eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Diabetes Mellitus, Type 2: Follow-up

Author: Jean-Claude DesMangles, MD, Assistant Professor, Department of Pediatrics, Creighton University School of Medicine
Contributor Information and Disclosures

Updated: Jul 30, 2009

Follow-up

Further Inpatient Care

  • Unless an acute complication (eg, recurrent hypoglycemia, persistent ketosis, hyperglycemic hyperosmolar state, or poor compliance with treatment) occurs, type 2 diabetes is usually managed in an outpatient setting.

Further Outpatient Care

  • The goal of treatment is normalization of glycemia. Blood sugar monitoring should be done 2-3 times daily and more often than this when treatment is being adjusted.
  • The patient should be seen every 3 months at the diabetes clinic and more often, as necessary, when treatment adjustment being done.
  • HbA1c values should be monitored at each quarterly visit. An international expert committee, composed of appointed representatives of the American Diabetes Association, the European Association for the Study of Diabetes, and others, recommend HbA 1c assay for diagnosing diabetes mellitus.5 The committee’s recommendation to diagnose diabetes is an HbA 1c level of 6.5% or higher, with confirmation from repeat testing (unless clinical symptoms are present and glucose level is >200 mg/dL). Glucose measurement should remain the choice for diagnosing pregnant women or if HbA 1c assay is unavailable. The advantages of HbA 1c listed by the committee cite the following advantages over glucose measurement: 
    • Captures long-term glucose exposure
    • Has less biologic variability
    • Does not require fasting or timed samples
    • Is currently used to guide management decisions
  • Albuminuria and fasting lipid profile should be checked yearly.
  • Dilated eye examination should be done annually.
  • Blood pressure evaluation and careful neurologic should be performed at each clinic visit.
  • Weight loss, increased physical activity, and better food choices should be encouraged because they improve fasting lipid profile.
  • Statins may be needed to treat hypercholesterolemia.
  • Angiotensin-converting enzyme inhibitors are the agents of choice to treat hypertension and microalbuminuria.
  • Growth assessment is important.

Inpatient & Outpatient Medications

  • Oral agents
  • Insulin

Deterrence/Prevention

  • Because type 2 diabetes in children and adolescents is strongly associated with obesity and sedentary lifestyle, any intervention designed to increase physical activity and improve dietary habits should be encouraged.
  • The American Diabetes Association has established the following criteria when testing for diabetes is considered:6
    • Overweight (eg, BMI at the 85th percentile for age and sex, weight at the 85th percentile, weight 120% of ideal for height)
    • Plus any 2 of the following factors:
      • Family history of type 2 diabetes in first- or second-degree relative
      • Minority race or ethnicity (eg, American Indian, black, Hispanic, Asian or Pacific Islander)
      • Signs of insulin resistance or conditions associated with insulin resistance (eg, acanthosis nigricans, hypertension dyslipidemia, PCOS)
  • Recommendations for screening are as follows?
    • Initial screening may begin at age 10 years or at onset of puberty if puberty occurs at a young age.
    • Screening should be performed every 2 years.
    • A fasting plasma glucose test is the preferred screening study.
  • In children who do not meet the criteria described above but in whom diabetes is highly suspected, clinical judgment should be applied.

Complications

  • Although the natural history of type 2 diabetes mellitus in children is not well studied, the experience accumulated over years of treating adults may help minimize the occurrence of complications in children.
  • Acute complications of type 2 diabetes include hyperglycemia, diabetic ketoacidosis, hyperglycemic-hyperosmolar state, and hypoglycemia.
  • Complications from insulin resistance include hypertension, dyslipidemia, and PCOS.
  • As many as 4% of patients with type 2 diabetes initially present in a hyperglycemic-hyperosmolar coma, which is potentially fatal if not recognized and treated promptly.
  • Long-term complications include the following:
    • Nephropathy
    • Neuropathy
    • Retinopathy
    • Coronary artery disease

Prognosis

  • After 30 years of postpubertal diabetes, 44.4% of people with type 2 and 20.2% of people with type 1 diabetes develop diabetic nephropathy. Overall, the incidence of nephropathy has declined among patients with type 1 diabetes in the past 20 years; however, it has not for those with type 2.
  • So far, no population-based follow-up study has been conducted to determine the long-term prognosis of type 2 diabetes among children and adolescents. It can be supposed that mortality rates and standardized mortality ratios in type 2 diabetes would be higher than those in type 1 diabetes, given that the major cause of death in type 1 diabetes is end-stage renal disease.

