1
|
White B, Ng SM, Agwu JC, Barrett TG, Birchmore N, Kershaw M, Drew J, Kavvoura F, Law J, Moudiotis C, Procter E, Paul P, Regan F, Reilly P, Sachdev P, Sakremath R, Semple C, Sharples K, Skae M, Timmis A, Williams E, Wright N, Soni A. A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus. BMC Med 2024; 22:144. [PMID: 38561783 PMCID: PMC10986054 DOI: 10.1186/s12916-024-03349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.
Collapse
Affiliation(s)
- Billy White
- University College London Hospitals NHS Foundation Trust, London, UK
| | - S M Ng
- Mersey And West Lancashire Teaching Hospitals NHS Trust, Ormskirk, UK
| | - J C Agwu
- Wye Valley NHS Trust, Hereford, UK
| | - T G Barrett
- Birmingham Women's And Children NHS Foundation Trust, Birmingham, UK
| | - N Birchmore
- Great Ormond Street Hospital For Children, NHS Foundation Trust, London, UK
| | - M Kershaw
- Birmingham Women's And Children NHS Foundation Trust, Birmingham, UK
| | - J Drew
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - F Kavvoura
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | - J Law
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - C Moudiotis
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - E Procter
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - P Paul
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - F Regan
- Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - P Reilly
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - P Sachdev
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - R Sakremath
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - C Semple
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - M Skae
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - A Timmis
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - E Williams
- Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - N Wright
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, S102TH, UK
| | - A Soni
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, S102TH, UK.
| |
Collapse
|
2
|
Gubitosi-Klug RA, Bebu I, White NH, Malone J, Miller R, Lorenzi GM, Hainsworth DP, Trapani VR, Lachin JM, Tamborlane WV. Screening eye exams in youth with type 1 diabetes under 18 years of age: Once may be enough? Pediatr Diabetes 2019; 20:743-749. [PMID: 31206973 PMCID: PMC7217664 DOI: 10.1111/pedi.12877] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/11/2019] [Indexed: 01/25/2023] Open
Abstract
Case series and registry data suggest that diabetic retinopathy requiring treatment is rare in youth with type 1 diabetes (T1D) prior to 18 years of age. We evaluated this question in the standardized clinical trial setting by retrospectively reviewing diabetic retinopathy examinations from participants in the Diabetes Control and Complications Trial (DCCT) who were 13 to <18 years of age at randomization. Standardized stereoscopic 7-field fundus photographs were obtained every 6 months during DCCT (1983-1993). Photographs were graded centrally using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Transitions in diabetic retinopathy status over time were described. A total of 195 participants with median baseline glycated hemoglobin (HbA1c) of 9.3% (103 in the conventional and 92 in the intensive treatment groups) had an average of 5.3 diabetic retinopathy assessments during 2.3 years of follow-up (range 1-11) while under 18 years of age during the DCCT. No participant developed severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy and only one participant (in the intensive group) reached clinically significant macular edema (CSME) while less than 18 years of age. In this incident case, baseline characteristics included diabetes duration 9.3 years, HbA1c 10.3%, LDL 131 mg/dL, and mild non-proliferative diabetic retinopathy (35/35 ETDRS scale); CSME resolved without treatment. Similar analyses using age cut-offs of <19, 20, or 21 years showed a slight rise in diabetic retinopathy requiring treatment over late adolescence. Clinical trial evidence suggests that frequent eye exams may not be universally necessary in youth <18 years of age with T1D.
Collapse
Affiliation(s)
| | - Ionut Bebu
- George Washington University, Rockville, MD
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Carvalho KS, Grunwald T, De Luca F. Neurological Complications of Endocrine Disease. Semin Pediatr Neurol 2017; 24:33-42. [PMID: 28779864 DOI: 10.1016/j.spen.2016.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The endocrine system is a complex group of organs and glands that relates to multiple other organs and systems in the body with the ultimate goal of maintaining homeostasis. This complex network functions through hormones excreted by several glands and released in the blood, targeting different body tissues and modulating their function. Any primary disorders affecting the endocrine glands and altering the amount of hormones synthesized and released will lead to disruption in the functions of multiple organs. The central nervous system of a developing child is particularly sensitive to endocrine disorders. A variety of neurological manifestations have been described as features of several endocrine diseases in childhood. Their knowledge may contribute to an early diagnosis of a particular endocrine condition, especially when more typical features are not present yet. In this article, we discuss specific neurological manifestations found in various endocrine disorders in children.
