ED: TD2 diabetes occurs more often in (mainly overweight) children, and careful management is thwarted by adolescent behaviours but is needed to prevent long-term complications.
Many countries, including Australia, are experiencing a dramatic rise in childhood onset Type 2 Diabetes (T2D) – an annual rise of 18% in WA. This rise mirrors the obesity epidemic seen in recent decades across most of the globe.
To date, public health campaigns to halt the rise in childhood obesity have been mostly unsuccessful, resulting in children experiencing complications of their obesity at very young ages including the development of T2D. Reports have described T2D in pre-pubertal children as young as four years.
A recent review of the WA Children’s Diabetes Database found that 6% of children were under 10 years at the time of diagnosis. These children had multiple risk factors for developing T2D including having one or more first degree relatives with T2D, obesity, presence of acanthosis nigricans, female, Aboriginal Australian heritage, and several of these children had additional complex medical problems.
Diagnosing diabetes is simple – a glucometer in a symptomatic child or an oral glucose tolerance test in children with several of the previously mentioned risk factors.
Aboriginal children are most at risk – 60% of the childhood T2D cohort in WA (but comprising just 3.5% of WA’s population). Many Aboriginal children at risk of T2D live outside of metropolitan Perth and have limited health care access. The astute clinician can use opportunistic glucose or HbA1c testing when assessing these children, identify asymptomatic T2D and in this way reduce delays in diagnosis.
The Treatment Options for Adolescents and Youth study (TODAY) was a US nationwide study aimed to find the best ways to treat young people with T2D. This study showed that diabetes complications such as hypertension, lipid abnormalities, albuminuria were commonly present at the time of diagnosis. TODAY also showed that T2D in youth is an aggressive disease with rapid acceleration of complications and many participants failed to achieve adequate glycaemic control with first line medications such as metformin.
Childhood T2D is best managed by a paediatric diabetes multidisciplinary team with expertise in aggressively treating T2D. At diagnosis, admission to a centre with a specialised team is often required to ensure modifiable lifestyle behaviours can be addressed e.g. dietary changes and physical activity. Insulin therapy can also be commenced with the aim of achieving euglycemia quickly.
Clinicians must be wary of assigning a diabetes type in obese children before gathering all necessary clinical information. Why? Type 1 diabetes still remains more common in all children, regardless of BMI status. All children with a new diagnosis of diabetes require immediate referral to a diabetes team for management; they determine diabetes type, look for signs of insulin resistance (acanthosis nigricans), determine Type 1 diabetes antibodies, C-peptide, the presence of comorbid conditions and (occasional) genetic testing.
Any delay in diagnosis or appropriate therapy can result in significant morbidity such as diabetic ketoacidosis or hyperglycaemic hyperosmolar state.
Author competing interests: No relevant disclosures.
References on request
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