What is contained in the 2018 ADA position statement on pediatric type 1 diabetes mellitus (DM)?

Updated: Mar 23, 2021
  • Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Sasigarn A Bowden, MD  more...
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In August 2018, the American Diabetes Association released a position statement on type 1 diabetes in children and adolescents, which included the following guidelines [66, 67] :

  • Consult a pediatric endocrinologist before diagnosing type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in patients with acute illness in the absence of classic symptoms
  • Differentiating type 1 diabetes, type 2 diabetes, monogenic diabetes, and other forms of diabetes is based on patient history and characteristics, as well as on laboratory tests, such as an islet autoantibody panel
  • The majority of children with type 1 diabetes should be treated with intensive insulin regimens using multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
  • A 1C should be measured every 3 months
  • Blood glucose levels should be monitored up to 6-10 times daily
  • Continuous glucose monitors (CGM) should be considered in all children and adolescents with type 1 diabetes; the benefits of CGM correlate with adherence to ongoing use of the device
  • Blood or urine ketone levels should be monitored in children with type 1 diabetes in the presence of prolonged/severe hyperglycemia or acute illness
  • Individualized medical nutrition therapy is recommended for children and adolescents
  • Exercise is recommended, with a goal of 60 minutes a day of moderate to vigorous aerobic activity, along with vigorous muscle-strengthening and bone-strengthening activities at least 3 days a week
  • It is important to frequently monitor glucose before, during, and after exercise (with or without CGM use) to prevent, detect, and treat hypoglycemia and hyperglycemia
  • All individuals with type 1 diabetes should have access to an uninterrupted supply of insulin; lack of access and insulin omissions are major causes of diabetic ketoacidosis
  • Glucagon should be prescribed for all individuals with type 1 diabetes, and caregivers or family members should be instructed regarding administration
  • Once the child has had diabetes for 5 years, annual screening for albuminuria, using a random spot urine sample (morning sample preferred to avoid effects of exercise) to assess the albumin-to-creatinine ratio, should be considered at puberty or at age greater than 10 years, whichever occurs earlier
  • Once the youth has had diabetes for 3-5 years, an initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, and an annual routine follow-up is generally recommended
  • For adolescents who have had type 1 diabetes for 5 years, consider an annual comprehensive foot exam at the start of puberty or at age 10 years, whichever is earlier
  • Blood pressure should be measured at each routine visit; children who have high-normal blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP] at 90th percentile for age, sex, and height) or hypertension (SBP or DBP at 95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days
  • Initial treatment of high-normal blood pressure (SBP or DBP consistently at the 90th percentile for age, sex, and height) includes dietary modification and increased exercise for weight control; if target blood pressure is not reached within 3-6 months after lifestyle intervention, consider pharmacologic treatment
  • Because of their potential teratogenic effects, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be considered for initial pharmacologic treatment of hypertension after reproductive counseling
  • The blood pressure treatment goal is consistently less than the 90th percentile for age, sex, and height
  • If low-density lipoprotein (LDL) cholesterol is within an acceptable risk level (< 100 mg/dL [2.6 mmol/L]), a lipid profile every 3-5 years is reasonable
  • If lipid levels are abnormal, initial therapy should consist of optimizing glucose control and initiating a Step 2 American Heart Association diet (restricting saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day)
  • After age 10 years, consider adding a statin if, despite 6 months of medical nutrition therapy and lifestyle changes, LDL cholesterol remains greater than 160 mg/dL (4.1 mmol/L) or LDL cholesterol remains greater than 130 mg/dL (3.4 mmol/L) with one or more cardiovascular disease (CVD) risk factors present (after reproductive counseling because of the potential teratogenic effects of statins)
  • The LDL therapy goal is less than 100 mg/dL (2.6 mmol/L)
  • In children with type 1 diabetes, consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis
  • In children and adolescents with type 1 diabetes, an A 1C target of less than 7.5% should be considered but individualized
  • Glucose (15 g) is preferred treatment for conscious individuals with hypoglycemia (blood glucose < 70 mg/dL [3.9 mmol/L]), but any form of carbohydrate may be used; treatment should be repeated if self-monitoring blood glucose (SMBG) 15 minutes after treatment shows hypoglycemia is still present; when blood glucose concentration returns to normal, consider a meal or snack and/or reduce insulin to prevent recurrence of hypoglycemia
  • In patients with classic symptoms, blood glucose measurement is sufficient to diagnose diabetes (symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [11.1 mmol/L])
  • Measure thyroid-stimulating hormone concentrations when the patient is clinically stable or once glycemic control has been established; if normal, suggest rechecking every 1-2 years (or sooner if the patient develops symptoms or signs that suggest thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability)
  • Screen children for celiac disease by measuring IgA tissue transglutaminase antibodies
  • Criteria for diagnosis of diabetes is fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
  • In asymptomatic children and adolescents at high risk for diabetes, if FPG ≥126 mg/dL (7 mmol/L), if 2-hr PG ≥200 mg/dL (11.1 mmol/L), or if A 1C ≥6.5%, testing should be repeated on a separate day to confirm the diagnosis

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