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Pediatric Outpatient Management of Type 2 Diabetes

Pediatric Outpatient Management of Type 2 Diabetes - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related

Key Recommendations for Outpatient Management of Type 2 Diabetes Mellitus in Children
Screening in Children (10-18 years)
Diagnosis (ADA Grade B)
A diagnosis should be given when a positive
test result is exhibited on more than one
ξA1C: > 6.5%
ξFasting plasma glucose*: > 126 mg/dL
ξ2-hr plasma glucose on 75-g oral glucose
tolerance test (OGTT): > 200 mg/dL
ξRandom plasma glucose: > 200 mg/dL
*Fasting is defined as no caloric intake for > 8 hrs.
When to
Screen patients > 10 yrs. (or at onset of puberty if earlier) with BMI > 85th percentile for age
and sex, weight for height > 85th percentile, or weight > 120% of ideal for height AND two or
more additional risk factors. (ADA Grade E)
Risk Factors:
ξ First or second-degree relative with type 2 diabetes
ξ High risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific
ξ Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, HTN, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth
ξ Maternal history of diabetes or GDM during pregnancy
A1C, fasting plasma glucose with insulin level, or oral glucose tolerance test (preferred with
fasting and 2-hour insulin levels) (ADA Grade B)
Frequency If results normal, repeat testing every 3 years. (ADA Grade C)
If results abnormal (prediabetes), repeat testing annually. (ADA Grade E)
First Line Therapy
Nutrition Physical Activity
All patients with type 2 diabetes need to be evaluated by a registered
dietitian at every visit with expertise in addressing the nutritional needs of
children with Type 2 diabetes and obesity. (ADA Grade A)
Healthy eating is encouraged with 3 meals and planned snacks, reducing
portion size (ADA Grade C), encouraging water consumption of water,
reducing juice intake, increasing consumption of fruits and vegetables.
(ADA Grade B)
Consider referral to Pediatric Fitness Clinic.
Children with diabetes should be encouraged to engage in at
least 60 minutes of daily physical activity (vigorous-intensity
aerobic activity, bone/muscle-strengthening 3 days/week).
(ADA Grade B)
All patients should be encouraged to reduce sedentary time,
particularly by breaking up extended amounts of time (> 90
min.) spent sitting. (ADA Grade B)
Interventions Metformin (ADA Grade A) Insulin (ADA Grade E)
1. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017;40(Suppl 1):S6-127.
2. Springer SC, Silverstein J, Copeland K, et al. Management of type 2 diabetes mellitus in children and adolescents. Pediatrics. 2013;131(2):e648-664.
3. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
4. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247-2256.
Copyright © 2017 Univ ersity of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Test Frequency Notes
Tobacco Use Interview patient/parent ξEvery visit (ADA Grade B) Consider secondhand smoke exposure and use of e-cigarettes
ξCheck blood glucose
levels fasting, pre-
meal and at bedtime
until at target level
ξAt diagnosis
ξReview self-monitored blood
glucose (SMBG) at each visit
ξRepeat A1C every 3 months
Once at target level:
ξPatients on metformin only: To be determined by individual provider
ξPatients on basal insulin: Daily fasting blood sugars and 2-hour postprandial
ξPatients on basal/bolus insulin therapy: Pre-meals and at bedtime.
Hypertension Blood pressure ξEvery visit (ADA Grade B)
ξGoal: < 90th percentile for age, sex and height (ADA Grade E)
ξIf elevated, first line therapy is diet and exercise (ADA Grade E)
ξIf still elevated after 3-6 months, recommend further evaluation with laboratory
evaluation of sodium, potassium, chloride, bicarbonate, BUN, creatinine, urinalysis
without microscopy renal ultrasound and referral to Hypertension Clinic. Consider
ACE Inhibitor following appropriate reproductive counseling. (ADA Grade E)
Retinopathy Dilated eye exam ξAt diagnosis
ξAnnually thereafter (ADA Grade E)
Less frequent examinations (i.e., every 2 years) may be acceptable on the advice of an
eye care professional. (ADA Grade E)
Random urine sample
for microalbumin/
creatinine ratio (UACR)
glomerular filtration rate
ξAt diagnosis
ξConsider annual urine screen
(UACR) once patient has
diabetes for 5 yrs. (ADA Grade B)
ξMeasure creatinine clearance at
diagnosis, then based on age,
diabetes duration and treatment
thereafter (ADA Grade E)
ξIf initial positive screen, repeat on separate occasion
ξIf repeat screen is positive, recommend a 24 hour urine study for protein and
ξIf elevated (UACR > 30 mg/g) on 2/3 urine samples, consider renal consult and
initiation of an ACE inhibitor. (ADA Grade B)
Dyslipidemia Fasting lipid profile
(ADA Grade E)
ξAt diagnosis (ADA Grade E)
ξIf abnormal, repeat annually
(ADA Grade E)
ξIf normal, repeat every 5 years
(ADA Grade E)
ξInitial therapy diet and exercise with counseling with a registered dietician (ADA Grade B)
ξIf patient 10 years old and LDL > 160 mg/dL after 6 months or LDL > 130 mg/dL and
one or more CVD risk factors, consider statins with goal of LDL < 100 mg/dL
(ADA Grade E)
ξIf triglycerides > 150 mg/dL and < 600 mg/dL, decrease simple carbohydrates, fat,
and increase exercise. If > 700 mg/dL, consider niacin therapy to prevent pancreatitis.
ξConsider referral to Pediatric Preventive Cardiology Clinic
ξConsider Omega 3 fatty acids.
Fatty Liver
Liver Enzymes
ξAt diagnosis
ξAnnually thereafter
Sleep Apnea Interview patient/parent ξEvery visit
ξPHQ-2, with follow-up
for children > 12 yrs.
ξAt diagnosis (ADA Grade E)
ξEvery visit (ADA Grade E)
ξPositive screen on PHQ-2 (> 3 points)
ξMay further assessment using PHQ-A or PHQ-9 (> 10 points)
Copyright © 2017 Univ ersity of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org