Type 2 Diabetes Mellitus in Children

 

Am Fam Physician. 2018 Nov 1;98(9):590-594.

  Patient information: See related handout on type 2 diabetes mellitus in children.

Author disclosure: No relevant financial affiliations.

The prevalence of type 2 diabetes mellitus in children and adolescents has increased worldwide over the past three decades. This increase has coincided with the obesity epidemic, and minority groups are disproportionately affected. The American Diabetes Association recommends screening for type 2 diabetes beginning at 10 years of age or the onset of puberty in children who are overweight or obese and have two additional risk factors. Diagnostic criteria include a fasting blood glucose level of 126 mg per dL or greater, a two-hour plasma glucose level of 200 mg per dL or greater during an oral glucose tolerance test, an A1C level of 6.5% or more, or a random plasma glucose level of 200 mg per dL or greater plus symptoms of polyuria, polydipsia, or unintentional weight loss. Management should be focused on a multidisciplinary, family-centered approach. Nutrition and exercise counseling should be started at the time of diagnosis and as a part of ongoing management. Metformin is the first-line therapy in conjunction with lifestyle changes. Insulin therapy should be initiated if there are signs of ketosis or ketoacidosis, or if the patient has significant hyperglycemia (A1C greater than 9% or a random plasma glucose level of 250 mg per dL or greater).

Type 2 diabetes mellitus is characterized by hyperglycemia with insulin resistance and impaired insulin secretion. In contrast with type 1 diabetes, pancreatic beta cell dysfunction in type 2 diabetes is not mediated by an autoimmune process.

WHAT IS NEW ON THIS TOPIC

Type 2 diabetes accounts for one in three newly diagnosed cases of diabetes in U.S. children and adolescents.

Up to 32% of adolescents with type 2 diabetes have hypertension at the time of diagnosis.

The American Diabetes Association recommends that screening for type 2 diabetes begin at 10 years of age or the onset of puberty in children who are overweight and have two additional risk factors.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Management of type 2 diabetes mellitus should be focused on a multidisciplinary, family-centered, culturally appropriate approach.

C

2

Nutritional and exercise counseling should be initiated when type 2 diabetes is diagnosed, then addressed as part of ongoing management.

C

2

Metformin in combination with diet and exercise is first-line therapy in children and adolescents 10 years and older who have type 2 diabetes.

C

2, 19

Insulin therapy must be initiated in children and adolescents with type 2 diabetes if they have signs of ketosis or ketoacidosis.

C

2

Insulin therapy should be initiated in children and adolescents without signs of ketosis or ketoacidosis who have random plasma glucose levels of at least 250 mg per dL (13.9 mmol per L), or whose A1C level is greater than 9%.

C

2, 21

A1C levels should be checked every three months in children and adolescents with type 2 diabetes.

C

2

Comorbidities such as hypertension, hyperlipidemia, nephropathy, and retinopathy should be assessed in children and adolescents with type 2 diabetes.

C

6, 11, 22


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Management of type 2 diabetes mellitus should be focused on a multidisciplinary, family-centered, culturally appropriate approach.

C

2

Nutritional and exercise counseling should be initiated when type 2 diabetes is diagnosed, then addressed as part of ongoing management.

C

2

Metformin in combination with diet and exercise is first-line therapy in children and adolescents 10 years and older who have type 2 diabetes.

C

2, 19

Insulin therapy must be initiated in children and adolescents with type 2 diabetes if they have signs of ketosis or ketoacidosis.

C

2

Insulin therapy should be initiated in children and adolescents without signs of ketosis or ketoacidosis who have random plasma glucose levels of at least 250 mg per dL (13.9 mmol per L), or whose A1C level is greater than 9%.

C

2, 21

A1C levels should be checked every three months in children and adolescents with type 2 diabetes.

C

2

Comorbidities such as hypertension, hyperlipidemia, nephropathy, and retinopathy should be assessed in children and adolescents with type 2 diabetes.

