Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents

Abstract

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10-to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of 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). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child' s age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

Reversal of type 2 diabetes in youth who adhere to a very-low-energy diet: a pilot study

“…The TODAY study, a large US multicentre randomised clinical trial comparing treatment options for 699 10-to 17-year-olds with type 2 diabetes, found that therapy based on current clinical practice guidelines [6] (metformin plus lifestyle intervention) was ineffective for maintaining glycaemic control in nearly 50% of participants after 1 year of treatment, despite 6 months of weekly face-to-face sessions [36]; hence, the TODAY study, together with the evidence for early diabetes-related complications [3,4], highlights the need for aggressive therapies that commence immediately or early after diagnosis. Bariatric surgery may be a feasible alternative, with one study demonstrating reversal of type 2 diabetes in ten of 11 adolescents [37].…”

“…However, regular physical activity was encouraged, consistent with guidelines for type 2 diabetes management in youth [6]. Participants were given an interactive pedometer (Fitbit One; Fitbit, San Francisco, CA, USA) to encourage activity, allowing monitoring and appropriate support from the study dietitian.…”

“…Current treatment guidelines aim to optimise glycaemic control and prevent complications through lifestyle intervention with metformin therapy [5,6]. However, findings from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study (ClinicalTrials.gov identifier: NCT00081328) suggest this treatment may be ineffective in nearly 50% of youth [7].…”

Fatty Liver Disease among other Comorbidities Requiring Early Diagnosis in Pediatric Obesity

“…Bariatric surgery has proved its usefulness in adults and now it is being applied to children and adolescents with notable improvements of comorbidities, although an experienced setting is required. Concerning the use of metformin in T2D, the initial enthusiasm has waned and probably the concomitant use of insulin would be advisable [70]. The long-acting basal insulin analogs such as insulin detemir, insulin glargine or even insulin degludec [71] used in the adult reduce nocturnal hypoglycemic episodes and can be used in pediatric patients in not well controlled type 2 diabetic patients.…”

Efecto de un programa educativo en el nivel de conocimiento sobre diabetes mellitus 2 en niños de una institucion educativa de Lima

“…Al ser la obesidad y sobrepeso, los factores de riesgo modificables más importantes para la aparición de DM2 en niños, es importante desarrollar programas educativos que incidan en el control del peso corporal y la adopción de estilos de vida saludables (10) . Experiencias anteriores en otros países han tenido efectos contradictorios, probablemente debido al uso incorrecto de los componentes encargados de la modificación sostenible de conductas de riesgo (11,12) .…”