Care recommendations

Type 2 diabetes in children


By 2002 The National Diabetes Audit (1) had identified 102 children with Type 2 diabetes, an increase of 36 per cent from the previous year.
Up to 85 per cent of children with Type 2 diabetes are either obese or overweight at diagnosis. They are mainly from the African Caribbean and South Asian groups but this number continues to rise and spread through all cultures as children become less active and more overweight. (2)

 

In October 2004 a Diabetes UK report Diabetes in the UK stated that the number  of children with Type 2 diabetes in the UK could be as high as 1,400 (3). This figure was based on a survey of the number of overweight and obese schoolchildren in the UK.

In the past, because of the relative rarity of Type 2 diabetes in children, it was assumed that any child presenting with symptoms of diabetes had Type 1 diabetes, usually presenting with an acute condition such as diabetic ketoacidosis (DKA)    

Although Type 2 has a slower more insidious onset, some children with Type 2 can present clinically in exactly the same way as those with Type 1, making diagnosis difficult.

Some clinicians make the diagnosis of Type 2 on clinical features alone, including:

  • a family history of Type 2 diabetes.
  • obesity.
  • acanthosis nigricans.
  • polycystic ovary syndrome.

Common antibodies tested for in diabetes include glutamic acid decarboxylase-65 (GAD-65). As the presence of these antibodies can confirm autoimmune diabetes in children, their absence strongly suggests Type 2. However, because 10 per cent of children with Type 2 diabetes test positive for these antibodies, other clinical features need to be taken into consideration. These can include diabetes where insulin is not needed, very low insulin requirements, suspiciously good control on insulin, or diabetes as part of or secondary to another condition.

Obesity is strongly associated with insulin resistance, so once the diagnosis has been made referral to a paediatric diabetes specialist team, including a registered dietitian, is necessary. Close monitoring by the specialist multidisciplinary healthcare team is important in helping to encourage the changes in lifestyle needed in the management of the child’s diabetes. Increasing the level of physical activity to the recommended one hour per day (4) and a healthy eating plan are at the top of the list of changes that can make a big difference in managing weight control and achieving optimum blood glucose levels. It is essential that the whole family is involved so that the goals set can be achieved.

Medication to help achieve good glycaemic control may be used, usually Metformin.(5) This works by reducing the amount of glucose produced by the liver and increasing the sensitivity of the muscle cells to insulin thereby enabling the glucose in the blood to pass into the cells more effectively. Because Metformin doesn’t cause the pancreas to produce more insulin, its use avoids hypoglycaemia. At first some patients may complain of gastric upset, but starting on a low dose, which is increased gradually, and taking the tablets with food can avoid this.

Advice on alcohol consumption is needed as the combination of alcohol and Metformin may cause lactic acidosis. This can apply to children as young as 12 who may be drinking alcohol regularly.

Regular monitoring of kidney function is important as Metformin is excreted through the kidneys. Unless there is decreased kidney function, continuation of the treatment must be encouraged to prevent complications, especially retinopathy and nephropathy, developing by early adulthood.

The psychological impact of the diagnosis of Type 2 diabetes in a child may require expert counselling, not only for the child but for parents and siblings too, as feelings of guilt, anger, blame and anxiety about the future will need to be addressed. Some families will not even have recognised that the child is overweight, and may deny that the problem exists.

The importance of preventing Type 2 diabetes in children at high risk must be stressed, as this is a chronic progressive condition which brings with it the risk of serious complications.

Childhood obesity is following the upward trend seen in adults and brings with it an elevated risk of cardiovascular disease. Prevention of obesity should be started in childhood. The two most significant periods in a child’s life span for the development of obesity are between the ages of five and seven and adolescence. Obesity established during these periods tends to become more fixed for life (2).

Measurement of the child’s weight and height ratio and, as they grow older, weight and waist circumference should be an integral part of health care work.

Children are targeted as consumers and are vulnerable to sophisticated marketing techniques and intense, repetitive advertising for the high-calorie, energy-dense foods and drinks which are significant contributory factors to obesity. Diabetes UK supports restrictions on this type of advertising and supports government measures which help to ensure that children have the freedom to play and exercise in safety. (6)

We understand that the International Society for Paediatric and Adolescent Diabetes (ISPAD) is preparing guidelines for the management of paediatric Type 2 diabetes and we hope to be able to link to these when they are published.

References:
1 Diabetes UK in collaboration with Royal College of Nursing, Royal College of Paediatrics and Child Health & British Society for Paediatric Endocrinology and Diabetes (2004) The National Paediatric Diabetes Audit: Results from the audit year 2002 London: Diabetes UK
2  Finnish Diabetes Association (2003) Programme for the Prevention of Type 2 Diabetes in Finland 2003-2010 Finland: Finnish Diabetes Association
3  Lobstein T & Leach R (2004) Diabetes may be undetected in many children in the UK British Medical Journal 328: 1261-1262 (22 May)
4  Department of Health (2004) At least five a week: Evidence on the impact of physical activity and its relationship to health  London: Department of Health
5  Jones KL, Arslanian S, Peter et al (2002) Effect of Metformin in pediatric patients with Type 2 diabetes Diabetes Care 25(1): 89-94  
6  International Obesity TaskForce & European Association for the Study of Obesity (2002) Obesity in Europe: The Case for Action  London: International Obesity TaskForce


With thanks to the paediatric SMART group for their assistance in preparing this document.