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.


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.


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.


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 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 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).


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
  • 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
  • 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
  • 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
  • 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
  • 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 ).


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


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.


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).


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).


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)].


  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].

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


  1. 1 A.M. Glasgow J. Weissberg-Benchell W.D. Tynan Readmissions of children with diabetes mellitus to a children's hospital Pediatrics 88 1991 98 104
  2. 2 S.S. von E. Muller-Godeffroy S. Hager Mobile diabetes education and care: intervention for children and young people with Type 1 diabetes in rural areas of northern Germany Diabet Med 23 2006 122 127
  3. 3 C. Clar N. Waugh S. Thomas Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus Cochrane Database Syst Rev 2 2006 CD004099
  4. 4 The Diabetes Control and Complications Trial Research Group. Effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med 329 1993 977 986
  5. 5 The Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial J Pediatr 125 1994 177 188
  6. 6 P.A. Gaudieri R. Chen T.F. Greer C.S. Holmes Cognitive function in children with type 1 diabetes: a meta-analysis Diabetes Care 31 2008 1892 1897
  7. 7 E.J. Schoenle D. Schoenle L. Molinari Impaired intellectual development in children with Type I diabetes: association with HbA(1c), age at diagnosis and sex Diabetologia 45 2002 108 114
  8. 8 S.C. Ferguson A. Blane J. Wardlaw Influence of an early-onset age of type 1 diabetes on cerebral structure and cognitive function Diabetes Care 28 2005 1431 1437
  9. 9 S.K. Strudwick C. Carne J. Gardiner Cognitive functioning in children with early onset type 1 diabetes and severe hypoglycemia J Pediatr 147 2005 680 685
  10. 10 B.O. Asvold T. Sand K. Hestad M.R. Bjorgaas Cognitive function in type 1 diabetic adults with early exposure to severe hypoglycemia: a 16-year follow-up study Diabetes Care 33 2010 Sep 1945 1947
  11. 11 P.G. Swift T.C. Skinner C.E. de Beaufort Hvidoere Study Group on Childhood Diabetes Target setting in intensive insulin management is associated with metabolic control: the Hvidoere childhood diabetes study group centre differences study 2005 Pediatr Diabetes 11 2010 271 278
  12. 12 K.J. Robertson E. Schoenle Z. Gucev Insulin detemir compared with NPH insulin in children and adolescents with Type 1 diabetes Diabet Med 24 2007 27 34
  13. 13 H.P. Chase S. Arslanian N.H. White W.V. Tamborlane Insulin glargine versus intermediate-acting insulin as the basal component of multiple daily injection regimens for adolescents with type 1 diabetes mellitus J Pediatr 153 2008 547 553
  14. 14 M. Phillip T. Battelino H. Rodriguez Use of insulin pump therapy in the pediatric age-group. Consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care 30 2007 1653 1662
  15. 15 M.L. Misso K.J. Egberts M. Page Subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus Cochrane Database Syst Rev 1 2010 CD005103
  16. 16 S.A. Weinzimer K.A. Sikes A.T. Steffen Insulin pump treatment of childhood type 1 diabetes Pediatr Clin North Am 52 2005 1677 1688
  17. 17 R.M. Bergenstal W.V. Tamborlane A. Ahmann Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes N Engl J Med 363 2010 311 320
  18. 18 R. Alemzadeh T. Berhe D.T. Wyatt Flexible insulin therapy with glargine insulin improved glycemic control and reduced severe hypoglycemia among preschool-aged children with type 1 diabetes mellitus Pediatrics 115 2005 1320 1324
