Introduction
Type 2 diabetes mellitus (T2DM) is a metabolic disorder characterized by peripheral insulin resistance and a failure of beta cells to compensate, leading to hyperglycemia.[1][2][3] While once considered an adult pathology, it is increasingly prevalent in children.[4] Risk factors for children are similar to those in adults: ethnicity, family history, obesity, and a sedentary lifestyle. However, presentation and management differ from adults with the disorder. Children with diabetes of any kind are at an increased risk of many complications. Early recognition, screening, and treatment of children and adolescents with T2DM are important for preventing long-term complications from the disease.[5]
Etiology
Register For Free And Read The Full Article
- Search engine and full access to all medical articles
- 10 free questions in your specialty
- Free CME/CE Activities
- Free daily question in your email
- Save favorite articles to your dashboard
- Emails offering discounts
Learn more about a Subscription to StatPearls Point-of-Care
Etiology
Hyperglycemia results when there is a relative lack of insulin compared to glucose in the blood. In T2DM, insulin resistance first leads to increased insulin production by the beta cells of the pancreas.[5] Hyperglycemia results when the beta cells cannot produce enough insulin to maintain euglycemia. Hyperglycemia damages multiple organs, including kidneys, eyes, heart, and nerves. Further, hyperglycemia puts children at risk for other electrolyte disturbances.[6]. Compared to adults, children with T2DM develop complications earlier and are often more challenging to manage.[7]
There has been an increase in the diagnosis of T2DM secondary to the ever-increasing rates of obesity.[8][9] The general cause of adult and T2DM is similar, with some pathophysiological differences as mentioned below.[5]
Epidemiology
Type 1 diabetes mellitus (T1DM) remains the most prevalent form of diabetes in children. However, T2DM is estimated to occur in 1 in 3 (20% to 33%) of new diagnoses of diabetes in children today. The rate of T2DM in children continues to rise even as the obesity rates have plateaued in these age groups.[10][11][12] Girls are more affected than boys.[12] Risk factors include high-risk ethnicity (African American, Hispanic, Native American, Pacific Islanders, Asian Americans), a positive first-degree relative with the disorder, obesity, low birth weight, a mother with gestational diabetes, and female sex. It is more likely to be diagnosed during adolescence when insulin resistance is common due to multiple factors, including hormonal changes. [10][11]
Pathophysiology
Obesity leads to peripheral insulin resistance, which in turn leads to hyperglycemia. Insulin resistance occurs in multiple organs and tissues, eventually leading to beta-cell failure.[7] Generally speaking, insulin resistance can be present for a significant period of time before the diagnosis of T2DM.[7] It is important to note that visceral obesity, rather than BMI, may be a better predictor for the complications of insulin resistance, including T2DM and hypertension.[7] Independent of obesity, certain ethnicities have higher risks of insulin resistance and beta cell dysfunction. In addition, hormonal changes at puberty result in temporary insulin resistance, leading to hyperglycemia and the risk of developing T2DM.[13] Hyperglycemia leads to an osmotic diuresis (polyuria), which increases thirst (polydipsia). This diuresis causes moderate to severe dehydration.
Prolonged hyperglycemia can produce 2 distinct emergent states in T2DM in children: [14]
- Diabetic Ketoacidosis (DKA): much more common in children with T2DM than adults. Lack of insulin inhibits the body's ability to use glucose for energy and reverts to breaking down fat for energy. This leads to ketosis, acidosis, and electrolyte abnormalities and may lead to coma and death.
- Hyperglycemic Hyperosmolar State (HHS): characterized by hypertonicity, extreme hyperglycemia (>600 mg/dl), and severe dehydration. The profound hyperglycemia results in continued osmotic diuresis and intravascular depletion.
History and Physical
Children with T2DM most often present during asymptomatic screening.
Children may have the typical symptoms of polyuria, polydipsia, polyphagia, and weight loss. Children with T2DM are more likely than adults with the disorder to present in DKA (5% to 13%), especially if they are of ethnic minority descent. Adolescents with T2DM may also present in HHS.
