Updated Guidelines for Type 2 Diabetes in Children and Adolescents

The Australian and New Zealand Society for Paediatric Endocrinology and Diabetes (ANZSPED) have recently updated their guidelines on the assessment and management of diabetes in children and adolescents. Type 2 diabetes is becoming increasingly common in young people, particularly among those living with obesity and within First Nations populations. Youth-onset type 2 diabetes is typically more aggressive than adult-onset disease, with more rapid deterioration in β-cell function, earlier development of complications, and a greater need for intensive management.

Screening and assessment:

The guidelines recommend targeted screening of children and adolescents who have overweight or obesity and additional risk factors. These include a family history of type 2 diabetes, maternal diabetes during pregnancy, signs of insulin resistance, and belonging to high-risk populations. Screening should also be considered in high-risk populations with any risk factor, regardless of body weight, recognising that type 2 diabetes can occur in the absence of overweight or obesity. Atypical presentations should prompt specialist review.

A key focus of the guideline is the early detection and management of complications. Screening for retinopathy, kidney disease, neuropathy, cardiovascular risk factors, and mental health concerns should be routine following a diagnosis of diabetes.

Pharmacotherapy

Metformin remains the recommended first-line pharmacological treatment for most young people with type 2 diabetes. However, the updated guidelines place greater emphasis on earlier use of newer glucose-lowering therapies when glycaemic targets are not achieved.

A notable change is the recommendation that glucagon-like peptide‑1 (GLP-1) analogues should be the preferred second-line treatment for most children and adolescents with type 2 diabetes whose glycaemic targets are not achieved despite metformin therapy. These medicines are not currently approved by the Therapeutic Goods Administration (TGA) for the treatment of type 2 diabetes in patients under 18 years of age. However, their recommendation reflects evidence that GLP-1 analogues generally produce greater HbA_1c reductions than sodium-glucose co-transporter 2 (SGLT2) inhibitors and have favourable effects on weight. Current evidence suggests that the safety and efficacy of GLP-1 analogues in paediatric populations is largely consistent with what is seen in adult populations. However, longer follow-up from future trials and real-world studies is required to establish the long-term effects of GLP-1 analogues in children.

Metformin should be started promptly when HbA_1c is ≤8.5% at diagnosis, while insulin is recommended at diagnosis for those with HbA_1c >8.5%, diabetic ketoacidosis (DKA), ketosis or hyperglycaemic hyperosmolar state (HHS). For patients presenting with DKA or HHS at diagnosis, metformin should also be commenced once these complications have resolved.

A target HbA_1c of 48 mmol/mol or below (≤ 6.5%) is recommended for most young people due to the expected longer duration of disease and the more aggressive nature of the condition compared to adult-onset type 2 diabetes. However, individualisation may be required to achieve targets without hypoglycaemia or undue treatment burden. Where the target is not achieved after three months, addition of second-line options should be considered, e.g. a GLP-1 analogue (semaglutide, dulaglutide or liraglutide) or an SGLT2 inhibitor (empagliflozin or dapagliflozin). These medications should be initiated in consultation with a paediatric endocrinologist or diabetes specialist. While GLP-1 analogues are preferred for most of these patients due to their greater glucose-lowering effect, treatment choice should also consider weight, cardiovascular and metabolic risk, renal function, cost, route of administration, patient preferences, and adverse effects.

Sulfonylureas and dipeptidyl peptidase‑4 (DPP-4) inhibitors are not recommended due to reduced efficacy in youth-onset type 2 diabetes, while thiazolidinediones should be avoided due to safety concerns.

Ongoing management:

The guidelines stress that management should be delivered by a multidisciplinary team and combine lifestyle interventions with pharmacological treatment, as appropriate. Pharmacotherapy is guided by the severity of hyperglycaemia and individual patient factors, with regular monitoring of glycaemic control. However, support for nutrition, physical activity, weight management, and family engagement remains the foundation of care.

Particular attention is given to culturally safe care for First Nations peoples, acknowledging the disproportionate burden of disease in this population. The guidelines also highlight the importance of planned transition from paediatric to adult services. Structured transition processes are recommended to support ongoing engagement with healthcare services and reduce the risk of poor outcomes during adolescence and young adulthood.

Summary:

Overall, the updated guidelines reflect a shift towards earlier identification of at-risk young people, proactive screening for complications, and more intensive treatment of youth-onset type 2 diabetes. The recommendations support earlier use of newer therapies such as GLP-1 analogues and emphasise multidisciplinary, culturally safe, and coordinated long-term care to reduce the burden of diabetes-related complications.