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

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

• *CHILD-1 (Cardiovascular Health Integrated Lifestyle Diet) – see Table 5-1 in the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 

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

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

• *CHILD-1* (Cardiovascular Health Integrated Lifestyle Diet) – see Table 5-1 in the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 

• **DASH (Dietary Approaches to Stop Hypertension) – see Table 5-3 in the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 
  • The original clinical study by Appel et. al. (1997), A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure, can be found here.
    

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

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

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

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 >97th 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 least 1 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

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

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 counselling 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