C

6, 11, 22


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The incidence of type 2 diabetes in children and adolescents has increased worldwide over the past three decades.1 Type 2 diabetes accounts for one in three new cases of diabetes diagnosed in children and adolescents in the United States.2 This increase has coincided with the obesity epidemic, and minority groups are disproportionately affected at all ages.3,4 Some studies have shown that children of women with gestational diabetes are at greater risk of type 2 diabetes.5

Physicians and health care systems are ill-equipped to handle the challenges associated with type 2 diabetes in children. Most education materials designed for children address type 1 diabetes.2 This article reviews recommendations from a clinical practice guideline by the American Academy of Pediatrics.2 It also highlights the American Diabetes Association's current clinical practice recommendations.6

Clinical Presentation, Diagnosis, and Screening

Children with type 2 diabetes may present as symptomatic or asymptomatic. As in type 1 diabetes, the symptoms of hyperglycemia include polyuria, polydipsia, and unintentional weight loss. The initial presentation can also include diabetic ketoacidosis. Asymptomatic children (up to 40% of cases) are typically early in the disease process and are often identified during screening for hyperglycemia because of the presence of diabetes risk factors.7

There is considerable overlap between type 1 and type 2 diabetes in children, and patients can have features of both. Although overweight and obesity are associated with type 2 diabetes, 24% of children with type 1 diabetes are overweight at diagnosis.6 Autoantibodies to insulin, islet cell cytoplasm, glutamic acid decarboxylase, tyrosine phosphatase (insulinoma associated), or zinc-activated channels are present in 85% to 98% of children with type 1 diabetes and can be useful in confirming this diagnosis.8 However, glutamic acid decarboxylase and islet antigen-2 antibodies may be present in up to 10% of children with clinically diagnosed type 2 diabetes.9 Reports suggest that up to 25% of children and adolescents who present with ketoacidosis have type 2 diabetes.10

Accurate diagnosis is based on a combination of clinical presentation and the patient history. There are currently no recommendations for diagnostic laboratory testing in children.

The American Diabetes Association recommends screening for type 2 diabetes beginning at 10 years of age or the onset of puberty in children who are overweight (body mass index or weight for height greater than the 85th percentile, or weight for ideal height greater than the 120th percentile) and have two additional risk factors (Table 1).2,6,11,12

 Enlarge     Print

TABLE 1

Indications to Screen for Type 2 Diabetes Mellitus in Children and Adolescents

Patient is overweight (body mass index > 85th percentile for age and sex, weight for height > 85th percentile, or weight for ideal height > 120th percentile)

Plus any two of the following risk factors:

Family history of type 2 diabetes (first- or second-degree relatives)

High-risk race/ethnicity: Asian, black, Hispanic, Native American, or Pacific Islander

Maternal history of diabetes or gestational diabetes

Signs of insulin resistance or conditions associated with insulin resistance (e.g., acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, small-for-gestational age birth weight)


Note: Screening should be performed at 10 years of age or onset of puberty, whichever is earlier. If results are negative, screening should be repeated at least every three years (more frequently if body mass index increases).

Adapted with permission from American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):386, with additional information from references 2, 6, and 11.

TABLE 1

Indications to Screen for Type 2 Diabetes Mellitus in Children and Adolescents

Patient is overweight (body mass index > 85th percentile for age and sex, weight for height > 85th percentile, or weight for ideal height > 120th percentile)

Plus any two of the following risk factors:

Family history of type 2 diabetes (first- or second-degree relatives)

High-risk race/ethnicity: Asian, black, Hispanic, Native American, or Pacific Islander

Maternal history of diabetes or gestational diabetes

Signs of insulin resistance or conditions associated with insulin resistance (e.g., acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, small-for-gestational age birth weight)


Note: Screening should be performed at 10 years of age or onset of puberty, whichever is earlier. If results are negative, screening should be repeated at least every three years (more frequently if body mass index increases).

Adapted with permission from American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):386, with additional information from references 2, 6, and 11.

Diagnostic criteria for type 2 diabetes in children are the same as for adults: a fasting blood glucose level of at least 126 mg per dL (7.0 mmol per L), a two-hour plasma glucose level of at least 200 mg per dL (11.1 mmol per L) during an oral glucose tolerance test, an A1C level of 6.5% or greater, or a random plasma glucose level of at least 200 mg per dL plus symptoms of polyuria, polydipsia, or unintentional weight loss11 (Table 2 2,6,11,12).

 Enlarge     Print

TABLE 2

Diagnostic Criteria for Type 2 Diabetes Mellitus

A1C ≥ 6.5%

Fasting (more than eight hours) blood glucose ≥ 126 mg per dL (7.0 mmol per L)

Random plasma glucose ≥ 200 mg per dL (11.1 mmol per L) with signs or symptoms of type 2 diabetes (e.g., polyuria, polydipsia, unintentional weight loss)

Two-hour plasma glucose ≥ 200 mg per dL during oral glucose tolerance test using 1.75 g glucose per kg body weight (up to 75 g)


Adapted with permission from American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):382, with additional information from references 2, 6, and 11.