Collapse
Affiliation(s)
- Karen S Carvalho
- From the Section of Neurology, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA.
| | - Tal Grunwald
- Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA
| | - Francesco De Luca
- Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA
| |
Collapse
|
4
|
Diagnosis of retinopathy in children younger than 12 years of age: implications for the diabetic eye screening guidelines in the UK. Eye (Lond) 2016; 30:949-51. [PMID: 27080488 DOI: 10.1038/eye.2016.59] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/10/2016] [Indexed: 11/08/2022] Open
Abstract
AimTo assess whether the current starting age of 12 is suitable for diabetic retinopathy (DR) screening and whether diabetes duration should be taken into account when deciding at what age to start screening patients.Materials and methodsA retrospective analysis of 143 patients aged 12 years or younger who attended diabetic eye screening for the first time in the Birmingham, Solihull and Black Country Diabetic Eye Screening Programme was performed.ResultsThe mean age of the patients was 10.7 (7-12) years with 73 out of 143 aged below 12 years and 70 were 12 years of age. 98% had type 1 diabetes and mean diabetes duration was 5 (1 month-11 years) years. For those younger than 12 years, 7/73 (9.6%) had background DR (BDR), of these mean diabetes duration was 7 years (6-8). The youngest patient to present with DR was aged 8 years. In those aged 12 years, 5/70 (7.1%) had BDR; of these mean diabetes duration was 8 years (6-11). No patient developed DR before 6 years duration in either group.ConclusionsThe results show that no patient younger than the age of 12 had sight-threatening DR (STDR), but BDR was identified. Based on the current mission statement of the Diabetic Eye Screening Programme to identify STDR, 12 years of age is confirmed as the right age to start screening, but if it is important to diabetic management to identify first development of DR, then screening should begin after 6 years of diabetes diagnosis.
Collapse
|
5
|
Geloneck MM, Forbes BJ, Shaffer J, Ying GS, Binenbaum G. Ocular Complications in Children with Diabetes Mellitus. Ophthalmology 2015; 122:2457-64. [PMID: 26341461 DOI: 10.1016/j.ophtha.2015.07.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The effectiveness of annual eye examinations in diabetic children is unclear. We sought to determine the prevalence and onset of ocular pathology in children with diabetes mellitus (DM), identify risk factors for ocular disease, and recommend a screening regimen for asymptomatic children. DESIGN Retrospective, consecutive cohort study. PARTICIPANTS Children aged less than 18 years with type 1 or 2 DM examined over a 4-year period. METHODS All children underwent a complete eye examination, including dilated fundoscopy and cycloplegic refraction. A literature review was performed, identifying the youngest reported age and shortest reported duration of DM before the diagnosis of diabetic retinopathy (DR). MAIN OUTCOME MEASURES Prevalence of DR, cataract, high refractive error, and strabismus. RESULTS A total of 370 children (mean age, 11.2 years; range, 1-17.5 years) had 693 examinations, with a mean DM duration of 5.2 years (range, 0.1-16.2 years) and a mean hemoglobin A1c (HbA1c) of 8.6 (range, 5-≥14). No children had DR. A total of 12 children had cataract; 5 required extraction but were identified by decreased vision, not diabetic screening. A total of 19 children had strabismus; only 1 was microvascular paralytic strabismus. A total of 41 children had high refractive error. There were no associations between these conditions and duration or control of DM. In the literature, the youngest age at diagnosis of severe DR was 15 years, and the shortest duration of disease was 5 years. CONCLUSIONS Diabetic retinopathy is rare in children regardless of duration and control of DM. On the basis of our study and literature review, screening examinations for type 1 diabetes could begin at age 15 years or at 5 years after the diagnosis of DM, whichever occurs later, unless the child is judged by the endocrinologist as being at unusually high risk. Other ocular complications are identifiable through existing amblyopia screening methods.
