How to Diagnose Children with Diabetes

Is there an ideal approach to screen and diagnose children and adolescents for prediabetes and diabetes?

Diabetes is an ongoing issue in the United States, and it can appear as early as childhood. Children with health issues such as obesity have a higher chance of developing diabetes in childhood and adulthood. Being able to notice these problems early and intervene can help children with prediabetes in the future. The American Diabetes Association has screened asymptomatic children over ten who are deemed overweight and pose two or more health risks: family history of type 2 diabetes, insulin resistance, non-white race, and maternal gestational diabetes. In addition, the ADA changed its guidelines, allowing more children with obesity issues to be screened if they had one or more of the health risks associated with diabetes. The three standard tests usually recommended for screening children for prediabetes and diabetes are fasting plasma glucose, 2-hour plasma glucose, and hemoglobin A1C.

A cross-sectional analysis was conducted to discover the ideal approach to screen and diagnose children and adolescents for prediabetes and diabetes in this study. This analysis was conducted using the National Health and Nutrition Examination Survey, a survey that consists of interviews, physical at-home examinations, and lab tests. They collected surveys of more than 6,000 participants for a 17-year period. Screening eligibility was based on obesity problems and having one of the three main risk factors: non-white race, family history of diabetes, and hypertension, or dyslipidemia. The study focused on clinical definitions of prediabetes and undiagnosed diabetes to identify children and adolescents at high cardiometabolic risk. The definitions used for prediabetes and undiagnosed diabetes were: HbA1c, fasting glucose, elevations in either or both of these tests, and total hyperglycemia. The high cardiometabolic risk was defined as waist circumference higher than 90th percentile for age, sex, and ethnicity, and having a test result of one of these risk factors: high triglyceride, HDL-C under 40 mg/dL, systolic blood pressure over 130 mm Hg or diastolic blood pressure over 85 mm Hg.

The analysis was conducted by the United States Census and the percentage of youth that were eligible to be screened for prediabetes and undiagnosed diabetes under the ADA rules. The screening rules’ sensitivity, specificity, positive predictive value, and negative predictive value were calculated to recognize children and adolescents with prediabetes or undiagnosed diabetes. About 0.3% of these undiagnosed patients with diabetes had a hemoglobin A1C higher than 6.5% (95% confidence interval [CI]: 0.1%–0.5%). Also, patients who were not diagnosed with diabetes had a higher fasting blood glucose of greater than 100 mg/dL than patients who were already diagnosed with diabetes and had a lower FBG. Patients with cardiometabolic risk factors were more common in children with high FPG and hemoglobin A1C. One of the main factors for detecting metabolic syndrome was HbA1C higher than 5.7%, with a 98.6% specificity, compared to FPG with a value higher than 100 mg/dL and specificity of 90.1%.

The study concluded that screening patients when they are young is critical to prevent diabetes and cardiovascular risk in the future. One study recommended children over ten years old who had at least one risk factor to screen for prediabetes. Two critical tests, such as HbA1C and FPG, can diagnose if a patient has prediabetes. HbA1C is a more specific test and has an advantage over FPG in that it does not require fasting. One of the main strengths of this study was that it included all the cardiometabolic risk factors that other studies had not done previously. A weakness was that the surveys did not ask the patients about their family history; therefore, it would be hard to correlate that patient with diabetes in the future.

Practice Pearls:

• The most common tests that can screen and diagnose youth for prediabetes and diabetes are HbA1C, FPG, and 2-hour plasma glucose.
• Children that are not diagnosed with diabetes, with HgA1C higher than 5.7% and PFG higher than 100 mg/dL, meet the criteria for prediabetes.
• HbA1C was the most specific and helpful test to diagnose young children for diabetes.

Amelia S. Wallace, Dan Wang, Jung-Im Shin, and Elizabeth Selvin. “Screening and Diagnosis of Prediabetes and Diabetes in US Children and Adolescents.” Official Journal of the American Academy of Pediatrics, 1 Aug. 2020. Web. 13 Aug. 2020.    https://doi.org/10.1542/peds.2020-0265

Tamara S. Hannon. “Promoting Prevention, Identification, and Treatment of Prediabetes and Type 2 Diabetes in Youth.” Official Journal of the American Academy of Pediatrics, 1 Aug. 2020. Web. 13 Aug. 2020.    https://doi.org/10.1542/peds.2020-010272

Joan Prifti, PharmD. Candidate, LECOM College of Pharmacy