Clinical Practice Guidelines
Type 1 Diabetes in Children and Adolescents

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Introduction

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.

Section snippets

Education

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

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

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

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.

Nutrition

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

Hypoglycemia

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

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.

DKA

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

Immunization

Historically, national guidelines have recommended influenza and pneumococcal immunization for children with type 1 diabetes 58, 59, 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

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.

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.

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

Diabetes Complications

There are important age-related considerations regarding surveillance for diabetes complications and interpretation of investigations (Table 5).

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.

Recommendations

Delivery of care

  1. 1.

    All children with

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