Physical examination findings may include acanthosis nigricans (a dark, velvety rash on the axillae and/or neck). The American Diabetes Association (ADA) recommends screening children at 10 years old or at the start of puberty in children who are obese (>95th percentile BMI for age) or are overweight (BMI >85th percentile for age or >120% ideal body weight) and have 2 risk factors. These factors include a positive family history, high-risk ethnicity, signs of insulin resistance (polycystic ovary syndrome (PCOS), acanthosis nigricans, diabetic symptoms), or a history of maternal gestational diabetes mellitus.
Evaluation
The American Diabetes Association (ADA) recommends screening for T2DM every 3 years starting at age 10 years (or at the onset of puberty) for patients who are: [15][16][17]
- Obese (BMI ≥95th percentile for age)
- Overweight (BMI ≥ 85th percentile for age) and have at least 2 risk factors (positive family history, high-risk race or ethnicity, signs of insulin resistance, maternal history of gestational diabetes).
Diagnostic Criteria:
- Random plasma blood glucose ≥200 mg/dl with symptoms of polyuria, polydipsia, or weight loss
- Fasting blood glucose ≥126 mg/dl in an asymptomatic patient.
- Oral glucose tolerance test (GTT) with blood sugar ≥ 200 mg/dl at 2 hours post-ingestion.
- Hemoglobin A1c >6.5%
If the diagnosis between T1DM and T2DM is unclear, helpful labs include fasting insulin or C-peptide (both usually high or normal in T2DM, low in T1DM) and autoantibodies for T1DM.
Treatment / Management
The American Academy of Pediatrics (AAP) recommends lifestyle modifications and metformin as the first-line therapy. Lifestyle changes include moderate to vigorous exercise for 60 minutes daily, limiting screen time to less than 2 hours per day, and a dietary referral.[18][19][20][21](A1)
Metformin and/or insulin should be started at diagnosis. Metformin is first-line and available as a liquid. It can be started at 500 mg/day and increased by 500 mg every 1 to 2 weeks to a maximum of 2000 mg twice per day. The gradual increase of the medication and taking it with food helps to prevent adverse gastrointestinal effects.
Insulin should be started for patients who are ketotic or in DKA, have a random blood glucose >250 mg/dl, a hemoglobin A1c >8.5%, or in whom the diagnosis of T1DM versus T2DM is unclear. A basal/bolus regimen like in T1DM may be used, but typically, T2DM patients require higher doses (2 units/kg/day to 3 units/kg/day). Insulin should be initiated and managed by pediatric endocrinologists. Insulin takers have a risk of hypoglycemia; therefore, frequent monitoring is required.[13]
Home glucose monitoring is recommended for those who take insulin, have not met glucose control goals, are changing medications, or are sick.
Hemoglobin A1c test goals vary by association. The ADA and AAP list an A1c test goal of <7%, while the American Association of Clinical Endocrinologists places the goal at <6.5%.
Differential Diagnosis
The differential diagnosis for pediatric T2DM includes the following:
- Atypical diabetes mellitus (ADM)
- Maturity-onset diabetes of the young (MODY)
- Diabetes secondary to mutations in DNA
- Diseases of the exocrine pancreas
- Drug or chemical-induced diabetes
- Diabetic ketoacidosis (DKA)
- Endocrinopathies
- Genetic defects of beta cells
- Genetic defects in insulin action
- Type 1 diabetes mellitus (T1DM)
Prognosis
There have been no long-term prognosis studies for pediatric T2DM. The prognosis is of great concern in the medical community, primarily due to its potential for long-term complications. Many children and adolescents can achieve good glycemic control and lead healthy lives with proper treatment, lifestyle modifications, and regular monitoring. While the condition is manageable, it can lead to significant health challenges if not well-controlled. The risk of complications, including cardiovascular disease, kidney problems, and retinopathy, remains a real and persistent threat. The long-term prognosis is intricately tied to the child's ability to adhere to treatment plans, maintain a healthy lifestyle, and receive consistent medical care. Early diagnosis, comprehensive education, and robust support systems are crucial for improving the prognosis and minimizing the risk of severe complications in pediatric patients with T2DM.