Patient Education

  • Education is an essential component of the treatment plan; it is a continuing process involving the child, family, and all members of the diabetes team. The following strategies may be employed:
    • Appropriate teaching of survival skills at diagnosis
    • Explanation and discussion about the possible causes of type 2 diabetes
    • Discussion about the need for blood glucose monitoring and importance of compliance with drug regimen
    • Practical skills training

      • Insulin injections (if insulin is part of the treatment plan)
      • Blood and/or urine testing for ketone bodies
      • Hypoglycemia recognition and treatment
      • Emergency telephone contact procedure
      • Psychosocial adjustment to the diagnosis
      • Importance of regular follow-up
      • Basic dietary advice
  • Diabetes education is an ongoing continuous process and should address the following issues.
    • Formal education during clinic visits or during diabetes classes
    • Educational holidays and camps
    • Support groups
    • Complications: Use times of crisis or acute complications as opportunities to reinforce the importance of some aspects of self-diabetes management that may have been neglected.
  • For excellent patient education materials see the eMedicine articles Obesity in Children and Diabetes and for more information on diabetes see the Diabetes Center. All these materials may be printed free of charge.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize and treat hypoglycemia
  • Failure to look for and recognize potential complications (eg, nephropathy, retinopathy) of type 2 diabetes
  • Failure to educate the patient about potential side effects of oral hypoglycemic agents (eg, presence of ketonuria or of any condition predisposing to the accumulation of lactate in patients on metformin)
  • Failure to promptly recognize and treat hyperglycemic hyperosmolar state can eventually lead to cerebral edema and death

Special Concerns

  • Sexual health
    • Provide advice about contraception.
    • Provide advice about genital hygiene, sexually transmitted diseases, and fungal infections.
  • Pregnancy
    • Emphasize the importance of good glycemic control before and during pregnancy.
    • Discuss the effect of maternal diabetes on the fetus.
    • Recognized that, in patients with PCOS who are receiving metformin, possible resumption of normal ovulation and menstrual cycles increases the risk of pregnancy
    • Transfer care to an obstetrician when pregnancy is established.
 


More on Diabetes Mellitus, Type 2

Overview: Diabetes Mellitus, Type 2
Differential Diagnoses & Workup: Diabetes Mellitus, Type 2
Treatment & Medication: Diabetes Mellitus, Type 2
Follow-up: Diabetes Mellitus, Type 2
References
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References

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Further Reading

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Keywords

diabetes mellitus type 2, type 2 diabetes mellitus, NIDDM, non–insulin-dependent diabetes mellitus, adult-onset diabetes mellitus, type 2 diabetes mellitus, insulin resistance, type 2 diabetes, diabetes, type 2 diabetes in children

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Contributor Information and Disclosures

Author

Jean-Claude DesMangles, MD, Assistant Professor, Department of Pediatrics, Creighton University School of Medicine
Jean-Claude DesMangles, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Bone and Mineral Research, and Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Arlan L Rosenbloom, MD, Adjunct Distinguished Service Professor Emeritus of Pediatrics, University of Florida; Fellow of the American Academy of Pediatrics; Fellow of the American College of Epidemiology
Arlan L Rosenbloom, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Epidemiology, American Pediatric Society, Endocrine Society, Florida Pediatric Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London), Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece
George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD, Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's Hospital
Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Genentech, Inc. Honoraria Speaking and teaching; Pfizer, Inc. Honoraria Consulting

 
 
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