Diabetes screen – fasting or random blood glucose and HbA1c; to be done every 2 years

If 3-11 years old, based on blood pressure norms for boys and girls, continue weight management and repeat in 6 months as per expert panel guidelines (referenced)

If 12-17 years old, based on blood pressure norms for boys and girls, continue weight management, recommend CHILD-1* diet and repeat in 6 months as per expert panel guidelines (referenced)

Test HbA1c; if discrepancy with fasting plasma glucose or random plasma glucose, repeat tests or conduct 2-hour oral glucose tolerance test (OGTT) (1.75g/kg to max 75g), if available (6.1-6.9 mmol/L)

If impaired random or fasting glucose level persists on above testing, repeat HbA1c in 3-6 months

Ensure results used are averaged from 2 fasting lipid profiles at least 2 weeks apart but no more than 3 months.

Refer to dietitian.  Follow-up in 6 months for fasting lipid profile.

Ensure results used are averaged from 2 fasting lipid profiles at least 2  weeks apart but no more than 3 months.

Refer to dietitian. Follow-up in 6 months for fasting lipid profile.

Ensure results used are averaged from 2 fasting lipid profiles at least 2 weeks apart but no more than 3 months.

Reduction of simple carbohydrates such as added or processed sugars and those found in items such as fruit and milk.

Refer to dietitian. 

Follow-up in 6 months for fasting lipid profile.

Repeat in 1-6 months.

Consider imaging including Ultrasound or MRI and spectroscopy (latter preferred) to assess for hepatic steatosis if not already done.

Evaluate causes of hepatic steatosis (genetic/metabolic, infectious, dietary, medication-induced)

If persistent elevation or unchanged on repeat testing, refer to Pediatric Gastroenterology.

Perform ALT blood test if not already done.

Refer to Pediatric Gastroenterology

Refer to Dietitian and Clinical Exercise Physiologist to consider implementation of intensive lifestyle changes – sugar avoidance, balanced diet, moderate to high intensity exercise daily, <2 hours screen time

Liver biopsy as gold standard for diagnosis; Consider MRI and spectroscopy to assess for hepatic steatosis; CT not recommended due to radiation exposure

Metformin (titrated dosing over 3-4 weeks to maximum 1,000mg twice daily, starting with 500mg daily for 7 days) and healthy behaviour intervention; if glycemic targets not achieved within 3-6

months of monotherapy, start once-daily basal insulin.

If initial HbA1c is ≥9.0% basal insulin should be started alongside metformin, with insulin weaned once glycemic targets are achieved.

Goal of initial treatment is HbA1c <6.5%

Screen for complications annually, with the exception of hypertension and mental health which should be evaluated at minimum twice per year.

Confirm diagnosis with ensuring blood pressure has been recorded on 3 separate occasions (including one outside of the context of a medical visit, ie. ABPM) as being greater than the 95th percentile for age, sex and height.

If stage 2 hypertension (blood pressure >99^th percentile + 5 mmHg for age, sex and height) then initiate investigations as below and refer to pediatric hypertension specialist.

Investigations:

• Bloodwork including electrolytes, blood gas, creatinine, fasting blood glucose, serum total cholesterol, HDL-C, LDL-C, triglycerides, and first-morning albumin-to-creatinine ratio

• Urinalysis and retinal examination.
• Imaging including renal ultrasound and echocardiogram.

Recommended combination of CHILD-1* and DASH** eating plans and reduced sodium intake.

Refer to pediatric hypertension specialist if blood pressure goals (<95^th percentile for age, sex and height) are not achieved on standard lowdose monotherapy (ACE inhibitor or angiotension receptor blocker) for 6 months.

Ensure results used are averaged from 2 fasting lipid profiles at least 2 weeks apart but no more than 3 months.

