Type 1 Diabetes in Children and Adolescents

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Diane Wherrett MD, FRCPC Céline Huot MD, MSc, FRCPC Beth Mitchell PhD, Cpsych Danièle Pacaud MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis (DKA).
  • Management of pediatric DKA differs from DKA in adults because of the increased risk for cerebral edema. Pediatric protocols should be used.
  • Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise.
  • Note: Unless otherwise specified, the term “child” or “children” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age.

Introduction

Diabetes mellitus is the most common endocrine disease and one of the most common chronic conditions in children. Type 2 diabetes and other types of diabetes, including genetic defects of beta cell function, such as maturity-onset diabetes of the young, are being increasingly recognized in children and should be considered when clinical presentation is atypical for type 1 diabetes. This section addresses those areas of type 1 diabetes management that are specific to children.

Education

Children with new-onset type 1 diabetes and their families require intensive diabetes education by an interdisciplinary pediatric diabetes healthcare (DHC) team to provide them with the necessary skills and knowledge to manage this disease. The complex physical, developmental and emotional needs of children and their families necessitate specialized care to ensure the best long-term outcomes (1,2). Education topics must include insulin action and administration, dosage adjustment, blood glucose (BG) and ketone testing, sick-day management and prevention of diabetic ketoacidosis (DKA), nutrition therapy, exercise, and prevention, detection, and treatment of hypoglycemia. Anticipatory guidance and lifestyle counselling should be part of routine care, especially during critical developmental transitions (e.g. upon school entry, beginning high school). Healthcare providers should regularly initiate discussions with children and their families about school, diabetes camp, psychological issues, substance use, obtaining a driver's license and career choices.

Children with new-onset diabetes who present with DKA require a short period of hospitalization to stabilize the associated metabolic derangements and to initiate insulin therapy. Outpatient education for children with new-onset diabetes has been shown to be less expensive than inpatient education and associated with similar or slightly better outcomes when appropriate resources are available (3).

Glycemic Targets

As improved metabolic control reduces both the onset and progression of diabetes-related complications in adults and adolescents with type 1 diabetes (4,5), aggressive attempts should be made to reach the recommended glycemic targets outlined in Table 1. However, clinical judgement is required to determine which children can reasonably and safely achieve these targets. Treatment goals and strategies must be tailored to each child, with consideration given to individual risk factors. Young age at diabetes onset (<7 years of age) has been associated with poorer cognitive function in many studies (6). Episodes of severe hypoglycemia have been associated with poorer cognitive function in some follow-up studies, while other studies have found chronic hyperglycemia in young children to be associated with poorer cognitive performance (7–10). Analysis from a large multicentre observational study found that knowledge of glycemic targets by patients and parents, and consistent target setting by the diabetes team, was associated with improved metabolic control (11).

Table 1
Recommended glycemic targets for children and adolescents with type 1 diabetes
A1C, glycated hemoglobin; PG, plasma glucose.
Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available.
In adolescents in whom it can be safely achieved, consider aiming toward normal PG range (i.e. A1C ≤6.0%, fasting/preprandial PG 4.0–6.0 mmol/L and 2-hour postprandial PG 5.0–8.0 mmol/L).
Age (years) A1C (%) Fasting/preprandial PG (mmol/L) Two-hour postprandial PG (mmol/L) Considerations
<6 <8.0 6.0–10.0 Caution is required to minimize hypoglycemia because of the potential association between severe hypoglycemia and later cognitive impairment. Consider target of <8.5% if excessive hypoglycemia occurs
6–12 ≤7.5 4.0–10.0 Targets should be graduated to the child's age. Consider target of <8.0% if excessive hypoglycemia occurs.
13–18 ≤7.0 4.0–7.0 5.0–10.0 Appropriate for most adolescents.

Insulin Therapy

Insulin therapy is the mainstay of medical management of type 1 diabetes. A variety of insulin regimens can be used, but few have been studied specifically in children with new-onset diabetes. The choice of insulin regimen depends on many factors, including the child's age, duration of diabetes, family lifestyle, socioeconomic factors, and family, patient, and physician preferences. Regardless of the insulin regimen used, all children should be treated to meet glycemic targets.

