What investigations are recommended for pediatric diabetes diagnosis and management?

Recommended Investigations for Pediatric Diabetes Diagnosis and Management

For accurate diagnosis and optimal management of pediatric diabetes, comprehensive laboratory and clinical investigations are essential, with fasting plasma glucose, 2-hour glucose tolerance test, and A1C being the primary diagnostic tests for both type 1 and type 2 diabetes in children and adolescents. 1

Diagnostic Investigations

Initial Diagnosis

• Fasting plasma glucose, 2-h plasma glucose during a 75-g oral glucose tolerance test, and A1C can be used to test for prediabetes or diabetes in children and adolescents 1
• For suspected type 2 diabetes in children with overweight/obesity, a panel of pancreatic autoantibodies should be tested to exclude autoimmune type 1 diabetes 1
• In children with clinical features of type 2 diabetes (obesity, acanthosis nigricans), testing for diabetes-associated autoantibodies is crucial as these may be present despite type 2 phenotype 1

Risk-Based Screening

• Risk-based screening for prediabetes/type 2 diabetes should be considered after puberty onset or ≥10 years of age (whichever occurs earlier) in youth with:
  • BMI ≥85th percentile (overweight) or ≥95th percentile (obesity) 1
  • One or more additional risk factors for diabetes 1
• If screening is normal, repeat at minimum 3-year intervals, or more frequently if BMI is increasing 1

Monitoring and Management Investigations

Glycemic Control Monitoring

• A1C testing every 3 months to assess glycemic status 1
• Blood glucose monitoring should be individualized based on pharmacologic treatment 1
• Real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered for diabetes management in youth capable of using the device safely 1

Complication Screening for Type 1 Diabetes

Nephropathy

• Albumin-to-creatinine ratio screening should begin at:
  • Puberty or ≥10 years old (whichever is earlier) AND
  • After 5 years of diabetes duration 1
• If normal, repeat annually; if abnormal, confirm with two additional samples over 6 months 1

Retinopathy

• Initial dilated and comprehensive eye examination once youth have had type 1 diabetes for 3-5 years, provided they are ≥10 years or puberty has started (whichever is earlier) 1
• After initial examination, repeat every 2 years; less frequent examinations (every 4 years) may be acceptable with A1C <8% and eye care professional's advice 1

Neuropathy

• Annual comprehensive foot exam at the start of puberty or age ≥10 years (whichever is earlier), once the youth has had type 1 diabetes for 5 years 1
• Examination should include inspection, assessment of foot pulses, pinprick, 10-g monofilament sensation tests, vibration sensation using 128-Hz tuning fork, and ankle reflex tests 1

Cardiovascular Risk

• Blood pressure measurement at every routine visit 1
• Lipid profile screening starting at age 10, then every 3 years if normal 1

Autoimmune Conditions

• Test for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis 1
• Measure thyroid-stimulating hormone at diagnosis when clinically stable or after optimizing glycemia 1
• Screen for celiac disease by measuring IgA tissue transglutaminase antibodies with documentation of normal total serum IgA levels soon after diagnosis 1
• If IgA deficient, test IgG tissue transglutaminase and deamidated gliadin antibodies 1
• Repeat celiac screening within 2 years of diagnosis and then after 5 years 1

Complication Screening for Type 2 Diabetes

• Similar monitoring for nephropathy, retinopathy, neuropathy as type 1 diabetes 1
• Additional considerations for type 2 diabetes in youth:
  • Screening for polycystic ovarian syndrome in female adolescents 1
  • Liver function tests (AST/ALT) at diagnosis and follow-up visits 1
  • Screening for obstructive sleep apnea 1

Diagnostic Challenges

• Distinguishing between type 1 and type 2 diabetes in children can be difficult due to:
  • Increasing prevalence of obesity in children with type 1 diabetes 1
  • Presence of diabetes-associated autoantibodies and ketosis in patients with clinical features of type 2 diabetes 1
  • Diabetic ketoacidosis occurring in approximately 6% of youth with type 2 diabetes 1
  • Type 2 diabetes occasionally presenting in prepubertal children under age 10 1

Treatment Monitoring Considerations

• For patients on metformin: A pediatric clinical study showed significant reduction in fasting plasma glucose (-42.9 mg/dL vs. +21.4 mg/dL with placebo) in children aged 10-16 years with type 2 diabetes 2
• For patients on insulin: Regular monitoring of blood glucose levels is essential for dose adjustments, with pediatric studies showing similar HbA1c reductions with insulin detemir compared to NPH insulin 3

Complications to Monitor

• Hypoglycemia: One of the most common emergencies in pediatric patients with diabetes requiring prompt recognition and management 4
• Hyperglycemic hyperosmolar state (HHS): A rare but serious complication in pediatric patients with type 2 diabetes that requires early recognition of hyperosmolality for appropriate diagnosis and treatment 5

Age-Specific Considerations

• Different age groups face unique challenges in diabetes management that may affect monitoring requirements and treatment adherence 6
• Comprehensive diabetes self-management education should be provided to all youth with diabetes and their families, with content tailored to the specific type of diabetes and cultural considerations 1