With very young children being diagnosed with type 2 diabetes, clinicians are tasked with caring for a relatively newer patient population without the benefit of well-established treatment protocols and also have to overcome parental indifference towards the disease. Lynne Braxton, RN, MSN, CDE helps these patients and their families come to terms with the disease and navigate the long journey back to try and reclaim their lives.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
The girl got on the scale. She looked down, and she read the number aloud: “I’m 240 pounds.” She stepped off and looked over at her parents for their reaction and some comfort with this disturbing realization.
She was 11 years old and not only was she going to have to deal with her morbid obesity, she was diagnosed with type 2 diabetes.
People might think this is an extreme case, and in terms of the overall percentages of children who might fit this category, it still is, but it is a trend that is being seen more frequently. Clinicians on the front lines are battling some of the toughest cases they have ever had to deal with as they begin to see a patient base they never cared for in previous years—morbidly obese children as young as seven years old with type 2 diabetes.
These clinicians are grappling with having a limited number of medications they can prescribe and treating co-morbidities traditionally seen in adult patients who have advanced disease states.
In addition, these clinicians are having to deal with parental attitudes ranging from resignation that their children are destined to get the disease to an unwillingness to turn their kids’ lives around in doing the right things like correcting their dietary choices or getting their glucose under control.
Lynne Braxton, RN, MSN, CDE, (pictured, lower right) is one such front line clinician facing these challenges. Braxton is a pediatric clinical nurse specialist for the Vidant Medical Center in Greenville, North Carolina who treats newly-diagnosed type 2 children.

Braxton begins her care by helping patients’ families come to grips with the disease, and then she establishes a three-part treatment plan to rebuild these patients’ lives with healthier self-management. These steps are done incrementally, with the understanding it will be a long journey fraught with potential setbacks along the way.
DiabetesCare.net talked with Braxton about what it is like working with these clinically sick children and their families and how she incorporates treatment regimens.
DiabetesCare.net: Can you talk about what it is like for children first getting diagnosed and what you do in these situations? 
Braxton: Children have special needs when they are just diagnosed. Everyone is overwhelmed with the news, and you have to teach all this survival information while they are processing the diagnosis. Familes then have to go home and begin to take care of the children. There is so much more than having to go home and take a single pill everyday or having one procedure; it is such a complex lifestyle adjustment for the entire family.
I go to the schools of the children recently diagnosed to talk with the teachers and administrators because I think education is so vital. I also think it is unfair to the parents who just learned about the disease and that they then have to turn around and try to explain it to the teacher including the expectations for what should be done in school. 
DiabetesCare.net: Can you talk about what you are seeing in terms of how old your youngest patients with type 2 diabetes are?
Braxton: I have been collecting regional data for the last 13 years. We used to fit the national statistical profile that 90 percent of the people with type 2 diabetes were adults, and 10 percent would be children. Of those 10 percent of children, 90 percent of them would have type 1 diabetes and 10 percent would have type 2.
Over the last five years, the number of children being diagnosed here with type 2 diabetes overall has gone up and the age of the children has gone down. At one point, 75 percent of those diagnosed were type 1 and 25 percent were type 2 with the average ages being in the 13 to 15 year old range. Today, approximately 55 percent of our newly diagnosed children are type 1s and 45 percent are type 2s. The average age of diagnosis now is in the 7 to 9 year old range.
We do antibody studies and lab evaluations on these patients and they fit the model of type 2 diabetes. They have a laundry list of the symptoms that go along with being a type 2, including: being overweight; having a family history of diabetes; they are antibody negative; and they have high C-peptides. We also see more type 2 kids producing ketones.
That used to be one of the key differences between type 1 and type 2 diabetes. We would see type 1s produce high blood sugar and ketones, whereas type 2s would not. This is just not as clear cut for differentiating the two as the latter is exhibiting both symptoms. 
DiabetesCare.net: What are some of the biggest challenges associated with these young children who are in the 7 to 9 year old range who are diagnosed with type 2 diabetes?
Braxton: Medication is the biggest one because 90 percent of the adult hyperglycemic pharmaceuticals have not been approved for use in young children. There have been no studies or determination of long-term outcomes to see what would happen to children who start taking medicines in the pre-pubertal years.
Some studies have been done using metformin in patients down to the age of 10 years old. It appears to be safe and there were no long term effects that we know about; however, we don’t want to go below that age. 

