Review of literature on management of diabetes mellitus

Nonalcoholic fatty liver disease: Baseline aspartate aminotransferase and alanine aminotransferase concentrations should be obtained, especially if treatment with lipid-lowering drugs is instituted.


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Referral to a pediatric or internal medicine gastroenterologist may be indicated. Obstructive sleep apnea: The diagnosis of obstructive sleep apnea can only be made reliably by using a sleep study. If the diagnosis is made, an electrocardiogram and possibly an echocardiogram should be obtained to rule out right ventricular hypertrophy.

Diabetes mellitus (type 1, type 2) & diabetic ketoacidosis (DKA)

Referral to a pediatric cardiologist, internal medicine cardiologist, or sleep specialist may be indicated. Orthopedic problems: These comorbidities especially slipped capital femoral epiphysis and Blount disease require immediate referral to a specialist in orthopedics and will limit the physical activity that can be prescribed to the individual. The clinical practice guidelines do not present any evidence-based recommendations for the use of complementary and alternative medicine CAM to treat T2DM in children and adolescents.

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Limited data are available on CAM, and none is specific to this age group. However, noting that adult patients with diabetes are 1. One multicenter study conducted in Germany found that, among families with a T1DM diagnosis, Many forms of CAM are used because of patient-perceived inadequacies of current treatments. Common supplements used by individuals with diabetes include aloe, bitter melon, chromium, cinnamon, fenugreek, ginseng, gymnema, and nopal.

Adverse effects from dietary supplements can include gastrointestinal discomfort, hypoglycemia, favism, insomnia, and increased blood pressure. In addition to dietary supplements, patients may use forms of CAM that include prayer, acupuncture, massage, hot tub therapy, biofeedback, and yoga. The clinical practice guideline that this technical report accompanies provides evidence-based recommendations on the management of patients between 10 and 18 years of age who have been diagnosed with T2DM.

The document does not pertain to patients with impaired glucose tolerance, isolated insulin resistance, or prediabetes, nor does it pertain to obese but nondiabetic youth. It emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. The clinical practice guideline addresses situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM.

It suggests integrating lifestyle modifications ie, diet and exercise in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring HbA1c and finger-stick BG concentrations are presented. These recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated.

Richard N.

Shelley C. Stephen J. Vidhu V. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care.

Variations, taking into account individual circumstances, may be appropriate.

Pediatric type 2 diabetes mellitus complications: a systematic review of the literature

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Possible hearing implications of diabetes mellitus: a literature review

Moore , Greg E. Prazar , Terry Raymer , Richard N. Shiffman , Vidhu V. Thaker , Meaghan Anderson , Stephen J. Spann and Susan K. This article has a correction. Please see: Springer et al. Download PDF.

Abstract OBJECTIVE: Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus T2DM , which previously was not typically seen until much later in life. Statement of the Issue Over the last 3 decades, type 2 diabetes mellitus T2DM , a disease previously confined to adult patients, has markedly increased in prevalence among children and adolescents.

Although there are no pediatric studies evaluating this issue, the committee believes that this improved access to care might result in: Reduced wait times and increased timeliness of care. Composition of the Committee The ad hoc multidisciplinary committee was cochaired by 2 pediatric endocrinologists pre-eminent in their field and included experts in general pediatrics, family medicine, nutrition, Native American health, epidemiology, and medical informatics.

Overweight: BMI between 85th and 94th percentile for age and gender. Formulation and Articulation of the Question Addressed by the Committee The committee first formulated explicit questions for which evidence would be queried by the epidemiologist. Methods Primary Literature Search: Treatment of T2DM The committee unanimously agreed on the objectives of the guideline and scope of the evidence search. Secondary Literature Search: Comorbidities of T2DM After completion of the primary literature review, at the request of the committee, a second literature review was conducted to identify evidence relating to screening, diagnosis, and treatment of comorbidities of T2DM in children and adolescents.

Analysis of Available Evidence A strict evidence-based approach was used to extract data used to develop the recommendations presented in the accompanying clinical practice guideline. Level 2A: Systematic review with homogeneity of cohort studies. Level 3B: Individual case-control studies. View this table: View inline View popup. Recommended Key Action Statements After considering the available levels of evidence and grades of recommendations, the committee formulated several recommended key action statements, published in the companion clinical practice guideline.

Rejected Articles Of the articles meeting search criteria, were rejected, categorized as follows: Comorbidities: 69 studies. Medical treatment: 99 articles. Nonmedical treatment: 16 articles. Social issues: 12 articles. Provider behaviors: 3 articles. Secondary Literature Search: Comorbidities of T2DM Evidence is sparse in children and adolescents regarding the risks for developing various comorbidities of diabetes that are well recognized in adult patients.

The 26 articles that met the revised objective criteria had the following characteristics: Expert opinion global recommendations not based on evidence 5 articles. Cohort studies reporting natural history of disease and comorbidities 5 articles. Prevalence of nephropathy cohort: 3 articles. Retinopathy 1 case-control, 1 position statement: 2 articles. Peripheral vascular disease case series: 1 article. Rejected Articles A total of articles did not meet primary inclusion criteria and were rejected; details are presented in Supplemental Information F.

Profiles of the rejected articles are: Articles relating to T1DM articles ; specifically on the following topics: Retinopathy 42 articles. Vascular complications 34 articles. Nephropathy 29 articles. Natural history and epidemiology of T1DM 8 articles. Hyperlipidemia 5 articles. Risk factors for comorbidities ie, ethnicity, puberty: 4 articles.

Neuropathy 3 articles. Studies addressing methods of testing for comorbidities 12 articles. During the search, articles addressing the following themes were identified and reviewed: The pattern of comorbidities in T1DM versus T2DM and the role of puberty 9 articles. Recommendations Regarding Comorbidities Unlike T2DM in adult patients, data are scarce in children and adolescents regarding the diagnosis, natural history, progression, screening recommendations, and treatment recommendations.

Hypertension Hypertension is a significant comorbidity associated with endothelial dysfunction, vessel stiffness, and increased risk of future CVD and chronic kidney disease for the child with diabetes. Dyslipidemia Long-term complications of T2DM in children and adolescents are not as well documented as those found in adults. Screening: On the basis of current recommendations by the ADA and the AHA, at the initial evaluation, all patients with T2DM should have baseline lipid screening after initial glycemic control has been established consisting of a complete fasting lipid profile, with follow-up testing based on the findings or every 2 years thereafter, if initial results are normal.

Control of hypertension, per guidelines referenced previously. Intensification of management of hyperglycemia. Promotion of physical exercise and limitation of sedentary activities. Retinopathy The eye has been called a unique window into the neural and vascular health in patients with diabetes.

Screening: Patients with T2DM should have an initial dilated and comprehensive eye examination performed by an ophthalmologist or optometrist shortly after diabetes diagnosis. Treatment: Providers should promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy.

Microalbuminuria Microalbuminuria is a marker of vascular inflammation and a sign of early nephropathy; it has been found to be associated with CVD risk in adults. Screening: Screening for microalbuminuria should begin at the time of T2DM diagnosis and be repeated annually. Treatment: Treatment with an ACE inhibitor should be initiated in nonpregnant individuals with confirmed persistent microalbuminuria from 2 additional urine specimens, even if blood pressure is not elevated.

Depression Depression is a significant comorbidity that can complicate the medical management of diabetes and is associated with poor adherence.