Download pdf - Dm Tipe 2 Tatalaksana

8/13/2019 Dm Tipe 2 Tatalaksana

1/23

DOI: 10.1542/peds.2012-3494; originally published online January 28, 2013;2013;131;364Pediatrics

Anderson, Stephen J. Spann and Susan K. FlinnRaymer, Richard N. Shiffman, Shelley C. Springer, Vidhu V. Thaker, MeaghanKenneth C. Copeland, Janet Silverstein, Kelly R. Moore, Greg E. Prazar, Terry

and AdolescentsManagement of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children

http://pediatrics.aappublications.org/content/131/2/364.full.htmllocated on the World Wide Web at:

The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2013 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/131/2/364.full.htmlhttp://pediatrics.aappublications.org/content/131/2/364.full.htmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/content/131/2/364.full.html


2/23

DOI: 10.1542/peds.2012-3494; originally published online January 28, 2013;2013;131;364Pediatrics

Anderson, Stephen J. Spann and Susan K. FlinnRaymer, Richard N. Shiffman, Shelley C. Springer, Vidhu V. Thaker, MeaghanKenneth C. Copeland, Janet Silverstein, Kelly R. Moore, Greg E. Prazar, Terry

and AdolescentsManagement of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2013 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


3/23

ServicesUpdated Information &

mlhttp://pediatrics.aappublications.org/content/131/2/364.full.htincluding high resolution figures, can be found at:

References

ml#ref-list-1http://pediatr ics.aappublications.org/content/131/2/364.full.htat:

This article cites 72 articles, 25 of which can be accessed free

Citations

ml#related-urlshttp://pediatrics .aappublications.org/content/131/2/364.full.htThis article has been cited by 3 HighWire-hosted articles:

Rs)3Peer Reviews (PPost-Publication

http://pediatrics.aappublications.org/cgi/eletters/131/2/364

R has been posted to this article:3One P

Subspecialty Collections

ogy_subhttp://pe diatrics.aappublications.org/cgi/collection/endocrinol

Endocrinologythe following collection(s):This article, along with others on similar topics, appears in

Errata

l.htmlhttp:// pediatrics.aappublications.org/content/131/5/1014.1.fulsee:An erratum has been published regarding this article. Please

Permissions & Licensing

tmlhttp ://pediatrics.aappublications.org/site/misc/Permissions.xhtables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2013 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on September 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/131/2/364.full.htmlhttp://pediatrics.aappublications.org/content/131/2/364.full.htmlhttp://pediatrics.aappublications.org/content/131/2/364.full.htmlhttp://pediatrics.aappublications.org/content/131/2/364.full.html#ref-list-1http://pediatrics.aappublications.org/content/131/2/364.full.html#ref-list-1http://pediatrics.aappublications.org/content/131/2/364.full.html#ref-list-1http://pediatrics.aappublications.org/content/131/2/364.full.html#related-urlshttp://pediatrics.aappublications.org/content/131/2/364.full.html#related-urlshttp://pediatrics.aappublications.org/content/131/2/364.full.html#related-urlshttp://pediatrics.aappublications.org/cgi/eletters/131/2/364http://pediatrics.aappublications.org/cgi/eletters/131/2/364http://pediatrics.aappublications.org/cgi/eletters/131/2/364http://pediatrics.aappublications.org/cgi/collection/endocrinology_subhttp://pediatrics.aappublications.org/cgi/collection/endocrinology_subhttp://pediatrics.aappublications.org/content/131/5/1014.1.full.htmlhttp://pediatrics.aappublications.org/content/131/5/1014.1.full.htmlhttp://pediatrics.aappublications.org/content/131/5/1014.1.full.htmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/content/131/5/1014.1.full.htmlhttp://pediatrics.aappublications.org/cgi/collection/endocrinology_subhttp://pediatrics.aappublications.org/cgi/eletters/131/2/364http://pediatrics.aappublications.org/content/131/2/364.full.html#related-urlshttp://pediatrics.aappublications.org/content/131/2/364.full.html#ref-list-1http://pediatrics.aappublications.org/content/131/2/364.full.html


4/23

CLINICAL PRACTICE GUIDELINE

Management of Newly Diagnosed Type 2 Diabetes

Mellitus (T2DM) in Children and Adolescents

abstractOver the past 3 decades, the prevalence of childhood obesity has increaseddramatically in North America, ushering in a variety of health problems,including type 2 diabetes mellitus (T2DM), which previously was not typicallyseen until much later in life. The rapid emergence of childhood T2DM poseschallenges to many physicians who nd themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline

was developed to provide evidence-based recommendations on managing10- to 18-year-old patients in whom T2DM has been diagnosed. The AmericanAcademy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with thesupport of theAmerican DiabetesAssociation, thePediatric Endocrine Society, the American Academyof FamilyPhysicians, and the Academy of Nutrition and Dietetics (formerly the Amer-ican Dietetic Association). These groups collaborated to develop an evidencereport that served as a major source of information for these practice guide-line recommendations. The guideline emphasizes the use of managementmodalities that have been shown to affect clinical outcomes in this pediatricpopulation. Recommendations are made for situations in which either in-sulin or metformin is the preferred rst-line treatment of children and ado-

lescents with T2DM. The recommendations suggest integrating lifestylemodi cations (ie, diet and exercise) in concert with medication rather thanas an isolated initial treatment approach. Guidelines for frequency of mon-itoring hemoglobin A1c (HbA1c) and nger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematicgrading of the quality of evidence and strength of recommendation. Theclinical practice guideline underwent peer review before it was approvedby the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, andits recommendations may not provide the only appropriate approach to themanagement of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatmentgoals are not met or when therapy with insulin is initiated. The AAP acknowl-edges that some primary care clinicians may not be con dent of their ability to successfully treat T2DM in a child because of the child s age, coexistingconditions, and/or other concerns. At any point at which a clinician feels heor she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DMis made by a pediatric medical subspecialist, the primary care clinicianshould develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a med-ical home model in which the pediatrician partners with parents to ensure that all health needs are met. Pediatrics 2013;131:364 382

Kenneth C. Copeland, MD, Janet Silverstein, MD, Kelly R.Moore, MD, Greg E. Prazar, MD, Terry Raymer, MD, CDE,Richard N. Shiffman, MD, Shelley C. Springer, MD, MBA,Vidhu V. Thaker, MD, Meaghan Anderson, MS, RD, LD, CDE,Stephen J. Spann, MD, MBA, and Susan K. Flinn, MA

KEY WORDSdiabetes, type 2 diabetes mellitus, childhood, youth, clinicalpractice guidelines, comanagement, management, treatment

ABBREVIATIONSAAP American Academy of PediatricsAAFP American Academy of Family PhysiciansBG blood glucoseFDA US Food and Drug AdministrationHbA1c hemoglobin A1cPES Pediatric Endocrine SocietyT1DM type 1 diabetes mellitusT2DM type 2 diabetes mellitusTODAY Treatment Options for type 2 Diabetes in Adolescentsand Youth

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave led con ict of interest statements with the AmericanAcademy of Pediatrics. Any con icts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content of this publication.

The recommendations in this report do not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unlessreaf rmed, revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3494

doi:10.1542/peds.2012-3494

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2013 by the American Academy of Pediatrics

364 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and De ne the Child Health Care System and/or Improve the Health of all Children


5/23

Key action statements are as follows:

1. Clinicians must ensure that insulin therapy is initiated for childrenand adolescents with T2DM whoare ketotic or in diabetic ketoacidosis

and in whom the distinction between types 1 and 2 diabetes mel-litus is unclear and, in usual cases,should initiate insulin therapy forpatients

a. who have random venous orplasma BG concentrations 250mg/dL; or

b. whose HbA1c is > 9%.

2. In all other instances, clinicians

should initiate a lifestyle modi -cation program, including nutrition and physical act ivi ty, andstart metformin as rst-line therapy for chi ldren and adoles-

cents at the time of diagnosis of T2DM.

3. The committee suggests that clini-cians monitor HbA1c concentra-

tions every 3 months and intensify treatment if treatment goals fornger-stick BG and HbA1c concen-

trations are not being met (intensi-cation is de ned in the De nitions

box).

4. The committee suggests that clini-cians advise patients to monitor

nger-stick BG (see Key ActionStatement 4 in the guideline for

further details) concentrations inpatients who

a. are taking insulin or other med-ications with a risk of hypoglyce-mia; or

b. are initiating or changing theirdiabetes treatment regimen; or

c. have not met treatment goals; ord. have intercurrent illnesses.