The honeymoon period, which can last up to 2 years after diagnosis, is characterized by good glycemic control and low insulin requirements (<0.5 units/kg/day). At the end of this period, more intensive management may be required to continue meeting glycemic targets. Two methods of intensive diabetes management have been used: basal-bolus regimens (long-acting basal insulin analogues and rapid-acting bolus insulin analogues) and continuous subcutaneous insulin infusion (CSII; insulin pump therapy). Basal-bolus therapy has resulted in improved control over traditional twice daily NPH and rapid-acting bolus analogue therapy in some but not all studies (12,13). CSII is safe and effective and can be initiated at any age (14). A Cochrane review found that CSII gave slightly improved metabolic control over basal-bolus therapy (15). Some clinic-based studies of CSII in school-aged children and adolescents have shown a significant reduction in glycated hemoglobin (A1C) with reduced hypoglycemia 12 to 24 months after initiation of CSII when compared to pre-CSII levels (16). CSII, with use of a continuous glucose sensor, resulted in improved control over basal-bolus therapy alone (17). Most, but not all, pediatric studies of the long-acting basal insulin analogues, detemir and glargine, have demonstrated improved fasting BG levels and fewer episodes of nocturnal hypoglycemia with a reduction in A1C (12,18–20). Two large population-based observational studies have not found improved A1C in patients using basal-bolus therapy or CSII when compared to those using NPH and rapid-acting bolus analogues (21,22). Individualization of insulin therapy to reach A1C targets, minimize hypoglycemia and optimize quality of life is indicated.

Glucose Monitoring

Self-monitoring of BG is an essential part of management of type 1 diabetes (23). Subcutaneous continuous glucose sensors allow detection of asymptomatic hypoglycemia and hyperglycemia. Use has resulted in improved diabetes control with less hypoglycemia in some studies. A randomized controlled trial did not show improved control in children and adolescents but did in adults (24). Benefit correlated with duration of sensor use, which was much lower in children and adolescents.

Nutrition

All children with type 1 diabetes should receive counselling from a registered dietitian experienced in pediatric diabetes. Children with diabetes should follow a healthy diet as recommended for children without diabetes in Eating Well with Canada's Food Guide (25). This involves consuming a variety of foods from the 4 food groups (grain products, vegetables and fruits, milk and alternatives, and meat and alternatives). There is no evidence that 1 form of nutrition therapy is superior to another in attaining age-appropriate glycemic targets. Appropriate matching of insulin to carbohydrate content may allow increased flexibility and improved glycemic control (26,27), but the use of insulin to carbohydrate ratios is not required. The effect of protein and fat on glucose absorption must also be considered. Nutrition therapy should be individualized (based on the child's nutritional needs, eating habits, lifestyle, ability and interest) and must ensure normal growth and development without compromising glycemic control. This plan should be evaluated regularly and at least annually. Features suggestive of eating disorders and of celiac disease should be systematically sought out (28).

Hypoglycemia

Hypoglycemia is a major obstacle for children with type 1 diabetes and can affect their ability to achieve glycemic targets. Children with early-onset diabetes are at greatest risk for disruption of cognitive function and neuropsychological skills, but the respective roles of hypoglycemia and hyperglycemia in their development are still questioned (6,29). Significant risk of hypoglycemia often necessitates less stringent glycemic goals, particularly for younger children. There is no evidence in children that 1 insulin regimen or mode of administration is superior to another for resolving nonsevere hypoglycemia. As such, treatment must be individualized (30). Frequent use of continuous glucose monitoring in a clinical care setting may reduce episodes of hypoglycemia (31). Severe hypoglycemia should be treated with pediatric doses of intravenous (IV) dextrose in the hospital setting or glucagon in the home setting. In children, the use of mini-doses of glucagon has been shown to be useful in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate. A dose of 10 μg per year of age (minimum dose 20 μg, maximum dose 150 μg) is effective at treating and preventing hypoglycemia, with an additional doubled dose given if the BG has not increased in 20 minutes (32,33). See Table 2 for treatment of mild-to-moderate hypoglycemia.

