Monitoring
Type 2 diabetes mellitus (T2DM) is a progressive disorder. Optimal care requires control of blood glucose, blood pressure, lipids, haemoglobin A1c (HbA1c), and smoking habits. Achieving a HbA1c target of <7% has been shown to reduce microvascular complications.[1] Most children will require follow-up every 3 to 4 months.
The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends a fasting plasma glucose target of 4-6 mmol/L (70-110 mg/dL); a postprandial blood glucose target of 4-8 mmol/L (70-140 mg/dL); and an HbA1c target of <7% or in most cases <6.5%.[66] Once glycaemic goals have been achieved, frequency of home testing should be individualised according to treatment regimen and HbA1c value, and include a combination of fasting and postprandial glucose measurements.[66]
Routine self-monitoring of blood glucose may not be needed as frequently as with type 1 diabetes mellitus. However, frequent monitoring may be needed during periods of acute illness, during dosage adjustment, with symptoms that indicate hyper- or hypoglycaemia, or if glycaemic values consistently rise out of the target range.[66] Children and adolescents on insulin (or sulfonylureas) need to use self-monitoring blood glucose more frequently to monitor for asymptomatic hypoglycaemia, particularly at night.[66]
The American Diabetes Association recommends that real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered to children and adolescents with type 2 diabetes who are on multiple daily injections, or insulin pumps, and who are capable of using the device safely (either by themself or with a carer).[1] The Endocrine Society recommends using real-time continuous glucose monitoring for patients with type 2 diabetes who take insulin (and/or sulfonylureas) and are at risk of hypoglycaemia.[86] Hypoglycaemia unawareness, or one or more episode(s) of level 3 hypoglycaemia, should trigger hypoglycaemic avoidance education and re-evaluation and adjustment of the treatment plan to decrease hypoglycaemia.[1] Glucagon should be prescribed for all patients at increased risk of level 2 or 3 hypoglycaemia, and used on an as needed basis. Carers, school personnel, or family members providing support to children should know where it is and should be advised when and how to administer it.[1]
Patients undergoing surgery should, ideally, be in optimal diabetic control before an elective surgery or a major procedure.[106]
Metformin should be discontinued 24 hours before surgery, if possible.
Adequate hydration with intravenous fluids before, during, and after the procedure is essential.
Sulfonylureas or thiazolidinediones can be discontinued on the day of the surgery.
Patients on insulin should have close blood glucose monitoring and treatment with intravenous insulin if the blood glucose >10 mmol/L (180 mg/dL), or subcutaneous insulin for a minor surgery.
Assessments of glycaemic status (e.g., HbA1c concentration) should be done at least twice a year, and at least every 3 months if metabolic control is unsatisfactory or requires treatment adjustment.[1] In addition, the following periodic monitoring for complications is advised, with repeat testing more frequently if abnormality is detected:[1]
Blood pressure examination at every follow-up visit. Ambulatory blood pressure monitoring should be strongly considered if blood pressure is high (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥120/80 mmHg) on three separate measurements
Screen for symptoms of sleep apnoea at every follow-up visit. Referral to a sleep specialist for evaluation and a polysomnogram may be indicated in the presence of symptoms
Dilated fundoscopy at diagnosis and annually thereafter in most patients. Examination every 2 years may be appropriate if glycaemic targets are met and the previous eye exam is normal
Assessment of renal function with a test for urine albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) at diagnosis and annually thereafter. Referral to a specialist is warranted in the presence of worsening albumin-to-creatinine ratio or a decrease in eGFR
Blood lipids at diagnosis and annually thereafter
Neuropathy evaluation at diagnosis and annually thereafter. Involves inspection of the feet, assessment of foot pulses, pinprick and 10 g monofilament sensation tests, testing of vibration sensation using a 128 Hz tuning fork, and ankle reflex tests
Assessment for metabolic dysfunction-associated steatotic liver disease (formerly called non-alcoholic fatty liver disease) through measurement of aspartate transaminase and alanine aminotransferase levels at diagnosis and annually thereafter. Referral to a gastroenterologist should be considered for persistently elevated or worsening transaminases.
Polycystic ovary syndrome: female adolescents with T2DM should be evaluated for polycystic ovary syndrome symptoms at diagnosis and at subsequent reviews, with laboratory studies, where indicated.[1]
Psycho-social assessment is important; at diagnosis and during routine follow-up care, screen for psycho-social issues and family stressors which might impact negatively on diabetes management, such as diabetes distress, depressive symptoms, disordered eating, family factors, and behavioural health concerns. Refer to a trained mental health professional (preferably one experienced in childhood diabetes) as required for further assessment and treatment.[1] Specific screening for psycho-social and diabetes related distress is recommended from around the age of 7-8 years.[1] Developmentally appropriate family involvement in diabetes management tasks for children and adolescents should be encouraged, as premature or unsupportive transfer of diabetes care responsibility to the youth can contribute to diabetes distress, lower engagement in diabetes self management behaviours, and deterioration in glycaemia.[1]
Starting at puberty, pre-conception counselling should be incorporated into routine diabetes clinic visits for all individuals of childbearing potential according to the ADA, because of the adverse pregnancy outcomes in this population.[1] Ensure that all adolescents of childbearing potential who are using potentially teratogenic treatments (e.g., ACE inhibitors or angiotensin receptor blockers) are aware of the teratogenic effects of their treatment(s), and that they are using reliable contraception.[1]
Use of this content is subject to our disclaimer