Management of Type 2 Diabetes Mellitus in Children and Adolescents

Abstract

OBJECTIVE: Over the last 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. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, "Management of Type 2 Diabetes Mellitus in Children and Adolescents," and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline' s recommendations. METHODS:A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM' s comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist.RESULTS: Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following:

Type 2 diabetes mellitus in children and adolescents

“…However, in the mid-1990s, investigators began to observe an increasing incidence of type 2 diabetes mellitus worldwide [1] . This is particularly the case in the United States [1,2] but has also been reported in other countries like Canada, Japan, Austria, United Kingdom and Germany [3][4][5][6][7][8][9][10] . In some regions in the United States, type 2 diabetes mellitus is as frequent as type 1 diabetes mellitus in adolescents [11] .…”

“…Within the whole pediatric cohort surveyed, Table 1 Comparison between Caucasian and non-Caucasian children and adolescents with type 2 diabetes mellitus the overall incidence of type 2 diabetes mellitus remained low when compared with type 1 diabetes mellitus. This had led some researchers to question the claims of an "epidemic" of pediatric type 2 diabetes mellitus [33] , although there is general agreement that type 2 diabetes mellitus in youth appears to be emerging as a serious clinical issue [9,34] .…”

“…Obesity and puberty are important factors for developing insulin resistance in childhood and adolescence [22] . Apart from β-cell autoantibodies in children clinically classified as type 2 diabetes mellitus, negative autoantibodies in children with type 1 diabetes mellitus with acute-onset of diabetes mellitus, severe metabolic impairment and insulin requirement only in the early stage of disease are reported [7,9] . In conclusion, type 1 and type 2 diabetes mellitus do not seem to be completely distinctive and can overlap considerably.…”

“…The American Academy of Pediatrics has, very recently, published management guidelines how to treat children and adolescents with type 2 diabetes mellitus [9] . The ideal goal of treatment is normalization of blood glucose values and HbA1c [10] .…”

“…Most of the recommended guidelines for treatment in children with type 2 diabetes mellitus are extrapolated from experience gained in adults [7,9,10] . Despite of severe manifestation, initial management of obese children and adolescents with type 2 diabetes mellitus should consist of behaviour modification strategies for lifestyle change such as decreasing high-caloric high-fat food choice and sedentary behaviour, while increasing physical activity [58] .…”