Chronic Poor Metabolic Control

Diabetes control may worsen during adolescence. Factors responsible for this deterioration include adolescent adjustment issues, psychosocial distress, intentional insulin omission and physiological insulin resistance. A careful multidisciplinary assessment should be undertaken for every child with chronic poor metabolic control (e.g. A1C >10.0%) to identify potential causative factors, such as depression and eating disorders, and to identify and address barriers to improved control. Multipronged interventions that target emotional, family and coping issues show a modest reduction in A1C with reduced rates of hospital admission (34,35).

Table 2
Examples of carbohydrate for treatment of mild-to-moderate hypoglycemia
Patient weight <15 kg 15–30 kg >30 kg
Amount of carbohydrate 5 g 10 g 15 g
Carbohydrate source      
Glucose tablet (4 g) 1 2 or 3 4
Dextrose tablet (3 g) 2 3 5
Apple or orange juice, regular soft drink, sweet beverage (cocktails) 40 mL 85 mL 125 mL

DKA

DKA occurs in 15% to 67% of children with new-onset diabetes and at a frequency of 1 to 10 episodes per 100 patient years in those with established diabetes (36). As DKA is the leading cause of morbidity and mortality in children with diabetes, strategies are required to prevent the development of DKA (37). In new-onset diabetes, DKA can be prevented through earlier recognition and initiation of insulin therapy. Public awareness campaigns about the early signs of diabetes have significantly reduced the frequency of DKA in new-onset diabetes (38). In children with established diabetes, DKA results from failing to take insulin or poor sick-day management. Risk is increased in children with poor metabolic control or previous episodes of DKA, peripubertal and adolescent girls, children on insulin pumps or long-acting basal insulin analogues, children with psychiatric disorders and those with difficult family circumstances (39–41). The frequency of DKA in established diabetes can be decreased with education, behavioural intervention and family support (42,43), as well as access to 24-hour telephone services for parents of children with diabetes (44,45).

Management of DKA

While most cases of DKA are corrected without event, 0.7% to 3.0% of pediatric cases are complicated by cerebral edema (CE) (46), which is associated with significant morbidity (21% to 35%) and mortality (21% to 24%) (47). In contrast, CE has rarely been reported in adults (39,47). Although the cause of CE is still unknown, several factors are associated with increased risk ( Table 3 ) (48–52). A bolus of insulin prior to infusion is not recommended since it does not offer faster resolution of acidosis (53,54) and may contribute to CE (55). Recent evidence suggests early insulin administration (within the first hour of fluid replacement) may increase the risk for CE (52). Special caution should be exercised in young children with DKA and new-onset diabetes or a greater degree of acidosis and extracellular fluid volume depletion because of the increased risk of CE. Use of bedside criteria may allow earlier identification of patients who require treatment for CE (56). DKA should be managed according to published protocols for management of pediatric DKA ( Figure 1) (57).

Immunization

Historically, national guidelines have recommended influenza and pneumococcal immunization for children with type 1 diabetes (58–60). Currently, there is no evidence supporting increased morbidity or mortality from influenza or pneumococcus in children with type 1 diabetes (61,62). However, the management of type 1 diabetes can be complicated by illness, requiring parental knowledge of sick-day management and increased attention during periods of illness. For this reason, parents may choose to immunize their children. Long-lasting immunogenicity to influenza vaccination has been shown to be adequate in these children (63).

Smoking Prevention and Cessation

Smoking is a significant risk factor for both macrovascular and microvascular complications of diabetes (64) and, in adolescents, is associated with worse metabolic control (65). Smoking prevention should be emphasized throughout childhood and adolescence.

Table 3
Risk factors for cerebral edema
IV, intravenous.
  • Younger age (<5 years)
  • New-onset diabetes
  • High initial serum urea
  • Low initial partial pressure of arterial carbon dioxide (pCO 2 )
  • Rapid administration of hypotonic fluids
  • IV bolus of insulin
  • Early IV insulin infusion (within first hour of administration of fluids)
  • Failure of serum sodium to rise during treatment
  • >Use of bicarbonate

Contraception and Sexual Health Counselling

Adolescents with diabetes should receive regular counselling about sexual health and contraception. Unplanned pregnancies should be avoided, as pregnancy in adolescent females with type 1 diabetes with suboptimal metabolic control may result in higher risks of maternal and fetal complications than in older women with type 1 diabetes who are already at increased risk compared to the general population (66).