5. The committee suggests that clini-cians incorporate the Academyof Nutrition and Dietetics Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines in theirdietary or nutrition counseling of patients with T2DM at the time of diagnosis and as part of ongoingmanagement.

6. The committee suggests that clini-cians encourage children and ado-

lescents with T2DM to engage inmoderate-to-vigorous exercise forat least 60 minutes daily and tolimit nonacademic screen time

to less than 2 hours a day.

De nitions

Adolescent : an individual in various stages of maturity, generally considered to be between 12 and 18 years of age.

Childhood T2DM : disease in the child who typically

is overweight or obese (BMI 85th 94th and > 95th percentile for age and gender, respectively);

has a strong family history of T2DM;

has substantial residual insulin secretory capacity at diagnosis (re ected by normal or elevated insulin andC-peptide concentrations);

has insidious onset of disease;

demonstrates insulin resistance (including clinical evidence of polycystic ovarian syndrome or acanthosisnigricans);

lacks evidence for diabetic autoimmunity (negative for autoantibodies typically associated with T1DM). These patientsare more likely to have hypertension and dyslipidemia than are those with T1DM.

Clinician : any provider within his or her scope of practice; includes medical practitioners (including physicians andphysician extenders), dietitians, psychologists, and nurses.Diabetes : according to the American Diabetes Association criteria, de ned as

1. HbA1c 6.5% (test performed in an appropriately certi ed laboratory); or

2. fasting (de ned as no caloric intake for at least 8 hours) plasma glucose 126 mg/dL (7.0 mmol/L); or

3. 2-hour plasma glucose 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test performed as described by the World Health Organization by using a glucose load containing the equivalent of 75 g anhydrous glucose dissolvedin water; or

4. a random plasma glucose 200 mg/dL (11.1 mmol/L) with symptoms of hyperglycemia.

PEDIATRICS Volume 131, Number 2, February 2013 365

FROM THE AMERICAN ACADEMY OF PEDIATR


6/23

INTRODUCTION

Over the past 3 decades, the preva-lence of childhood obesity has in-creased dramatically in NorthAmerica, 15 ushering in a variety of health problems, including type 2 di-abetes mellitus (T2DM), which pre-viously was not typically seen untilmuch later in life. Currently, in theUnited States, up to 1 in 3 new casesof diabetes mellitus diagnosed inyouth younger than 18 years is T2DM

(depending on the ethnic composition

of the patient population),6,7

witha disproportionate representationin ethnic minorities 8,9 and occurringmost commonly among youth between 10 and 19 years of age. 5,10

This trend is not l imited to theUnited States but is occurring in- ternationally 11 ; it is projected thatby the year 2030, an estimated 366million people worldwide will havediabetes mellitus. 12

The rapid emergence of childhood

T2DM poses challenges to manyphysicians who nd themselves gen-erally ill-equipped to treat adult dis-eases encountered in children. Mostdiabetes education materials designedfor pediatric patients are directedprimarily to families of children with type 1 diabetes mellitus (T1DM) andemphasize insulin treatment and glu-cose monitoring, which may or maynot be appropriate for children with

(In the absence of unequivocal hyperglycemia, criteria 1 3 should be con rmed by repeat testing.)

Diabetic ketoacidosis : acidosis resulting from an absolute or relative insulin de ciency, causing fat breakdown andformation of hydroxybutyrate. Symptoms include nausea, vomiting, dehydration, Kussmaul respirations, and alteredmental status.

Fasting blood glucose : blood glucose obtained before the rst meal of the day and after a fast of at least 8 hours.

Glucose toxicity : The effect of high blood glucose causing both insulin resistance and impaired -cell production of insulin.

Intensi cation : Increase frequency of blood glucose monitoring and adjustment of the dose and type of medication in anattempt to normalize blood glucose concentrations.

Intercurrent illnesses : Febrile illnesses or associated symptoms severe enough to cause the patient to stay home fromschool and/or seek medical care.

Microalbuminuria: Albumin:creatinine ratio 30 mg/g creatinine but < 300 mg/g creatinine.

Moderate hyperglycemia : blood glucose = 180 250 mg/dL.

Moderate-to-vigorous exercise : exercise that makes the individual breathe hard and perspire and that raises his or her

heart rate. An easy way to de ne exercise intensity for patients is the

talk test

: during moderate physical activitya person can talk, but not sing. During vigorous activity, a person cannot talk without pausing to catch a breath.

Obese : BMI 95th percentile for age and gender.

Overweight : BMI between the 85th and 94th percentile for age and gender.

Prediabetes : Fasting plasma glucose 100 125 mg/dL or 2-hour glucose concentration during an oral glucose tolerance test 126 but < 200 mg/dL or an HbA1c of 5.7% to 6.4%.

Severe hyperglycemia : blood glucose > 250 mg/dL.

Thiazolidinediones (TZDs): Oral hypoglycemic agents that exert their effect at least in part by activation of the peroxisomeproliferator-activated receptor .

Type 1 diabetes mellitus (T1DM) : Diabetes secondary to autoimmune destruction of cells resulting in absolute (complete

or near complete) insulin de ciency and requiring insulin injections for management.Type 2 diabetes mellitus (T2DM) : The investigators designation of the diagnosis was used for the purposes of the lit-erature review. The committee acknowledges the distinction between T1DM and T2DM in this population is not alwaysclear cut, and clinical judgment plays an important role. Typically, this diagnosis is made when hyperglycemia is sec-ondary to insulin resistance accompanied by impaired -cell function resulting in inadequate insulin production tocompensate for the degree of insulin resistance.

Youth : used interchangeably with adolescent in this document.



7/23

T2DM.13,14 The National Diabetes Edu-cation Program TIP sheets (which canbe ordered or downloaded from www.yourdiabetesinfo.org or ndep.nih.gov)provide guidance on healthy eating,physical activity, and dealing with

T2DM in children and adolescents, butfew other resources are available thatare directly targeted at youth with thisdisease. 15 Most medications used forT2DM have been tested for safety andef cacy only in people older than 18years, and there is scant scienti cevidence for optimal management of children with T2DM.16,17 Recognizing thescarcity of evidence-based data, thisreport provides a set of guidelines for

the management and treatment of children with T2DM that is based ona review of current medical literaturecovering a period from January 1, 1990, to July 1, 2008.

Despite these limitations, the practic-ing physician is likely to be faced with the need to provide care for childrenwith T2DM. Thus, the American Acad-emy of Pediatrics (AAP), the PediatricEndocrine Society (PES), the American

Academy of Family Physicians (AAFP),American Diabetes Association, and the Academy of Nutrition and Dietetics(formerly the American Dietetic Asso-ciation) partnered to develop a set of guidelines that might bene t endo-crinologists and generalists, includingpediatricians and family physiciansalike. This clinical practice guidelinemay not provide the only appropriateapproach to the management of chil-

dren with T2DM. It is not expected toserve as a sole source of guidance in the management of children and ado-lescents with T2DM, nor is it intended toreplace clinical judgment or establisha protocol for the care of all childrenwith this condition. Rather, it is intended to assist clinicians in decision-making.

Primary care providers should en-deavor to obtain the requisite skills tocare for children and adolescents with

T2DM, and should communicate andwork closely with a diabetes team of subspecialists when such consultationis available, practical, and appropriate.The frequency of such consultationswill vary, but should usually be

obtained at diagnosis and then at leastannually if possible. When treatmentgoals are not met, the committeeencourages clinicians to consult withan expert trained in the care of chil-dren and adolescents with T2DM. 18,19

When rst-line therapy (eg, metfor-min) fails, recommendations for intensifying therapy should be generally the same for pediatric and adultpopulations. The picture is constantly

changing, however, as new drugs areintroduced, and some drugs that initially appeared to be safe demon-strate adverse effects with wider use.Clinicians should, therefore, remainalert to new developments with regard to treatment of T2DM. Seeking the ad-vice of an expert can help ensure that the treatment goals are appropriatelyset and that clinicians bene t fromcutting-edge treatment information in this rapidly changing area.

