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Type 2 Diabetes Mellitus in Children

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Type 2 Diabetes Mellitus in Children, Pediatric Type II Diabetes Mellitus, Non-Insulin Dependent Diabetes in Children, Youth Onset Type 2 Diabetes Mellitus, Y-T2DM

  • See Also
  1. Maturity Onset Diabetes of the Young
  2. Type 2 Diabetes Mellitus
  3. Type 1 Diabetes Mellitus
  • Epidemiology
  1. Overall 20% Prevalence of Prediabetes or diabetes in U.S. adolescents
  2. Of the 210,000 persons age <20 years diagnosed with Diabetes in 2018 in U.S., 11% were due to Type 2 Diabetes
    1. Type 2 Diabetes has accounted for as much as a third of U.S. pediatric diabetes cases in some studies
  • Risk Factors
  1. Overweight
    1. Body Mass Index (BMI) >85th percentile for age and gender or
    2. Weight for Height >85th percentile for age and gender or
    3. Ideal Weight for height >120th percentile for age and gender
  2. Family History of Type 2 Diabetes in first or second degree relative
  3. Maternal diabetes or Gestational Diabetes history
  4. Higher risk ethnic and racial groups
    1. Asian
    2. Black
    3. Hispanic
    4. Native American
    5. Pacific Islander
  5. Insulin Resistance related findings
    1. Acanthosis Nigricans
    2. Polycystic ovarian syndrome
    3. Small for Gestational Age birth weight
  • Screening
  • Indications (per ADA)
  1. See Diabetes Screening
  2. Child over age 10 years (or Puberty) AND
  3. Meets Overweight criteria (see above) AND
  4. Two additional risk factors (see above)
  • Findings
  • Presentations
  1. Asymptomatic Hyperglycemia in 40% of cases
  2. Symptomatic Hyperglycemia (e.g. Polyuria, polydipsia, Blurred Vision, Unintentional Weight Loss)
  3. Diabetic Ketoacidosis (25% of new Type II cases)
  • Diagnosis
  1. See Diabetes Mellitus Diagnostic Criteria
  2. Pitfalls
    1. Overweight Children represent 24% of new onset Type I Diabetes
    2. Diabetic Ketoacidosis is present in up to 25% of children at Type II Diabetes diagnosis
    3. Autoimmune labs used to identify Type I Diabetes may be present in Type II Diabetes in up to 10% of children
      1. Glutamic Acid decarboxylase
      2. Islet Antigen-2 Antibodies
    4. Transient physiologic Insulin Resistance during Puberty
      1. Some teens in Prediabetes state, esp. with Obesity, may revert to normoglycemia after Puberty
      2. Optimize weight, Exercise and diet as well as other management as below in these children with Prediabetes
  • Associated Conditions
  1. Hypertension
    1. Present in up to 32% of teens at time of diagnosis
  2. Hyperlipidemia
  3. Nephropathy
  4. Retinopathy
  1. Hemoglobin A1C
    1. Obtain every 3 months
    2. Goal <7% for teens and children
  2. Other labs (at diagnosis and annually)
    1. Lipid profile
    2. Liver Function Tests
    3. Urine Microalbumin
  • Labs
  • Self-monitored fingerstick Glucose Indications
  1. Insulin (check 3 times daily)
  2. Change in medication dosing or treatment regimen
  3. Comorbid illness
  4. Inadequate glycemic control
  5. Symptoms of Hypoglycemia
  • Evaluation
  1. Time of diagnosis
    1. Labs: Hemoglobin A1C, Lipid profile, Liver Function Tests, Urine Microalbumin
    2. Retinopathy screening
    3. Sleep Apnea screening
    4. Diabetes education including Glucose, nutrition goals, and weight goals for child
    5. Blood Pressure
  2. Every 3 months
    1. Hemoglobin A1C
    2. Lifestyle, weight, exexrcise and Medication Compliance
    3. Self-monitored Glucose log review
  3. Annually
    1. Influenza Vaccine
    2. Labs: Lipid profile, Liver Function Tests, Urine Microalbumin
    3. Sleep Apnea screening
    4. Retinopathy screening
  • Management
  1. General measures
    1. Weight loss goal of 7 to 10% (or BMI <85 percentile)
    2. Overall Approach: 5-2-1-0
      1. Five or more fruits and vegetables per day
      2. Two hours or less Screen Time per day
      3. One hour or more of Physical Activity per day
