In the past, children who developed diabetes were described as having “juvenile-onset diabetes mellitus,” as contrasted with adults who were diagnosed with diabetes, who were described as having “adult-onset diabetes mellitus.” That terminology has changed, but still isn’t perfect. The first big change was to describe children who developed diabetes as having type 1 diabetes (T1DM), and adults as having type 2 diabetes (T2DM). But labeling the patient based on their age at the time of onset never worked out, as there were some adults who developed typical T1DM or atypical versions such as LADA diabetes, and some children who developed type 2 diabetes. And sometimes kids developed other variants of diabetes, including six different types of MODY diabetes (Maturity-Onset Diabetes of the Young).
It’s confusing enough for those of us physicians who deal with adults with diabetes every day, but I’d expect most physicians who care for adults have learned the fundamentals of how to treat adults with type 2 diabetes, and if not, they can look up the American Diabetes Association’s Standards of Care for Diabetes.
But for pediatricians and other physicians who occasionally are confronted with a new case of T2DM in an obese child, there haven’t been any guidelines. In the past, seeing an obese child with diabetes was quite rare, but now-a-days, up to a third of cases of diabetes being diagnosed in kids these days are T2DM. Should these kids be started on insulin? Or diabetes pills – only one of which is approved for use in kids? Or diet and exercise only?
Today, the American Academy of Pediatrics (AAP) published the first guidelines about how to manage T2DM in children. The guidelines were written with input from the American Diabetes Association, the Pediatric Endocrine Society, and other organizations including the American Academy of Family Physicians and the Academy of Nutrition and Dietetics (which previously called itself the American Dietetic Association).
As a press release from the AAP points out, “The guidelines recommend beginning treatment with insulin at the time of diagnosis in all patients who are ketotic or in ketoacidosis, markedly hyperglycemic, or in whom the distinction between type 1 and type 2 diabetes is not clear. In all others, metformin is recommended as first-line therapy, along with a lifestyle modification program including nutrition and physical activity. The guidelines include recommendations for monitoring pediatric patients’ glycemic control, implementing insulin regimens, and diet and physical activity recommendations.”
The guidelines are available on-line as a PDF file, at Management of Type 2 Diabetes Mellitus in Children and Adolescents. A warning to those of you who might be interested in reading the guidelines: they are very lengthy and very wordy. So don’t expect to be able to hand a copy to your physician and have the doc scan it and comment upon it while you wait… But if your medical team sees kids with diabetes, and isn’t aware of these guidelines, it would be worthwhile to let them know these guidelines exist.