The Importance of Family-CenteredDiabetes Care

Family structure, support, and educa- tionhelp inform clinical decision-makingand negotiations with the patient andfamily about medical preferences thataffect medical decisions, independentof existing clinical recommendations.Because adherence is a major issue inany lifestyle intervention, engaging the

family is critical not only to maintainneeded changes in lifestyle but also tofoster medication adherence. 20 22 Thefamilys ideal role in lifestyle inter-ventions varies, however, depend-ing on the child s age. Behavioralinterventions in younger childrenhave shown a favorable effect. Withadolescents, however, interventionsbased on target-age behaviors (eg,including phone or Internet-based

interventions as well as face-to-face or peer-enhanced activities)appear to foster better results, atleast for weight management. 23

Success in making lifestyle changes to attain therapeutic goals requires

the initial and ongoing education of thepatient and the entire family abouthealthy nutrition and exercise. Any be-havior change recommendations mustestablish realistic goals and take intoaccount the families health beliefsand behaviors. Understanding the patient and family s perception of thedisease (and overweight status) beforeestablishing a management plan is im-portant to dispel misconceptions and

promote adherence. 24 Because T2DMdisproportionately affects minority pop-ulations, there is a need to ensure cul- turally appropriate, family-centered carealong with ongoing education. 25 28 Sev-eral observational studies cite the im-portance of addressing cultural issueswithin the family. 20 22

Restrictions in Creating ThisDocument

In developing these guidelines, thefollowing restrictions governed thecommittee s work:

Although the importance of diabetes detection and screening of at-risk populations is acknowledgedand referenced, the guidelinesare restricted to patients meeting the diagnostic criteria for diabetes(eg, this document focuses on treatment postdiagnosis). Speci -

cally, this document and its recom-mendations do not pertain topatients with impaired fastingplasma glucose (100 125 mg/dL)or impaired glucose tolerance (2-hour oral glucose tolerance testplasma glucose: 140 200 mg/dL)or isolated insulin resistance.

Although it is noted that the distinction between types 1 and 2 di-abetes mellitus in children may be


http://www.yourdiabetesinfo.org/http://www.yourdiabetesinfo.org/http://www.yourdiabetesinfo.org/http://www.yourdiabetesinfo.org/


8/23

dif cult, 29,30 these recommendationspertain speci cally to patients 10 to less than 18 years of age withT2DM (as de ned above).

Although the importance of high-risk care and glycemic control in preg-

nancy, including pregravid glycemia,is af rmed, the evidence consideredand recommendations contained in this document do not pertain to di-abetes in pregnancy, including dia-betes in pregnant adolescents.

Recommended screening sched-ules and management tools forselect comorbid conditions (hypertension, dyslipidemia, nephropathy,microalbuminuria, and depression)

are provided as resources in theaccompanying technical report. 31

These therapeutic recommendations were adapted from other rec-ommended guideline documentswith references, without an inde-pendent assessment of their sup-porting evidence.

METHODS

A systematic review was performedand is described in detail in the ac-companying technical report. 31 To de-velop the clinical practice guideline on the management of T2DM in childrenand adolescents, the AAP convened the Subcommittee on Management of T2DM in Children and Adolescentswith the support of the American Di-abetes Association, the PES, the AAFP,and the Academy of Nutrition andDietetics. The subcommittee was

co-chaired by 2 pediatric endocrinol-ogists preeminent in their eld andincluded experts in general pediat-rics, family medicine, nutrition, NativeAmerican health, epidemiology, andmedical informatics/guideline method-ology. All panel members reviewed theAAP policy on Conict of Interest andVoluntary Disclosure and declared allpotential con icts (see con icts state-ments in the Task Force member list).

These groups partnered to developan evidence report that served as amajor source of information for thesepractice guideline recommendations. 31

Speci c clinical questions addressedin the evidence review were as fol-

lows: (1) the effectiveness of treat-ment modalities for T2DM in childrenand adolescents, (2) the ef cacy of pharmaceutical therapies for treat-ment of children and adolescents withT2DM, (3) appropriate recommen-dations for screening for comorbid-ities typically associated with T2DMin children and adolescents, and (4) treatment recommendations for comor-bidities of T2DM in children and ado-

lescents. The accompanying technicalreport contains more information oncomorbidities. 31

Epidemiologic project staff searchedMedline, the Cochrane Collaboration,and Embase. MESH terms used invarious combinations in the searchincluded diabetes, mellitus, type 2, type1, treatment, prevention, diet, pediat-ric, T2DM, T1DM, NIDDM, metformin,lifestyle, RCT, meta-analysis, child, ad-

olescent, therapeutics, control, adult,obese, gestational, polycystic ovarysyndrome, metabolic syndrome, car-diovascular, dyslipidemia, men, andwomen. In addition, the Boolean

operators NOT, AND, OR were included invarious combinations. Articles address-ing treatment of diabetes mellitus wereprospectively limited to those that werepublished in English between January1990 and June 2008, included abstracts,

and addressed children between theages of 120 and 215 months with anestablished diagnosis of T2DM. Studiesin adults were considered for inclusionif > 10% of the study population was45 years of age or younger. The Med-line search limits included the fol-lowing: clinical trial; meta-analysis;randomized controlled trial; review;child: 6 12 years; and adolescent:13 18 years. Additional articles were

identi ed by review of reference listsof relevant articles and ongoingstudies recommended by a technicalexpert advisory group. All articleswere reviewed for compliance with the search limitations and appro-priateness for inclusion in thisdocument.

Initially, 199 abstracts were identi edfor possible inclusion, of which 52were retained for systematic review.

Results of the literature review werepresented in evidence tables andpublished in the nal evidence report.An additional literature search of Medline and the Cochrane Database of

FIGURE 1Evidence quality. Integrating evidence quality appraisal with an assessment of the anticipated balancebetween bene ts and harms if a policy is carried out leads to designation of a policy as a strongrecommendation, recommendation, option, or no recommendation. 32 RCT, randomized controlled trial; Rec, recommendation.



9/23

Systematic Reviews was performedin July 2009 for articles discussingrecommendations for screening and

treatment of 5 recognized comorbiditiesof T2DM: cardiovascular disease, dysli-pidemia, retinopathy, nephropathy, andperipheral vascular disease. Searchcriteria were the same as for the searchon treatment of T2DM, with the inclusionof the term type 1 diabetes mellitus.

Search terms included, in various com-binations, the following: diabetes, mellitus, type 2, type 1, pediatric, T2DM,T1DM, NIDDM, hyperlipidemia, retinopa-

thy, microalbuminuria, comorbidities,screening, RCT, meta-analysis, child, andadolescent. Boolean operators andsearch limits mirrored those of theprimary search.

An additional 336 abstracts wereidenti ed for possible inclusion, of which 26 were retained for systematicreview. Results of this subsequentliterature review were also presentedin evidence tables and published in

the nal evidence report. An epide-miologist appraised the methodo-logic quality of the research before it

was considered by the committeemembers.

The evidence-based approach toguideline development requires that the evidence in support of each keyaction statement be identi ed, ap-praised, and summarized and that anexplicit link between evidence andrecommendations be de ned. Evidence-based recommendations re ect thequality of evidence and the balance of

bene t and harm that is anticipatedwhen the recommendation is followed.The AAP policy statement, ClassifyingRecommendations for Clinical PracticeGuidelines, 32 was followed in desig-nating levels of recommendation (seeFig 1 and Table 1).

To ensure that these recommendationscan be effectively implemented, theGuidelines Review Group at Yale Centerfor Medical Informatics provided feedback

on a late draft of these recommendations,using the GuideLine ImplementabilityAppraisal. 33 Several potential obsta-

cles to successful implementationwere identi ed and resolved in the

nal guideline. Evidence was in-corporated systematically into 6 keyaction statements about appropriatemanagement facilitated by BRIDGE-Wizsoftware (Building Recommendationsin a Developer s Guideline Editor; YaleCenter for Medical Informatics).

A draft version of this clinical practiceguideline underwent extensive peer re-

view by 8 groups within the AAP, theAmerican Diabetes Association, PES,AAFP, and the Academy of Nutrition andDietetics. Members of the subcommitteewere invited to distribute the draft toother representatives and committeeswithin their specialty organizations. Theresulting comments were reviewed by the subcommittee and incorporated into the guideline, as appropriate. All AAPguidelines are reviewed every 5 years.

TABLE 1 De nitions and Recommendation Implications

Statement De nition Implication

Strong recommendation A strong recommendation in favor of a particular action ismade when the anticipated bene ts of the recommendedintervention clearly exceed the harms (as a strongrecommendation against an action is made when theanticipated harms clearly exceed the bene ts) and the

quality of the supporting evidence is excellent. In someclearly identi ed circumstances, strong recommendationsmay be made when high-quality evidence is impossible toobtain and the anticipated bene ts strongly outweigh theharms.