There are some sulfonylureas that have been studied for use in children, but by no means are these class of drugs considered the standard of care.  

Therefore, insulin is the only option to manage their blood sugars--for both the type 1s and type 2s.
DiabetesCare.net: So you are actually using insulin on young type 2s to help get them into better glucose control?
Braxton: Yes, it is the only drug that we know we can use with long-term safe results. We will use it as part of an aggressive therapy to get their glucose under control. If they are eligible for an oral agent, then we’ll add that in.
We don’t give them a few months to see if lifestyle management habits work, which is often done with adults. We want to emphasize from the beginning the importance of good glucose management.

DiabetesCare.net: How does the insulin regimen for type 2 kids differ from type 1s?

Braxton: It is an identical plan. What we try to do at our medical center is a combination of using basal insulin and supplementing bolus insulin at mealtime to correct the highs and match the carbohydrates that patients eat.
DiabetesCare.net: Is there a metric you use to either scale back or take them off insulin altogether?
Braxton: It is all based on their glucose control and their ability to stay within their target range. If their lifestyle management allows them to wean themselves off insulin of course we do that--each case varies and it depends on the individual.
Children with type 2 diabetes need to be checking their glucose four times a day, correcting their blood sugars when they are high, and act accordingly when the food and activity they engage in affects their blood sugars.
Most young kids say they want to get off these shots no matter what. 
DiabetesCare.net: Are these patient populations experiencing co-morbidities?
Braxton: Not so much in the youngest patients, but we do see in some of the younger teens they are experiencing fatty liver disease and some kids in their middle teen years having to take renal medication because they are beginning to spill albumin in their urine, which is an early sign of kidney complications. Some teens have vision problems and undergo laser surgery to correct it—sometimes a couple of times before they are even old enough to vote. These health issues are very worrisome.
DiabetesCare.net: What are some of the strategies you work on with the kids and their parents in determining alternatives to their lifestyle management? 
Braxton: The kids that have the most success have their families adopt the patient’s lifestyle together. For example, they won’t separate the types of foods out and say something like, ‘these are our soda drinks and this is your healthier drink.’
The first thing we want to do is get good glucose control. We work on monitoring and managing blood sugar, then we begin working on lifestyle changes. We want to begin to make small steps in the right direction.
There is no more “diabetic diet.” We coach the families to eat moderate amounts from all the food groups. It can be difficult to get that message across. It is not just about “sugar.” It’s about changing the way we eat to improve our overall health as well as our blood sugars.
After that we try to get the patients to be active. In North Carolina, there is a public initiative titled, “Eat Smart, Move More.” It is about being active and not coming home and going right to the couch to watch tv and eat chips.  
DiabetesCare.net: After young children with type 2 diabetes are into your program and given a specific lifestyle regimen, do you do anything differently with these patients as opposed to what you would do with teens with type 2 diabetes?
Braxton: We put more responsibility on the parents in the younger patients to help with outcomes. For example, if a parent is not supervising or being accountable for the diabetes care being done, we may involve the authorities like child protective services. We might say something to these services like, ‘this child has an A1c of over 10, and it has been that way for the last two years and the child is eight years old, this is medical neglect. This parent is not ensuring a safe environment for this child.’

DiabetesCare.net: Are the circumstances especially difficult on the parent who may feel a sense of guilt or other emotions in grappling with their child’s diagnosis?

Braxton: In my opinion, many parents that have type 2 diabetes themselves who are not keeping up with their own disease management do not feel a strong responsibility to improve the health of their child. They might say some things like, ‘I don’t check my sugar or I eat what I want to and I’m doing OK.’ These parents have a tendency to think their child’s diabetes diagnosis was just bound to happen. These parents do not see the correlation between their lifestyle and their children getting type 2 diabetes.

DiabetesCare.net: Why such a high prevalence of type 2 diabetes in kids in the last few years? 
Braxton: As a general population, we are not eating healthy foods; we are not being physically active; we are not paying attention to risk factors we know we have. If there is a family history of type 2 diabetes, children should be taught about the risk factors and how to minimize them. Unfortunately, that is not happening. There are many parents who say, ‘everybody else in the family has diabetes, so it is just your turn.’

I believe it is going to take a couple of generations before we can begin to turn things around and get a handle on this. But that doesn’t mean we need to wait and see if things turn around. Each of us as healthcare professionals has a responsibility to help move these children towards improved glucose management and healthier lifestyles.