Complications
There are significant long-term complications for children with T2DM, and they often occur earlier in the disease course than their adult counterparts.[7] Evidence shows that these patients begin to experience renal and neurological complications within 10 years of the disease, including the need for dialysis, amputation, and blindness.[22] Compared with children who do not have diabetes, those with diabetes increase their risk of dialysis almost 40-fold.[23]
For adult patients with T2DM, there is a significant reduction in life expectancy compared to patients without T2DM.[24] Given the recent increase in pediatric T2DM amongst the general population, no data on life expectancy associated with pediatric T2DM exists.
There is also data to suggest that having adult T2DM puts patients at higher risk of further complications such as cancers and other non-vascular causes[25]. In pediatric patients, approximately a quarter of children with T2DM will have hypertension, and slightly over 20% have albuminuria.[26]
Consultations
The specialties often consulted for patients with pediatric T2DM include the following:
- Pediatric Endocrinology
- Pediatric Opthalmology
- Pediatric Nephrology
- Registered Dietician
- Child and Adolescent Psychiatry
Deterrence and Patient Education
There is a sizeable familial component to pediatric T2DM.[27] Preventing T2DM in children primarily involves addressing modifiable risk factors, such as obesity and a sedentary lifestyle. Encouraging healthy eating habits, regular physical activity, and weight management can significantly reduce the risk of developing the condition.[28] Public health campaigns, school programs, and community initiatives promoting a healthy lifestyle are essential for deterrence.
Educating pediatric patients and their caregivers about T2DM is paramount. They should understand the importance of dietary choices, portion control, and the significance of regular exercise in managing the condition. Patients need to learn self-monitoring techniques, such as blood glucose testing and the proper administration of medications if prescribed. Patient education should be ongoing and tailored to the child's age and comprehension level.
Incorporating both deterrence strategies and comprehensive patient education into clinical practice can lead to better outcomes and a reduced incidence of pediatric T2DM. By empowering children and their families with the knowledge and the tools to make healthy choices, the medical community can help mitigate the impact of this growing health concern.
Pearls and Other Issues
Complications of T2DM in children are similar to those of adults. Complications tend to occur after a patient has had the disease for many years. Those who are diagnosed in childhood have the disease for longer periods of time. Therefore, strict control and management of blood glucose are crucial to help prevent these complications. All people with diabetes should have regular dilated eye exams (to examine for diabetic retinopathy), urine microalbumin screening at appropriate intervals (to evaluate for renal involvement), hyperlipidemia screens/treatment, hypertension screening/treatment, and regular monitoring.[29]
Enhancing Healthcare Team Outcomes
T2DM in children is best managed by an interprofessional team that includes a pediatrician or primary care provider, endocrinologist, pharmacist, diabetic nurse, dietician, and relevant specialists. It is vital to ensure that these children are also evaluated by an ophthalmologist, nephrologist, cardiologist, and dental surgeon.
Physicians should have proficiency in diagnosis, medication management, and complication prevention. Nurses play a crucial role in patient education and ongoing monitoring. Pharmacists ensure appropriate medication selection and dosing. Open, transparent communication among team members is essential to meet the patient's needs. Regular case discussions and updates are crucial for optimal care. Efficient care coordination is vital, including aligning appointments and services to provide holistic, patient-centered care.
A cohesive strategy should encompass regular patient education, dietary guidance, medication management, and exercise plans. Monitoring blood glucose levels and identifying early signs of complications is pivotal. An interprofessional team approach ensures that the patient receives well-rounded, evidence-based care and significantly improves outcomes in managing pediatric T2DM.