  19. 19 N.P. Murphy S.M. Keane K.K. Ong Randomized cross-over trial of insulin glargine plus lispro or NPH insulin plus regular human insulin in adolescents with type 1 diabetes on intensive insulin regimens Diabetes Care 26 2003 799 804
  20. 20 K. Hassan L.M. Rodriguez S.E. Johnson A randomized, controlled trial comparing twice-a-day insulin glargine mixed with rapid-acting insulin analogs versus standard neutral protamine Hagedorn (NPH) therapy in newly diagnosed type 1 diabetes Pediatrics 121 2008 e466 e472
  21. 21 C.E. de Beaufort P.G. Swift C.T. Skinner Hvidoere Study Group on Childhood Diabetes 2005 Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? Diabetes Care 30 2007 2245 2250
  22. 22 Rosenbauer J Dost A Karges B the DPV Initiative and the German BMBF Competence Network Diabetes Mellitus Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria Diabetes Care 35 2012 80 86
  23. 23 S. Nordly H.B. Mortensen A.H. Andreasen Factors associated with glycaemic outcome of childhood diabetes care in Denmark Diabet Med 22 2005 1566 1573
  24. 24 W.V. Tamborlane R.W. Beck B.W. Bode Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group Continuous glucose monitoring and intensive treatment of type 1 diabetes N Engl J Med 359 2008 1464 1476
  25. 25 Health Canada Eating Well with Canada's Food Guide 2007 Health Canada, Health Products and Food Branch, Office of Nutrition Policy and Promotion Ottawa, ON Publication H39–166/1990E
  26. 26 S.R. Patton L.M. Dolan S.W. Powers Dietary adherence and associated glycemic control in families of young children with type 1 diabetes J Am Diet Assoc 107 2007 46 52
  27. 27 S.N. Mehta N. Quinn L.K. Volkening L.M.B. Laffel Impact of carbohydrate counting on glycemic control in children with type 1 diabetes Diabetes Care 32 2009 1014 1016
  28. 28 J.T. Markowitz D.A. Butler L.K. Volkening Brief screening tool for disordered eating in diabetes internal consistency and external validity in a contemporary sample of pediatric patients with type 1 diabetes Diabetes Care 33 2010 495 500
  29. 29 J.M. Naguib E. Kulinskaya C.L. Lomax M.E. Garralda Neuro-cognitive performance in children with type 1 diabetes: a meta-analysis J Pediatr Psychol 34 2009 271 282
  30. 30 S. Garg E. Moser M.P. Dain A. Rodionova Clinical experience with insulin glargine in type 1 diabetes Diabetes Technol Ther 12 2010 835 846
  31. 31 Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group Effectiveness of continuous glucose monitoring in a clinical care environment. Evidence from the Juvenile Diabetes Research Foundation Continuous Glucose Monitoring (JDRF-CGM) trial Diabetes Care 33 2010 17 22
  32. 32 M. Hartley M.J. Thomsett A.M. Cotterill Mini-dose glucagon rescue for mild hypoglycaemia in children with type 1 diabetes: the Brisbane experience J Paediatr Child Health 42 2006 108 111
  33. 33 M.W. Haymond B. Schreiner Mini-dose glucagon rescue for hypoglycemia in children with type 1 diabetes Diabetes Care 24 2001 643 645
  34. 34 K. Winkley K. Ismail S. Landau Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials BMJ 333 2006 65
  35. 35 K.K. Hood J.M. Rohan C.M. Peterson D. Drotar Interventions with adherence-promoting components in pediatric type 1 diabetes: meta-analysis of their impact on glycemic control Diabetes Care 33 2010 1658 1664
  36. 36 C. Levy-Marchal C.C. Patterson A. Green Geographic variation of presentation at diagnosis of type 1 diabetes in children: the EURODIAB study Diabetologia 44 suppl 3 2001 B75 B80
  37. 37 C.C. Patterson G. Dahlquist V. Harjutsalo Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989 Diabetologia 50 2007 2439 2442
  38. 38 M. Vanelli G. Chiari L. Ghizzoni Effectiveness of a prevention program for diabetic ketoacidosis in children: an 8-year study in schools and private practices Diabetes Care 22 1999 7 9
  39. 39 H.T. Keenan C.M. Foster S.L. Bratton Social factors associated with prolonged hospitalization among diabetic children Pediatrics 109 2002 40 44
  40. 40 R. Hanas F. Lindgren B. Lindblad A 2-yr national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use Pediatr Diabetes 10 2009 33 37
