Diabetes Standards of Care and Resources for Clinicians and Educators
Youth and Type 2 Diabetes
American Indian/Alaska Native (AI/AN) youth have the highest prevalence rate of type 2 diabetes compared with youth of all other racial and ethnic groups in the United States. Providers need to consider several important differences in approaches to testing and treatment of youth with diabetes, as compared with adults.
AI/AN youth with type 2 diabetes are at risk for developing or may even present with the same comorbidities as adults. Therefore, it is essential to measure blood pressure, blood lipids, and urine albumin upon diagnosis. While much of diabetes management for youth is similar to that for adults, there are a few differences to be aware of.
Clinical Practice Recommendations
Recommendations for Youth and Type 2 Diabetes
Recommendations for Testing for Type 2 Diabetes in Youth
- Test overweight (BMI > 85th percentile) AI/AN youth with any of the following risk factors:
- Family history of diabetes.
- Signs of insulin resistance or conditions associated with it (e.g., acanthosis nigricans, PCOS, hypertension, dyslipidemia, small-for-gestational-age (SGA) or large-for-gestational-age (LGA) birth weight).
- Maternal history of diabetes or gestational diabetes during child’s gestation.
- Start testing these higher risk children at age 10 years (or younger if puberty occurs earlier).
- Test at-risk children ≤ every 3 years.
Recommendations for Glycemic Control in Youth
- Glycemic control targets for youth with type 2 diabetes are:
- A1C < 8% for ages 6 to 12 years
- A1C < 7.5% for ages 13 to 19 years.
- The only FDA-approved diabetes medications for use in children are metformin and insulin. While other medications are sometimes used in clinical practice, there is less evidence to support their use, and that use would be off-label.
All targets and medication regimens need to take into consideration not only the age of the child but also adverse effects of medications such as hypoglycemia, the amount of appropriate and consistent adult assistance, and family resources.
Recommendations for Blood Pressure (BP) Control in Youth
- Screen youth with type 2 diabetes for hypertension at diabetes diagnosis and at every diabetes visit.
- Consider pharmacologic treatment for patients with blood pressure (BP) > 95th percentile for gender, age, and height; or > 130/80 mmHg – whichever is less.
- ACE inhibitors and ARBs are FDA-approved for treating hypertension in children.
Unlike in adults, BP norms in youth vary by gender, age, and height. To determine a patient’s BP percentile, categorized by gender, age, and height, use these tables Exit Disclaimer: You Are Leaving www.ihs.gov [PDF] developed by the National Heart, Lung, and Blood Institute. Once the BP percentile is obtained, use the table below to classify and diagnose hypertension in children and adolescents.
Classification of Blood Pressure in Children and Adolescents
|Blood Pressure Category||Definition|
|Normal||< 90th percentile|
|Prehypertension||90th-95th percentile or 120/80 mmHg|
|Hypertension Stage 1||95th-99th percentile + 5 mmHg|
|Hypertension Stage 2||> 99th percentile + 5 mmHg|
|Source: National Heart, Lung, and Blood Institute, National Institutes of Health. Blood Pressure Tables for Children and Adolescents from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, 2004. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]|
Recommendations for Chronic Kidney Disease (CKD) in Youth
- Order a UACR and eGFR at diabetes diagnosis and then at least annually:
- Consider treatment with an ACE inhibitor for youth with albuminuria.
Youth should be screened for chronic kidney disease using the same two screening tests used in adults: eGFR and UACR. There is no difference in UACR testing between adults and youth. However, while eGFR in adults with diabetes is calculated using the MDRD equation, this equation is not accurate in youth. Instead, the Bedside Schwartz equation should be used to calculate eGFR in patients < 18 years of age.
Clinician and Educator Resources
Featured Youth and Type 2 Diabetes Resources
Integrating Case Management Into Your Practice [PDF – 290 KB]
Integrating DSMES Into Your Practice [PDF – 275 KB]
Clinical Practice Guideline: Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents Exit Disclaimer: You Are Leaving www.ihs.gov [PDF] Pediatrics 2013;131:364–382. doi:10.1542/peds.2012-3494
American Diabetes Association. 13. Children and Adolescents: Standards of Medical Care in Diabetes 2021 Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care 2021;44(Suppl.1):S180-S199. doi:10.2337/dc21-S013
Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities (2016) Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care 2016;39(9):1635-1642. doi:10.2337/dc16-1066:
Youth and Type 2 Diabetes CME Trainings
|Session Title||Session Material||CME/CE Information|
|New Putting Prevention and Treatment of Childhood Obesity in Context Exit Disclaimer: You Are Leaving www.ihs.gov
Jason Kurland, MD
Past Diabetes Director, Zuni IHS
Current Emergency Department Director, Zuni IHS
Thomas Faber, MD, MPH, FAAP
Clinical Director, Zuni IHS
IHS Chief Clinical Consultant for Pediatrics
(Originally presented on 5/19/21.)
|Conference Alaska’s Most Important Infrastructure: Improving the Health and Wellness of Families with Young Children Exit Disclaimer: You Are Leaving www.ihs.gov
Matthew Hirschfeld, MD, PhD
(Originally presented on 8/8/19.)