Psychological Issues

For children, and particularly adolescents, there is a need to identify psychological disorders associated with diabetes and to intervene early to minimize the impact over the course of development.

Psychological/psychiatric risks

Children and adolescents with diabetes have significant risks for psychological problems, including depression, anxiety, eating disorders and externalizing disorders (67–69). The risks increase exponentially during adolescence (70,71). Studies have shown that psychological disorders predict poor diabetes management and control (72–75) and, consequently, negative medical outcomes (76–79). Conversely, as glycemic control worsens, the probability of psychological problems increases (80).

The presence of psychological symptoms and diabetes problems in children and adolescents are often strongly affected by caregiver/family distress. Research has demonstrated that while parental psychological issues may distort perceptions of the child's diabetes control (81), often, they are related to poor psychological adjustment and diabetes control (82–85). Maternal anxiety and depression are associated with poor diabetes control in younger adolescents and with reduced positive effect and motivation in older teens (86).

Eating disorders

Ten percent of adolescent females with type 1 diabetes meet the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) criteria for eating disorders compared to 4% of their age-matched peers without diabetes (87). Furthermore, eating disorders are associated with poor metabolic control and earlier onset and more rapid progression of microvascular complications (88). Eating disorders should be suspected in those adolescent and young adult females who are unable to achieve and maintain metabolic targets, especially when insulin omission is suspected. It is important to identify individuals with eating disorders because different management strategies are required to optimize metabolic control and prevent microvascular complications (87–89).

Prevention and intervention

Children and adolescents with diabetes, along with their families, should be screened throughout their development for psychological disorders (90). Given the prevalence of psychological issues, screening in this area can be seen as equally important as screening for microvascular complications in children and adolescents with diabetes (91).

Psychological interventions with children and adolescents, as well as families, have been shown to improve mental health (67,92), including overall well-being and perceived quality of life (93), along with depressive symptoms (94,95). In addition, there is some evidence that psychosocial interventions can positively affect glycemic control (34,92,96). Most importantly, some studies have demonstrated that psychological interventions can increase both diabetes treatment adherence and glycemic control, as well as psychosocial functioning (97,98).

Figure 1
Immediate assessment and management of diabetic ketoacidosis (DKA) in children.

BG, blood glucose; ECG, electrocardiogram; ICU, intensive care unit; IV, intravenous; PG, plasma glucose; SC, subcutaneous. Adapted with permission from 57. Wolfsdorf J, Craig ME, Daneman D, et al; for the International Society for Pediatric and Adolescent Diabetes. Diabetic ketoacidosis. Pediatr Diabetes. 2007;8:28-43.

Table 4
Recommendations for screening for comorbid conditions in children with type 1 diabetes
TSH, thyroid-stimulating hormone.
Condition Indications for screening Screening test Frequency
Autoimmune thyroid disease All children with type 1 diabetes Serum TSH level + thyroperoxidase antibodies At diagnosis and every 2 years thereafter
Positive thyroid antibodies, thyroid symptoms or goiter Serum TSH level + thyroperoxidase antibodies Every 6–12 months
Addison's disease Unexplained recurrent hypoglycemia and decreasing insulin requirements 8 am serum cortisol + serum sodium and potassium As clinically indicated
Celiac disease Recurrent gastrointestinal symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic control Tissue transglutaminase + immunoglobulin A levels As clinically indicated

Comorbid Conditions

Autoimmune thyroid disease

Clinical autoimmune thyroid disease (AITD) occurs in 15% to 30% of individuals with type 1 diabetes (99). The risk for AITD during the first decade of diabetes is directly related to the presence or absence of thyroid antibodies at diabetes diagnosis (100). Hypothyroidism is most likely to develop in girls at puberty (101). Early detection and treatment of hypothyroidism will prevent growth failure and symptoms of hypothyroidism ( Table 4 ). Hyperthyroidism also occurs more frequently in association with type 1 diabetes than in the general population.