  41. 41 B. Karges T. Kapellen A. Neu Diabetes Prospective Documentation DPV Initiative German Federal Ministry for Education and Research BMBF Competence Network of Diabetes Mellitus Long-acting insulin analogs and the risk of diabetic ketoacidosis in children and adolescents with type 1 diabetes: a prospective study of 10,682 patients from 271 institutions Diabetes Care 33 2010 1031 1033
  42. 42 D.J. Drozda V.A. Dawson D.J. Long Assessment of the effect of a comprehensive diabetes management program on hospital admission rates of children with diabetes mellitus Diabetes Educ 16 1990 389 393
  43. 43 D. Ellis S. Naar-King T. Templin Multisystemic therapy for adolescents with poorly controlled type 1 diabetes: reduced diabetic ketoacidosis admissions and related costs over 24 months Diabetes Care 31 2008 1746 1767
  44. 44 W.H. Hoffman P. O'Neill C. Khoury Service and education for the insulin-dependent child Diabetes Care 1 1978 285 288
  45. 45 G. Chiari B. Ghidini M. Vanelli Effectiveness of a toll-free telephone hotline for children and adolescents with type 1 diabetes. A 5-year study Acta Biomed 74 suppl 1 2003 45 48
  46. 46 J.A. Edge M.M. Hawkins D.L. Winter The risk and outcome of cerebral oedema developing during diabetic ketoacidosis Arch Dis Child 85 2001 16 22
  47. 47 A.L. Rosenbloom Intracerebral crises during treatment of diabetic ketoacidosis Diabetes Care 13 1990 22 33
  48. 48 N. Glaser P. Barnett I. McCaslin Risk factors for cerebral edema in children with diabetic ketoacidosis N Engl J Med 344 2001 264 269
  49. 49 G.D. Harris I. Fiordalisi W.L. Harris Minimizing the risk of brain herniation during treatment of diabetic ketoacidemia: a retrospective and prospective study J Pediatr 117 1990 22 31
  50. 50 G.D. Harris I. Fiordalisi Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes Arch Pediatr Adolesc Med 148 1994 1046 1052
  51. 51 P.M. Hale I. Rezvani A.W. Braunstein Factors predicting cerebral edema in young children with diabetic ketoacidosis and new onset type I diabetes Acta Paediatr 86 1997 626 631
  52. 52 J.A. Edge R.W. Jakes Y. Roy The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children Diabetologia 49 2006 2002 2009
  53. 53 P. Fort S.M. Waters F. Lifshitz Low-dose insulin infusion in the treatment of diabetic ketoacidosis: bolus versus no bolus J Pediatr 96 1980 36 40
  54. 54 R. Lindsay R.G. Bolte The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis Pediatr Emerg Care 5 1989 77 79
  55. 55 E.J. Hoorn A.P. Carlotti L.A. Costa Preventing a drop in effective plasma osmolality to minimize the likelihood of cerebral edema during treatment of children with diabetic ketoacidosis J Pediatr 150 2007 467 473
  56. 56 A.B. Muir R.G. Quisling M.C. Yang Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification Diabetes Care 27 2004 1541 1546
  57. 57 J. Wolfsdorf M.E. Craig D. Daneman International Society for Pediatric and Adolescent Diabetes Diabetic ketoacidosis Pediatr Diabetes 8 2007 28 43
  58. 58 National Advisory Committee on Immunization Canadian Immunization Guide 7th ed. 2006 Public Health Agency of Canada Ottawa, ON
  59. 59 Infectious Diseases and Immunization Committee Canadian Paediatric Society Pneumococcal vaccine for children Paediatr Child Health 6 2002 214 217
  60. 60 Infectious Diseases and Immunization Committee Canadian Paediatric Society Recommendations for the use of influenza vaccine for children Paediatr Child Health 9 2004 283 284
  61. 61 P. Davies C. Nwokoro M. Leigh Vaccinations against influenza and pneumococcus in children with diabetes: telephone questionnaire survey BMJ 328 2004 203
  62. 62 D.E. Irwin L.B. Weatherby W.Y. Huang Impact of patient characteristics on the risk of influenza/ILI-related complications BMC Health Serv Res 1 2001 8
  63. 63 G.V. Zuccotti A. Scaramuzza S. Riboni Long-lasting immunogenicity of a virosomal vaccine in older children and young adults with type 1 diabetes mellitus Vaccine 27 2009 5357 5362
  64. 64 L.J. Scott J.H. Warram L.S. Hanna A nonlinear effect of hyperglycemia and current cigarette smoking are major determinants of the onset of microalbuminuria in type 1 diabetes Diabetes 50 2001 2842 2849
  65. 65 S.E. Hofer J. Rosenbauer J. Grulich-Henn DPV-Wiss Study Group Smoking and metabolic control in adolescents with type 1 diabetes J Pediatr 154 2009 20 23
  66. 66 D. Carmody A. Doyle R.G.R. Firth Teenage pregnancy in type 1 diabetes mellitus Pediatr Diabetes 11 2010 111 115
