First-Ever Guidelines for Children With Diabetes
By Miriam E. Tucker
Medscape Medical News
Type 2 diabetes is rising rapidly among children and teens because of soaring obesity rates. It now accounts for up to 1 in 3 new cases of diabetes in those younger than 18. These guidelines are for children between the ages of 10 and 18.
"Few providers have been trained in managing type 2 diabetes in children and, to date, few medications have been evaluated for safety and [effectiveness] in children," says co-author Janet Silverstein, MD, professor of pediatrics at the University of Florida and chief of endocrinology at Shands Hospital in Gainesville.
"This is a real issue in the pediatric population. It's something that many of us as pediatricians didn't grow up with because we just didn't see it very often," she says.
Central to the recommendations is the proper diagnosis of either type 1 or type 2 diabetes. But this can often take time and is not always clear-cut.
Because of that, the guidelines recommend giving insulin to patients if it's not clear whether they have type 1 or type 2 diabetes. If type 2 diabetes is confirmed, lifestyle changes along with the medication metformin are recommended. Metformin and insulin are the only two blood sugar-lowering medications approved for those younger than 18, but others are being studied, Silverstein says.
The panel also recommended that children with type 2 diabetes get their hemoglobin A1c levels measured every three months. The test measures blood sugar levels for the past two or three months.
The panel that wrote the guidelines endorsed an A1c goal of less than 7% for young people with type 2 diabetes, but noted it may be adjusted depending on the person.
Finger-stick self-glucose monitoring is advised for all patients taking insulin or another class of diabetes medication called sulfonylureas, along with those starting or changing therapy and those who haven't met treatment goals.
Recommendations on frequency of monitoring vary, but generally the panel endorsed the ADA's guidelines, which include three or more times daily for those on insulin and less frequent measurement, including after-meal checks, for those not on insulin.
The panel also recommended nutrition counseling, moderate to vigorous exercise for at least 60 minutes daily, and limiting screen time at home to less than two hours per day.
The Doctor's Role
Silverstein says primary care doctors should be on the alert for type 2 diabetes, since the diagnosis may not be obvious. "We need to think about it in all children who are overweight or obese. The symptoms aren't as obvious as in type 1 diabetes. ... Type 2 is insidious. It occurs much more gradually."
Many children with type 2 diabetes don't exhibit the classic symptoms seen with type 1, she says. Kids with type 2 may have no symptoms and are found to have diabetes only on a school screening test or when they get a yeast infection or a urinary tract infection.
Silverstein says there is one more important piece of advice not included in the guidelines: Prediabetes is even more common in overweight children than is diabetes. It's vital to intervene when a child is gaining too much weight. "It's important to advise parents that it's much easier to prevent type 2 diabetes than to treat it."
Center for Drug Evaluation and Research, Meeting of the Drug Safety and Risk Management Advisory Committee, Silver Spring, Md., Jan. 24-25, 2013.
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