Addison's disease

Addison's disease is rare, even in those with type 1 diabetes (102). Targeted screening is required in those with unexplained recurrent hypoglycemia and decreasing insulin requirements ( Table 4 ).

Celiac disease

Celiac disease can be identified in 4% to 9% of children with type 1 diabetes (99), but in 60% to 70% of these children the disease is asymptomatic (silent celiac disease). Children with type 1 diabetes are at increased risk for classic or atypical celiac disease during the first 10 years of diabetes (103). There is good evidence that treatment of classic or atypical celiac disease with a gluten-free diet improves intestinal and extraintestinal symptoms (104) and prevents the long-term sequelae of untreated classic celiac disease (105). However, there is no evidence that untreated asymptomatic celiac disease is associated with short- or long-term health risks (106) or that a gluten-free diet improves health in these individuals (107). Thus, universal screening for and treatment of asymptomatic celiac disease remains controversial ( Table 4 ).

Table 5
Screening for diabetes complications, dyslipidemia and hypertension in children with type 1 diabetes
ACR, albumin to creatinine ratio.
Complication Indications and intervals for screening Screening method
Nephropathy
  • Yearly screening commencing at 12 years of age in those with duration of type 1 diabetes >5 years
  • First morning (preferred) or random ACR
  • Abnormal ACR requires confirmation at least 1 month later with a first morning ACR and, if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate
  • Repeated sampling should be done every 3–4 months over a 12-month period to demonstrate persistence
Retinopathy
  • Yearly screening commencing at 15 years of age with duration of type 1 diabetes >5 years
  • Screening interval can increase to 2 years if good glycemic control, duration of diabetes <10 years and no retinopathy at initial assessment
  • Standard field, stereoscopic colour fundus photography with interpretation by a trained reader (gold standard), or
  • Direct ophthalmoscopy or indirect slit-lamp funduscopy through dilated pupil, or
  • Digital fundus photography
Neuropathy
  • Postpubertal adolescents with poor metabolic control should be screened yearly after 5 years' duration of type 1 diabetes
  • Question and examine for symptoms of numbness, pain, cramps and paraesthesia, as well as skin sensation, vibration sense, light touch and ankle reflexes
Dyslipidemia
  • Delay screening after diabetes diagnosis until metabolic control has stabilized
  • Screen at 12 and 17 years of age
  • <12 years of age: screen only those with body mass index >95th percentile, family history of hyperlipidemia or premature cardiovascular disease
  • Fasting total cholesterol, high-density lipoprotein cholesterol, triglycerides, calculated low-density lipoprotein cholesterol
Hypertension
  • Screen all children with type 1 diabetes at least twice a year
  • Use appropriate cuff size

Diabetes Complications

There are important age-related considerations regarding surveillance for diabetes complications and interpretation of investigations ( Table 5 ).

Nephropathy

Prepubertal children and those in the first five years of diabetes should be considered at very low risk for microalbuminuria (108,109). A first morning urine albumin to creatinine ratio (ACR) has high sensitivity and specificity for the detection of microalbuminuria (110,111). Although screening with a random ACR is associated with greater compliance than with a first morning sample, its specificity may be compromised in adolescents due to their higher frequency of exercise-induced proteinuria and benign postural proteinuria. Abnormal random ACRs (>2.5 mg/mmol) require confirmation with a first morning ACR or timed urine overnight collection (112).

Microalbuminuria is rare in prepubertal children, regardless of the duration of diabetes or metabolic control (108). Furthermore, the likelihood of transient or intermittent microalbuminuria is higher during the early peripubertal years (109). Individuals with transient or intermittent microalbuminuria may be at increased risk of progression to overt nephropathy (113). Abnormal screening results require confirmation and follow-up to demonstrate persistent abnormalities.

Treatment is indicated only for those adolescents with persistent microalbuminuria. One short-term randomized controlled trial in adolescents demonstrated that angiotensin-converting enzyme (ACE) inhibitors were effective in reducing microalbuminuria compared to placebo (114). However, there are no long-term intervention studies assessing the effectiveness of ACE inhibitors or angiotensin II receptor antagonists in delaying progression to overt nephropathy in adolescents with microalbuminuria. Therefore, treatment of adolescents with persistent microalbuminuria is based on the effectiveness of treatments in adults with type 1 diabetes (115).