Refer to dietitian

• If >6.5 mmol/L at any age, refer to lipid specialist
• If <10 years old, no initial pharmacologic management; if severe primary hyperlipidemia, a high-risk condition or evident cardiovascular disease present, refer to lipid specialist
• If >10 years old, conduct 6 month trial of CHILD-1 to CHILD-2-LDL lifestyle management and repeat fasting lipid profile

Begin statin therapy if:

• >10 years old and BMI >97^th percentile

• >10 years old with failed lifestyle management as above and repeat LDL-C >4.9 mmol/L

• >10 years old with failed lifestyle management as above and repeat LDL-C 4.1-4.9 mmol/L with positive family history or at least 1 high risk factor or 2 mod risk factors

• >10 years old with failed lifestyle management as above and repeat LDL-C 3.4-4.1 mmol/L with 2 high risk factors or at least1 high risk factor and 2 mod risk factors or clinical cardiovascular disease

• <10 years old with severe risk factors as above, at discretion of specialist consultant

Pharmacotherapy should be considered if hypertension is symptomatic or severe (stage 2 or persistent >6 months stage 1), or in the presence of risk factors such as chronic kidney disease or target organ damage including left ventricular hypertrophy, hypertensive retinopathy or albuminuria. Except in rare cases, pharmacologic treatment should be reserved for children 12 years of age or older.

If stage 1 hypertension (blood pressure at 95^th-99^th percentile + 5 mmHg for age, sex and height) then initiate investigations as below.

Ensure results used are averaged from 2 fasting lipid profiles at least 2 weeks apart but no more than 3 months.

Refer to dietitian.

Ensure results used are averaged from 2 fasting lipid profiles at least 2 weeks apart but no more than 3 months.

Refer to dietitian; Aimed diet focus on specifically CHILD-1 or CHILD-2-TG diet

If <10 years old and 1.1-2.3 mmol/L or 10-19 years old and 1.5-2.3 mmol/L, intensify dietary regime, increase dietary fish content and repeat fasting lipid profile in 6 months

If <10 years old and <1.1 mmol/L or 10-19 years old and <1.5 mmol/L, continue lifestyle change and dietary regime and repeat fasting lipid profile in 12 months

All children with triglyceride levels 2.3-5.6 mmol/L should be managed with goal of non-HDL <3.8 mmol/L; if non-HDL level not achieved, may need fish oil supplementation and repeat in 3-6 months.

If >5.6 mmol/L at any age, refer to lipid specialist.

Complete history for red flags of advanced liver disease including jaundice, peripheral edema, and bleeding (easy bruising and/or melena).

Complete full liver panel including ALT, AST, protein, albumin, bilirubin; CBC and differential; HbA1c

Evaluate causes of hepatic steatosis (genetic/metabolic, infectious, dietary, medication-induced)

Consider non-alcoholic fatty liver disease (NAFLD) in children >10 years with sex-specific ALT values ≥ 2x normal values, in the absence of the above causes of hepatic steatosis

If persistent elevation, refer to Pediatric Gastroenterology and Dietitian

Consider imaging including ultrasound or MRI and spectroscopy (latter preferred) to assess for hepatic steatosis if not already done.

Perform ALT blood test if not already done.

Liver biopsy as gold standard for diagnosis; Consider MRI and spectroscopy to assess for hepatic steatosis; CT not recommended due to radiation exposure.

Implement intensive lifestyle changes – sugar avoidance, balanced diet, moderate to high intensity exercise daily, <2 hours screen time.

Refer to Pediatric Gastroenterology.

Initiate lifestyle modification including exercise and nutrition to manage overweight/obesity component.

Hormonal contraceptives (pill [estrogen-progestin combined pill preferred], patch, ring) as first line pharmacotherapy to treat menstrual abnormalities and clinical/biochemical hyperandrogenism; progestin monotherapy as alternative if above contraindicated.

Metformin to be used in those with metabolic syndrome/impaired glucose tolerance who have failed lifestyle modifications, or as a second-line therapy in those unable to take hormonal contraceptives.

Routine follow-up; once complete pubertal maturity is reached, withdraw hormone therapy for 3 months and re-assess for hyperandrogenism.

Expectant management.

Patient counseling around symptoms of biliary colic.

Refer to Pediatric Nephrology.

Consider glucocorticoids or immunosuppressive therapy if primary FSGS with proteinuria >3.5 g/day and other signs of nephrotic syndrome (hypoalbuminemia (<3.5 g/dL) or edema or hyperlipidemia).

If secondary FSGS or no nephrotic syndrome present, no treatment necessary; follow-up in 6 months.

Involve tertiary care level multidisciplinary healthcare team – physician, dietitian, diabetes nurse educator, mental health professional.

If A1C >9% in a new patient OR >8% in an established patient, start insulin therapy which may be weaned once glycemic targets met, and metformin (unless acidosis present).

Follow-up dependent on specific complications.

Refer to dietitian.

