Until recently, pediatricians have mostly had to deal with type 1 diabetes, which has a different cause and usually requires different management than type 2 diabetes. But, today, due largely to the rise in childhood obesity, as many as one in three children diagnosed with diabetes has type 2.
Dr. Janet Silverstein, division chief of pediatric endocrinology at the University of Florida, in Gainesville, one of the authors of the guidelines said, "Pediatricians and pediatric endocrinologists are used to dealing with type 1 diabetes." "Most have had no formal training in the care of children with type 2."
"The major reason for the guidelines is that there's been an increase in overweight and obesity in children and adolescents, with more type 2 diabetes in that population, making it important for general pediatricians as well as endocrinologists to have structured guidelines to follow," she said.
For example, it can be very difficult to distinguish immediately whether or not a child has type 1 or type 2 diabetes, especially if a child is overweight. The only way to tell for sure is a test for islet antibodies. Because type 1 diabetes is an autoimmune disease, a child or teen with type 1 will have islet antibodies that destroy the insulin-producing cells in the pancreas. But, it can take weeks to get the results of these tests.
Weight doesn't play a role in the development of type 1 diabetes, but it's possible that someone with type 1 could be overweight, making an immediate diagnosis of the type of diabetes very hard. If someone with type 1 diabetes is mistakenly diagnosed with type 2 diabetes, and given oral medications such as metformin instead of the insulin they must have, they can get very sick, very quickly.
That's why the first new guideline is to start a child or teen on insulin if it's at all unclear whether a child has type 1 or type 2 diabetes. The guideline further recommends that they continue using insulin until the diabetes type can be definitively determined.
Other key guidelines include the following:
- Once a child or teen has been diagnosed with type 2 diabetes, prescribe metformin and lifestyle changes, including nutrition and physical activity.
- Monitor A1c levels every three months. If treatment goals aren't being met, the physician should make appropriate changes to the treatment regimen.
- Home monitoring of blood glucose is appropriate for those using insulin, anyone changing their treatment regimen, those who aren't meeting their treatment goals and during times of illness.
- Physicians should incorporate the Academy of Nutrition and Dietetics' Pediatric Weight Management Evidence-Based Nutrition Practice Guideline in nutrition counseling of children with type 2 diabetes.
- Children with type 2 diabetes should be encouraged to exercise at least 60 minutes a day and to limit their nonacademic "screen time" (video games, television) to less than two hours a day.
Dr. Rubina Heptulla, chief of the division of pediatric endocrinology and diabetes at Children's Hospital at Montefiore in New York City, stated that, "There's a need for type 2 guidelines in the pediatric population, and I think the new guidelines are good. But, there are a lot of unanswered questions." Dr. Heptulla added that, "There's really only one large study on type 2 diabetes and children." "These guidelines are a first step, and they highlight the critical need for more research."
The U.S. Centers for Disease Control and Prevention estimates that about 3,600 children are being diagnosed with type 2 diabetes every year, so pediatricians need to be aware that they may begin seeing children with type 2 in their practices.
Silverstein said that pediatricians should monitor A1C levels in overweight children, because it's much easier to prevent the disease than to treat it after it has occurred.
Type 1 diabetes tends to cause excessive thirst and frequent urination, but Silverstein said these symptoms aren't always present or as evident in children with type 2. If children have urethritis (inflammation of the tube that drains the bladder) or yeast infections in girls, doctors should consider testing their blood sugar levels.
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 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.
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.
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.