  67. 67 N.R. Fogel J. Weissberg-Benchell Preventing poor psychological and health outcomes in pediatric type 1 diabetes Current Diab Rep 10 2010 436 443
  68. 68 J.M. Lawrence D.A. Standiford B. Loots Prevalence and correlates of depressed mood among youth with diabetes: The SEARCH for Diabetes in Youth Study Pediatrics 117 2006 1348 1358
  69. 69 K.K. Hood S. Huestis A. Maher Depressive symptoms in children and adolescents with type 1 diabetes Diabetes Care 29 2006 1389 1391
  70. 70 E.A. Northam L.K. Matthews P.J. Anderson Psychiatric morbidity and health outcome in Type 1 diabetes: perspectives from a prospective longitudinal study Diabet Med 22 2005 152 157
  71. 71 K. Kakleas B. Kandyla C. Karayianni K. Karavanaki Psychosocial problems in adolescents with type 1 diabetes mellitus Diabetes Metab 35 2009 339 350
  72. 72 D.M. McDonnell E.A. Northam S.M. Donath Hyperglycemia and externalizing behavior in children with type 1 diabetes Diabetes Care 30 2007 2211 2215
  73. 73 D.C. Korbel D.J. Wiebe C.A. Berg D.L. Palmer Gender differences in adherence to type 1 diabetes management across adolescence: the medicating role of depression Children's Healthcare 36 2007 83 98
  74. 74 K.S. Bryden A. Neil R.A. Mayou Eating habits, body weight, and insulin misuse: a longitudinal study of teenagers and young adults with type 1 diabetes Diabetes Care 22 1999 1956 1960
  75. 75 M. Herzer K.K. Hood Anxiety symptoms in adolescents with type 1 diabetes: association with blood glucose monitoring and glycemic control J Pediatr Psychol 35 2009 415 425
  76. 76 Y. Chida M. Hamer An association of adverse psychosocial factors with diabetes mellitus: a meta-analytic review of longitudinal cohort studies Diabetologia 51 2008 2168 2178
  77. 77 J.S. Gonzalez M. Peyrot L.A. McCarl Depression and diabetes treatment nonadherence: a meta-analysis Diabetes Care 31 2008 2398 2403
  78. 78 S.W.M. Stewart U. Rao G.J. Emslie Depressive symptoms predict hospitalization for adolescents with type 1 diabetes mellitus Pediatrics 115 2005 1315 1319
  79. 79 M.M. Garrison W.J. Katon L.P. Richardson The impact of psychiatric comorbidities on readmissions for diabetes in youth Diabetes Care 28 2005 2150 2154
  80. 80 K. Hassan R. Loar B.J. Anderson R.A. Heptulla The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus J Pediatr 149 2006 526 531
  81. 81 K.K. Hood The influence of caregiver depressive symptoms on proxy report of youth depressive symptoms: a test of the depression-distortion hypothesis in pediatric type 1 diabetes J Pediatr Psychol 34 2009 294 303
  82. 82 N.R. Cunningham A.T. Vesco L.M. Dolan K.K. Hood From caregiver psychological distress to adolescent glycemic control: the mediating role of perceived burden around diabetes management J Pediatc Psychol 36 2011 196 295
  83. 83 J.M. Butler M. Skinner D. Gelfand Maternal parenting style and adjustment in adolescents with type 1 diabetes J Pediatr Psychol 32 2007 1227 1237
  84. 84 S.S. Jaser R. Whittemore J.M. Ambrosino Mediators of depressive symptoms in children with type 1 diabetes and their mothers J Pediatr Psychol 33 2008 509 519
  85. 85 D. Eckshtain D.A. Ellis K. Kolmodin S. Naar-King The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes J Pediatr Psychol 35 2010 426 435
  86. 86 L.D. Cameron M.J. Young D.J. Wiebe Maternal trait anxiety and diabetes control in adolescents with type 1 diabetes J Pediatr Psychol 32 2007 733 744
  87. 87 J.M. Jones M.L. Lawson D. Daneman Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study BMJ 320 2000 1563 1566
  88. 88 A.C. Rydall G.M. Rodin M.P. Olmsted Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus N Engl J Med 336 1997 1849 1854
  89. 89 D.L. Young-Hyman C.L. Davis Disordered eating behavior in individuals with diabetes. importance of context, evaluation, and classification Diabetes Care 33 2010 683 689
  90. 90 D.D. Schwartz V.D. Cline J.A. Hansen Early risk factors for nonadherence in pediatric type 1 diabetes: a review of the recent literature Curr Diabetes Rev 6 2010 167 183
  91. 91 F.J. Cameron E.A. Northam G.R. Ambler D. Daneman Routine psychological screening in youth with type 1 diabetes and their parents Diabetes Care 30 2007 2716 2724
