DOI: 10.1542/peds.2012-3496
; originally published online January 28, 2013;Pediatrics
Stephen J. Spann and Susan K. Flinn
Prazar, Terry Raymer, Richard N. Shiffman, Vidhu V. Thaker, Meaghan Anderson,
Shelley C. Springer, Janet Silverstein, Kenneth Copeland, Kelly R. Moore, Greg E.
Management of Type 2 Diabetes Mellitus in Children and Adolescents
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TECHNICAL REPORT
Management of Type 2 Diabetes Mellitus in Children and
Adolescents
abstract
OBJECTIVE: Over the last 3 decades, the prevalence of childhood obe-
sity has increased dramatically in North America, ushering in a variety
of health problems, including type 2 diabetes mellitus (T2DM), which
previously was not typically seen until much later in life. This technical
report describes, in detail, the procedures undertaken to develop the
recommendations given in the accompanying clinical practice guide-
line, “Management of Type 2 Diabetes Mellitus in Children and Ado-
lescents,” and provides in-depth information about the rationale for
the recommendations and the studies used to make the clinical
practice guideline’s recommendations.
METHODS: A primary literature search was conducted relating to the
treatment of T2DM in children and adolescents, and a secondary lit-
erature search was conducted relating to the screening and treatment
of T2DM’s comorbidities in children and adolescents. Inclusion criteria
were prospectively and unanimously agreed on by members of the
committee. An article was eligible for inclusion if it addressed treat-
ment (primary search) or 1 of 4 comorbidities (secondary search) of
T2DM, was published in 1990 or later, was written in English, and
included an abstract. Only primary research inquiries were consid-
ered; review articles were considered if they included primary data or
opinion. The research population had to constitute children and/or
adolescents with an existing diagnosis of T2DM; studies of adult
patients were considered if at least 10% of the study population
was younger than 35 years. All retrieved titles, abstracts, and
articles were reviewed by the consulting epidemiologist.
RESULTS: Thousands of articles were retrieved and considered in both
searches on the basis of the aforementioned criteria. From those, in
the primary search, 199 abstracts were identified for possible inclu-
sion, 58 of which were retained for systematic review. Five of these
studies were classified as grade A studies, 1 as grade B, 20 as grade
C, and 32 as grade D. Articles regarding treatment of T2DM selected
for inclusion were divided into 4 major subcategories on the basis of
type of treatment being discussed: (1) medical treatments (32 stud-
ies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8
studies); and (4) social issues (9 studies). From the secondary search,
an additional 336 abstracts relating to comorbidities were identified
for possible inclusion, of which 26 were retained for systematic re-
view. These articles included the following: 1 systematic review of
literature regarding comorbidities of T2DM in adolescents; 5 expert
Shelley C. Springer, MD, MBA, MSc, JD, Janet Silverstein,
MD, Kenneth Copeland, MD, Kelly R. Moore, MD, Greg E.
Prazar, MD, Terry Raymer, MD, CDE, Richard N. Shiffman,
MD, Vidhu V. Thaker, MD, Meaghan Anderson, MS, RD, LD,
CDE, Stephen J. Spann, MD, MBA, and Susan K. Flinn, MA
KEY WORDS
childhood, clinical practice guidelines, comanagement, diabetes,
management, treatment, type 2 diabetes mellitus, youth
ABBREVIATIONS
AAP—American Academy of Pediatrics
ACE—angiotensin-converting enzyme
ADA—American Diabetes Association
AHA—American Heart Association
BG—blood glucose
CAM—complementary and alternative medicine
CES-D—Center for Epidemiologic Studies Depression Scale
CVD—cardiovascular disease
HbA1c—hemoglobin A1c
LDL-C—low-density lipoprotein cholesterol
PCP—primary care provider
QDS—Quality Data Set
RCT—randomized controlled trial
T1DM—type 1 diabetes mellitus
T2DM—type 2 diabetes mellitus
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors
have filed conflict of interest statements with the American
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
this publication.
The guidance in this report does not indicate an exclusive
course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be
appropriate.
All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
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doi:10.1542/peds.2012-3496
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Copyright © 2013 by the American Academy of Pediatrics
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opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease
and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and
clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control,
1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2
discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association
position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown
of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With
regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available
literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and
depression were summarized from expert guideline documents and are presented in detail in the guideline. The references
are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the
Supplemental Information. Pediatrics 2013;131:e648–e664
INTRODUCTION
This technical report details the pro-
cedures undertaken to develop the
recommendations given in the accom-
panying clinical practice guideline,
“Management of Type 2 Diabetes Melli-
tus in Children and Adolescents.” What
follows is a description of the process,
including the committee’s objectives;
methods of evidence identification, re-
trieval, review, and analysis; and sum-
maries of the committee’s conclusions.