Collapse
Affiliation(s)
- Megan M Geloneck
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian J Forbes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James Shaffer
- Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gui-shuang Ying
- Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
6
|
Abstract
In this article, the author reviews the long-term outcomes and their precursors of type 1 diabetes starting in youth. The author also contrasts the changing incidence of these long-term complications as we have moved from the pre-Diabetes Control and Complications Trial (DCCT) to the post-DCCT standard of care and reviews the emerging data related to complications in youths with type 2 diabetes. Finally, the author reviews the recent understanding related to the effects of diabetes on the brain and cognition.
Collapse
Affiliation(s)
- Neil H White
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Box 8116, St Louis, MO 63110, USA.
| |
Collapse
|
7
|
Kolomeyer AM, Nayak NV, Simon MA, Szirth BC, Shahid K, Sheng IY, Xia T, Khouri AS. Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus. J Pediatr Ophthalmol Strabismus 2014; 51:299-306. [PMID: 25020279 DOI: 10.3928/01913913-20140709-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 04/28/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy. METHODS Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement. RESULTS One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896. CONCLUSIONS The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.
Collapse
|
8
|
Moore DJ, Gregory JM, Kumah-Crystal YA, Simmons JH. Mitigating micro-and macro-vascular complications of diabetes beginning in adolescence. Vasc Health Risk Manag 2009; 5:1015-31. [PMID: 19997571 PMCID: PMC2788594 DOI: 10.2147/vhrm.s4891] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Indexed: 01/26/2023] Open
Abstract
Diabetes is a chronic disorder, which manifests when insulin levels or resistance to insulin action becomes insufficient to control systemic glucose levels. Although the number of available agents to manage diabetes continues to expand rapidly, the maintenance of euglycemia by individuals with diabetes remains a substantial challenge. Unfortunately, many patients with type 1 and type 2 diabetes will ultimately experience diabetes complications. These complications result from the toxic effects of chronic hyperglycemia combined with other metabolic derangements that afflict persons with diabetes. This review will present a comprehensive look at the complications of diabetes, the risk factors for their progression, the mechanistic basis for their development, and the clinical approach to screening for, preventing, and treating these sequelae. In addition, since diabetes is commonly diagnosed in childhood, we will provide a special focus on the care of the adolescent patient.
Collapse
Affiliation(s)
- Daniel J Moore
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt Children's Hospital, Nashville, TN 37232-9170, USA
| | | | | | | |
Collapse
|
9
|
|
10
|
Yilmaz Ovali G, Ersoy B, Tuncyurek O, Urk V, Ozkol M, Ozhan B, Baser E, Pabuscu Y. Doppler ultrasonography imaging of hemodynamic alteration of retrobulbar circulation in type 1 diabetic children and adolescents without retinopathy. Diabetes Res Clin Pract 2008; 79:243-8. [PMID: 17950483 DOI: 10.1016/j.diabres.2007.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Accepted: 09/05/2007] [Indexed: 01/18/2023]
Abstract
AIM We aimed to investigate the retrobulbar blood circulation using Colour Doppler Imaging (CDI) in type 1 diabetic children and adolescents who had no diabetic retinopathy and to compare the results with their healthy peers. METHODS Forty-nine patients with type 1 diabetes mellitus with no retinopathy on fundoscopic examination were included in the study. Forty-nine healthy children were defined as the control group. Central retinal artery (CRA), ophthalmic artery (OA) and posterior ciliary artery (PCA) were examined with Doppler US bilaterally. Peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive indices (RI) for each artery were recorded. RESULTS Blood flow velocity of the OA was significantly different in diabetic patients (p<0.05). EDV of the OA was significantly higher (p=0.011) and RI was significantly lower (p=0.027) in patients with diabetes duration of longer than 5 years. RI of the CRA was significantly higher in patients who had higher microalbuminuria levels (p=0.016). CONCLUSION EDV of the OA increases and RI of the OA decreases in diabetes duration longer 5 years. Raised AER increases RI of the CRA. These findings may be the initial changes in the arterial circulation before vascular rigidity develops.
Collapse
Affiliation(s)
- Gulgun Yilmaz Ovali
- Celal Bayar University, School of Medicine, Department of Radiology, Manisa, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Stefánsson E. Risk of retinopathy in children with type 1 diabetes mellitus before two years of age. Am J Ophthalmol 2006; 141:979; author reply 979. [PMID: 16678530 DOI: 10.1016/j.ajo.2005.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 12/29/2005] [Indexed: 10/24/2022]
|