  92. 92 E. Harkness W. MacDonald J. Valderas Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes Diabetes Care 33 2010 926 930
  93. 93 M. De Wit H.A. Dellemarre-Van De Waal J.A. Bokma Monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychosocial well-being Diabetes Care 31 2008 1521 1526
  94. 94 C.M. Van der Feltz-Cornelis J. Nuyen C. Stoop Effective of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis Gen Hosp Psychiatry 32 2010 380 395
  95. 95 J.M. Rossello M.I. Jimenez-Chafety Cognitive-behavioral group therapy for depression in adolescents with diabetes: a pilot study Interam J Psychol 40 2006 219 226
  96. 96 R. Alam J. Sturt R. Lall K. Winkley An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status Patient Educ Couns 75 2009 25 36
  97. 97 A.M. Delamater A.M. Jacobson B. Anderson Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group Diabetes Care 24 2001 1286 1292
  98. 98 F.J. Mendez M. Belendez Effects of a behavioral intervention on treatment adherence and stress management in adolescents with IDDM Diabetes Care 20 1997 1370 1375
  99. 99 J.M. Barker Clinical review: type 1 diabetes-associated autoimmunity: natural history, genetic associations, and screening J Clin Endocrinol Metab 91 2006 1210 1217
  100. 100 S.J. Glastras M.E. Craig C.F. Verge The role of autoimmunity at diagnosis of type 1 diabetes in the development of thyroid and celiac disease and microvascular complications Diabetes Care 28 2005 2170 2175
  101. 101 O. Kordonouri R. Hartmann D. Deiss Natural course of autoimmune thyroiditis in type 1 diabetes: association with gender, age, diabetes duration, and puberty Arch Dis Child 90 2005 411 414
  102. 102 S.D. Marks R. Girgis R.M. Couch Screening for adrenal antibodies in children with type 1 diabetes and autoimmune thyroid disease Diabetes Care 26 2003 3187 3188
  103. 103 F. Cerutti G. Bruno F. Chiarelli Younger age at onset and sex predict celiac disease in children and adolescents with type 1 diabetes: an Italian multicenter study Diabetes Care 27 2004 1294 1298
  104. 104 M. Mayer L. Greco R. Troncone Compliance of adolescents with celiac disease with a gluten-free diet Gut 32 1991 881 885
  105. 105 G.K. Holmes P. Prior M.R. Lane Malignancy in coeliac disease: effect of a gluten free diet Gut 30 1989 333 338
  106. 106 M. Lang-Muritano L. Molinari C. Dommann-Scherrer Incidence of enteropathy-associated T-cell lymphoma in celiac disease: implications for children and adolescents with type 1 diabetes Pediatr Diabetes 3 2002 42 45
  107. 107 B. Rami Z. Sumnik E. Schober Screening detected celiac disease in children with type 1 diabetes mellitus: effect on the clinical course (a case control study) J Pediatr Gastroenterol Nutr 41 2005 317 321
  108. 108 K.C. Donaghue M.E. Craig A.K. Chan Prevalence of diabetes complications 6 years after diagnosis in an incident cohort of childhood diabetes Diabet Med 22 2005 711 718
  109. 109 C.J. Schultz T. Konopelska-Bahu R.N. Dalton Microalbuminuria prevalence varies with age, sex, and puberty in children with type 1 diabetes followed from diagnosis in a longitudinal study. Oxford Regional Prospective Study Group Diabetes Care 22 1999 495 502
  110. 110 W. Gatling C. Knight R.D. Hill Screening for early diabetic nephropathy: which sample to detect microalbuminuria? Diabet Med 2 1985 451 455
  111. 111 J.P. Shield L.P. Hunt J.D. Baum Screening for diabetic microalbuminuria in routine clinical care: which method? Arch Dis Child 72 1995 524 525
  112. 112 R.I. Hogg S. Furth K.V. Lemley National Kidney Foundation's Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease in Children and Adolescents: Evaluation, Classification, and Stratification Pediatrics 111 2003 1416 1421
  113. 113 M.L. Stone M.E. Craig A.K. Chan Natural history and risk factors for microalbuminuria in adolescents with type 1 diabetes: a longitudinal study Diabetes Care 29 2006 2072 2077
  114. 114 J. Cook D. Daneman M. Spino Angiotensin converting enzyme inhibitor therapy to decrease microalbuminuria in normotensive children with insulin-dependent diabetes mellitus J Pediatr 117 1990 39 45
  115. 115 ACE Inhibitors in Diabetic Nephropathy Trialist Group Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data Ann Intern Med 134 2001 370 379
