What are the diagnostic criteria for diabetes mellitus (DM) in pediatric patients?

From the Guidelines

Testing for diabetes in pediatrics should begin with screening high-risk children, including those who are overweight with additional risk factors such as family history, signs of insulin resistance, or certain ethnic backgrounds, using the fasting plasma glucose (FPG) as the primary test, with values ≥126 mg/dL indicating diabetes, as recommended by the most recent guidelines 1. The diagnostic process for diabetes in children can be challenging due to the overlap of symptoms between type 1 and type 2 diabetes, and the increasing prevalence of obesity in the pediatric population, which is a major risk factor for type 2 diabetes 2, 1. Key considerations in the diagnostic approach include:

• The use of FPG, with a threshold of ≥126 mg/dL for diagnosis, as the primary diagnostic test 1, 3.
• The role of oral glucose tolerance tests (OGTT) and HbA1c in the diagnostic process, with HbA1c ≥6.5% being a less reliable but still useful indicator of diabetes in children 2, 4.
• The importance of distinguishing between type 1 and type 2 diabetes, given the differences in treatment approaches and outcomes between the two conditions 2, 1.
• The need for immediate referral to pediatric endocrinology for management of confirmed diabetes, which may include insulin therapy for type 1 diabetes or lifestyle modifications and possibly metformin for type 2 diabetes 2, 1. Early detection and accurate diagnosis of diabetes in children are critical to prevent complications such as diabetic ketoacidosis and to improve long-term outcomes, highlighting the importance of a thorough and evidence-based approach to testing and diagnosis 2, 1.

From the Research

Diagnostic Tests for Diabetes in Pediatrics

• The most suitable diagnostic test for risk-based screening of prediabetes and type 2 diabetes in children and adolescents with overweight or obesity is still a matter of debate 5.
• Currently recommended screening tools include fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), and glycated hemoglobin A1c (HbA1c) 5.
• The advantages and disadvantages of each test should be considered, as well as the possibility of performing different tests at once 5.

Screening Practices in Pediatric Clinicians

• A study found that most pediatric clinicians reported type 2 diabetes screening practices that differed from current American Diabetes Association (ADA) recommendations 6.
• The study suggested that type 2 diabetes screening tests must be practical for clinicians and patients if they are to be used in pediatric practice 6.
• Further study of the benefits and cost-effectiveness of type 2 diabetes screening in children is warranted to clarify the role and optimal methods for screening in pediatric primary care 6.

Diagnostic Rate of Diabetes

• A study evaluated the diagnostic rate of diabetes using FPG, 2-hour plasma glucose (2h PG) after 75 g OGTT, and HbA1c levels 7.
• The study found that the rate of diabetes diagnosis by one of the individual criteria was 56.7%, 53.6%, and 84.5% for FPG, HbA1c, and 2h PG, respectively 7.
• The study suggested that performing additional OGTT for patients with FPG ≥110 mg/dL or HbA1c ≥6.1% is helpful to reclassify their glucose tolerance status and evaluate their potential for progressing to overt diabetes 7.

Accuracy of 1-Hour Plasma Glucose

• A meta-analysis found that 1-hour plasma glucose (1-h PG) during the OGTT is an accurate predictor of type 2 diabetes 8.
• The study determined the optimal 1-h PG threshold and its accuracy at this cutoff for detection of diabetes (2-h PG ≥11.1 mmol/L) 8.
• The study suggested that prescreening with a diabetes-specific risk calculator to identify high-risk individuals is suggested to decrease the proportion of false-positive cases 8.

Treatment and Management

• Treatment of type 2 diabetes in pediatric patients usually begins with dietary modification, weight loss, and a structured program of physical exercise 9.
• Oral antidiabetic agents are added when lifestyle intervention alone fails to maintain glycemic control 9.
• Insulin therapy is often required, and improved glycemic control and reduced frequency of hypoglycemia can be achieved with insulin analogs 9.