Retinopathy

Retinopathy is rare in prepubertal children with type 1 diabetes and in postpubertal adolescents with good metabolic control (116,117).

Neuropathy

When present, neuropathy is mostly subclinical in children (118). While prospective nerve conduction studies and autonomic neuropathy assessment studies have demonstrated increased prevalence of abnormalities over time (119), persistence of abnormalities is an inconsistent finding (120). Vibration and monofilament testing have suboptimal sensitivity and specificity in adolescents (121). With the exception of intensifying diabetes management to achieve and maintain glycemic targets, no other treatment modality has been studied in children and adolescents.

Dyslipidemia

Most children with type 1 diabetes should be considered at low risk for vascular disease associated with dyslipidemia (122,123). The exceptions are those with longer duration of disease, microvascular complications or other cardiovascular disease (CVD) risk factors, including smoking, hypertension, obesity and/or family history of premature CVD (124). Dyslipidemia screening should be targeted at those >12 years of age and younger children with specific risk factors for dyslipidemia. Statin therapy has only rarely been studied specifically in children with diabetes, and there is no evidence linking specific low-density lipoprotein cholesterol (LDL-C) cutoffs in children with diabetes with long-term outcomes. In pubertal children without diabetes but with familial hypercholesterolemia, statin therapy is safe and effective at lowering LDL-C levels and attenuating progression of surrogate markers for future vascular disease (125).

Hypertension

Up to 16% of adolescents with type 1 diabetes have hypertension (126). Twenty-four-hour ambulatory blood pressure (BP) monitoring has been used to exclude white coat hypertension and to identify loss of diurnal systolic rhythm (nondippers) with nocturnal hypertension in some normotensive adolescents with type 1 diabetes (127). These abnormalities may be predictive of future microalbuminuria (127). However, the role of ambulatory BP monitoring in routine care remains uncertain. Children with type 1 diabetes and confirmed hypertension should be treated according to the guidelines for children without diabetes (128).

Transition to Adult Care

The change of physician or DHC team can have a major impact on disease management and metabolic control in the person with diabetes (129). Between 25% and 65% of young adults have no medical follow-up during the transition from pediatric to adult diabetes care services (130,131). Those with no follow-up are more likely to experience hospitalization for DKA during this period. Organized transition services may decrease the rate of loss of follow-up (132,133).

Recommendations

Delivery of care

  1. 1.All children with diabetes should have access to an experienced pediatric DHC team and specialized care starting at diagnosis [Grade D, Level 4 (1)].
  2. 2.Children with new-onset type 1 diabetes who are medically stable should receive their initial education and management in an outpatient setting, provided that appropriate personnel and daily communication with the DHC are available [Grade B, Level 1A (3)].
  3. 3.To ensure ongoing and adequate diabetes care, adolescents should receive care from a specialized program aimed at creating a well-prepared and supported transition to adult care that includes a transition coordinator, patient reminders, and support and education, with or without a joint pediatric and adult clinic [Grade C, Level 3 (132,133)].

Glycemic targets

  1. 4.Glycemic targets should be graduated with age (see Table 1 ):
    1. Children <6 years of age should aim for an A1C <8.0% [Grade D, Consensus]. Caution should be used to minimize hypoglycemia because of the potential association in this age group between severe hypoglycemia and later cognitive impairment [Grade D, Level 4 (134)].
    2. Children 6–12 years of age should aim for a target A1C ≤7.5% [Grade D, Consensus].
    3. Adolescents should aim for the same glycemic targets as adults [Grade A, Level 1A (5)].
  2. 5.Children with persistently poor glycemic control (e.g. A1C >10%) should be assessed by a specialized pediatric diabetes team for a comprehensive interdisciplinary assessment and referred for psychosocial support as indicated [Grade D, Consensus]. Intensive family and individualized psychological interventions aimed at improving glycemic control should be considered to improve chronically poor metabolic control [Grade A, Level 1A (34,35,135)].

