There is an increased incidence of Type 2 Diabetes Mellitus in the pediatric age group. It now exceeds Type1 and appears to be increasing.

Definition

Type 1 Diabetes- Absolute insulin deficiency often associated with autoimmune disease

Type 2 Diabetes- There is insulin resistance and relative insulin deficiency

Epidemiology-Associated with an increase incidence of childhood obesity and physical inactivity

Pathogenesis

1. Insulin resistance leads to hyperinsulinism to compensate. This may occur long before the diagnosis of Type 2 Diabetes is made. Hyperinsulinism is associated with hypertension, lipid abnormalities, and acanthosis nigricans.

2. There is associated decrease uptake of glucose by muscle tissue and increased glucose production by the liver

3. Eventually, the pancreas beta cells are unable to produce enough insulin to maintain normal glucose levels.

Diagnosis

1. The presentation is usually more indolent than Type 1 and increased levels of glucose may be picked up on routine screening with the presence of glucosuria. There may be mild polyuria and polydypsia.

2. Uncommonly may present with ketoacidosis (5-25%)

3. Guidelines for testing for type 2 diabetes in children ( >85% BMI, weight> 120% ideal weight for height, or weight for height >85%) plus 2 of the following risk factors:

     a. Positive family history for Type 2 Diabetes in a first or second degree relative (45-80%)

     b. American-Indian, African-American, Hispanic, or Asian/Pacific Islander

     c. Signs of insulin resistance

          i. Acanthosis nigricans

         ii. Hypertension

        iii. Dyslipediemia

        iv. Polycystic ovary syndrome

4. Fasting glucose > 126mg.dL This is the preferred method of screening.

5. 2 hour post prandial glucose after glucose challenge of > 200mg/dL

6, Evaluate blood lipids and cholesterol

Complications

1. Visual loss

2. Renal failure

3. Microvascular disease

4. Neuropathy

5. Cardiovascular disease

Management

1. May initially require insulin therapy

2. Oral agents to stimulate insulin production (Sulfonylureas)

3. Weight loss

4. Increase physical activity

5. Good diet

6. Biguanides- Decrease hepatic glucose production and enhance hepatic and muscle tissue insulin sensitivity

7. Thiazolidenediones- increase insulin sensitivity

8. Glucosidase inhibitors- decreases GI absorption of glucose.

Goals of Therapy

1. Improvement of glycemic control through weight reduction and increased activity has been associated with decreased insulin resistance and reversal of complications.

2. HbA1C < 7%

3. Fasting glucose 90-130 mg/dL

4. Post-prandial glucose < 180mg/dL

5. Frequent eye examinations

6. Control hypertension

7. Treat hyperlipedemias

References

1. Nesmith J. Darrell. Type 2 Diabetes Mellitus in children and Adolescents. Pediatrics in Review May 2001

2. Nathan DM. Initial Management of Type 2 Diabetes Mellitus NEJM Vol. 347 No. 17 October 24, 2002

3. American Diabetes Association. Type 2 Diabetes in Children and Adolescents. Pediatrics Vol. 105 No. 3 March 2000

4. Dunger et.al Diabetic Ketoacidosis: Consensus Statement.Pediatrics 2004;113:e133