First-ever guidelines issued for treating type 2 diabetes in kids

Until recently, pediatricians have mostly had to deal with type 1 diabetes, which has a different cause and usually a 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.

"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," said one of the authors of the new guidelines, Dr. Janet Silverstein, division chief of pediatric endocrinology at the University of Florida, in Gainesville.

"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, according to Silverstein.

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 hemoglobin A1c (HbA1c) levels every three months. HbA1c provides a measure of the past two to three months of blood sugar levels. 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.

"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," said Dr. Rubina Heptulla, chief of the division of pediatric endocrinology and diabetes at Children's Hospital at Montefiore in New York City.

"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," Heptulla said. For her part, Silverstein agreed that more well-designed research is needed.

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 HbA1C 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.

The new guidelines were published online Jan. 28 and in the February print issue of Pediatrics.

More information: Learn more about preventing type 2 diabetes from the U.S. National Diabetes Education Program.

Journal reference: Pediatrics

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