Clinicians should follow a strong recommendation unlessa clear and compelling rationale for an alternative approachis present.

Recommendation A recommendation in favor of a particular action is made when the anticipated bene ts exceed the harms but the quality of evidence is not as strong. Again, in some clearly identi edcircumstances, recommendations may be made when high-quality evidence is impossible to obtain but the anticipatedbene ts outweigh the harms.

Clinicians would be prudent to follow a recommendation butshould remain alert to new information and sensitive topatient preferences.

Option Options de ne courses that may be taken when either thequality of evidence is suspect or carefully performed studieshave shown little clear advantage to 1 approach overanother.

Clinicians should consider the option in their decision-making,and patient preference may have a substantial role.

No recommendation No recommendation indicates that there is a lack of pertinentpublished evidence and that the anticipated balance of bene ts and harms is presently unclear.

Clinicians should be alert to new published evidence thatclari es the balance of bene t versus harm.

It should be noted that, because childhood T2DM is a relatively recent medical phenomenon, there is a paucity of evidence for many or most of the recommendations provided. In somecases, supporting references for a speci c recommendation are provided that do not deal speci cally with childhood T2DM, such as T1DM, childhood obesity, or childhood prediabetes,

or that were not included in the original comprehensive search. Committee members have made every effort to identify those references that did not affect or alter the level of evidencefor speci c recommendations.


http://-/?-http://-/?-http://-/?-http://-/?-


10/23

KEY ACTION STATEMENTS

Key Action Statement 1

Clinicians must ensure that insulin therapy is initiated for childrenand adolescents with T2DM who

are ketotic or in diabetic ketoaci-dosis and in whom the distinctionbetween T1DM and T2DM is unclear;and, in usual cases, should initiateinsulin therapy for patients:

a. who have random venous orplasma BG concentrations 250 mg/dL; or

b. whose HbA1c is > 9%.

(Strong Recommendation: evidencequality X, validating studies cannot

be performed, and C, observationalstudies and expert opinion; pre-ponderance of bene t over harm.)

The presentation of T2DM in childrenand adolescents varies according to the disease stage. Early in the disease,before diabetes diagnostic criteria aremet, insulin resistance predominateswith compensatory high insulin se-cretion, resulting in normoglycemia.Over time, cells lose their ability tosecrete adequate amounts of insulin to overcome insulin resistance, andhyperglycemia results. Early in this

process, blood glucose (BG) concentrations may be normal much of the time and the patient likely will beasymptomatic. At this stage, the dis-ease may only be detected by abnor-mal BG concentrations identi ed

during screening. As insulin secretiondeclines further, the patient is likely todevelop symptoms of hyperglycemia,occasionally with ketosis or frank ketoacidosis. High glucose concentrations can cause a reversible toxic-ity to islet cells that contributesfurther to insulin de ciency. Of ado-lescents in whom T2DM is subse-quently diagnosed, 5% to 25% presentwith ketoacidosis. 34

Diabetic ketoacidosis must be treatedwith insulin and uid and electrolytereplacement to prevent worsening

metabolic acidosis, coma, and death.Children and adolescents with symptoms of hyperglycemia (polyuria,polydipsia, and polyphagia) who arediagnosed with diabetes mellitusshould be evaluated for ketosis (serumor urine ketones) and, if positive, forketoacidosis (venous pH), even if theirphenotype and risk factor status(obesity, acanthosis nigricans, positivefamily history of T2DM) suggests

T2DM. Patients in whom ketoacidosisis diagnosed require immediate treatment with insulin and uid re-placement in an inpatient settingunder the supervision of a physicianwho is experienced in treating this

complication.Youth and adolescents who present withT2DM with poor glycemic control (BGconcentrations 250 mg/dL or HbA1c> 9%) but who lack evidence of ketosisor ketoacidosis may also bene t frominitial treatment with insulin, at least ona short-term basis. 34 This allows forquicker restoration of glycemic control and, theoretically, may allow islet cells to rest and recover. 35,36

Furthermore, it has been noted thatinitiation of insulin may increaselong-term adherence to treatmentin children and adolescents withT2DM by enhancing the patient s per-ception of the seriousness of the dis-ease. 7,37 40 Many patients with T2DMcan be weaned gradually from insulin therapy and subsequently managedwith metformin and lifestyle modi cation.34

As noted previously, in some childrenand adolescents with newly diagnoseddiabetes mellitus, it may be dif cult todistinguish between type 1 and type 2disease (eg, an obese child presentingwith ketosis). 39,41 These patients arebest managed initially with insulin therapy while appropriate tests areperformed to differentiate betweenT1DM and T2DM. The care of chil-dren and adolescents who haveeither newly diagnosed T2DM orundifferentiated-type diabetes andwho require initial insulin treatmentshould be supervised by a physicianexperienced in treating diabeticpatients with insulin.


In all other instances, cliniciansshould initiate a lifestyle modi cation program, including nutrition

Action Statement Pro le KAS 1Aggregate evidence quality X (validating studies cannot be performed)Bene ts Avoidance of progression of diabetic ketoacidosis (DKA) and

worsening metabolic acidosis; resolution of acidosis andhyperglycemia; avoidance of coma and/or death. Quickerrestoration of glycemic control, potentially allowing islet cells to rest and recover, increasing long-term adherence to treatment; avoiding progression to DKA if T1DM. Avoidinghospitalization. Avoidance of potential risks associated with the use of other agents (eg, abdominal discomfort, bloating,loose stools with metformin; possible cardiovascular riskswith sulfonylureas).

Harms/risks/cost Potential for hypoglycemia, insulin-induced weight gain, cost,patient discomfort from injection, necessity for BG testing,more time required by the health care team for patient training.

Bene ts-harms assessment Preponderance of bene t over harm.Value judgments Extensive clinical experience of the expert panel was relied on in

making this recommendation.Role of pa tient preferences Minimal.Exclusions None.Intentional vagueness None.Strength Strong recommendation.



11/23

and physical activity, and startmetformin as rst-line therapy

for children and adolescents at

the time of diagnosis of T2DM.

(Strong recommendation: evidence

quality B; 1 RCT showing improvedoutcomes with metformin versus

lifestyle; preponderance of bene-

ts over harms.)

Metformin as First-Line Therapy

Because of the low success rate withdiet and exercise alone in pediatricpatients diagnosed with T2DM, met-formin should be initiated along with the promotion of lifestyle changes,unless insulin is needed to reverseglucose toxicity in the case of signi -cant hyperglycemia or ketoacidosis(see Key Action Statement 1). Becausegastrointestinal adverse effects arecommon with metformin therapy, the

committee recommends starting thedrug at a low dose of 500 mg daily,increasing by 500 mg every 1 to 2weeks, up to an ideal and maximumdose of 2000 mg daily in divideddoses. 41 It should be noted that the

main gastrointestinal adverse effects(abdominal pain, bloating, loosestools) present at initiation of met-formin often are transient and often

disappear completely if medication is

continued. Generally, doses higher than 2000 mg daily do not provideadditional therapeutic bene t.34,42,43 Inaddition, the use of extended-releasemetformin, especially with eveningdosing, may be considered, althoughdata regarding the frequency of ad-verse effects with this preparation arescarce. Metformin is generally better tolerated when taken with food. It isimportant to recognize the paucity of

credible RCTs in adolescents withT2DM. The evidence to recommendinitiating metformin at diagnosis alongwith lifestyle changes comes from 1RCT, several observational studies, andconsensus recommendations.

Lifestyle modi cations (including nutrition interventions and increasedphysical activity) have long been thecornerstone of therapy for T2DM. Yet,medical practitioners recognize thateffecting these changes is both chal-lenging and often accompanied byregression over time to behaviors notconducive to maintaining the targetrange of BG concentrations. In pedi-atric patients, lifestyle change is most

likely to be successful when a multi-disciplinary approach is used and theentire family is involved. (Encourage-ment of healthy eating and physicalexercise are discussed in Key ActionStatements 5 and 6.) Unfortunately,efforts at lifestyle change often fail fora variety of reasons, including highrates of loss to follow-up; a high rate of depression in teenagers, which affectsadherence; and peer pressure to

participate in activities that oftencenter on unhealthy eating.

Expert consensus is that fewer than10% of pediatric T2DM patients will attain their BG goals through lifestyleinterventions alone. 6,35,44 It is possible that the poor long-term success ratesobserved from lifestyle interventionsstem from patients perception that theintervention is not important becausemedications are not being prescribed.