References
Chen Y, Wang T, Liu X, Shankar RR. Prevalence of type 1 and type 2 diabetes among US pediatric population in the MarketScan Multi-State Database, 2002 to 2016. Pediatric diabetes. 2019 Aug:20(5):523-529. doi: 10.1111/pedi.12842. Epub 2019 Apr 25 [PubMed PMID: 30861241]
Winhusen T, Theobald J, Kaelber DC, Lewis D. Medical complications associated with substance use disorders in patients with type 2 diabetes and hypertension: electronic health record findings. Addiction (Abingdon, England). 2019 Aug:114(8):1462-1470. doi: 10.1111/add.14607. Epub 2019 Apr 25 [PubMed PMID: 30851217]
Crawford R, Sims ED, Wang KW, Youssef M, Nadarajah A, Rivas A, Banfield L, Thabane L, Samaan MC. Traditional knowledge-based lifestyle interventions in the prevention of obesity and type 2 diabetes in Indigenous children in Canada: a systematic review protocol. Systematic reviews. 2019 Mar 6:8(1):69. doi: 10.1186/s13643-019-0961-4. Epub 2019 Mar 6 [PubMed PMID: 30841917]
Level 1 (high-level) evidenceHannon TS, Arslanian SA. The changing face of diabetes in youth: lessons learned from studies of type 2 diabetes. Annals of the New York Academy of Sciences. 2015 Sep:1353():113-37. doi: 10.1111/nyas.12939. Epub 2015 Oct 8 [PubMed PMID: 26448515]
Shah AS, Zeitler PS, Wong J, Pena AS, Wicklow B, Arslanian S, Chang N, Fu J, Dabadghao P, Pinhas-Hamiel O, Urakami T, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents. Pediatric diabetes. 2022 Nov:23(7):872-902. doi: 10.1111/pedi.13409. Epub 2022 Sep 25 [PubMed PMID: 36161685]
Level 3 (low-level) evidenceHernández-Montoya D, Soriano-Flores A, Esparza-Aguilar M, Benjet C, Llanes-Díaz N. Variation in incidence of type 2 diabetes mellitus: time series of Mexican adolescents. Annals of epidemiology. 2019 Feb:30():15-21. doi: 10.1016/j.annepidem.2018.11.006. Epub 2018 Nov 22 [PubMed PMID: 30528324]
Valaiyapathi B, Gower B, Ashraf AP. Pathophysiology of Type 2 Diabetes in Children and Adolescents. Current diabetes reviews. 2020:16(3):220-229. doi: 10.2174/1573399814666180608074510. Epub [PubMed PMID: 29879890]
Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, Bell R, Badaru A, Talton JW, Crume T, Liese AD, Merchant AT, Lawrence JM, Reynolds K, Dolan L, Liu LL, Hamman RF, SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014 May 7:311(17):1778-86. doi: 10.1001/jama.2014.3201. Epub [PubMed PMID: 24794371]
Level 2 (mid-level) evidenceCopeland KC, Zeitler P, Geffner M, Guandalini C, Higgins J, Hirst K, Kaufman FR, Linder B, Marcovina S, McGuigan P, Pyle L, Tamborlane W, Willi S, TODAY Study Group. Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline. The Journal of clinical endocrinology and metabolism. 2011 Jan:96(1):159-67. doi: 10.1210/jc.2010-1642. Epub 2010 Oct 20 [PubMed PMID: 20962021]
Level 2 (mid-level) evidenceJensen ET, Dabelea D. Type 2 Diabetes in Youth: New Lessons from the SEARCH Study. Current diabetes reports. 2018 May 8:18(6):36. doi: 10.1007/s11892-018-0997-1. Epub 2018 May 8 [PubMed PMID: 29737424]