Refer to lipid specialist if:

• TG >5.6 mmol/L or LDL-C >6.5 mmol/L

• Age <10 years with a high-risk condition or evident cardiovascular disease
• TG or LDL-C are less than above targets but higher than agespecific thresholds; continue dietary and lifestyle intervention while also considering combination pharmacotherapy (statin plus fibrate or niacin)

Consult pediatric cardiologist

Complete history for red flags of advanced liver disease including jaundice, peripheral edema, and bleeding (easy bruising and/or melena)

Complete full liver panel including ALT, AST, protein, albumin, bilirubin; CBC and differential; HbA1c

Evaluate causes of hepatic steatosis (genetic/metabolic, infectious, dietary, medication-induced)

Consider non-alcoholic fatty liver disease (NAFLD) in children >10 years with sex-specific ALT values ≥ 2x normal values, in the absence of the above causes of hepatic steatosis.

If persistent elevation, refer to Pediatric Gastroenterology and Dietitian.

MRI and spectroscopy to assess for hepatic steatosis if not already done.

Dependent on specific symptoms experienced and severity.

Consideration of surgical (removal or drainage) vs non-surgical management (antibiotics, hydration and supportive care).

Consider referral to subspecialty care.

Consider switch in pharmacotherapy; approved anti-hypertensive drugs as per expert guidelines

If not already completed, perform echocardiogram for assessment of left ventricular mass.

Consider referral to subspecialty care.

If not already completed, perform echocardiogram for assessment of left ventricular mass.

Refer for polysomnogram for assessment and/or confirmation of diagnosis; if unavailable, alternative such as nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography

Examine for adenotonsillar hypertrophy 

• if present, refer to pediatric ENT surgeon for assessment and follow-up 
• if absent or surgery contraindicated, considerations include anti-inflammatory medication such as inhaled corticosteroids with 6-week follow-up evaluation and referral for consideration of BiPAP or CPAP support

Adjunctive therapy including positioning with pillows or belts may be helpful.

Regular outpatient follow-up with primary care physician; 6-8 weeks maximum post-operatively, where applicable with ENT surgeon.

Continued weight management and lifestyle modification as per baseline.

No pharmacologic intervention.

Refer to clinical exercise physiologist

Consider ECG to assess for arrhythmia, signs of heart failure, or myocardial dysfunction.

Consider pulmonary function testing (PFTs) to assess for *** (as per Dr. Legault’s paper – to be reviewed) +/- referral to respirology.

Reassess in 3-6 months

Referral to (if not completed) and management by pediatric respirologist/sleep specialist

Examine for adenotonsillar hypertrophy

• if present, refer to pediatric ENT surgeon for assessment and follow-up
• if absent or surgery contraindicated, considerations include anti-inflammatory medication such as inhaled corticosteroids with 6-week follow-up evaluation with primary care physician

Regular outpatient follow-up with primary care physician; 6-8 weeks maximum post-operatively, where applicable with ENT surgeon.

Stepwise approach:

• If diet and lifestyle management not effective, acid suppression for 4-8 weeks; if improved, attempt wean after 4-8 weeks

• If above acid suppression not effective or wean fails, refer to Pediatric Gastroenterology

Refer to physiotherapist and/or clinical exercise physiologist.

Consider limited use of pain medication with short-term course and close follow-up within 3-6 months.

Conduct ECG, consider chest x-ray and echocardiogram to assess for arrhythmia or signs or cardiac failure.

Consult to clinical exercise physiologist/occupational therapist – explore whether accommodations are required at home or at school.

Referral to (if not completed) and management by pediatric respirologist/sleep specialist

Examine for adenotonsillar hypertrophy

• if present, referral to pediatric ENT surgeon for assessment and follow-up

• if absent or surgery contraindicated, considerations include anti-inflammatory medication such as inhaled corticosteroids with 6-week follow-up evaluation with primary care physician

Regular outpatient follow-up with primary care physician; 6-8 weeks maximum post-operatively, where applicable with ENT surgeon

Evaluate for underlying cause and concerning symptoms including dyspnea and/or syncope with exertion, cyanosis or failure to thrive.