One might speculate that prescribingmedications, particularly insulin ther-apy, may convey a greater degree of concern for the patient s health and theseriousness of the diagnosis, relative to that conveyed when medications arenot needed, and that improved treat-ment adherence and follow-up mayresult from the use of medication. In-deed, 2 prospective observationalstudies revealed that treatment with

Action Statement Pro le KAS 2 Aggregate evidence quality B (1 randomized controlled trial showing improved outcomes

with metformin versus lifestyle combined with expertopinion).

Bene t Lower HbA1c, target HbA1c sustained longer, less earlydeterioration of BG, less chance of weight gain, improvedinsulin sensitivity, improved lipid pro le.

Harm (of using metformin) Gastrointestinal adverse effects or potential for lactic acidosis

and vitamin B 12 de ciency, cost of medications, cost toadminister, need for additional instruction about medication,self-monitoring blood glucose (SMBG), perceived dif culty of insulin use, possible metabolic deterioration if T1DM ismisdiagnosed and treated as T2DM, potential risk of lacticacidosis in the setting of ketosis or signi cant dehydration.It should be noted that there have been no cases reported of vitamin B12 de ciency or lactic acidosis with the use of metformin in children.

Bene ts-harms assessment Preponderance of bene t over harm.Value judgments Committee members valued faster achievement of BG control

over not medicating children.Role of patient preferences Moderate; precise implementation recommendations likely will

be dictated by patient preferences regarding healthynutrition, potential medication adverse reaction, exercise,and physical activity.

Exclusions Although the recommendation to star t metformin applies to al l,certain children and adolescents with T2DM will not be able to tolerate metformin. In addition, certain older or moredebilitated patients with T2DM may be restricted in theamount of moderate-to-vigorous exercise they can performsafely. Nevertheless, this recommendation applies to the vastmajority of children and adolescents with T2DM.

Intentional vagueness None.Policy level Strong recommendation.




12/23

lifestyle modi cation alone is associ-ated with a higher rate of loss tofollow-up than that found in patientswho receive medication. 45

Before initiating treatment with met-formin, a number of important con-siderations must be taken intoaccount. First, it is important to determine whether the child with a newdiagnosis has T1DM or T2DM, and it iscritical to err on the side of caution if there is any uncertainty. The 2009Clinical Practice Consensus Guidelines on Type 2 Diabetes in Children and Adolescents from the InternationalSociety for Pediatric and AdolescentDiabetes provides more informationon the classi cation of diabetes inchildren and adolescents with newdiagnoses. 46 If the diagnosis is un-clear (as may be the case when anobese child with diabetes presentsalso with ketosis), the adolescentmust be treated with insulin until theT2DM diagnosis is con rmed. 47 Al- though it is recognized that somechildren with newly diagnosed T2DMmay respond to metformin alone, the

committee believes that the presenceof either ketosis or ketoacidosis dic- tates an absolute initial requirementfor insulin replacement. (This isaddressed in Key Action Statement 1.)

Although there is little debate thata child presenting with signi canthyperglycemia and/or ketosis requiresinsulin, children presenting with moremodest levels of hyperglycemia (eg,random BG of 200 249 mg/dL) or

asymptomatic T2DM present additional therapeutic challenges to theclinician. In such cases, metforminalone, insulin alone, or metforminwith insulin all represent reasonableoptions. Additional agents are likely tobecome reasonable options for initialpharmacologic management in thenear future. Although metformin andinsulin are the only antidiabetic agentscurrently approved by the US Food and

Drug Administration (FDA) for use inchildren, both thiazolidinediones andincretins are occasionally used inadolescents younger than 18 years. 48

Metformin is recommended as theinitial pharmacologic agent in ado-

lescents presenting with mild hyper-glycemia and without ketonuria orsevere hyperglycemia. In addition toimproving hepatic insulin sensitivity,metformin has a number of practicaladvantages over insulin:

Potential weight loss or weightneutrality. 37,48

Because of a lower risk of hypogly-cemia, less frequent nger-stick BG measurements are requiredwith metformin, compared with insu-lin therapy or sulfonylureas. 37,42,49 51

Improves insulin sensitivity andmay normalize menstrual cyclesin females with polycystic ovarysyndrome. (Because metforminmay also improve fertility inpatients with polycystic ovary syn-drome, contraception is indicatedfor sexually active patients who wish

to avoid pregnancy.) Taking pills does not have the discom-fort associated with injections.

Less instruction time is required tostart oral medication, making it iseasier for busy practitioners toprescribe.

Adolescents do not always acceptinjections, so oral medicationmight enhance adherence. 52

Potential advantages of insulin overmetformin for treatment at diabetesonset include the following:

Metabolic control may be achievedmore rapidly with insulin com-pared with metformin therapy. 37

With appropriate education and tar-geting the regimen to the individual,adolescents are able to accept anduse insulin therapy with improvedmetabolic outcomes. 53

Insulin offers theoretical bene tsof improved metabolic controlwhile preserving -cell function oreven reversing -cell damage. 34,35

Initial use of insulin therapy mayconvey to the patient a sense of seriousness of the disease. 7,53

Throughout the writing of theseguidelines, the authors have beenfollowing the progress of the NationalInstitute of Diabetes and Digestive andKidney Diseases supported Treat-ment Options for type 2 Diabetes inAdolescents and Youth (TODAY) trial,54

designed to compare standard (met-formin alone) therapy versus moreaggressive therapy as the initial treatment of youth with recent-onsetT2DM. Since the completion of theseguidelines, results of the TODAY trialhave become available and reveal that metformin alone is inadequatein effecting sustained glycemic control in the majority of youth with di-abetes. The study also revealed that the addition of rosiglitazone to met-formin is superior to metforminalone in preserving glycemic control.Direct application of these ndings to clinical practice is problematic,however, because rosiglitazone is notFDA-approved for use in children, andits use, even in adults, is now se-verely restricted by the FDA becauseof serious adverse effects reportedin adults. Thus, the results suggest that therapy that is more aggressive than metformin monotherapy may berequired in these adolescents to

prevent loss of glycemic control, but they do not provide speci c guidancebecause it is not known whether theeffect of the additional agent wasspeci c to rosiglitazone or would beseen with the addition of otheragents. Unfortunately, there are lim-ited data for the use of other cur-rently available oral or injectedhypoglycemic agents in this agerange, except for insulin. Therefore,



13/23

the writing group for these guide-lines continues to recommend met-formin as rst-line therapy in thisage group but with close monitoringfor glycemic deterioration and theearly addition of insulin or another

pharmacologic agent if needed.

Lifestyle Modi cation, Including Nutrition and Physical Activity

Although lifestyle changes are con-sidered indispensable to reaching treatment goals in diabetes, no sig-ni cant data from RCTs provide in-formation on success rates with suchan approach alone.

A potential downside for initiatinglifestyle changes alone at T2DM onsetis potential loss of patients to follow-up and worse health outcomes. Thevalue of lifestyle modi cation in themanagement of adolescents withT2DM is likely forthcoming after a moredetailed analysis of the lifestyle intervention arm of the multicenter TODAY trial becomes available. 54 As noted pre-viously, although it was published after

this guideline was developed, the TODAY trial indicated that results from themetformin-plus-lifestyle intervention werenot signi cantly different from eithermetformin alone or the metformin-

plus-rosiglitazone intervention in maintaining glycemic control over time. 54

Summary

As noted previously, metformin is a safeand effective agent for use at the time of

diagnosis in conjunction with lifestylechanges. Although observational studiesand expert opinion strongly supportlifestyle changes as a key component of the regimen in addition to metformin,randomized trials are needed to de-lineate whether using lifestyle optionsalone is a reasonable rst step in treating any select subgroups of chil-dren with T2DM.


The committee suggests that clini-cians monitor HbA1c concentrationsevery 3 months and intensify treat-ment if treatment goals for BG andHbA1c concentrations are not beingmet. (Option: evidence quality D;expert opinion and studies in chil-dren with T1DM and in adults withT2DM; preponderance of bene tsover harms.)