TABLE 2

Diagnostic Criteria for Type 2 Diabetes Mellitus

A1C ≥ 6.5%

Fasting (more than eight hours) blood glucose ≥ 126 mg per dL (7.0 mmol per L)

Random plasma glucose ≥ 200 mg per dL (11.1 mmol per L) with signs or symptoms of type 2 diabetes (e.g., polyuria, polydipsia, unintentional weight loss)

Two-hour plasma glucose ≥ 200 mg per dL during oral glucose tolerance test using 1.75 g glucose per kg body weight (up to 75 g)


Adapted with permission from American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):382, with additional information from references 2, 6, and 11.

The validity of A1C in the diagnosis of type 2 diabetes in children has been questioned because of inaccuracies among certain ethnicities and comorbidities (e.g., sickle-cell trait).13 The American Diabetes Association continues to support the use of A1C levels for diagnosis, while acknowledging a lack of studies supporting its use in children with type 2 diabetes.6

Management

Management of type 2 diabetes should be focused on a multidisciplinary, family-centered, culturally appropriate approach.2 Primary care physicians should work closely with a team of subspecialists trained in the care of children and adolescents with type 2 diabetes if available, practical, and appropriate,2 especially if treatment goals are not met.2

NONPHARMACOLOGIC MANAGEMENT

Nutritional Counseling. Clinicians should focus on nutritional counseling for children with type 2 diabetes at the time of diagnosis and as a part of ongoing management.2 Clinicians should consider referral to a registered dietitian who has expertise in treating children with type 2 diabetes. Healthy eating patterns should be encouraged, with an emphasis on consuming nutrient-dense, high-quality foods and reducing calorie-dense, nutrient-poor foods.6,14 The target body mass index for children with type 2 diabetes is less than the 85th percentile for age and sex.6

Exercise Counseling. Exercise counseling should also be addressed at the time type 2 diabetes is diagnosed and as a part of ongoing management.2 Clinicians should encourage patients to engage in moderate to vigorous exercise for at least 60 minutes per day and to limit nonacademic screen time to less than two hours per day.2 Exercise can be completed in multiple shorter sessions. Clinicians should recognize the potential effects of exercise on the need for hypoglycemic medication and adjust the dosage accordingly, especially in patients receiving insulin.2,15

Family Involvement. Lifestyle changes are most successful when the patient's entire family is involved.2,16 Engaging family members also improves medication adherence.2 Because type 2 diabetes disproportionately affects minorities, clinicians should ensure that family-centered education is culturally appropriate.2 Children and adolescents should self-manage their diabetes to the extent appropriate for their age.17 The psychosocial effects of diabetes should be addressed to help children and adolescents cope with the disease.17

PHARMACOLOGIC MANAGEMENT

Metformin and insulin are the only medications for type 2 diabetes that are approved by the U.S. Food and Drug Administration for use in children and adolescents.18 Metformin in combination with diet and exercise is first-line therapy in children 10 years and older.2,19 Metformin should be initiated at a dosage of 500 mg per day, regardless of the patient's weight, then titrated in 500-mg intervals over four weeks to the maximum dosage of 2,000 mg per day.20

Although newly diagnosed type 2 diabetes may respond to metformin and lifestyle changes, insulin therapy must be initiated if the patient has signs of ketosis or ketoacidosis.2 Insulin is also recommended for patients without signs of ketosis or ketoacidosis who have random plasma glucose levels of 250 mg per dL (13.9 mmol per L) or greater, or whose A1C level is greater than 9%.2 Insulin may be beneficial for these patients on a short-term basis and can be discontinued after initiating metformin therapy and lifestyle changes.21

Monitoring Glycemic Control. The American Academy of Pediatrics recommends that clinicians monitor A1C levels every three months in children and adolescents with type 2 diabetes.2 The suggested target is less than 7%; however, this is supported only by expert opinion because no randomized controlled trials have established the relationship between glycemic control and the risk of microvascular complications in this population.2 Individualized goals are acceptable if an A1C target of less than 7% is unattainable.2 If glycemic control is not achieved, the treatment regimen should be intensified (e.g., more frequent clinic visits and blood glucose monitoring, modification or addition of medication, change in diet and exercise regimens).