  116. 116 A. Maguire A. Chan J. Cusumano The case for biennial retinopathy screening in children and adolescents Diabetes Care 28 2005 509 513
  117. 117 B. Huo A.T. Steffen K. Swan Clinical outcomes and cost-effectiveness of retinopathy screening in youth with type 1 diabetes Diabetes Care 30 2007 362 363
  118. 118 K. Karavanaki J.D. Baum Coexistence of impaired indices of autonomic neuropathy and diabetic nephropathy in a cohort of children with type 1 diabetes mellitus J Pediatr Endocrinol Metab 16 2003 79 90
  119. 119 B.S. Olsen A.-K. Sjølie P. Hougaard A 6-year nationwide cohort study of glycaemic control in young people with type 1 diabetes. Risk markers for the development of retinopathy, nephropathy, and neuropathy J Diabetes Complications 14 2000 295 300
  120. 120 K.C. Donaghue A.T.W. Fung J.M. Fairchild Prospective assessment of autonomic and peripheral nerve function in adolescents with diabetes Diabet Med 13 1996 65 71
  121. 121 D. Nelson J.K. Mah C. Adams Comparison of conventional and non-invasive techniques for the early identification of diabetic neuropathy in children and adolescents with type 1 diabetes Pediatr Diabetes 7 2006 305 310
  122. 122 K.O. Schwab J. Doerfer W. Marg DPV Science Initiative and the Competence Network Diabetes mellitus Characterization of 33 488 children and adolescents with type 1 diabetes based on the gender-specific increase of cardiovascular risk factors Pediatr Diabetes 11 2010 357 363
  123. 123 H.D. Margeirsdottir J.R. Larsen C. Brunborg Norwegian Study Group for Childhood Diabetes High prevalence of cardiovascular risk factors in children and adolescents with type 1 diabetes: a population-based study Diabetologia 51 2008 554 561
  124. 124 D.S. Celermajer J.G.J. Ayer Childhood risk factors for adult cardiovascular disease and primary prevention in childhood Heart 92 2006 1701 1706
  125. 125 A. Vuorio J. Kuoppala P.T. Kovanen Statins for children with familial hypercholesterolemia Cochrane Database Syst Rev 7 2010 CD006401
  126. 126 M.C. Eppens M.E. Craig J. Cusumano Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes Diabetes Care 29 2006 1300 1306
  127. 127 E. Lurbe J. Redon A. Kesani Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes N Engl J Med 347 2002 797 805
  128. 128 National Heart, Lung and Blood Institute. Blood Pressure Tables for Children and Adolescents from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. 2004. Available here . Accessed June 24, 2011.
  129. 129 M. Nakhla D. Daneman T. To Transition to adult care for youths with diabetes mellitus: findings from a Universal Health Care System Pediatrics 124 2009 e1134 e1141
  130. 130 M. Frank Factors associated with non-compliance with a medical follow-up regimen after discharge from a pediatric diabetes clinic Can J Diabetes 20 1996 13 20
  131. 131 D. Pacaud J.F. Yale D. Stephure Problems in transition from pediatric care to adult care for individuals with diabetes Can J Diabetes 29 2005 13 18
  132. 132 N. Van Walleghem C.A. Macdonald H.J. Dean Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes Diabetes Care 31 2008 1529 1530
  133. 133 D.J. Holmes-Walker A.C. Llewellyn K. Farrell A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15-25 years Diabet Med 24 2007 764 769
  134. 134 T. Hershey D.C. Perantie S.L. Warren Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes Diabetes Care 28 2005 2372 2377
  135. 135 T.A. Armour S.L. Norris L. Jack Jr. The effectiveness of family interventions in people with diabetes mellitus: a systematic review Diabet Med 22 2005 1295 1305
  136. 136 S.K. McMahon F.L. Airey D.A. Marangou Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life Diabet Med 22 2005 92 96
  137. 137 C.A. Houlihan C. Tsalamandris A. Akdeniz Albumin to creatinine ratio: a screening test with limitations Am J Kidney Dis 39 2002 1183 1189
  138. 138 A.P. Rocchini V. Katch J. Anderson Blood pressure in obese adolescents: effect of weight loss Pediatrics 82 1988 16 23
  139. 139 A.F.R. Fischl W.H. Herman S.M. Sereika Impact of a preconception counseling program for teens with type 1 diabetes (READY-Girls) on patient-provider interaction, resource utilization, and cost Diabetes Care 33 2010 701 705
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