HbA1c provides a measure of glyce-mic control in patients with diabetesmellitus and allows an estimation of the individual s average BG over theprevious 8 to 12 weeks. No RCTs have

evaluated the relationship betweenglycemic control and the risk of de-veloping microvascular and/or mac-rovascular complications in childrenand adolescents with T2DM. A num-ber of studies of children with

T1DM55 57 and adults with T2DM have,however, shown a signi cant relation-ship between glycemic control (asmeasured by HbA1c concentration) and the risk of microvascular complications(eg, retinopathy, nephropathy, and neu-ropathy). 58,59 The relationship betweenHbA1c concentration and risk of mi-crovascular complications appears tobe curvilinear; the lower the HbA1cconcentration, the lower the downstream

risk of microvascular complications, with the greatest risk reduction seen at thehighest HbA1c concentrations. 57

It is generally recommended thatHbA1c concentrations be measuredevery 3 months. 60 For adults withT1DM, the American Diabetes Associ-ation recommends target HbA1c con-centrations of less than 7%; theAmerican Association of Clinical Endo-crinologists recommends target con-

centrations of less than 6.5%. AlthoughHbA1c target concentrations for childrenand adolescents with T1DM are higher, 13

several review articles suggest targetHbA1c concentrations of less than 7%for children and adolescents withT2DM.40,61 63 The committee concurs that, ideally, target HbA1c concentrationshould be less than 7% but notes thatspeci c goals must be achievable for theindividual patient and that this concen-

tration may not be applicable for allpatients. For patients in whom a targetconcentration of less than 7% seemsunattainable, individualized goals shouldbe set, with the ultimate goal of reachingguideline target concentrations. In addition, in the absence of hypoglycemia,even lower HbA1c target concentrationscan be considered on the basis of anabsence of hypoglycemic events andother individual considerations.

Action Statement Pro le KAS 3 Aggregate evidence quality D (expert opinion and studies in children with T1DM and in adults with

T2DM; no studies have been performed in children and adolescentswith T2DM).

Bene t Diminishing the risk of progression of disease and deteriorationresulting in hospitalization; prevention of microvascularcomplications of T2DM.

Harm Potentia l for hypoglycemia from overintensifying treatment to reachHbA1c target goals; cost of frequent testing and medical consultation;possible patient discomfort.

Bene ts-harms assessment Preponderance of bene ts over harms.Value judgments Recommendation dictated by widely accepted standards of diabetic care.Role of patient

preferencesMinimal; recommendation dictated by widely accepted standards of

diabetic care.

Exclusions None.Intentional vagueness Intentional vagueness in the recommendation as faras setting goals and

intensifying treatment attributable to limited evidence.Policy level Option.




14/23

When concentrations are found to beabove the target, therapy should beintensi ed whenever possible, with thegoal of bringing the concentration to target. Intensi cation activities mayinclude, but are not limited to, in-

creasing the frequency of clinic visits,engaging in more frequent BG monitoring, adding 1 or more antidiabeticagents, meeting with a registered di-etitian and/or diabetes educator, andincreasing attention to diet and exer-cise regimens. Patients whose HbA1cconcentrations remain relatively sta-ble may only need to be tested every 6months. Ideally, real-time HbA1c con-centrations should be available at the

time of the patient

s visit with the clini-cian to allow the physician and patientand/or parent to discuss intensi cationof therapy during the visit, if needed.


The committee suggests that clini-cians advise patients to monitor

nger-stick BG concentrations in those who

a. are taking insulin or other

medications with a risk of hy-poglycemia; or

b. are initiating or changing theirdiabetes treatment regimen; or

c. have not met treatment goals; ord. have intercurrent illnesses.

(Option: evidence quality D; expertconsensus. Preponderance of ben-e ts over harms.)

Glycemic control correlates closelywith the frequency of BG monitoring inadolescents with T1DM. 64,65 Althoughstudies evaluating the ef cacy of fre-quent BG monitoring have not beenconducted in children and adoles-

cents with T2DM, bene ts have beendescribed in insulin-treated adultswith T2DM who tested their BG 4 timesper day, compared with adults fol-lowing a less frequent monitoringregimen. 66 These data support thevalue of BG monitoring in adults treated with insulin, and likely arerelevant to youth with T2DM as well,especially those treated with insulin,at the onset of the disease, when

treatment goals are not met, andwhen the treatment regimen ischanged. The committee believes thatcurrent (2011) ADA recommendationsfor nger-stick BG monitoring apply tomost youth with T2DM67 :

Finger-stick BG monitoring shouldbe performed 3 or more times dailyfor patients using multiple insulininjections or insulin pump therapy.

For patients using less-frequent in-

sulin injections, noninsulin thera-pies, or medical nutrition therapyalone, nger-stick BG monitoringmay be useful as a guide to thesuccess of therapy.

To achieve postprandial glucose targets, postprandial nger-stick BG monitoring may be appropri-ate.

Recognizing that current practicesmay not always re ect optimal care,a 2004 survey of practices amongmembers of the PES revealed that36% of pediatric endocrinologistsasked their pediatric patients with

T2DM to monitor BG concentrations twice daily; 12% asked patients to doso once daily; 13% asked patients todo so 3 times per day; and 12% askedpatients to do so 4 times daily. 61 Thequestionnaire provided to the pedi-atric endocrinologists did not ask about the frequency of BG monitor-ing in relationship to the diabetesregimen, however.

Although normoglycemia may be

dif cult to achieve in adolescentswith T2DM, a fasting BG concentrationof 70 to 130 mg/dL is a reasonable target for most. In addition, becausepostprandial hyperglycemia has beenassociated with increased risk of cardiovascular events in adults,postprandial BG testing may bevaluable in select patients. BG con-centrations obtained 2 hours aftermeals (and paired with pre-meal

concentrations) provide an index of glycemic excursion, and may beuseful in improving glycemic control,particularly for the patient whosefasting plasma glucose is normal butwhose HbA1c is not at target. 68 Rec-ognizing the limited evidence forbene t of FSBG testing in this pop-ulation, the committee providessuggested guidance for testing fre-quency, tailored to the medicationregimen, as follows:

BG Testing Frequency for Patients With Newly Diagnosed T2DM: Fasting,Premeal, and Bedtime Testing

The committee suggests that allpatients with newly diagnosed T2DM,regardless of prescribed treatmentplan, should perform nger-stick BGmonitoring before meals (includinga morning fasting concentration) and

Action Statement Pro le KAS 4

Aggregate evidence quality D (expert consensus).Bene t Potential for improved metabolic control, improved potential for

prevention of hypoglycemia, decreased long-term complications.Harm Patient discomfort, cost of materials.Bene ts-harms assessment Bene t over harm.Value judgments Despite lack of evidence, there were general committee perceptions that

patient safety concerns related to insulin use or clinical statusoutweighed any risks from monitoring.

Role of patient preferences Moderate to low; recommendation driven primarily by safety concerns.Exclusions None.Intentional vagueness Intentional vagueness in the recommendation about speci c

approaches attributable to lack of evidence and the need toindividualize treatment.

Policy level Option.



15/23

at bedtime until reasonable metaboliccontrol is achieved. 69 Once BG con-centrations are at target levels, thefrequency of monitoring can be mod-i ed depending on the medicationused, the regimen s intensity, and the

patient

s metabolic control. Patientswho are prone to marked hypergly-cemia or hypoglycemia or who are ona therapeutic regimen associated withincreased risk of hypoglycemia willrequire continued frequent BG testing.Expectations for frequency and timingof BG monitoring should be clearly de-

ned through shared goal-setting between the patient and clinician. Theadolescent and family members should

be given a written action plan stating the medication regimen, frequency and timing of expected BG monitoring, aswell as follow-up instructions.

BG Testing Frequency for Patients on Single Insulin Daily Injections and Oral Agents

Single bedtime long-acting insulin :The simplest insulin regimen con-sists of a single injection of long-acting insulin at bedtime (basalinsulin only). The appropriateness of the insulin dose for patients using this regimen is best de ned by thefasting/prebreakfast BG test. Forpatients on this insulin regimen, thecommittee suggests daily fasting BGmeasurements. This regimen is as-sociated with some risk of hypogly-cemia (especially overnight orfasting hypoglycemia) and may not

provide adequate insulin coveragefor mealtime ingestions throughout the day, as re ected by fasting BGconcentrations in target, but day- time readings above target. In suchcases, treatment with meglitinide(Prandin [Novo Nordisk Pharma-ceuticals] or Starlix [Novartis Phar-maceuticals]) or a short-actinginsulin before meals (see below)may be bene cial.

