New AAP Guideline on Type 2 Diabetes: FAQ with Dr. Craig Taplin
Craig Taplin, MD
The American Academy of Pediatrics (AAP) published a new guideline for the management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Dr. Craig Taplin, a pediatric endocrinologist at Seattle Children’s, provides answers to frequently asked questions about managing T2DM patients in primary care.
Q. When is it appropriate to start medications instead of advising lifestyle changes related to nutrition and exercise?
A. This guideline recommends initiation of metformin at the time of diagnosis of T2DM in conjunction with intensive lifestyle modification. In adults, lifestyle modification alone may be the initial management strategy, so these recommendations for children differ in this regard.
In children and adolescents with T2DM, lifestyle changes intensive enough to reverse abnormal glucose metabolism are hard to implement successfully, and the evidence does not support lifestyle modification as an effective standalone intervention. However, it is still very important to promote intensive lifestyle modification while beginning medication because it makes a big difference when it is successful.
Although metformin and lifestyle modification are the initial treatment choice, the TODAY study published in the New England Journal of Medicine in 2012 found that many patients do not achieve adequate diabetes control within the first two years of therapy and require insulin. Therefore, preventing T2DM in youth is critically important because it’s very difficult to treat.
Patients who are more metabolically unstable at diagnosis – as defined by a blood glucose level greater than 250 mg/dL or hemoglobin A1c greater than 9% – should be started on insulin. Metformin may also be started at diagnosis.
Q. Should you start metformin before a diagnosis of diabetes if there is clinical evidence of pre-diabetes or insulin resistance?
A. As a general rule, that is not the standard of care. The evidence in this area is still somewhat weak. Pediatric endocrinologists typically don’t prescribe metformin until there is an established diagnosis of T2DM, although there is some evidence that metformin can be useful in the achievement of weight loss as an adjunct to lifestyle change in metabolic syndrome.
Unlike adults, however, children and adolescents generally should not start metformin before a diagnosis of T2DM unless there is a specific indication, such as polycystic ovarian syndrome.
Q. What labs should you order if you suspect T2DM?
A. Diagnostic labs are critical to differentiate type 1 diabetes (T1DM) from T2DM. It is not unusual for the type of diabetes to be unclear at the time of diagnosis. A patient who presents with significant hyperglycemia but who is also obese may have T1DM complicated by insulin resistance. We would manage that patient very differently from someone with T2DM.
When you suspect T2DM, I recommend ordering:
- Blood glucose
- Hemoglobin A1c
- C peptide
- Diabetes autoantibodies
- Liver function tests
- Fasting lipid panel
- Kidney function
- Vitamin D
If a patient who appears to have T2DM is autoantibody positive, the patient actually has type 1 diabetes. It may be complicated by insulin resistance, but the fundamental disorder is insulin deficiency due to autoimmune disease. However, sometimes this is not clear and treatment depends on the clinical picture.
Liver function tests with particular reference to the ALT and AST are helpful because these patients have a high prevalence of fatty liver disease. This tends to have an ALT-predominant profile.
Once diagnosed with T2DM, the patient should also have a urine test for a microalbumin/creatinine ratio. At or soon after the time of diagnosis, about one in three youth with T2DM has early nephropathy, a prevalence much higher than in type 1 diabetes.
Q. What risk factors should determine who should be screened in primary care?
A. I would recommend screening if the patient is obese (defined as a body mass index above the 95th percentile for age and sex) and has any of the following risk factors: a strong family history of T2DM; Hispanic, Native American or African American ethnicity; or clinical evidence of insulin resistance, such as acanthosis nigricans.
T2DM is unusual in the prepubertal population, but it often develops in peripubertal and postpubertal patients with preexisting insulin resistance. Because puberty is a time of physiological insulin resistance, puberty can be a trigger, or “second hit,” that leads to overt type 2 diabetes if there were other risk factors previously.
African American, Native American and Hispanic adolescents are at higher risk of T2DM because they have a more profound increase in insulin resistance during normal puberty than other adolescents, and thus must make more insulin during puberty to overcome this insulin resistance.
If insulin secretion can no longer compensate for increasing insulin resistance, T2DM may result. Girls are also at higher risk than boys for similar reasons.
According to the largest epidemiological study of youth with diabetes in the United States (the SEARCH study), about half of post-pubertal patients of minority background newly diagnosed with diabetes have T2DM, whereas in other populations, T1DM is still more common.