      4. No sugary drinks (and more water every day)
    3. Nutrition counseling with diabetic educator or dietician
      1. Increase nutrient dense, high quality foods (e.g. vegetables)
      2. Decrease calorie-dense, nutrient poor foods (e.g. simple Carbohydrates)
      3. Weight goal <85th percentile for age and gender
    4. Exercise
      1. Moderate to vigorous Exercise for 60 minutes per day (one session or split multiple times daily)
      2. Limit non-academic Screen Time to <2 hours per day
      3. Adjust medication dosing and timing to reduce the risk of Hypoglycemia with Exercise
    5. Family Involvement
      1. Lifestyle changes as a family are more likely to result in success for the individual child
      2. Recognize the need for psychosocial support for the child
  2. Medications
    1. Metformin (age 10 years old and older)
      1. Start at 500 mg and increase in 500 mg increments to max of 2000 mg (regardless of weight)
      2. Contraindicated if Ketoacidosis history, or Liver Function Tests >3 fold above upper limit of normal
      3. Coadminister B Vitamin Supplement or Multivitamin
    2. Insulin
      1. Indications
        1. Ketosis or Ketoacidosis
        2. Random plasma Glucose 250 mg/dl or greater
        3. Hemoglobin A1C >8.5%
      2. Dosing (much higher than adult dosing)
        1. Start long acting, Basal insulin (e.g. Insulin Glargine) at 0.2 to 1 unit/kg
        2. Consider splitting high Long-Acting Insulin requirements (>50 units/day)
        3. Consider Continuous Glucose Monitors
      3. Protocol to taper off Insulin as Glucose targets are met
        1. Indications: Effective other medications, lifestyle changes result in a1c<8.5%, Glucose <250 mg/dl
        2. Taper Insulin off over 2 to 6 weeks by 10 to 30% every few days while monitoring Glucose
    3. Semaglutide (age >= 12 years)
      1. Dosed weekly
      2. BMI decreased >16% at 68 weeks
      3. Nausea and Vomiting occurs in 36 to 42% of patients
      4. Weghuberj (2022) N Engl J Med 387(24):2245-57 +PMID: 36322838 [PubMed]
    4. Victoza (Liraglutide)
      1. Approved in 2019 for use in age 10 years and older with Type 2 Diabetes Mellitus
      2. Expensive (approaches $1000/month) and only lower Hemoglobin A1C 0.6% in children
      3. (2019) presc lett 26(10): 57
    5. Dulaglutide (Trulicity)
      1. Approved in 2022 for use in age 10 years and older with Type 2 Diabetes Mellitus
      2. Arslanian (2022) N Engl J Med 387(5):433-43 +PMID: 35658022 [PubMed]
    6. Empagliflozin (Jardiance)
      1. Approved in 2023 for use in age 10 years and older with Type 2 Diabetes Mellitus
      2. Associated with Hgb A1C decrease of 0.8% when added to other agents over 26 weeks
            1. Laffel (2023) Lancet Diabetes Endocrinol 11(3):169-81 +PMID: 36738751 [PubMed]
  3. Comorbidities
    1. Hypertension Management indications
      1. Systolic or diastolic Blood Pressure >90th or 95% percentile AND
      2. Criteria met on 3 separate occasions
  • Complications
  1. See Type 2 Diabetes Mellitus
  2. Pediatric Type 2 diabetes is associated with earlier complication rates (e.g. CKD) than with adult Type 2 Diabetes
  • Prevention
  1. Influenza Vaccine yearly
  2. Prevnar 13 followed at least 8 weeks later by Pneumovax (once)
  • Prognosis
  1. Youth Onset Type 2 diabetes doubles the cardiovascular disease risk over Type 1 Diabetes Mellitus
  2. Associated with decreased lifespan by 30 to 40 years
  3. Onset of micro and macrovascular complications often have onset at a young age (by 20 to 30 years)
    1. Y-T2DM is associated with longterm Hypertension, Chronic Kidney Disease and Hyperlipidemia in >50%
  4. References
    1. Bjornstad (2021) N Engl J Med 385(5):416-26 +PMID: 34320286 [PubMed]
  • References
  1. Creo (2024) Mayo Clinic Pediatric Days, lecture attended 1/17/2024
  2. Mangione (2022) JAMA 328(10):963-67 +PMID: 36098719 [PubMed]
  3. Xu (2018) Am Fam Physician 98(9): 590-4 [PubMed]