Oral agents : Once treatment goals aremet, the frequency of monitoring can bedecreased; however, the committeerecommends some continued BG test-ing for all youth with T2DM, at a fre-quency determined within the clinical

context (e.g. medication regimen, HbA1c,willingness of the patient, etc.). For ex-ample, an infrequent or intermittentmonitoring schedule may be adequatewhen the patient is using exclusively anoral agent associated with a low risk of hypoglycemia and if HbA1c concentrations are in the ideal or non-diabeticrange. A more frequent monitoringschedule should be advised during times of illness or if symptoms of hy-

perglycemia or hypoglycemia develop.

Oral agent plus a single injection of a long-acting insulin: Some youth withT2DM can be managed successfully witha single injection of long-acting insulin inconjunction with an oral agent. Twice aday BG monitoring (fasting plus a sec-ond BG concentration ideally 2-hourpost prandial) often is recommended, aslong as HbA1c and BG concentrationsremain at goal and the patient remainsasymptomatic.

BG Testing Frequency for Patients Receiving Multiple Daily Insulin Injections (eg, Basal Bolus Regimens): Premeal and Bedtime Testing

Basal bolus regimens are commonlyused in children and youth with T1DMand may be appropriate for some youthwith T2DM as well. They are the mostlabor intensive, providing both basal

insulin plus bolus doses of short-actinginsulin at meals. Basal insulin is pro-vided through either the use of long-acting, relatively peak-free insulin (byneedle) or via an insulin pump. Bolusinsulin doses are given at meal-time,using one of the rapid-acting insulinanalogs. The bolus dose is calculated byusing a correction algorithm for thepremeal BG concentration as well asa carb ratio, in which 1 unit of

a rapid-acting insulin analog is givenfor X grams of carbohydrates inges- ted (see box below). When using thismethod, the patient must be willing andable to count the number of grams of carbohydrates in the meal and divide

by the assigned

carb ratio (X)

toknow how many units of insulin shouldbe taken. In addition, the patient mustalways check BG concentrations before the meal to determine how much ad-ditional insulin should be given asa correction dose using an algorithmassigned by the care team if the fastingBG is not in target. Insulin pumps arebased on this concept of basal-bolus

insulin administration and have the

capability of calculating a suggestedbolus dosage, based on inputted gramsof carbohydrates and BG concentrations. Because the BG value deter-mines the amount of insulin to be givenat each meal, the recommended testingfrequency for patients on this regimenis before every meal.

Box 1 Example of Basal BolusInsulin RegimenIf an adolescent has a BG of 250

mg/dL, is to consume a mealcontaining 60 g of carbohydrates,with a carbohydrate ratio of 1:10and an assigned correction doseof 1:25> 125 (with 25 being theinsulin sensitivity and 125 mg/dL the target blood glucose level), the mealtime bolus dose of insulin would be as follows:

60 g/10 carb ratio =

6 units rapid-acting insulin formeal

plus

(250 125)/25 = 125/25 =

5 units rapid-acting insulin forcorrection

Thus, total bolus insulin coverageat mealtime is: 11 U (6 + 5) of rapid-acting insulin.




16/23


The committee suggests that clini-cians incorporate the Academy of Nutrition and Dietetics Pediatric Weight Management Evidence- Based Nutrition Practice Guide- lines in the nutrition counseling of

patients with T2DM both at the timeof diagnosis and as part of ongoingmanagement. (Option; evidencequality D; expert opinion; pre-ponderance of bene ts overharms. Role of patient preference

is dominant.)

Consuming more calories than oneuses results in weight gain and isa major contributor to the increasingincidence of T2DM in children andadolescents. Current literature is in-conclusive about a single best mealplan for patients with diabetes mel-litus, however, and studies speci -cally addressing the diet of childrenand adolescents with T2DM are

limited. Challenges to making rec-ommendations stem from the smallsample size of these studies, limit-ed speci city for children andadolescents, and dif culties in gen-eralizing the data from dietary re-search studies to the generalpopulation.

Although evidence is lacking in chil-dren with T2DM, numerous studieshave been conducted in overweight

children and adolescents, because the great majority of children withT2DM are obese or overweight atdiagnosis. 26 The committee suggests that clinicians encourage childrenand adolescents with T2DM to follow the Academy of Nutrition and Di-etetics recommendations for maintaining healthy weight to promotehealth and reduce obesity in this

population. The committee recom-mends that clinicians refer patients to a registered dietit ian who hasexpertise in the nutritional needs of youth with T2DM. Clinicians shouldincorporate the Academy of Nutri- tion and Dietetics Pediatric Weight Management Evidence-Based Nutri- tion Practice Guidelines , which de-scribe effective, evidence-based treatment options for weight man-

agement, summarized below (Acomplete list of these recom-mendations is accessible to healthcare professionals at: http://www.andevidencelibrary.com/topic.cfm?cat=4102&auth = 1.)

According to the Academy of Nutri- tion and Dietetics guidelines, whenincorporated with lifestyle changes,balanced macronutrient diets at 900 to 1200 kcal per day are associatedwith both short- and long-term (eg, 1 year) improvements in weightstatus and body composition inchildren 6 to 12 years of age. 70

These calorie recommendationsare to be incorporated with lifestyle

changes, including increased activ-ity and possibly medication. Re-strictions of no less than 1200 kcalper day in adolescents 13 to 18years old result in improved weightstatus and body composition aswell. 71 The Diabetes Prevention Pro-gram demonstrated that partic-ipants assigned to the intensivelifestyle-intervention arm had a re-duction in daily energy intake of 450

kcal and a 58% reduction in pro-gression to diabetes at the 2.8-yearfollow-up. 71 At the study s end, 50%of the lifestyle-arm participants hadachieved the goal weight loss of atleast 7% after the 24-week curricu-lum and 38% showed weight loss of at least 7% at the time of their mostrecent visit. 72 The Academy of Nutri- tion and Dietetics recommends thatprotein-sparing, modi ed-fast (keto-

genic) diets be restricted to childrenwho are > 120% of their ideal bodyweight and who have a seriousmedical complication that wouldbene t from rapid weight loss. 71

Speci c recommendations are for the intervention to be short-term(typically 10 weeks) and to be con-ducted under the supervision of a multidisciplinary team specializ-ing in pediatric obesity.

Action Statement Pro le KAS 5 Aggregate evidence quality D (expert opinion).Bene t Promotes weight loss; improves insulin sensitivity; contributes

to glycemic control; prevents worsening of disease; facilitatesa sense of well-being; and improves cardiovascular health.

Harm Costs of nutrition counseling; inadequate reimbursement of clinicians time; lost opportunity costs vis-a-vis time andresources spent in other counseling activities.

Bene ts-harms assessment Bene t over harm.Value judgments There is a broad societa l agreement on the bene ts of dietary

recommendations.Role of patient preference Dominant. Patients may have different preferences for how theywish to receive assistance in managing their weight-lossgoals. Some patients may prefer a referral to a nutritionistwhile others might prefer accessing online sources of help.Patient preference should play a signi cant role indetermining an appropriate weight-loss strategy.

Exclusions None.Intentional vagueness Intentional vagueness in the recommendation about speci c

approaches attributable to lack of evidence and the need toindividualize treatment.


http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1http://www.andevidencelibrary.com/topic.cfm?cat=4102&tnqh_x0026;auth&tnqh_x003D;1


17/23

Regardless of the meal plan pre-scribed, some degree of nutritioneducation must be provided tomaximize adherence and positiveresults. This education should en-courage patients to follow healthy

eating patterns, such as consuming 3meals with planned snacks per day,not eating while watching televisionor using computers, using smallerplates to make portions appearlarger, and leaving small amounts of food on the plate. 73 Common dietaryrecommendations to reduce calorieintake and to promote weight loss inchildren include the following: (1)eating regular meals and snacks; (2)

reducing portion sizes; (3) choosingcalorie-free beverages, except formilk; (4) limiting juice to 1 cup perday; (5) increasing consumption of fruits and vegetables; (6) consuming3 or 4 servings of low-fat dairyproducts per day; (7) limiting intakeof high-fat foods; (8) limiting fre-quency and size of snacks; and (9)reducing calories consumed in fast-food meals. 74


The committee suggests that clini-cians encourage children and ado-lescents with T2DM to engage inmoderate-to-vigorous exercise forat least 60 minutes daily and tolimit nonacademic screen time to

less than 2 hours per day. (Option:evidence quality D, expert opinionand evidence from studies of met-abolic syndrome and obesity; pre-ponderance of bene ts over harms.Role of patient preference is domi-

nant.)