Q. What is the best screening test?
A. Unfortunately, all tests have their limitations. A random blood glucose in the clinic or a urinalysis is a reasonable first step. A glucose tolerance test (GTT) is a good option with lower rates of false negative results (that is, a missed diagnosis).
The oral GTT has problems with reproducibility in patients early in the spectrum of disease, but in general detects more patients than a fasting blood glucose or a hemoglobin A1c because these may be the last to change. In general, post-meal blood glucose rises before fasting glucose in the evolution of diabetes.
Q. Are there any issues with metformin, and how is it dosed?
A. We don’t usually use doses more than 1 gram twice a day for metformin, as there is minimal evidence that higher doses improve efficacy.
Metformin can cause gastrointestinal side effects, so the dose is typically increased slowly over two to four weeks to 1 gram twice daily. I usually start with 500 mg once daily and increase the dose weekly to a final dose of 1 gram twice a day. With this regimen, we don’t see frequent gastrointestinal upset.
Q. If metformin and lifestyle modification aren’t working, what is the next step? And how does treatment of children compare to adults?
A. If adequate glucose control is not obtained on metformin alone, escalation to insulin is needed. We may add a long-acting basal insulin first and monitor blood sugars accordingly.
It is important for the primary care pediatrician and the pediatric endocrinologist to work together to ensure adequate control is achieved. If long-acting insulin alone does not achieve adequate control, then meal-time insulin is added.
In addition, an important difference between adults and children is that another oral agent may be added before insulin when treating adults with T2DM, but only metformin and insulin are approved by the Food and Drug Administration (FDA) for children with T2DM.
This may change over time as new studies are performed, and indeed the TODAY study did look at a class of agents called thiazolidinediones in children, but in general we move to insulin as the next step in escalation of therapy if metformin alone fails. Other classes of drugs have evidence to support their safety and efficacy in adults, but currently there is minimal or no evidence to support their use in children.
- TODAY Study Group. A Clinical Trial to Maintain Glycemic Control in Youth with Type 2 Diabetes. N Engl J Med 2012;366:2247-56.
- SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006 Oct;118(4):1510-8.
Treating Eating Disorders: FAQ with Dr. Yolanda Evans
Yolanda Evans, MD, MPH
Dr. Yolanda Evans, an adolescent medicine specialist who frequently treats patients with eating disorders, provides answers to frequently asked questions. Adolescent Medicine has an eating disorders team that includes dietitians, mental health therapists and adolescent medicine specialists with expertise in the medical management of eating disorders.
Q. What are the risk factors for eating disorders?
A. Risk factors include:
- Being female
- Family history of eating disorders
- Perfectionistic in school and with parents
- Introverted
- Difficulty communicating negative emotions
- Difficulty resolving conflict
- Low self-esteem
Though being female is a risk factor, adolescent males are also at risk. In fact, we are seeing more and more males developing restrictive eating disorders.
Most people develop eating disorders in adolescence. Eating disorders of different levels of severity are very common. According to the Youth Risk Behavior Surveillance Survey from the Centers for Disease Control, among all high school student respondents (9th to 12th grade):
- 12% went a full day without eating to lose weight
- 5% took diet pills, powders or liquids to lose weight
- 4% vomited or took laxatives to lose weight
Q. How do these patients present in clinic?
A. Patients with eating disorders often feel dizzy and faint because they have been starving and their body has shut down. Often they will say that they can’t eat more because they feel full, bloated or nauseous; that sensation is real because their stomach has shrunk and they need to learn to eat again.
In terms of mental health, these patients often had a history of anxiety or depression before the onset of the eating disorder. They or their parents may report that they don’t want to spend time with their friends and family and prefer to stay in their room.
With respect to exercise, these patients often have compulsive patterns of running five miles every day or doing 300 crunches, compared to other teens, who will say they sometimes play basketball with their friends or they like to go for a jog for fun.
Q. What should you look for and what tests should you order if you suspect an eating disorder?
A. When I see patients in clinic, I check a complete metabolic panel, TSH, free thyroxine, CBC with differential, and ESR as a baseline. For teens who purge, I also order an EKG. If a patient has been amenorrheic for over a year, I will check a DEXA scan to assess bone mineral density.
When I physically examine patients with bulimia, those who have been purging will sometimes have swollen salivary glands or parotid glands. I may see calluses on their knuckles from using their fingers to induce vomiting, although many patients are so used to vomiting that they don’t need to use their fingers. Occasionally I see dental erosion.