Pelham JH, Hanks L, Aslibekyan S, Dowla S, Ashraf AP. Higher hemoglobin A1C and atherogenic lipoprotein profiles in children and adolescents with type 2 diabetes mellitus. Journal of clinical & translational endocrinology. 2019 Mar:15():30-34. doi: 10.1016/j.jcte.2018.11.006. Epub 2018 Nov 30 [PubMed PMID: 30547005]
Mayer-Davis EJ, Lawrence JM, Dabelea D, Divers J, Isom S, Dolan L, Imperatore G, Linder B, Marcovina S, Pettitt DJ, Pihoker C, Saydah S, Wagenknecht L, SEARCH for Diabetes in Youth Study. Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002-2012. The New England journal of medicine. 2017 Apr 13:376(15):1419-1429. doi: 10.1056/NEJMoa1610187. Epub [PubMed PMID: 28402773]
Flint A, Arslanian S. Treatment of type 2 diabetes in youth. Diabetes care. 2011 May:34 Suppl 2(Suppl 2):S177-83. doi: 10.2337/dc11-s215. Epub [PubMed PMID: 21525452]
Caprio S, Pierpont B, Kursawe R. The "adipose tissue expandability" hypothesis: a potential mechanism for insulin resistance in obese youth. Hormone molecular biology and clinical investigation. 2018 Mar 29:33(2):. pii: /j/hmbci.2018.33.issue-2/hmbci-2018-0005/hmbci-2018-0005.xml. doi: 10.1515/hmbci-2018-0005. Epub 2018 Mar 29 [PubMed PMID: 29596053]
Lee AM, Fermin CR, Filipp SL, Gurka MJ, DeBoer MD. Examining trends in prediabetes and its relationship with the metabolic syndrome in US adolescents, 1999-2014. Acta diabetologica. 2017 Apr:54(4):373-381. doi: 10.1007/s00592-016-0958-6. Epub 2017 Jan 9 [PubMed PMID: 28070750]
Hagman E, Danielsson P, Brandt L, Ekbom A, Marcus C. Association between impaired fasting glycaemia in pediatric obesity and type 2 diabetes in young adulthood. Nutrition & diabetes. 2016 Aug 22:6(8):e227. doi: 10.1038/nutd.2016.34. Epub 2016 Aug 22 [PubMed PMID: 27548712]
Oester IM, Kloppenborg JT, Olsen BS, Johannesen J. Type 2 diabetes mellitus in Danish children and adolescents in 2014. Pediatric diabetes. 2016 Aug:17(5):368-73. doi: 10.1111/pedi.12291. Epub 2015 Jun 26 [PubMed PMID: 26111830]
Bhatt M, Nahari A, Wang PW, Kearsley E, Falzone N, Chen S, Fu E, Jeyakumar Y, Zukowski J, Banfield L, Thabane L, Samaan MC. The quality of clinical practice guidelines for management of pediatric type 2 diabetes mellitus: a systematic review using the AGREE II instrument. Systematic reviews. 2018 Nov 15:7(1):193. doi: 10.1186/s13643-018-0843-1. Epub 2018 Nov 15 [PubMed PMID: 30442196]
Level 2 (mid-level) evidenceAlbert Pérez E, Mateu Olivares V, Martínez-Espinosa RM, Molina Vila MD, Reig García-Galbis M. New Insights about How to Make an Intervention in Children and Adolescents with Metabolic Syndrome: Diet, Exercise vs. Changes in Body Composition. A Systematic Review of RCT. Nutrients. 2018 Jul 6:10(7):. doi: 10.3390/nu10070878. Epub 2018 Jul 6 [PubMed PMID: 29986479]
Level 1 (high-level) evidenceCha E, Paul S, Braxter BJ, Umpierrez G, Faulkner MS. Dietary Behaviors and Glucose Metabolism in Young Adults at Risk for Type 2 Diabetes. The Diabetes educator. 2018 Apr:44(2):158-167. doi: 10.1177/0145721718756057. Epub 2018 Mar 1 [PubMed PMID: 29495910]
