2008 Clinical Practice Guidelines - Canadian Diabetes Association
2008 Clinical Practice Guidelines - Canadian Diabetes Association
2008 Clinical Practice Guidelines - Canadian Diabetes Association
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RECOMMENDATIONS<br />
1. Anticipatory guidance promoting healthy eating, the maintenance<br />
of a healthy weight and regular physical activity is<br />
recommended as part of routine pediatric care [Grade D,<br />
Consensus].<br />
2. Intensive lifestyle intervention, including dietary and exercise<br />
interventions, family counselling and family-oriented<br />
behaviour therapy, should be undertaken for obese children<br />
in order to achieve and maintain a healthy body<br />
weight [Grade D, Consensus].<br />
3. Children 10 years of age, or younger if puberty is established,<br />
should be screened for type 2 diabetes every 2<br />
years using an FPG test if they have ≥2 of the following<br />
risk factors [Grade D, Consensus]:<br />
• Obesity (BMI ≥95th percentile for age and gender)<br />
• Member of high-risk ethnic group and/or family history<br />
of type 2 diabetes and/or exposure to diabetes in utero<br />
• Signs or symptoms of insulin resistance (including acanthosis<br />
nigricans, hypertension, dyslipidemia, NAFLD)<br />
• IGT<br />
• Use of antipsychotic medications/atypical neuroleptics<br />
4.Very obese children (BMI ≥99th percentile for age and gender)<br />
who meet the criteria in recommendation 3 should<br />
have an OGTT performed annually [Grade D, Consensus].<br />
5. Commencing at the time of diagnosis of type 2 diabetes,<br />
all children should receive intensive counselling, including<br />
lifestyle modification, from an interdisciplinary pediatric<br />
healthcare team [Grade D, Consensus].<br />
6.The target A1C for most children with type 2 diabetes<br />
should be ≤7.0% [Grade D, Consensus].<br />
OTHER RELEVANT GUIDELINES<br />
Definition, Classification and Diagnosis of <strong>Diabetes</strong> and<br />
Other Dysglycemic Categories, p. S10<br />
Screening for Type 1 and Type 2 <strong>Diabetes</strong>, p. S14<br />
Prevention of <strong>Diabetes</strong>, p. S17<br />
Hyperglycemic Emergencies in Adults, p. S65<br />
Dyslipidemia, p. S107<br />
Treatment of Hypertension, p. S115<br />
Retinopathy, p. S134<br />
Type 1 <strong>Diabetes</strong> in Children and Adolescents, p. S150<br />
Type 2 <strong>Diabetes</strong> in Aboriginal Peoples, p. S187<br />
REFERENCES<br />
1. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al.Type 2 diabetes<br />
among North American children and adolescents: an epidemiologic<br />
review and a public health perspective. J Pediatr.<br />
2000;136:664-672.<br />
2. Dean HJ, Young TK, Flett B, et al. Screening for type-2 diabetes<br />
in aboriginal children in northern Canada [letter]. Lancet.<br />
1998;352:1523-1524.<br />
3. Harris SB, Perkins BA, Whalen-Brough E. Non-insulin<br />
dependent diabetes mellitus among First Nations children.<br />
New entity among First Nations people of north western<br />
7. In children with type 2 diabetes and an AIC ≥9.0%, and in<br />
those with severe metabolic decompensation (e.g. DKA),<br />
insulin therapy should be initiated, but may be successfully<br />
weaned once glycemic targets are achieved, particularly<br />
if lifestyle changes are effectively adopted [Grade D, Level<br />
4 (38)].<br />
8. In children with type 2 diabetes, if glycemic targets are not<br />
achieved within 3 to 6 months using lifestyle modifications<br />
alone, 1 of the following should be initiated: metformin<br />
[Grade B, Level 2 (39)] or insulin [Grade D, Consensus].<br />
Metformin may be used at diagnosis in those children<br />
presenting with an A1C >7.0% [Grade B, Level 2 (39)].<br />
9. Children with type 2 diabetes should be screened annually<br />
for microvascular complications (nephropathy, neuropathy,<br />
retinopathy) beginning at diagnosis of diabetes [Grade D,<br />
Level 4 (46)].<br />
10.All children with type 2 diabetes and persistent albuminuria<br />
(2 abnormal of 3 samples over a 6- to 12-month<br />
period) should be referred to a pediatric nephrologist<br />
for assessment of etiology and treatment [Grade D,<br />
Consensus].<br />
11. Children with type 2 diabetes should have a fasting lipid<br />
profile measured at diagnosis of diabetes and every 1<br />
to 3 years thereafter as clinically indicated [Grade D,<br />
Consensus].<br />
12. Children with type 2 diabetes should be screened for<br />
hypertension beginning at diagnosis of diabetes and at<br />
every diabetes-related clinical encounter thereafter (at<br />
least biannually) [Grade D, Consensus].<br />
Ontario. Can Fam Physician. 1996;42:869-876.<br />
4. Fagot-Campagna A. Emergence of type 2 diabetes mellitus in<br />
children: epidemiological evidence. J Pediatr Endocrinol Metab.<br />
2000;13(suppl 6):1395-1402.<br />
5. Taylor JS, Kacmar JE, Nothnagle M, et al.A systematic review<br />
of the literature associating breastfeeding with type 2 diabetes<br />
and gestational diabetes. J Am Coll Nutr. 2005;24:320-326.<br />
6. Shields M. Measured Obesity: Overweight <strong>Canadian</strong> Children and<br />
Adolescents. Nutrition: Findings from the <strong>Canadian</strong> Community<br />
Health Survey. Ottawa, ON: Statistics Canada; 2005(1).<br />
Catalogue no. 82-620-MWE2005001.<br />
7. Summerbell CD, Waters E, Edmunds LD, et al. Interventions<br />
for preventing obesity in children. Cochrane Database Syst Rev.<br />
2005;(3):CD001871.<br />
8. Freemark M. Pharmacotherapy of childhood obesity: an evidence-based<br />
conceptual approach. <strong>Diabetes</strong> Care. 2007;30:395-<br />
402.<br />
9. McDuffie JR, Calis KA, Uwaifo GI, et al. Efficacy of orlistat as<br />
an adjunct to behavioral treatment in overweight African<br />
American and Caucasian adolescents with obesity-related comorbid<br />
conditions. J Pediatr Endocrinol Metab. 2004;17:307-319.<br />
10. Ozkan B, Bereket A,Turan S, et al. Addition of orlistat to conventional<br />
treatment in adolescents with severe obesity. Eur J<br />
S165<br />
DIABETES IN CHILDREN AND ADOLESCENTS