Pediatric Primary Care Case Studies (71 page)

You congratulate her on her excellent progress, noting her improved laboratory results, weight loss, and work to improve her diet and exercise habits. You also note that the family changes will be helpful to everyone. You tell Mary that you will continue to slowly reduce her insulin each week and titrate her metformin upward to the appropriate therapeutic dose.

When do you want this patient to return for follow-up?

Children and adolescents with type 2 diabetes should be evaluated every 3 months. In most cases, these children will receive diabetes follow-up from the diabetes care team with primary care services provided by the primary care provider. In cases where access to a pediatric diabetes team is geographically limited, primary care providers will assume a greater role in diabetes management. In either case, ongoing communication between primary and diabetes care providers is essential for achieving glycemic goals for adolescents with type 2 diabetes.

Today, you make no changes in Mary’s metformin therapy, and encourage her to keep up the good work with her exercise and diet habits. You provide Mary’s mother with a prescription for Mary’s brother (fasting blood glucose) in preparation for his office visit next week. You schedule Mary for primary care follow-up in 3 months and send a note to the diabetes team regarding her progress.

Key Points from This Case

1. The incidence of type 2 diabetes is rising, particularly among African American teens. The presence of diabetic ketoacidosis at onset of disease does not exclude this diagnosis.

2. Screening for presence of diabetes comorbidities and complications should be initiated at diagnosis.

3. Type 2 diabetes is a family affair. Frequently, others in the family may have type 2 diabetes and may be either a positive or negative influence for the newly diagnosed adolescent. The diagnosis of type 2 diabetes in an adolescent may prompt screening in siblings or other family members for presence of the disease. The hallmark of management of type 2 diabetes is behavioral change leading to improvement in eating and physical activity behaviors for the entire family.

4. Diabetes management requires a team approach and coordination of services between primary care providers and the diabetes specialty team. In rural areas, this may require creative approaches for access to the diabetes team.

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