Refer to Pediatric Cardiology

Ensure echocardiogram and pulmonary function tests have been conducted

Consider diuretics, oxygen, anticoagulation, digoxin

Conduct acute vasoreactivity testing following initial therapy; algorithm as per AAP guidelines based on outcome of testing

Complete history and physical exam to determine etiology

Refer to physiotherapist/occupational therapist and/or clinical exercise physiologist; consider imaging if localized suspected cause

Consider limited use of pain medication with short-term course and close follow-up within 3-6 months

Conduct ECG and echocardiogram to assess for arrhythmia or signs of cardiac failure; consider pulmonary function tests.

If evidence of or concern for cardiac or respiratory failure, refer to appropriate specialist.

Bloodwork including CBC, urea, creatinine, ALT, AST, INR, albumin; conduct ECG; consider ECHO.

Lifestyle intervention including dietary and activity changes and weight management; consider referral to dietitian and/or exercise specialist; supportive stockings.

If evidence of or concern for cardiac, liver, kidney or lung disease, refer to appropriate specialist.

Referral to orthopedic surgery

Consider leg bracing depending on age

Reassessment by orthopedic surgery at 6-12 months

Referral to orthopedic surgery

Complete history and examination for assessment of onset and comorbid symptoms.

Ensure x-rays of affected joints have been done

Referral to clinical exercise physiologist and/or physiotherapist and/or sports medicine specialist

First-line medical management is NSAID therapy unless contraindicated

Referral to pediatric rheumatologist if

• Unsuccessful medical management after 6 months of NSAID therapy

• Consideration of the use of disease-modifying anti-rheumatic drug (DMARD) therapy

• Continued progression of disease/failed pharmacotherapy

Determine primary or secondary etiology with underlying cause, if present

Lifestyle modifications in terms of toileting education for patient and family, schedules and rewards

Consider mental health counselling if cause determined to be stress/psychosocial in nature or if distress experienced with events

Consider medical therapy with oxybutynin to help control bladder muscle tone if above measures fail

Referral to Urology – urotherapy with urology nurse

Complete history and physical exam for assessment of underlying causes

Psychoeducation around cause of encopresis and limiting associated “shame and blame”

Referral to and initiation of behavioural intervention as well as laxative therapy (specific therapy dependent on patient age)

Work with the patient and family to establish regular and healthy bowel patterns.

Complete a mental health screen. Depending on the nature of your patients and your clinical setting, you may choose tool(s) to support your practice.

Provide mental health resources (attached)

Continue to monitor

No referral is required

Screen for body image concerns. Consult 5As: Ask Video. E.g., lead question: in the last 3 months, has your weight or shape affected how you feel about yourself?

If positive: A discussion regarding preoccupation and frequency of this preoccupation is recommended

Continue to monitor, consider discussingweight scienceHealth at Every Size (HAES)* approach - a patient can make gains in health with little change in weight

Screen for restrictive/emotional/binge eating or secretive eating.

E.g., In the last 3 months, are there times where you have eaten too little (skipped 2 meals in a row or reduced your quantity of food during meals) or too much in one sitting? In the last 3 months, has it ever been hard to control how much you eat?

Continue to monitor; provide informational resources on emotional eating (attached)

Ensure proper management as per Canadian Pediatric Society

Guidelines– may need to refer for assessment and/or treatment.

Determine whether appropriate supports are in place at school (e.g., Individualized Education Plan (IEP) in Ontario), consider initiating a school meeting.

If there are symptoms of a learning disorder, suggest a psychoeducational assessment (completed by psychologist via school or community)

Consider referral for developmental assessment (ie. Developmental Pediatrician, Psychologist)

Review Canadian Pediatric Society Guidelines

Determine whether appropriate supports are in place at school (ie. individualized education plan (IEP) in Ontario), consider initiating a school meeting, or suggest caregiver request for a psychodiagnostic assessment

Complete a mental health screen. Depending on the nature of your patients and your clinical setting, you may choose tool(s) to support your practice.

Continue to monitor

Advise on management and treatment options. Refer to appropriate providers for psychotherapy and/or psychopharmacology

Provide mental health resources (attached)

Full assessment with screen for restrictive/emotional/binge eating or secretive eating if not already completed. (E.g., In the last 3 months, are there times where you have eaten too little (skipped 2 meals in a row or reduced your quantity of food during meals) or too much in one sitting?)

Assess for perceptions of out of control eating. (e.g., Lead question: In the last 3 months, has it ever been hard to control how much you eat?)

