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Diabetes Standards of Care & Clinical Practice Resources

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.

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Youth and Type 2 Diabetes Sections

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Clinical Practice Recommendations

 

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

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]

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

Recommendations for Chronic Kidney Disease (CKD) in Youth

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.