Q. What are the criteria for admission to the hospital for an eating disorder?
A. Seattle Children’s admits patients with:
- Bradycardia, defined as a heart rate of less than 40 beats/minute
- Symptomatic orthostatic changes: major changes in their blood pressure or heart rate between lying down, sitting down and standing up, with dizziness
- Electrolyte abnormalities
- Abnormalities noted on an EKG
- Extremely low weight or rapid weight loss (e.g., greater than 10% loss of their body weight in one to two weeks)
Q. What medications are needed?
A. Some patients need antidepressants or anti-anxiety medications, especially if they had a history of depression or anxiety before the onset of the eating disorder. However, I always make sure they also have mental health therapy because the medication will not fix the underlying reason for the eating disorder.
I do not recommend giving a patient a prescription for a birth control pill to ensure that their period will start again or to restore bone density. There is no good evidence that birth control pills can improve bone health. I only prescribe birth control pills if needed for contraception.
I don’t prescribe anything for appetite stimulation either. For children with chronic abdominal pain with some anxiety, every once in a while I use something like Periactin or cyproheptadine, but I don’t prescribe it often.
Q. What are the different types of treatment for different levels of severity?
A. There are several levels of care:
Outpatient care at Seattle Children’s
In outpatient treatment at Children’s, patients typically have three visits each week to see an adolescent medicine specialist, a nutritionist and a mental health specialist.
Intensive outpatient care and residential care at other organizations
If the patient isn’t progressing but is medically stable, then we look at more intensive outpatient or residential care options offered at other organizations. Both types of care involve a multidisciplinary team approach.
Intensive outpatient care may involve coming four or five times a week for four or five hours per visit. If the patient is not improving despite intensified efforts, residential care may be needed. The patient will be housed in a facility dedicated to recovery, but it is not a hospital setting.
Medical inpatient care at Seattle Children’s
If patients are medically unstable, they could be admitted to the Medical Unit at Seattle Children’s for medical treatment only. In that case, we would not be treating the eating disorder and working on the psychological aspect of eating disorders; we only try to feed the patient and make sure they are medically stable.
Psychiatric inpatient care at Seattle Children’s
Patients who are medically stable but who have not improved can be admitted to the Inpatient Psychiatric Unit (IPU) at Seattle Children’s to treat the eating disorder.
The IPU is organized by age group for school and other activities. Eating disorder patients participate in activities with patients who have other diagnoses, but they also participate in separate group activities focused on eating disorders, and there is special supervision of meals. Parents learn how to support their children at meals and how to talk about food.
Eating disorder patients also have one-on-one therapy and medication management. A dietitian sees the patient each day, and an adolescent medicine specialist sees the patient at least once a week, if not more often, for medical management. The length of stay is usually about three weeks.
Other organizations also offer residential programs, which are often comparable to psychiatric inpatient care.
Q. What types of treatment are covered by insurance?
A. Public and private insurance typically cover outpatient care and about three weeks of inpatient psychiatric care. Intensive outpatient care and long-term residential treatment are often out-of-pocket, but may be covered. (Neither is provided at Seattle Children’s.)
Q. What is the entry point for outpatients and what is the wait time?
A. The entry point is the Adolescent Medicine Clinic. We typically have appointments available within one to two weeks, depending on the location. We have providers in clinic every day in Seattle and once a week at Seattle Children’s Bellevue Clinic and Surgery Center, Olympia Clinic and Federal Way Clinic.
If a patient with an eating disorder needs to be seen urgently, we work with the family to see the patient as soon as possible.
Proton Therapy Available for Pediatric Cancer Patients This Spring
The Seattle Cancer Care Alliance (SCCA), in partnership with ProCure, is the first in the Pacific Northwest to offer an advanced and highly precise form of radiation treatment called proton therapy. This radiation treatment more directly focuses radiation into the tumor, helping to minimize damage to surrounding tissue and reduce the risk of long-term side effects. Proton therapy is ideal for certain types of pediatric cancers such as brain tumors and neuroblastomas.
This treatment, which is currently available at only a few centers in the country, will be provided to adults and children in a new facility on the UW Medicine Northwest Hospital Campus. The center opened on March 5, but the first pediatric patients will not be treated until late spring. Seattle Children’s oncologists will supervise treatment of these patients as part of our partnership with the SCCA. To learn more, see the website.