Statement of the Issue
Over the last 3 decades, type 2 diabetes
mellitus (T2DM), a disease previously
confined to adult patients, has mark-
edly increased in prevalence among
children and adolescents. Currently, in
the United States, approximately 1 in 3
new cases of diabetes mellitus diag-
nosed in patients younger than 18 years
is T2DM,1,2 with a disproportionate re-
presentation in ethnic minorities,3,4
especially among adolescents.5 This
trend is not limited to the United States
but is occurring internationally as
well.6
The rapid emergence of childhood T2DM
poses challenges to the physician who is
unequipped to treat adult diseases en-
countered in children. Most diabetes
training and educational materials
designed for pediatric patients address
type 1 diabetes mellitus (T1DM) and em-
phasize insulin treatment and glucose
monitoring, which may or may not be
appropriate for children with T2DM.7,8
Most medications used for T2DM have
been tested for safety and efficacy only
in individuals older than 18 years, and
there is scant scientific evidence for
optimal management of children with
T2DM.9,10 Extrapolation of data from
adult studies to pediatric populations
may not be valid because the hormonal
milieu of the prepubescent and pubes-
cent patient with T2DM can affect
treatment goals and modalities in ways
heretofore unencountered in adult
patients.11
The United States has a severe shortage
of pediatric endocrinologists, making
access to these specialists difficult or, in
some cases, impossible.12 Vast geo-
graphic areas lack a pediatric endo-
crinologist: in 2011, 3 states had no
pediatric endocrinologists, and 22 had
fewer than 10, and the situation is un-
likely to improve in the near future.13 In
2004, the National Association of Child-
ren’s Hospitals and Related Institutions
performed a workforce survey and
found that patients had to wait almost
9 weeks for an appointment to see an
endocrinologist.14 Because the number
of patients with T1DM and T2DM has
increased since then, this situation is
presumably worse today. Regardless of
their age, most patients in the United
States who have T2DM are cared for
by primary care providers (PCPs).15
Furthermore, given the expected in-
creases in the national and global inci-
dence of T2DM and the near impossibility
that the pediatric endocrine workforce
will increase proportionately, PCPs must
be prepared for and capable of managing
children and adolescents who have un-
complicated T2DM.
Numerous experts have argued that
the ideal care of a child with T2DM is
provided through a team approach,
with care shared among a pediatric
endocrinologist, diabetes nurse edu-
cator, nutritionist, and behavioral spe-
cialist.16–18 In areas of limited access to
pediatric endocrinologists, however,
contact with the pediatric endocri-
nology team might involve contact at
diagnosis for initial diabetes educa-
tion and intermittently thereafter;
annually, with interval care by a PCP
and interval communication with the
pediatric endocrinology team; or at
every visit, for those patients who
are either doing poorly or are taking
insulin.
In areas where access to subspecialists
is hampered by geographic distances
and/or professional shortages, care
provided by local generalists who are
skilled in treating children and youth
with T2DM is likely to improve access to
medical care. Although there are no
pediatric studies evaluating this issue,
the committee believes that this im-
proved access to care might result in:
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� Reduced wait times and increased
timeliness of care.
� Reduced economic burden to the
patient, including reduced need to
travel and reduced time lost from
work and/or school.
� Potentially improved patient reten-
tion. Kawahara et al19 reported
that 56.9% of patients with T2DM
stopped coming to their hospital
diabetes clinic appointments, most
commonly because they were “too
busy” to keep their appointments.
Recent advances in medical technol-
ogy have the potential to ameliorate
limited access to specialists. Reporting
on the provision of clinical specialty
diabetes care to remote locations using
telemedicine, Malasanos et al20 found
that weekly telemedicine clinics were
able to effectively replace quarterly
face-to-face clinics after an initial face-
to-face clinic visit. This more frequent
contact provided by the telemedicine
clinics resulted in improved hemoglo-
bin A1c (HbA1c) concentrations, better
patient satisfaction, fewer days missed
from work or school, more time spent
with the patient during clinic visits,
and fewer subsequent hospitalizations
and emergency department visits. Tele-
medicine is costly, however, and
requires equipment to be in place at
both the subspecialist’s office and the
remote clinic; it is, therefore, not ap-
propriate for every practice. It is pos-
sible that a similar model of service
could be provided by a generalist
working locally and in close commu-
nication with a specialist.
For family physicians and others who
care for adult patients, managing T2DM
in children poses potential challenges.