Insulin therapy

  1. 6.Children with new-onset diabetes should be started on at least 2 daily injections of bolus insulin (e.g. short-acting bolus insulin or rapid-acting bolus insulin analogues) combined with basal insulin (e.g. intermediate-acting insulin or long-acting basal insulin analogue) [Grade D, Consensus].
  2. 7.Insulin therapy should be assessed at each clinical encounter to ensure it still enables the child to meet A1C targets, minimizes the risk of hypoglycemia and allows flexibility in carbohydrate intake, daily schedule and activities [Grade D, Consensus]. If these goals are not being met, an intensified diabetes management approach (including increased education, monitoring and contact with diabetes team) should be used [Grade A, Level 1 (4) for adolescents; Grade D, Consensus for younger children], and treatment options may include the following:
    • Increased frequency of injections [Grade D, Consensus].
    • Change in the type of basal and/or bolus insulin [Grade B, Level 2 (19), for adolescents; Grade D, Consensus, for younger children].
    • Change to continuous subcutaneous insulin infusion therapy [Grade C, Level 3 (136)].

Hypoglycemia

  1. 8.In children, the use of mini-doses of glucagon (10 μg per year of age with minimum dose 20 μg and maximum dose 150 μg) should be considered in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate [Grade D, Level 4 (32)].
  2. 9.In the home situation, severe hypoglycemia in an unconscious child >5 years of age should be treated with 1 mg glucagon subcutaneously or intramuscularly. In children ≤5 years of age, a dose of 0.5 mg glucagon should be given. The episode should be discussed with the diabetes healthcare team as soon as possible and consideration given to reducing insulin doses for the next 24 hours to prevent further severe hypoglycemia [Grade D, Consensus].
  3. 10.Dextrose 0.5–1 g/kg should be given over 1–3 minutes to treat severe hypoglycemia with unconsciousness when IV access is available [Grade D, Consensus].

Diabetic ketoacidosis (DKA)

  1. 11.To prevent DKA in children with diabetes:
    • Targeted public awareness campaigns should be considered to educate parents and other caregivers (e.g. teachers) about the early symptoms of diabetes [Grade C, Level 3 (42)].
    • Comprehensive education and support services [Grade C, Level 3 (43)], as well as 24-hour telephone services [Grade C, Level 3 (44)], should be available for families of children with diabetes.
  2. 12.DKA in children should be treated according to pediatric-specific protocols [Grade D, Consensus]. If appropriate expertise/facilities are not available locally, there should be immediate consultation with a centre with expertise in pediatric diabetes [Grade D, Consensus].
  3. 13.In children in DKA, rapid administration of hypotonic fluids should be avoided [Grade D, Level 4 (49)]. Circulatory compromise should be treated with only enough isotonic fluids to correct circulatory inadequacy [Grade D, Consensus]. Restoration of extracellular fluid volume should be extended over a 48-hour period with regular reassessments of fluid deficits [Grade D, Level 4 (49)].
  4. 14.In children in DKA, IV insulin bolus should not be given; an IV infusion of short-acting insulin should be used at an initial dose of 0.1 units/kg/h [Grade D, Level 4 (53)]. The insulin infusion should not be started until 1 hour after starting fluid replacement therapy [Grade D, Level 4 (52)].
  5. 15.In children in DKA, the insulin infusion rate should be maintained until the plasma anion gap normalizes. Once plasma glucose reaches 14.0–17.0 mmol/L, IV glucose should be started to prevent hypoglycemia [Grade D, Consensus].
  6. 16.In children in DKA, administration of sodium bicarbonate should be avoided except in extreme circulatory compromise, as this may contribute to cerebral edema [Grade D, Level 4 (48)].

