Monitoring

Type 2 diabetes mellitus (T2DM) is a progressive disorder. Optimal care requires control of blood glucose, blood pressure, lipids, and smoking habits. Achieving an HbA1c target of <48 mmol/mol (<6.5%) has been shown to reduce complications and is recommended by the American Diabetes Association (ADA) for most children and adolescents with T2DM who have a low risk of hypoglycaemia.[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 <48 mmol/mol (<6.5%) in most cases.[2]​​ A higher HbA1c target of <53 mmol/mol (<7%) may be considered at the initiation of therapy or in instances where the standard target may be detrimental to the overall well-being of the person with diabetes or their carers (e.g., significant risk of hypoglycaemia).[2]​ 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.[2]​​ If using continuous glucose monitoring (CGM), ISPAD recommends aligning with established CGM targets used for type 1 diabetes mellitus (T1DM) (>70% of the time between 3.9-10 mmol/L [70-180 mg/ dL] and <4% of the time <3.9 mmol/L [<70 mg/dL]) as no targets for T2DM have been established.[2]

Routine self-monitoring of blood glucose may not be needed as frequently as with T1DM. 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.[2]​​ Children and adolescents on insulin should be taught how to use self-monitoring of blood glucose to monitor for asymptomatic hypoglycaemia, particularly at night.[2]​​

The American Diabetes Association recommends that real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM) 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 rtCGM for patients with T2DM who take insulin and are at risk of hypoglycaemia.[94] UK National Institute of Health and Care Excellence (NICE) guidelines recommend that CGM should be considered for children and young people with type 2 diabetes on insulin therapy.[102]

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.[121]

  • Metformin should be discontinued 24 hours before surgery, if possible.

  • Adequate hydration with intravenous fluids before, during, and after the procedure is essential.

  • 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 every 3 months.[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 (MASLD; 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]

UK National Institute for Health and Care Excellence (NICE) guidelines recommend measuring height and weight and calculating body mass index at each clinic visit, noting that significant changes in weight may reflect changes in blood glucose levels.[102]

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 (including food insecurity, housing stability, health literacy, financial barriers, and social or community support), and behavioural health concerns.[1]​ Refer to a trained mental health professional (preferably one experienced in childhood diabetes) as required for further assessment and treatment.[1]

Starting at puberty, pre-conception counselling should be incorporated into routine diabetes clinic visits for all individuals of childbearing potential 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]

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