Seattle Children’s Hospital Opened Wenatchee Clinic in February
Seattle Children’s newest regional clinic in Wenatchee opened in February. The Wenatchee Clinic provides five medical specialties – cardiology, endocrinology, neurology, orthopedics and pulmonary care – for children, teens and young adults throughout north central Washington. The clinic is staffed by the same physicians and nurses who care for patients at Children’s main hospital in Seattle.
It also offers telemedicine consultations for psychiatry and behavioral health services, where patients and their families will be able to meet virtually with their care team located at Children’s main hospital. Language interpretation is available.
Children’s Wenatchee Clinic’s office hours are from 8 a.m. to 5 p.m., Monday through Thursday. For questions, call the clinic at 509-662-9266.
The clinic joins the family of Children’s regional clinics in Bellevue, Everett, Federal Way, Mill Creek, Olympia and the Tri-Cities. For more information on regional clinics, see the list of all Children’s locations.
Building Hope Open House for Community Providers and Their Office Staff, March 14
Please join us for a tour during our special Building Hope Open House for community providers and their office staff. Coffee and a hearty continental breakfast will be served.
Date: Thursday, March 14
Time: 7 to 10 a.m.
Location: Building Hope Tent, 4800 Sand Point Way NE, Seattle, WA 98105
Please register online to attend the open house and tours.
If time permits, please also join us for our weekly Pediatric Grand Rounds CME presentation the same morning.
Time: 8 to 9 a.m.
Location: Wright Auditorium
Topic: “Transparency: Communicating About Adverse Clinical Events”
Presenter: Jeff Sconyers, JD, Senior Vice President and General Counsel, Seattle Children’s
One-Day Duncan Seminar on Cerebral Palsy, March 22
Category 2 CME credit is available for this one-day conference, “What’s New About an Old Diagnosis: Updates in the Care of Children with Cerebral Palsy.” Learning objectives include understanding new research and developments in cerebral palsy such as stem cell, neural repair and regeneration; learning about clinical practice guidelines for osteopenia management in cerebral palsy; learning to administer the Hypertonia Assessment Tool; and understanding the implications of healthcare reform on children with complex chronic conditions, including children with cerebral palsy.
To learn more and register, see Seattle Children’s outreach page.
New Combined Online and In-Person PALS Renewal Option
If you already have Pediatric Advanced Life Support (PALS) certification, you can renew your card by taking the American Heart Association HeartCode PALS Part 1 online (5 to 12 hours, depending on computer simulation skills) and Part 2 in-person course (3.5 hours).
Learn more and register for April and June courses on Seattle Children’s PALS page.
Bellevue CME: Managing Autism and Navigating Schools
Seattle Children’s Autism Center presents Dr. Felice Orlich, director of community outreach, and Jim McDonagh, pediatric mental health specialist, who will discuss diagnosing and managing autism and navigating schools. The presentation will cover individualized education plans (IEPs) and 504 plans. Free category 2 CME credit is available.
Location: Seattle Children's Bellevue Clinic and Surgery Center, 500 116th Ave. NE, Bellevue, WA 98004
Date: April 16 from 6 to 7 p.m.
Appetizers will be served.
RSVP: Please reply by Friday, April 12 to Kristy Dobrauc.
New Medical Staff and Allied Health Professionals, March 2013
Medical Staff
Titus Chan, MD, Seattle Children's, Critical Care
Ruchi Gupta, MD, Seattle Children's, Hospital Medicine
Joel Hernandez, MD, Seattle Children's, Nephrology
Jesse Knight, MD, Olympic Medical Imaging Consultants, Radiology
Brianna Label, MD, Pediatric Associates – Bellevue, Pediatrics
Emily Law, PhD, Seattle Children's, Anesthesiology and Pain Medicine
Rachel Montague, PhD, Seattle Children's, Psychiatry and Behavioral Medicine
Sahar Rooholamini, MD, MPH, Seattle Children's, Hospital Medicine
Sonia Venkatraman, PhD, Seattle Children's, Psychiatry and Behavioral Medicine
Allied Health Professionals
Jamie Carey, ARNP, Seattle Children's, Neonatology
Christine Cooper, ARNP, Seattle Children's, Neonatology
Christine Grem, ARNP, Seattle Children's, Emergency Medicine
Katherine Harrison, ARNP, Seattle Children's, Psychiatry and Behavioral Medicine