What are the ADA treatment guidelines for pediatric type 1 diabetes mellitus (DM)?

Updated: Jul 03, 2019
  • Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Sasigarn A Bowden, MD  more...
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Answer

The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 include the following recommendations with regard to children and adolescents with type 1 diabetes [58] :

  • At diagnosis and routinely thereafter, youth with type 1 diabetes and parents/caregivers (for patients aged < 18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards
  • Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child can result in nonadherence and deterioration in glycemic control
  • Providers should consider asking youth and their parents about social adjustment (peer relationships) and school performance to determine whether further intervention is needed
  • Assess youth with diabetes for psychosocial and diabetes-related distress, generally starting at age 7-8 years
  • Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential
  • The majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion
  • All children and adolescents with type 1 diabetes should self-monitor blood glucose levels multiple times daily, including premeal and prebedtime; as needed for safety in specific clinical situations, such as exercise or driving; and for symptoms of hypoglycemia
  • Continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes, whether they are using injections or continuous subcutaneous insulin infusion, as an additional tool to help improve glycemic control; benefits of continuous glucose monitoring correlate with adherence to ongoing use of the device
  • Automated insulin delivery systems improve glycemic control and reduce hypoglycemia in adolescents and should be considered in adolescents with type 1 diabetes
  • Assess for the presence of autoimmune conditions associated with type 1 diabetes soon after the diabetes diagnosis and if autoimmune disease symptoms develop
  • Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or soon after glycemic control has been established; if normal, consider rechecking every 1-2 years (or sooner if the patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or an unexplained glycemic variation)
  • Screen individuals with type 1 diabetes for celiac disease soon after the diagnosis of diabetes by measuring immunoglobulin A (IgA) tissue transglutaminase antibodies, with documentation of normal total serum IgA levels or, if the patient is IgA deficient, IgG tissue transglutamine and deamidated gliadin antibodies
  • Repeat screening for celiac disease within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in children who have symptoms or a first-degree relative with celiac disease
  • Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing diabetes and celiac disease
  • Blood pressure should be measured at each routine visit; children found to have high-normal blood pressure (systolic blood pressure or diastolic blood pressure in the 90th percentile or above for age, sex, and height) or hypertension (systolic blood pressure or diastolic blood pressure in the 95th percentile or above for age, sex, and height) should have elevated blood pressure confirmed on 3 separate days
  • Initial therapy for dyslipidemia should consist of optimizing glucose control and the employment of medical nutrition therapy (using a Step 2 American Heart Association diet) to decrease the amount of saturated fat in the diet
  • After the age of 10 years, addition of a statin is suggested in patients who, despite medical nutrition therapy and lifestyle changes, continue to have a low-density lipoprotein (LDL) cholesterol level above 160 mg/dL (4.1 mmol/L) or an LDL cholesterol above 130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors; however, statin use should follow reproductive counseling and implementation of effective birth control, due to the potential teratogenic effects of statins
  • Elicit a smoking history at initial and follow-up diabetes visits; discourage smoking in youth who do not smoke, and encourage smoking cessation in those who do smoke
  • Annual screening for albuminuria with a random spot urine sample for albumin-to-creatinine ratio should be performed at puberty or at age 10 years or older, whichever is earlier, once the child has had diabetes for 5 years
  • When a persistently elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented with at least two of three urine samples, treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker may be considered and the dose titrated to maintain blood pressure within the age-appropriate normal range; the urine samples should be obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure
  • An initial dilated and comprehensive eye examination is recommended once a youth has had type 1 diabetes for 3-5 years, provided that he/she is age 10 years or older or puberty has started, whichever is earlier
  • Consider an annual comprehensive foot exam at the start of puberty or at age 10 years or older, whichever is earlier, once the youth has had type 1 diabetes for 5 years

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