The American Academy of Pediatrics (AAP) has issued its first ever clinical guidelines for Type 2 diabetes. The new guidelines reflect the growing childhood obesity epidemic and blurring lines when it comes to diagnosis of Type 1 versus Type 2 diabetes.
“It used to be so clear cut. If the patient was a child, they had Type 1. If they were an adult, they had Type 2. If it came upon you suddenly, it was Type 1. If it crept up on you, it was Type 2. Now, it’s not so easy to distinguish,” said Dr. Cydney Fenton, director of the Center for Diabetes and Endocrinology at Akron Children’s Hospital.
According to the guidelines published in Pediatrics, “The rapid emergence of the childhood Type 2 diabetes poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children.”
Adding to the problem, there is a national shortage of pediatric endocrinologists and pediatric endocrinologists themselves may have different levels of experience with Type 2 diabetes based on when they came out of fellowship.
While evidence-based data in how to best treat children with Type 2 diabetes is scarce, Dr. Fenton believes the AAP’s guidelines are a step in the right direction. They take a more aggressive approach, especially in recommending insulin therapy in more cases.
“This is important as Type 2 diabetes can actually lead to more complications in children than adults,” she said.
Type 1 diabetes, the autoimmune form of the disease, requires immediate and lifelong insulin injections. Type 2 diabetes is associated with obesity, family history and was more typically seen in adults 50 years and older.
Type 2 diabetes occurs when the body can’t effectively use insulin, which regulates blood sugar, and the disease can affect the body’s ability to produce the hormone.
Unlike Type 1 diabetes, Type 2 can be reversed.
Up to one in three new cases of diabetes diagnosed in adolescents is Type 2, with disproportionate representation among African Americans and Hispanics. Dr. Fenton has diagnosed Type 2 diabetes in a child as young as 6 years.
Like other centers nationwide, Akron Children’s has seen a steady rise in patients with Type 2 diabetes. To address this trend, the center has created an educational program for the newly diagnosed.
“Many of these patients are put on insulin and hospitalized for a few days,” said Dr. Fenton. “About 7 to 10 days later, we bring them back to meet with a dietitian, a social worker and a nurse practitioner. It’s a lot of intensive education.”
The AAP guidelines consider the drug metformin as the first-line therapy. It should be prescribed while also promoting diet and lifestyle changes.
The expert consensus is that fewer than 10 percent of pediatric Type 2 diabetes patients will attain their blood glucose goals through lifestyle interventions alone.
Concerns heightened last year when a study showed that metformin, the only drug approved in the United States for treatment of children with Type 2 diabetes, was less effective in children than in adults.
So insulin therapy is now recommended in more cases and even recommended during the period – sometimes up to a few weeks – that it takes for screening tests to be processed and a Type 2 diagnosis confirmed.
“Insulin therapy need not be forever,” said Dr. Fenton, “and sometimes it can be the wake-up call to get the patient and family motivated.”
Dr. Fenton and her team plan to help primary care doctors better diagnose and manage Type 2 diabetes in children through upcoming Grand Rounds and other learning opportunities.
Doctors can refer Type 2 patients to Dr. Fenton’s group or continue to provide the care in consultation with a pediatric endocrinologist.
Dr. Michelle Levitt, a pediatrician with a special interest in childhood obesity, is new to the center. She has been screening children in pre-diabetes stage and providing resources such as nutrition counseling and strategies for making lifestyle changes that are most effective when the whole family is involved and committed.