Self-monitored blood glucose (finger-prick) testing should be performed at least three times per day in children who are on insulin therapy, whose dosage or treatment regimen is changing, who have comorbid illness, or who are not meeting goals for glycemic control.2

Comorbidities

Comorbidities such as hypertension, hyperlipidemia, nephropathy, and retinopathy may already be present at the time of diagnosis of type 2 diabetes in children and adolescents.6,22 Because the risk of diabetes-related complications is related to the duration of the disease, prompt diagnosis and appropriate therapy are important.11 At diagnosis and annually thereafter, a lipid panel and liver function tests should be ordered, and the patient should be evaluated for microalbuminuria, retinopathy, and sleep apnea.11,23 The American Diabetes Association also recommends routine blood pressure checks in children and adolescents with type 2 diabetes.6  The timeline for these and other screening recommendations is summarized in Table 3.2,6,11,17,24,25 Children and adolescents with high-normal blood pressure (systolic or diastolic blood pressure in 90th percentile or greater for age, sex, and height) or hypertension (95th percentile or greater) on three separate occasions should be treated.6 Patients with high-normal blood pressure should focus on dietary modification and increased exercise. Those with hypertension should be started on an angiotensin-converting enzyme inhibitor.6

 Enlarge     Print

TABLE 3

Schedule for Recommended Care of Children and Adolescents with Type 2 Diabetes Mellitus

At diagnosis

Assess baseline A1C level, order lipid panel and liver function tests, and screen for retinopathy

Begin diabetes education for patient and family

Check blood pressure

Establish goals of care and treatment requirements

Evaluate for microalbuminuria and sleep apnea

Provide nutritional and exercise counseling

Once

Administer one dose of 23-valent pneumococcal polysaccharide vaccine (Pneumovax) at least eight weeks after previous dose of 13-valent pneumococcal conjugate vaccine (Prevnar 13)

Quarterly

Assess A1C level

Assess psychosocial adherence, self-management skills, dietary needs, and physical activity level

Check blood pressure

Review self-managed blood glucose records (when indicated)

Annually

Administer influenza vaccine

Evaluate for microalbuminuria and sleep apnea

Order lipid panel and liver function tests, and screen for retinopathy


Information from references 2, 6, 11, 17, 24, and 25.

TABLE 3

Schedule for Recommended Care of Children and Adolescents with Type 2 Diabetes Mellitus

At diagnosis

Assess baseline A1C level, order lipid panel and liver function tests, and screen for retinopathy

Begin diabetes education for patient and family

Check blood pressure

Establish goals of care and treatment requirements

Evaluate for microalbuminuria and sleep apnea

Provide nutritional and exercise counseling

Once

Administer one dose of 23-valent pneumococcal polysaccharide vaccine (Pneumovax) at least eight weeks after previous dose of 13-valent pneumococcal conjugate vaccine (Prevnar 13)

Quarterly

Assess A1C level

Assess psychosocial adherence, self-management skills, dietary needs, and physical activity level

Check blood pressure

Review self-managed blood glucose records (when indicated)

Annually

Administer influenza vaccine

Evaluate for microalbuminuria and sleep apnea

Order lipid panel and liver function tests, and screen for retinopathy


Information from references 2, 6, 11, 17, 24, and 25.

Further Study

There is only limited evidence for medical interventions in children and adolescents with type 2 diabetes. Future studies should explore whether lifestyle changes without pharmacotherapy are a reliable first step in treating selected children with type 2 diabetes. Although metformin and insulin are the only agents approved by the U.S. Food and Drug Administration for the management of type 2 diabetes in children, research studies are examining the use of thiazolidinediones and incretins in adolescents.24,25

This article updates a previous article on this topic by Peterson, et al.17

Data Sources: We searched Essential Evidence, the Cochrane database, the Agency for Healthcare Research and Quality evidence reports, Medline, PubMed, and the U.S. Preventive Services Task Force websites using the key words type 2 diabetes and children. Search dates: March 2017 and July 2018.

The Authors

show all author info

HANNA XU, MD, is a core faculty member in the Family Medicine Residency Program at Cook County Health and Hospitals System, Chicago, Ill....

MICHAEL C. VERRE, MD, is an instructor in the Department of Pediatrics at Northwestern University Feinberg School of Medicine, Chicago.

Address correspondence to Hanna Xu, MD, John H. Stroger Hospital of Cook County, 1969 W. Ogden Ave., Chicago, IL 60612 (e-mail: hanna.xu@cookcountyhhs.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Mayer-Davis EJ, Lawrence JM, Dabelea D, et al.; SEARCH for Diabetes in Youth Study. Incidence trends of type 1 and type 2 diabetes among youths, 2002–2012. N Engl J Med. 2017;376(15):1419–1429....

2. Copeland KC, Silverstein J, Moore KR, et al.; American Academy of Pediatrics. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents [published correction appears in Pediatrics. 2013;131(5):1014]. Pediatrics. 2013;131(2):364–382.

3. Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effectiveness of primary care interventions for weight management in children and adolescents: an updated, targeted systematic review for the USPSTF. Evidence synthesis no. 76. AHRQ publication no. 10-05144-EF-1. Rockville, Md.: Agency for Healthcare Research and Quality; 2010.

