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
  • Highlights
  • 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.

Highlights of Revisions

  • This chapter includes new glycemic targets:
    • Children <6 years of age: A1C <8.0%
    • Children 6 to 12 years of age: A1C ≤7.5%
    • Adolescents: same as adults
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.

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 (2)].
  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 (3,4)].

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 (5)].
    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 (6)].
  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 (7-9)].

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 (10) 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 (11), for adolescents; Grade D, Consensus, for younger children].
    • Change to continuous subcutaneous insulin infusion therapy [Grade C, Level 3 (12)].

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 (13)].
  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 (14)].
    • Comprehensive education and support services [Grade C, Level 3 (15)], as well as 24-hour telephone services [Grade C, Level 3 (16)], 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 (15)]. 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 (17)].
  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 (18)]. The insulin infusion should not be started until 1 hour after starting fluid replacement therapy [Grade D, Level 4 (19)].
  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 (20)].

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 (21)] or a random ACR [Grade D, Consensus]. Abnormal results should be confirmed [Grade B, Level 2 (22)] 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 (23,24)] 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 (25)]. 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 (26)].
  10. 31.Children with type 1 diabetes who have thyroid antibodies should be considered high risk for autoimmune thyroid disease [Grade C, Level 3 (27)]. 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 should undergo celiac screening [Grade D, Consensus] and, if confirmed, be treated with a gluten-free diet to improve symptoms [Grade D, Level 4 (28)] and prevent the long-term sequelae of untreated classic celiac disease [Grade D, Level 4 (29)]. 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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