Vaughan EM, Johnston CA, Cardenas VJ, Moreno JP, Foreyt JP. Integrating CHWs as Part of the Team Leading Diabetes Group Visits: A Randomized Controlled Feasibility Study. The Diabetes educator. 2017 Dec:43(6):589-599. doi: 10.1177/0145721717737742. Epub 2017 Oct 19 [PubMed PMID: 29047326]
Level 2 (mid-level) evidenceDart AB, Martens PJ, Rigatto C, Brownell MD, Dean HJ, Sellers EA. Earlier onset of complications in youth with type 2 diabetes. Diabetes care. 2014 Feb:37(2):436-43. doi: 10.2337/dc13-0954. Epub 2013 Oct 15 [PubMed PMID: 24130346]
Level 2 (mid-level) evidenceDart AB, Sellers EA, Martens PJ, Rigatto C, Brownell MD, Dean HJ. High burden of kidney disease in youth-onset type 2 diabetes. Diabetes care. 2012 Jun:35(6):1265-71. doi: 10.2337/dc11-2312. Epub 2012 Mar 19 [PubMed PMID: 22432116]
Level 2 (mid-level) evidenceKianmehr H, Zhang P, Luo J, Guo J, Pavkov ME, Bullard KM, Gregg EW, Ospina NS, Fonseca V, Shi L, Shao H. Potential Gains in Life Expectancy Associated With Achieving Treatment Goals in US Adults With Type 2 Diabetes. JAMA network open. 2022 Apr 1:5(4):e227705. doi: 10.1001/jamanetworkopen.2022.7705. Epub 2022 Apr 1 [PubMed PMID: 35435970]
Rao Kondapally Seshasai S, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, Whincup PH, Mukamal KJ, Gillum RF, Holme I, Njølstad I, Fletcher A, Nilsson P, Lewington S, Collins R, Gudnason V, Thompson SG, Sattar N, Selvin E, Hu FB, Danesh J, Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose, and risk of cause-specific death. The New England journal of medicine. 2011 Mar 3:364(9):829-841. doi: 10.1056/NEJMoa1008862. Epub [PubMed PMID: 21366474]
Cioana M, Deng J, Hou M, Nadarajah A, Qiu Y, Chen SSJ, Rivas A, Banfield L, Chanchlani R, Dart A, Wicklow B, Alfaraidi H, Alotaibi A, Thabane L, Samaan MC. Prevalence of Hypertension and Albuminuria in Pediatric Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA network open. 2021 Apr 1:4(4):e216069. doi: 10.1001/jamanetworkopen.2021.6069. Epub 2021 Apr 1 [PubMed PMID: 33929524]
Level 1 (high-level) evidenceWillemsen G, Ward KJ, Bell CG, Christensen K, Bowden J, Dalgård C, Harris JR, Kaprio J, Lyle R, Magnusson PK, Mather KA, Ordoňana JR, Perez-Riquelme F, Pedersen NL, Pietiläinen KH, Sachdev PS, Boomsma DI, Spector T. The Concordance and Heritability of Type 2 Diabetes in 34,166 Twin Pairs From International Twin Registers: The Discordant Twin (DISCOTWIN) Consortium. Twin research and human genetics : the official journal of the International Society for Twin Studies. 2015 Dec:18(6):762-71. doi: 10.1017/thg.2015.83. Epub [PubMed PMID: 26678054]
Rush E, Simmons D. Physical activity in children: prevention of obesity and type 2 diabetes. Medicine and sport science. 2014:60():113-21. doi: 10.1159/000357341. Epub 2014 Sep 9 [PubMed PMID: 25226806]
Zurita-Cruz JN, Manuel-Apolinar L, Arellano-Flores ML, Gutierrez-Gonzalez A, Najera-Ahumada AG, Cisneros-González N. Health and quality of life outcomes impairment of quality of life in type 2 diabetes mellitus: a cross-sectional study. Health and quality of life outcomes. 2018 May 15:16(1):94. doi: 10.1186/s12955-018-0906-y. Epub 2018 May 15 [PubMed PMID: 29764429]
Level 2 (mid-level) evidence