Microvascular complications

  1. 17.Screening for microalbuminuria should be performed annually, commencing at 12 years of age in children with type 1 diabetes >5 years' duration [Grade D, Consensus].
  2. 18.Children ≥12 years should be screened for microalbuminuria with a first morning urine ACR (preferred) [Grade B, Level 2 (111)] or a random ACR [Grade D, Consensus]. Abnormal results should be confirmed [Grade B, Level 2 (137)] at least 1 month later with a first morning ACR or timed, overnight urine collection for albumin excretion rate [Grade D, Consensus]. Microalbuminuria (ACR >2.5 mg/mmol) should not be diagnosed in children ≥12 years unless it is persistent, as demonstrated by 2 consecutive first morning ACR or timed collections obtained at 3- to 4-month intervals over a 6- to 12-month period [Grade D, Consensus].
  3. 19.Children ≥12 years with persistent microalbuminuria should be treated per adult guidelines (see Chronic Kidney Disease chapter, p. S129) [Grade D, Consensus].
  4. 20.In children ≥15 years of age with type 1 diabetes, screening and evaluation for retinopathy by an expert professional should be performed annually, starting 5 years after the onset of diabetes [Grade D, Consensus]. The screening interval can be increased to every 2 years in children with type 1 diabetes who have good glycemic control, duration of diabetes <10 years and no significant retinopathy (as determined by an expert professional) [Grade D, Consensus].
  5. 21.Postpubertal children with type 1 diabetes of >5 years' duration and poor metabolic control should be questioned about symptoms of numbness, pain, cramps and paresthesia, and examined for skin sensation, vibration sense, light touch and ankle reflexes [Grade D, Consensus].

Comorbid conditions and other complications

  1. 22.Children and adolescents with diabetes, along with their families, should be screened regularly for psychosocial or psychological disorders [Grade D, Level 4 (108,109)] and should be referred to an expert in mental health and/or psychosocial issues for intervention when required (Grade D, Consensus).
  2. 23.Adolescent females with type 1 diabetes should be regularly screened using nonjudgemental questions about weight and body image concerns, dieting, binge eating and insulin omission for weight loss [Grade D, Consensus].
  3. 24.Children with type 1 diabetes who are <12 years of age should be screened for dyslipidemia if they have other risk factors, such as obesity (body mass index >95th percentile for age and gender) and/or a family history of dyslipidemia or premature cardiovascular disease. Routine screening for dyslipidemia should begin at 12 years of age, with repeat screening after 5 years [Grade D, Consensus].
  4. 25.Once dyslipidemia is diagnosed in children with type 1 diabetes, the dyslipidemia should be treated per lipid guidelines for adults with diabetes [Grade D, Consensus].
  5. 26.All children with type 1 diabetes should be screened for hypertension at least twice annually [Grade D, Consensus].
  6. 27.Children with type 1 diabetes and BP readings persistently above the 95th percentile for age should receive lifestyle counselling, including weight loss if overweight [Grade D, Level 4 (138)]. If BP remains elevated, treatment should be initiated based on recommendations for children without diabetes [Grade D, Consensus].
  7. 28.Influenza immunization should be offered to children with diabetes as a way to prevent an intercurrent illness that could complicate diabetes management [Grade D, Consensus].
  8. 29.Formal smoking prevention and cessation counselling should be part of diabetes management for children with diabetes [Grade D, Consensus].
  9. 30.Adolescent females with type 1 diabetes should receive counselling on contraception and sexual health in order to prevent unplanned pregnancy [Grade D, Level 4 (139)].
  10. 31.Children with type 1 diabetes who have thyroid antibodies should be considered high risk for autoimmune thyroid disease [Grade C, Level 3 (100)]. Children with type 1 diabetes should be screened at diabetes diagnosis with repeat screening every 2 years using a serum thyroid-stimulating hormone and thyroid peroxidase antibodies [Grade D, Consensus]. More frequent screening is indicated in the presence of positive thyroid antibodies, thyroid symptoms or goiter [Grade D, Consensus].
  11. 32.Children with type 1 diabetes and symptoms of classic or atypical celiac disease (see Table 4 ) should undergo celiac screening [Grade D, Consensus] and, if confirmed, be treated with a gluten-free diet to improve symptoms [Grade D, Level 4 (104)] and prevent the long-term sequelae of untreated classic celiac disease [Grade D, Level 4 (105)]. Parents should be informed that the need for screening and treatment of asymptomatic (silent) celiac disease is controversial [Grade D, Consensus].

Abbreviations:
A1C, glycated hemoglobin; ACR , albumin to creatinine ratio; BP , blood pressure; DHC , diabetes healthcare; IV , intravenous.

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