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Management Guidelines for Childhood Type 2 Diabetes Mellitus

Guidelines for primary care management, including use of insulin, metformin, finger-stick blood glucose and HbA1c monitoring, and lifestyle modification


The American Academy of Pediatrics (AAP) Subcommittee on Management of T2DM in Children and Adolescents


Primary care clinicians


The prevalence of type 2 diabetes mellitus (T2DM) in youth is increasing, but the evidence base informing management in this population is not robust. Several professional groups collaborated to review existing evidence (from 1990–2008), including extrapolations from studies of T2DM in adults and T1DM in children, to develop an evidence-based clinical practice guideline for management of newly diagnosed T2DM in 10- to 18-year-olds. The guideline’s key action statements for clinicians are:

  • Initiate insulin therapy in children and adolescents with diabetes and ketosis, a clinical picture that is not clearly T1DM or T2DM (e.g., obese children presenting with ketosis), random blood glucose 250 mg/dL, or HbA1c >9% (strong recommendation). Up to 25% of adolescents with T2DM present with ketoacidosis.
  • Initiate metformin therapy with a program of lifestyle modification in all other children and adolescents with newly diagnosed T2DM (strong recommendation). Metformin is the only oral medication approved for use in patients <18 years with T2DM; it carries a low risk for hypoglycemia and can aid in weight control. Nutrition and physical activity changes alone have a low success rate (10%). In one randomized controlled trial, metformin was associated with better outcomes than lifestyle changes.
  • Monitor HbA1c concentrations every 3 months (optional recommendation, based on expert opinion and adult T2DM and child T1DM studies), with a target concentration <7% to minimize risk for microvascular complications. Check HbA1c every 6 months in stable patients.
  • Advise patients to monitor finger-stick blood glucose levels when taking insulin, initiating or changing treatment, not meeting goals, or sick with an intercurrent illness (optional recommendation, basedon consensus). The number of daily checks depends on the insulin regimen.
  • Incorporate nutrition counseling based on the Academy of Nutrition and Dietetics’ pediatric nutrition practice guidelines, including a nutrition “prescription” with decreased fat and sugary drinks and increased fruits and vegetables (optional recommendation, based on expert opinion). Recommended caloric restrictions are 900–1200 calories/day for children ages 6–12 years and not less than 1200 calories/day for adolescents aged 13–18 years.
  • Encourage moderate-to-vigorous physical activity for at least 60 minutes per day and less than 2 hours of nonacademic screen time per day (optional recommendation, based on expert opinion and evidence from studies in obese children). Provide a written prescription for physical activity with specific duration, intensity, and frequency, taking into account physical abilities, patient preferences, and family circumstances.

Pediatric T2DM management should embrace family-centered care. Patient preferences play a “dominant” role in nutrition and physical activity management. When HbA1c and finger-stick blood glucose goals are not met, intensification of therapy is indicated (increased blood glucose monitoring, medication adjustment, stronger focus on lifestyle changes, more frequent primary care visits, and referral to specialists).

Referral to specialists (e.g., endocrinologists, dieticians) is recommended whenever insulin therapy is initiated, treatment goals are not met, or the primary care clinician seeks support from consultants with more expertise. Screening and management tools for comorbid conditions (e.g., hypertension, dyslipidemia, depression, nephropathy) were adapted from other guidelines and included in the accompanying technical report.

Comment: This guideline assists primary care clinicians unfamiliar with the management of this previously uncommon condition in children. Management of pediatric T2DM is rapidly changing with the potential introduction of other oral medication classes (some with serious known side effects in adults) to adolescents with T2DM. Early initiation of metformin, regular HbA1c monitoring, and written “prescriptions” and referrals to help encourage lifestyle modification are key recommendations.

— Cornelius W. Van Niel, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 20, 2013