The first is that what works for adults
may not work for children. Experiences
and results observed in adults do not
necessarily apply to children. Children
(and even adolescents) are not small
adults; they have a changing hormonal
environment, have differences in phy-
siology, and their growth can have
effects on medication doses, toxicity,
and responses.11 As a result, general-
ists who are confident in caring for
adults with diabetes may attempt to
apply adult practice experiences to
children, in whom these may not nec-
essarily be appropriate. Kaufman cited
data on various drugs’ effects in chil-
dren and argued that harm may occur
if children with T2DM are treated like
adults with T2DM.11 The author called
for treatment trials for children with
T2DM, to “better define the risk-benefit
ratio in children and youth, since this
may differ substantially from that in
the adult type 2 diabetic population.” In
contrast, others have noted that most
adolescents with T2DM are similar to
adults in terms of size and reproduc-
tive maturity and argued that, in the
absence of studies specifically targeted
to adolescents, treatment regimens
can be extrapolated from studies of
adults with T2DM; they do agree, how-
ever, that more randomized controlled
trials (RCTs) are needed in the pedi-
atric population.1
A second challenge is presented by the
conflicting evidence regarding out-
comes in patients with diabetes who
are managed by generalists versus
subspecialists. Some studies in adult
patients indicate that generalists are
capable of achieving outcomes similar
to those of subspecialists. Greenfield
et al21 observed that physiologic and
functional status (ie, physical, psy-
chological, social functioning) were
similar at both 2 and 4 years and
mortality was similar at 7 years in
adult hypertensive patients with di-
abetes treated in multispecialty groups
versus health maintenance organiza-
tion general practices. Other studies
indicate that generalists may achieve
outcomes similar to those of diabetes
specialists, as long as they have input
from subspecialists.
Indeed, unlike diseases in several other
specialties, care for children with di-
abetes that is conducted by generalists
without input from specialists may be
inferior to that provided by specialists.
Ziemer et al22 used an RCT design to
examine the effect of providing 5
minutes of direct feedback from an
endocrinologist to a PCP every 2
weeks. Performance in the feedback
group was sustained after 3 years, and
performance decayed in a comparison
group that received computer-generated
decision support reminders, including
a flow-sheet section showing previous
clinical data and a recommendations
section. Specialist feedback contrib-
uted independently to intensification
of diabetes management. In addition,
“clinical inertia” (defined as failure by
providers to intensify pharmacologic
therapy for hyperglycemia) was more
likely in a primary care versus a di-
abetes clinic setting (91% vs 52%) and
resulted in higher HbA1c concentra-
tions among patients.23
How these observations might be ap-
plied to the child who has T2DM is not
entirely clear, but they suggest that
regular, direct contact between the
generalist and a specialist can have a
positive outcome on these patients. De
Berardis et al24 reported that, com-
pared with adult patients with diabetes
mellitus who were seen in general
practice offices, patients cared for in
diabetes clinics were more likely to
conform with process-of-care mea-
sures, including HbA1c concentrations,
blood pressure, total cholesterol and
low-density lipoprotein cholesterol
(LDL-C) levels, microalbuminuria test-
ing, and foot and eye examinations and
were more likely to have adequate
concentrations of total cholesterol. No
differences were found in glycemic,
blood pressure, or LDL-C control, how-
ever. In that same study, all process-of-
care measures improved when the
patient was seen by a single physician
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as opposed to being seen by several
different physicians. No similar studies
have been performed in children, and
it is therefore unknown whether simi-
lar outcomes can be achieved in the
pediatric population.
A third challenge is presented by the
fact that children with T2DM are
overrepresented among racial and
ethnic minority populations and are
more likely to be living in poverty;
therefore, they may face significant
challenges in accessing specialists, even
under the best situations.25 Recognizing
these barriers to care and patients’
real-world needs, it is the committee’s
consensus that it is impractical to ex-
pect every patient with T2DM to be able
to access a pediatric endocrinologist on
a regular basis. It is also unreasonable
to assume that these visits will be fre-
quent enough to provide the level of
care needed to maintain the best pos-
sible metabolic control. For this reason
alone, PCPs must have a thorough
knowledge of the management of T2DM,
including its unique aspects related to
childhood and adolescence.
The committee also believes it is the
PCP’s responsibility to obtain the re-
quisite skills for such care and to com-
municate and work closely with a
diabetes team of subspecialists when-
ever possible. For this reason, when
treatment goals are not met, the com-
mittee encourages clinicians to consult
with an expert trained in the care of
children and adolescents with T2DM.
When first-line therapy fails (eg, metfor-
min), recommendations for intensifying
therapy should be generally the same
for pediatric and adult populations. The
picture is constantly changing, however,
as new drugs are being introduced, and
some drugs that initially seemed to be
safe exhibit adverse effects with wider
use. Clinicians should, therefore, remain
alert to new developments in this area.
Seeking the advice of an expert can
help ensure that the treatment goals are
appropriately set and that clinicians
benefit from cutting-edge treatment in-
formation in this rapidly changing area.
Stated Objective of the American
Academy of Pediatrics
Because the PCP caring for children
will likely encounter T2DM, the Amer-
ican Academy of Pediatrics (AAP), the
Pediatric Endocrine Society, the
American Academy of Family Physi-
cians, the American Diabetes Associ-
ation (ADA), and the American Dietetic
Association undertook a cooperative
effort to develop clinical guidelines for
the treatment of T2DM in children and
adolescents, for the benefit of subspe-
cialists and generalists alike. Represen-
tatives from these groups collaborated on
developing an evidence profile that
served as a major source of information
for the accompanying clinical practice
guideline recommendations. This re-
port, based on a review of the current
medical literature covering a period
from January 1, 1990, to July 1, 2009,
provides a set of evidence-based guide-
lines for the management and treatment
of T2DM in children and adolescents.
It should b