4. Mayer-Davis EJ, Bell RA, Dabelea D, et al. The many faces of diabetes in American youth: type 1 and type 2 diabetes in five race and ethnic populations: the SEARCH for Diabetes in Youth Study. Diabetes Care. 2009;32(suppl 2):S99–S101.

5. American Diabetes Association. Classification and diagnosis of diabetes: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(suppl 1):S13–S27.

6. American Diabetes Association. Children and adolescents: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(suppl 1):S126–S136.

7. Mayer-Davis EJ, Beyer J, Bell RA, et al.; SEARCH for Diabetes in Yourth Study Group. Diabetes in African American youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study. Diabetes Care. 2009;32(suppl 2):S112–S122.

8. Dabelea D, Pihoker C, Talton JW, et al. Etiological approach to characterization of diabetes type: the SEARCH for Diabetes in Youth Study. Diabetes Care. 2011;34(7):1628–1633.

9. Klingensmith GJ, Pyle L, Arslanian S, et al. The presence of GAD and IA-2 antibodies in youth with a type 2 diabetes phenotype: results from the TODAY study. Diabetes Care. 2010;33(9):1970–1975.

10. Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents. Lancet. 2007;369(9575):1823–1831.

11. Dileepan K, Feldt MM. Type 2 diabetes mellitus in children and adolescents. Pediatr Rev. 2013;34(12):541–548.

12. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):381–389.

13. Buse JB, Kaufman FR, Linder B, Hirst K, El Ghormli L, Willi S; HEALTHY Study Group. Diabetes screening with hemoglobin A(1c) versus fasting plasma glucose in a multiethnic middle-school cohort. Diabetes Care. 2013;36(2):429–435.

14. Academy of Nutrition and Dietetics. Pediatric weight management (PWM) guideline (2015) [login required]. https://www.andeal.org/topic.cfm?menu=5296&cat=563. Accessed March 15, 2018.

15. Smart CE, Annan F, Bruno LP, Higgins LA, Acerini CL. ISPAD clinical practice consensus guidelines 2014. Nutritional management in children and adolescents with diabetes. Pediatr Diabetes. 2014;15(suppl 20):135–153.

16. Venditti EM, Tan K, Chang N, et al.; TODAY Study Group. Barriers and strategies for oral medication adherence among children and adolescents with type 2 diabetes. Diabetes Res Clin Pract. 2018;139:24–31.

17. Peterson K, Silverstein J, Kaufman F, Warren-Boulton E. Management of type 2 diabetes in youth: an update. Am Fam Physician. 2007;76(5):658–664.

18. Nadeau KJ, Anderson BJ, Berg EG, et al. Youth-onset type 2 diabetes consensus report: current status, challenges, and priorities. Diabetes Care. 2016;39(9):1635–1642.

19. Garber AJ, Duncan TG, Goodman AM, Mills DJ, Rohlf JL. Efficacy of metformin in type II diabetes: results of a double-blind, placebo-controlled, dose-response trial. Am J Med. 1997;103(6):491–497.

20. Zeitler P, Epstein L, Grey M, et al.; TODAY Study Group. Treatment options for type 2 diabetes in adolescents and youth: a study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes. Pediatr Diabetes. 2007;8(2):74–87.

21. Gungor N, Hannon T, Libman I, Bacha F, Arslanian S. Type 2 diabetes mellitus in youth: the complete picture to date. Pediatr Clin North Am. 2005;52(6):1579–1609.

22. Rodriguez BL, Dabelea D, Liese AD; et al.SEARCH Study Group. Prevalence and correlates of elevated blood pressure in youth with diabetes mellitus: the SEARCH for Diabetes in Youth Study. J Pediatr. 2010;157(2):245–251.e1.

23. Donaghue KC, Wadwa RP, Dimeglio LA, et al. ISPAD clinical practice consensus guidelines 2014. Microvascular and macrovascular complications in children and adolescents. Pediatr Diabetes. 2014;15(suppl 20):257–269.

24. Rapaport R, Silverstein JH, Garzarella L, Rosenbloom AL. Type 1 and type 2 diabetes mellitus in childhood in the United States: practice patterns by pediatric endocrinologists. J Pediatr Endocrinol Metab. 2004;17(6):871–877.

25. Centers for Disease Control and Prevention. Pneumococcal disease: pneumococcal vaccination. September 6, 2017. https://www.cdc.gov/pneumococcal/vaccination.html. Accessed March 15, 2018.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2019

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article