; > 95th percentile for age) presented at Dr Yafi's pediatric endocrinology clinic for evaluation of obesity.

Dr. Yafi noted that while she didn't seem ill, she had polyuria and polydipsia, so he screened her and found she had a fasting plasma glucose of 230 mg/dL (12.6 mmol/L)and an HbA1c of 7.2%. Her C-peptide was positive (6.9 ng/mL) and she was negative for antiglutamic acid decarboxylase or islet-cell antibodies, so he diagnosed her with type 2 diabetes.

The parents — who initially had very poor nutritional habits — were educated about lifestyle modification, and the girl started on a liquid form of metformin. She lost 25% of her body weight and eventually was taken off metformin. At 6 months' postdiagnosis, she continued to have normal blood glucose levels, with an HbA1c of 5.3%.

Although 40% of children in Texas who are newly diagnosed with diabetes have type 2, this case is believed to be the youngest. And there are probably others like her, Dr Yafi told Medscape Medical News. "It's scary. I think the problem is pediatric obesity."

He added that the liquid metformin — which had to be specially requested from a pharmacy — is a sign of the times. "That tells you the future of diabetes. Now they have to make liquid metformin for kids."

He advised that even in children that young, obesity should prompt clinicians to "think about the possibility of [type 2] diabetes and implement lifestyle modification."

Doctors have previously reported on a 2.5-year-old boy who is believed to have been the youngest child to undergo sleeve gastrectomy, in Saudi Arabia.

But Could It Be MODY?

After his presentation, Dr Tuomi asked Dr Yafi if he was sure that the child actually had type 2 diabetes, noting that if the girl had a MODY mutation it's possible that with the obesity, she could well have had very high hyperglycemia initially but then it may have reverted to normal with the lifestyle changes, so perhaps the metformin had nothing to do with it.

Dr Yafi responded that he had considered the possibility, but due to the lack of strong family history of diabetes — neither the child's parents nor siblings had it — and the high cost of the MODY test, he determined that it wasn't worth ordering it.

But Dr Tuomi said she would strongly suggest ordering the test, noting that "even without the family history, there are de novo mutations."

She told Medscape Medical News, "It's such a rare case and such a young age at presentation of type 2 diabetes. Of course it is possible — we're [seeing] younger and younger children [with type 2 diabetes] all the time — but just the fact that the child is obese doesn't mean that it has to be type 2 diabetes."

And if the child did have a MODY mutation, the obesity might make the diabetes appear earlier in life, she pointed out.

Screening for MODY costs between $2000 and $3000. "When you compare that with what it would cost to follow up a child like that for so many years, if that would give you an answer I actually think there would be cost/benefit," she told Medscape Medical News.

But Dr Tuomi did agree with Dr Yani on at least one thing: "In any case, lifestyle modification would be what this child needs."

Dr Yani and Dr Tuomi have no relevant financial relationsips.

European Association for the Study of Diabetes (EASD) 2015 Meeting. Stockholm, Sweden. Abstract 303, presented September 16, 2015.

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