Advise on management and treatment options. Refer to appropriate

providers for therapy (dietitian and registered psychotherapist/psychologist)

Consider discussing weight science Health at Every Size (HAES)* approach.

Refer to appropriate provider for psychotherapy or consider referral to Adolescent Medicine if age >12

Refer for developmental assessment (ie. Developmental Pediatrician, Psychologist) if not already done

Review Canadian Pediatric Society Guidelines

Determine whether appropriate supports are in place at school (ie. individualized education plan (IEP) in Ontario), consider initiating a school meeting, or suggest caregiver request for a psychodiagnostic assessment

Refer to appropriate providers for psychotherapy and/or psychopharmacology. 
Consider referral to pediatric mental health agencies/tertiary care facilities.

Full assessment required if not already completed.

Advise on management and treatment options.

Full assessment with screen for restrictive/emotional/binge eating or secretive eating if not already completed. (E.g., In the last 3 months, are there times where you have eaten too little (skipped 2 meals in a row or reduced your quantity of food during meals) or too much in one sitting?)

Assess for perceptions of out of control eating. (e.g., Lead question: In the last 3 months, has it ever been hard to control how much you eat?)

Advise on treatment options. Refer to appropriate providers for psychotherapy and/or psychopharmacology. Consider referral to pediatric mental health agencies/tertiary care facilities

Full mental health assessment required if not already completed.

Refer to appropriate provider for psychotherapy or consider referral to Adolescent Medicine if age >12

Refer for developmental assessment (ie. Developmental Pediatrician, Psychologist) if not already done

Review Canadian Pediatric Society Guidelines

Determine whether appropriate supports are in place at school (ie. individualized education plan (IEP) in Ontario), consider initiating a school meeting, or suggest caregiver request for a psychodiagnostic assessment

Determine whether families have accessed support, ie. financial, respite care etc.

Screen for bullying at school and at home. e.g., Lead question: Does anyone at school ever bother you or call you names?

Encourage caregivers to advocate for child at school.

Encourage caregivers to cease weight-based teasing and bullying within the home

Provide supportive care or counselling if possible

Refer to outside mental health or medical services such as community counseling and/or family therapy

Continue to monitor

Provide supportive care or counselling if possible

Refer to outside mental health or medical services such as parenting classes, counseling etc.

Continue to monitor

Provide supportive care or counselling if possible

Consider engaging other family members’ help.

Continue to monitor.

Provide supportive care or counselling if possible

Consider engaging other family members to help short-term

Refer to outside mental health or medical services

Consider this limitation in treatment planning with the family.

Ensure access to available supports/programming.

Continue to monitor.

Encourage caregivers to advocate at the school for intervention. If at home, recommend counseling for family relationships.

Encourage and support caregivers in talking with the school about an attendance plan/intervention

Review mental health screen and possible underlying mental health conditions

Consider referral to school counselor and/or social worker if available

Refer to outside mental health or medical services such as community counseling.

Refer to outside mental health or medical services such as parenting classes, counseling etc.

Consider caregivers’ health/mental health and explore possible supports for caregiver

Assist caregivers with seeking support outside of clinic for personal medical/mental health support

Consider child’s safety and need for Children’s Aid Society involvement.

Consider best time for intervention – it may have to wait.

Determine if additional supports (extended family, organizations) are available to the family.

Consider financial costs of recommendations (activities)

Provide information on financial resources

Determine eligibility for Assistance for Children with Severe Disability (ACSD)*

Referral to mental health provider.

Encourage and support caregivers in talking with the school about an attendance plan/intervention

Consider referral to school counselor and/or social worker if available

Refer to outside mental health or medical services such as community agencies or tertiary care mental health services.

Consider safety of child.

Consider safety of child

Refer to outside mental health or medical services such as parenting classes, counseling etc.

Consider safety of child

Refer to outside mental health or medical services such as parenting classes, counseling etc.

Tailor weight management accordingly. Consider timing of interventions

Provide resources on access to financial supports

Consider safety of child and role of Children’s Aid Society.

Assist caregivers with seeking support outside of clinic for personal medical/mental health support

Consider safety of child and role of Children’s Aid Society.

If Children’s Aid Society involved, consider involving them in treatment plan (making them aware).

May need to make worker aware of treatment goals, work with temporary guardians.

Consider financial costs of recommendations (activities)

Provide information on financial resources

Determine eligibility for Assistance for Children with Severe Disability (ACSD)*