Rise in kids with type 2 diabetes drives new AAP guidelines

With the increased rate of childhood obesity over the last 30 years, primary care physicians and pediatricians are seeing a rise in the cases of type 2 diabetes mellitus in kids and adolescents. So in February the American Academy of Pediatrics released for the first time clinical guidelines to manage this patient population.

The guidelines, published in the February issue of Pediatrics, provides healthcare professionals evidence-based recommendations for managing patients who are 10 to 18 years old and have received a diagnosis of type 2 diabetes mellitus. The guidelines were developed in collaboration with the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics.

The recommendations explain when insulin therapy or metformin should be started in children and adolescents with type 2 diabetes, the need for a lifestyle modification program that includes diet and physical activity, and the need to monitor HbA_1c concentrations and self-monitor blood glucose levels to meet treatment goals, according to Kenneth C. Copeland, MD, FAAP, and colleagues in the published guidelines.

“Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in whom the distinction between T1DM and T2DM is unclear,” the authors wrote.

Insulin should be started in patients who have blood glucose concentrations ≥250 mg/dL or whose HbA_1c is >9%. In other cases of type 2 diabetes, clinicians should request children and adolescents to modify their lifestyle in terms of nutrition and physical activity and start on metformin as first-line therapy at the time of diagnosis, the authors continued.

The recommendations also stated that HbA_1c concentrations should be monitored by the clinician every 3 months and adjustments in treatment made if the goals for blood glucose levels and HbA_1c concentrations are not met, they said.

Self-monitoring of blood glucose is recommended for patients who take insulin or other medications with a risk of hypoglycemia or who are changing their treatment regimen as well as those who have not achieved their treatment goals or have other illnesses. In addition, clinicians should recommend nutrition counseling for these diabetes patients as a component of their treatment.

Healthcare professionals also need to emphasize the need for daily physical activity of at least 1 hour that is moderate to vigorous exertion and to limit sedentary time in front of a screen to less than 2 hours per day.