Engaging in Physical Activity

Physical activity is an integral part of weight management for preventionand treatment of T2DM. Although thereis a paucity of available data fromchildren and adolescents with T2DM,several well-controlled studies per-formed in obese children and ado-lescents at risk of metabolic syndrome

and T2DM provide guidelines forphysical activity. (See the Resourcessection for tools on this subject.) Asummary of the references supporting the evidence for this guideline can befound in the technical report. 31

At present, moderate-to-vigorous ex-ercise of at least 60 minutes daily isrecommended for reduction of BMIand improved glycemic control inpatients with T2DM.75 Moderate to

Recommendations From the Academy of Nutrition and Dietetics

Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines

Recommendation Strength

Interventions to reduce pediatric obesity should bemulticomponent and include diet, physical activity,nutritional counseling, and parent or caregiverparticipation.

Strong

A nutrition prescription should be formulated as part of thedietary intervention in a multicomponent pediatric weightmanagement program.

Strong

Dietary factors that may be associated with an increased risk

of overweight are increased total dietary fat intake andincreased intake of calorically sweetened beverages.

Strong

Dietary factors that may be associated with a decreased risk of overweight are increased fruit and vegetable intake.

Strong

A balanced macronutrient diet that contains no fewer than 900kcal per day is recommended to improve weight status inchildren aged 6 12 y who are medically monitored.

Strong

A balanced macronutrient diet that contains no fewer than1200 kcal per day is recommended to improve weight statusin adolescents aged 13 18 y who are medically monitored.

Strong

Family diet behaviors that are associated with an increasedrisk of pediatric obesity are parental restriction of highlypalatable foods, consumption of food away from home,increased meal portion size, and skipping breakfast.

Fair

Action Statement Pro le KAS 6 Aggregate evidence quality D (expert opinion and evidence from studies of metabolic

syndrome and obesity).Bene t Promotes weight loss; contributes to glycemic control; prevents

worsening of disease; facilitates the ability to performexercise; improves the person s sense of well-being; andfosters cardiovascular health.

Harm Cost for patient of counseling, food, and time; costs for clinicianin taking away time that could be spent on other activities;inadequate reimbursement for clinician s time.

Bene ts-harms assessment Preponderance of bene t over harm.

Value judgments Broad consensus.Role of patient preference Dominant. Patients may seek various forms of exercise. Patient

preference should play a signi cant role in creating anexercise plan.

Exclusions Although cer ta in older or more debilit ated patients with T2DMmay be restricted in the amount of moderate-to-vigorousexercise they can perform safely, this recommendationapplies to the vast majority of children and adolescents withT2DM.

Intentional vagueness Intentional vagueness on the sequence of follow-up contactattributable to the lack of evidence and the need toindividualize care.





18/23

vigorous exercise is de ned as exercise that makes the individual breathe hardand perspire and that raises his or herheart rate. An easy way to de ne exer-cise intensity for patients is the talk test ; during moderate physical activity

a person can talk but not sing. Duringvigorous activity, a person cannot talk without pausing to catch a breath. 76

Adherence may be improved if clini-cians provide the patient with a written prescription to engage in physicalactivity, including a dose describingideal duration, intensity, and fre-quency. 75 When prescribing physicalexercise, clinicians are encouraged tobe sensitive to the needs of children,

adolescents, and their families. Rou- tine, organized exercise may be be-yond the family s logistical and/or

nancial means, and some familiesmay not be able to provide structuredexercise programs for their children.It is most helpful to recommend anindividualized approach that can beincorporated into the daily routine, is tailored to the patients physical abil-ities and preferences, and recognizes

the families circumstances. 77 For ex-ample, clinicians might recommendonly daily walking, which has beenshown to improve weight loss andinsulin sensitivity in adults withT2DM78 and may constitute moderate to vigorous activity for some childrenwith T2DM. It is also important torecognize that the recommended 60minutes of exercise do not have to beaccomplished in 1 session but can be

completed through several, shorterincrements (eg, 10 15 minutes).Patients should be encouraged toidentify a variety of forms of activity that can be performed both easily andfrequently. 77 In addition, providersshould be cognizant of the potentialneed to adjust the medication dosage,especially if the patient is receivinginsulin, when initiating an aggressivephysical activity program.

Reducing Screen Time

Screen time contributes to a sedentarylifestyle, especially when the child oradolescent eats while watching tele-vision or playing computer games. TheUS Department of Health and Human

Services recommends that individualslimit screen time spent watching television and/or using computersand handheld devices to less than 2hours per day unless the use is re-lated to work or homework. 79 Physicalactivity may be gained either throughstructured games and sports or through everyday activities, such aswalking, ideally with involvement of the parents as good role models.

Increased screen time and food intakeand reduced physical activity are asso-ciated with obesity. There is good evi-dence that modifying these factors canhelp prevent T2DM by reducing theindividual s rate of weight gain. The ev-idence pro le in pediatric patients withT2DM is inadequate at this time, how-ever. Pending new data, the committeesuggests that clinicians follow the AAPCommittee on Nutrition s guideline,

Prevention of Pediatric Overweight and Obesity . The guideline recommendsrestricting nonacademic screen time toa maximum of 2 hours per day anddiscouraging the presence of videoscreens and television sets in children sbedrooms. 80 82 The American MedicalAssociation s Expert Panel on ChildhoodObesity has endorsed this guideline.

Valuable recommendations for en-hancing patient health include the

following:

With patients and their families, jointly determining an individual-ized plan that includes speci cgoals to reduce sedentary behav-iors and increase physical activity.

Providing a written prescriptionfor engaging in 60-plus minutesof moderate-to-vigorous physicalactivities per day that includes

dose, timing, and duration. It is im-portant for clinicians to be sensitive to the needs of children,adolescents, and their families inencouraging daily physical exer-cise. Graded duration of exercise

is recommended for those youthwho cannot initially be active for60 minutes daily, and the exercisemay be accomplished through sev-eral, shorter increments (eg, 10

15 minutes).

Incorporating physical activities in- to children s and adolescents dailyroutines. Physical activity may begained either through structuredgames and sports or through ev-

eryday activities, such as walking. Restricting nonacademic screen time to a maximum of 2 hoursper day.

Discouraging the presence of videoscreens and television sets inchildren s bedrooms.

Conversations pertaining to the KeyAction Statements should be clearlydocumented in the patient s medicalrecord.

AREAS FOR FUTURE RESEARCH

As noted previously, evidence formedical interventions in children ingeneral is scant and is especiallylacking for interventions directed to-ward children who have developeddiseases not previously seen com-monly in youth, such as childhoodT2DM. Recent studies such as the

Search for Diabetes in Youth Study(SEARCH) an observational multi-center study in 2096 youth with T2DMfunded by the Centers for DiseaseControl and Prevention and the Na- tional Institute of Diabetes and Di-gestive and Kidney Diseases nowprovide a detailed description of childhood diabetes. Subsequent trialswill describe the short-term and en-during effects of speci c interventions



19/23

on the progression of the disease with time.

Although it is likely that children andadolescents with T2DM have an ag-gressive form of diabetes, as re ectedby the age of onset, future researchshould determine whether the associ-ated comorbidities and complications of diabetes also are more aggressive inpediatric populations than in adults andif they are more or less responsive to therapeutic interventions. Additionalresearch should explore whether earlyintroduction of insulin or the use of particular oral agents will preserve-cell function in these children, andwhether recent technologic advances

(such as continuous glucose monitor-ing and insulin pumps) will bene t this population. Additional issues thatrequire further study include thefollowing:

To delineate whether using lifestyleoptions without medication is a re-liable rst step in treating selectedchildren with T2DM.

To determine whether BG monitor-ing should be recommended to all

children and youth with T2DM, re-gardless of therapy used; what theoptimal frequency of BG monitor-ing is for pediatric patients on the basis of treatment regimen;and which subgroups will be able to successfully maintain glycemicgoals with less frequent monitor-ing.

To explore the ef cacy of school-and clinic-based diet and physical

activity interventions to preventand manage pediatric T2DM.

To explore the association betweenincreased screen time and re-duced physical activity with re-spect to T2DMs risk factors.

RESOURCES

Several tools are available online toassist providers in improving patient

adherence to lifestyle modi cations,including examples of activities to berecommended for patients:

The American Academy of Pediat-rics:

www.healthychildren.org

www.letsmove.gov

Technical Report: Managementof Type 2 Diabetes Mellitus inChildren and Adolescents. 31 Includes an overview and

screening tools for a varietyof comorbidities.

Gahagan S, Silverstein J; Com-mittee on Native American ChildH