2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S164 Table 1. Screening for diabetes complications and comorbidities in children with type 2 diabetes Complication/ Comorbid condition Indications and intervals for screening Dyslipidemia Screening should commence at diagnosis of diabetes and every 1–3 years thereafter as clinically indicated Hypertension At diagnosis of diabetes and at every diabetes-related clinical encounter thereafter (at least twice annually) NAFLD Yearly screening commencing at diagnosis of diabetes Nephropathy Yearly screening commencing at diagnosis of diabetes Neuropathy Yearly screening commencing at diagnosis of diabetes PCOS Yearly screening commencing at puberty in females with oligo/ amenorrhea, acne and/or hirsutism Retinopathy Yearly screening commencing at diagnosis of diabetes ACR = albumin to creatinine ratio ALT = alanine aminotransferase BP = blood pressure DHEAS = dehydroepiandrosterone sulfate HDL-C = high-density lipoprotein cholesterol LDL-C = low-density lipoprotein cholesterol NAFLD = nonalcoholic fatty liver disease PCOS = polycystic ovary syndrome TC = total cholesterol TG = triglycerides Screening test Fasting TC, HDL-C,TG, calculated LDL-C BP measurement using appropriate size cuff ALT • First morning (preferred) or random ACR • Abnormal ACR requires confirmation at least 1 month later with a first morning ACR and if abnormal, follow-up with timed, overnight or 24-hour split urine collections for albumin excretion rate • Repeated sampling should be done every 3–4 months over a 6- to 12-month period to demonstrate persistence Questioned and examined for: • symptoms of numbness, pain, cramps, and paresthesia • skin sensation • vibration sense • light touch, and • ankle reflexes Androgen levels, including DHEAS and free testosterone • 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard); or • Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil; or • Digital fundus photography
RECOMMENDATIONS 1. Anticipatory guidance promoting healthy eating, the maintenance of a healthy weight and regular physical activity is recommended as part of routine pediatric care [Grade D, Consensus]. 2. Intensive lifestyle intervention, including dietary and exercise interventions, family counselling and family-oriented behaviour therapy, should be undertaken for obese children in order to achieve and maintain a healthy body weight [Grade D, Consensus]. 3. Children 10 years of age, or younger if puberty is established, should be screened for type 2 diabetes every 2 years using an FPG test if they have ≥2 of the following risk factors [Grade D, Consensus]: • Obesity (BMI ≥95th percentile for age and gender) • Member of high-risk ethnic group and/or family history of type 2 diabetes and/or exposure to diabetes in utero • Signs or symptoms of insulin resistance (including acanthosis nigricans, hypertension, dyslipidemia, NAFLD) • IGT • Use of antipsychotic medications/atypical neuroleptics 4.Very obese children (BMI ≥99th percentile for age and gender) who meet the criteria in recommendation 3 should have an OGTT performed annually [Grade D, Consensus]. 5. Commencing at the time of diagnosis of type 2 diabetes, all children should receive intensive counselling, including lifestyle modification, from an interdisciplinary pediatric healthcare team [Grade D, Consensus]. 6.The target A1C for most children with type 2 diabetes should be ≤7.0% [Grade D, Consensus]. OTHER RELEVANT GUIDELINES Definition, Classification and Diagnosis of Diabetes and Other Dysglycemic Categories, p. S10 Screening for Type 1 and Type 2 Diabetes, p. S14 Prevention of Diabetes, p. S17 Hyperglycemic Emergencies in Adults, p. S65 Dyslipidemia, p. S107 Treatment of Hypertension, p. S115 Retinopathy, p. S134 Type 1 Diabetes in Children and Adolescents, p. S150 Type 2 Diabetes in Aboriginal Peoples, p. S187 REFERENCES 1. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al.Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664-672. 2. Dean HJ, Young TK, Flett B, et al. Screening for type-2 diabetes in aboriginal children in northern Canada [letter]. Lancet. 1998;352:1523-1524. 3. Harris SB, Perkins BA, Whalen-Brough E. Non-insulin dependent diabetes mellitus among First Nations children. New entity among First Nations people of north western 7. In children with type 2 diabetes and an AIC ≥9.0%, and in those with severe metabolic decompensation (e.g. DKA), insulin therapy should be initiated, but may be successfully weaned once glycemic targets are achieved, particularly if lifestyle changes are effectively adopted [Grade D, Level 4 (38)]. 8. In children with type 2 diabetes, if glycemic targets are not achieved within 3 to 6 months using lifestyle modifications alone, 1 of the following should be initiated: metformin [Grade B, Level 2 (39)] or insulin [Grade D, Consensus]. Metformin may be used at diagnosis in those children presenting with an A1C >7.0% [Grade B, Level 2 (39)]. 9. Children with type 2 diabetes should be screened annually for microvascular complications (nephropathy, neuropathy, retinopathy) beginning at diagnosis of diabetes [Grade D, Level 4 (46)]. 10.All children with type 2 diabetes and persistent albuminuria (2 abnormal of 3 samples over a 6- to 12-month period) should be referred to a pediatric nephrologist for assessment of etiology and treatment [Grade D, Consensus]. 11. Children with type 2 diabetes should have a fasting lipid profile measured at diagnosis of diabetes and every 1 to 3 years thereafter as clinically indicated [Grade D, Consensus]. 12. Children with type 2 diabetes should be screened for hypertension beginning at diagnosis of diabetes and at every diabetes-related clinical encounter thereafter (at least biannually) [Grade D, Consensus]. Ontario. Can Fam Physician. 1996;42:869-876. 4. Fagot-Campagna A. Emergence of type 2 diabetes mellitus in children: epidemiological evidence. J Pediatr Endocrinol Metab. 2000;13(suppl 6):1395-1402. 5. Taylor JS, Kacmar JE, Nothnagle M, et al.A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes. J Am Coll Nutr. 2005;24:320-326. 6. Shields M. Measured Obesity: Overweight Canadian Children and Adolescents. Nutrition: Findings from the Canadian Community Health Survey. Ottawa, ON: Statistics Canada; 2005(1). Catalogue no. 82-620-MWE2005001. 7. Summerbell CD, Waters E, Edmunds LD, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2005;(3):CD001871. 8. Freemark M. Pharmacotherapy of childhood obesity: an evidence-based conceptual approach. Diabetes Care. 2007;30:395- 402. 9. McDuffie JR, Calis KA, Uwaifo GI, et al. Efficacy of orlistat as an adjunct to behavioral treatment in overweight African American and Caucasian adolescents with obesity-related comorbid conditions. J Pediatr Endocrinol Metab. 2004;17:307-319. 10. Ozkan B, Bereket A,Turan S, et al. Addition of orlistat to conventional treatment in adolescents with severe obesity. Eur J S165 DIABETES IN CHILDREN AND ADOLESCENTS
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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