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.


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)].


  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].

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


  1. Glasgow AM, Weissberg-Benchell J, Tynan WD, et al. Readmissions of children with diabetes mellitus to a children’s hospital. Pediatrics 1991;88: 98-104.>
  2. Clar C, Waugh N, Thomas S. Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus. Cochrane Database Syst Rev 2006;2:CD004099.
  3. Holmes-Walker DJ, Llewellyn AC, Farrell K. 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 2007;24: 764-9.
  4. Van Walleghem N, Macdonald CA, Dean HJ. Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes. Diabetes Care 2008;31:1529-30.
  5. Hershey T, Perantie DC, Warren SL, et al. Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes. Diabetes Care 2005;28:2372e7.
  6. 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 1994;125:177e88.
  7. Winkley K, Ismail K, Landau S, et al. Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. BMJ 2006;333:65.
  8. Hood KK, Rohan JM, Peterson CM, Drotar D. Interventions with adherencepromoting components in pediatric type 1 diabetes: meta-analysis of their impact on glycemic control. Diabetes Care 2010;33:1658-64.
  9. Armour TA, Norris SL, Jack Jr L, et al. The effectiveness of family interventions in people with diabetes mellitus: a systematic review. Diabet Med 2005;22: 1295-305.
  10. The Diabetes Control and Complications Trial Research Group. Effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-86.
  11. Murphy NP, Keane SM, Ong KK, et al. 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 2003;26: 799-804.
  12. McMahon SK, Airey FL, Marangou DA, et al. Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life. Diabet Med 2005;22:92-6.
  13. Hartley M, Thomsett MJ, Cotterill AM. Mini-dose glucagon rescue for mild hypoglycaemia in children with type 1 diabetes: the Brisbane experience. J Paediatr Child Health 2006;42:108-11.
  14. Drozda DJ, Dawson VA, Long DJ, et al. Assessment of the effect of a comprehensive diabetes management program on hospital admission rates of children with diabetes mellitus. Diabetes Educ 1990;16:389e93.
  15. Ellis D, Naar-King S, Templin T, et al. Multisystemic therapy for adolescents with poorly controlled type 1 diabetes: reduced diabetic ketoacidosis admissions and related costs over 24 months. Diabetes Care 2008;31:1746-67.
  16. Hoffman WH, O’Neill P, Khoury C, et al. Service and education for the insulindependent child. Diabetes Care 1978;1:285e8.
  17. Harris GD, Fiordalisi I, Harris WL, et al. Minimizing the risk of brain herniation during treatment of diabetic ketoacidemia: a retrospective and prospective study. J Pediatr 1990;117:22-31.
  18. Fort P, Waters SM, Lifshitz F. Low-dose insulin infusion in the treatment of diabetic ketoacidosis: bolus versus no bolus. J Pediatr 1980;96:36-40.
  19. Edge JA, Jakes RW, Roy Y, et al. The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia 2006;49:2002-9.
  20. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med 2001;344:264-9.
  21. Shield JP, Hunt LP, Baum JD, et al. Screening for diabetic microalbuminuria in routine clinical care: which method? Arch Dis Child 1995;72:524-5.
  22. Houlihan CA, Tsalamandris C, Akdeniz A, et al. Albumin to creatinine ratio: a screening test with limitations. Am J Kidney Dis 2002;39:1183-9.
  23. Donaghue KC, Craig ME, Chan AK. Prevalence of diabetes complications 6 years after diagnosis in an incident cohort of childhood diabetes. Diabet Med 2005; 22:711-8.
  24. Schultz CJ, Konopelska-Bahu T, Dalton RN, et al. 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 1999;22:495-502.
  25. Rocchini AP, Katch V, Anderson J, et al. Blood pressure in obese adolescents: effect of weight loss. Pediatrics 1988;82:16-23.
  26. Fischl AFR, Herman WH, Sereika SM, et al. Impact of a preconception counseling program for teens with type 1 diabetes (READY-Girls) on patient-provider interaction, resource utilization, and cost. Diabetes Care 2010;33:701-5.
  27. Glastras SJ, Craig ME, Verge CF, et al. The role of autoimmunity at diagnosis of type 1 diabetes in the development of thyroid and celiac disease and microvascular complications. Diabetes Care 2005;28:2170-5
  28. Mayer M, Greco L, Troncone R, et al. Compliance of adolescents with celiac disease with a gluten-free diet. Gut 1991;32:881-5.
  29. Holmes GK, Prior P, Lane MR, et al. Malignancy in coeliac disease: effect of a gluten free diet. Gut 1989;30:333-8.

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on guidelines.diabetes.ca, CPG Apps and in our online store remains exactly the same. For questions, contact communication@diabetes.ca.