The evidence grading system for clinical practice recommendations (A through C, E) is defined at the end of the "Major Recommendations" field.
Children and Adolescents
Type 1 Diabetes
Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes. At the very least, education of the child and family should be provided by health care providers trained and experienced in childhood diabetes and sensitive to the challenges posed by diabetes in this age-group. At the time of initial diagnosis, it is essential that diabetes education is provided in a timely fashion, with the expectation that the balance between adult supervision and self-care should be defined by, and will evolve according to, physical, psychological, and emotional maturity. Medical nutrition therapy (MNT) should be provided at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets.
Glycemic Control
- Consider age when setting glycemic goals in children and adolescents with type 1 diabetes, with less stringent goals for younger children. (E)
Plasma Blood Glucose and A1C Goals for Type 1 Diabetes by Age Group
| |
Plasma Blood Glucose Goal Range (mg/dL) |
|
|
| Values by Age (years) |
Before Meals |
Bedtime/Overnight |
A1C (%) |
Rationale |
Toddlers and preschoolers
(0 to 6 years)
|
100 to 180 |
110 to 200 |
<8.5% (but >7.5%) |
High risk and vulnerability to hypoglycemia |
School age
(6 to 12 years)
|
90 to 180 |
100 to 180 |
<8% |
Risks of hypoglycemia and relatively low risk of complications prior to puberty |
Adolescents and young adults
(13 to 19 years)
|
90 to 130 |
90 to 150 |
<7.5% |
- Risk of severe hypoglycemia
- Developmental and psychological issues
- A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia
|
Key concepts in setting glycemic goals:
- Goals should be individualized and lower goals may be reasonable based on benefit-risk assessment.
- Blood glucose goals should be higher than those listed above in children with frequent hypoglycemia or hypoglycemia unawareness.
- Postprandial blood glucose values should be measured when there is a discrepancy between pre-prandial blood glucose values and A1C levels.
|
Screening and Management of Chronic Complications in Children and Adolescents with Type 1 Diabetes
Nephropathy
- Annual screening for microalbuminuria, with a random spot urine sample for microalbumin-to-creatinine ratio, should be initiated once the child is 10 years of age and has had diabetes for 5 years. (E)
- Confirmed, persistently elevated microalbumin levels on two additional urine specimens should be treated with an angiotensin-converting enzyme (ACE) inhibitor, titrated to normalization of microalbumin excretion if possible. (E)
Hypertension
- Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached within 3 to 6 months of lifestyle intervention, pharmacologic treatment should be initiated. (E)
- Pharmacologic treatment of hypertension (systolic or diastolic blood pressure consistently above the 95th percentile for age, sex, and height or consistently greater than 130/80 mmHg, if 95% exceeds that value) should be initiated as soon as the diagnosis is confirmed. (E)
- ACE inhibitors should be considered for the initial treatment of hypertension. (E)
Dyslipidemia
Screening
- If there is a family history of hypercholesterolemia (total cholesterol >240 mg/dL) or a cardiovascular event before age 55 years, or if family history is unknown, then a fasting lipid profile should be performed on children >2 years of age soon after diagnosis (after glucose control has been established). If family history is not of concern, then the first lipid screening should be performed at puberty (>10 years). All children diagnosed with diabetes at or after puberty should have a fasting lipid profile performed soon after diagnosis (after glucose control has been established). (E)
- For both age groups, if lipids are abnormal, annual monitoring is recommended. If low-density lipoprotein (LDL) cholesterol values are within the accepted risk levels (<100 mg/dL [2.6 mmol/L]), a lipid profile should be repeated every 5 years. (E)
Treatment
- Initial therapy should consist of optimization of glucose control and MNT using a Step 2 American Heart Association diet aimed at a decrease in the amount of saturated fat in the diet. (E)
- After the age of 10, the addition of a statin is recommended in patients who, after MNT and lifestyle changes, have LDL cholesterol >160 mg/dL (4.1 mmol/L) or have LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease (CVD) risk factors. (E)
- The goal of therapy is an LDL value <100 mg/dL (2.6 mmol/L). (E)
Retinopathy
- The first ophthalmologic examination should be obtained once the child is >10 years of age and has had diabetes for 3 to 5 years. (E)
- After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations may be acceptable on the advice of an eye care professional. (E)
Celiac Disease
- Patients with type 1 diabetes who become symptomatic for celiac disease should be tested by measuring tissue transglutaminase or anti-endomysial antibodies, with documentation of normal serum immunoglobulin A (IgA) levels. (E)
- Children with positive antibodies should be referred to a gastroenterologist for evaluation. (E)
- Children with confirmed celiac disease should have consultation with a dietitian and placed on a gluten-free diet. (E)
Hypothyroidism
- Patients with type 1 diabetes should be screened for thyroid peroxidase and thyroglobulin antibodies at diagnosis. (E)
- Thyroid-stimulating hormone (TSH) concentrations should be measured after metabolic control has been established. If normal, they should be rechecked every 1 to 2 years, or if the patient develops symptoms of thyroid dysfunction, thyromegaly, or an abnormal growth rate. Free T4 should be measured if TSH is abnormal. (E)
Type 2 Diabetes
Distinction between type 1 and type 2 diabetes in children can be difficult, since autoantigens and ketosis may be present in a substantial number of patients with features of type 2 diabetes (including obesity and acanthosis nigricans). Such a distinction at the time of diagnosis is critical since treatment regimens, educational approaches, and dietary counsel will differ markedly between the two diagnoses. Because type 2 diabetes has a significant incidence of hypertension, dyslipidemia, and microalbuminuria at diagnosis, it is recommended that screening for the comorbidities and complications of diabetes, including fasting lipid profile, microalbuminuria assessment, and dilated eye examinations, begin at the time of diagnosis. The American Diabetes Association (ADA) consensus statement provides guidance on the prevention, screening, and treatment of type 2 diabetes and its comorbidities in young people.
Preconception Care
- A1C levels should be normal or as close to normal as possible (<7%) in an individual patient before conception is attempted. (B)
- All women with diabetes and childbearing potential should be educated about the need for good glucose control before pregnancy and should participate in family planning. (E)
- Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, neuropathy, and cardiovascular disease. (E)
- Medications used by such women should be evaluated before conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, angiotensin receptor blockers (ARBs), and most noninsulin therapies. (E)
Older Adults
- Older adults who are functional, cognitively intact, and have significant life expectancy should receive diabetes treatment using goals developed for younger adults. (E)
- Glycemic goals for older adults who do not meet the above criteria may be relaxed using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. (E)
- Other cardiovascular risk factors should be treated in older adults with consideration of the timeframe of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid and aspirin therapy may benefit those with life expectancy at least equal to the timeframe of primary or secondary prevention trials. (E)
- Screening for diabetic complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. (E)
Definitions:
American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations
A
Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:
- Evidence from a well-conducted multicenter trial
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
- Compelling non-experimental evidence (i.e., "all or none" rule developed by the Center for Evidence Based Medicine at Oxford*)
Supportive evidence from well-conducted randomized, controlled trials that are adequately powered, including:
- Evidence from a well-conducted trial at one or more institutions
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
*
Either all patients died before therapy and at least some survived with therapy, or some patients died without therapy and none died with therapy. Example: use of insulin in the treatment of diabetic ketoacidosis.
B
Supportive evidence from well-conducted cohort studies, including:
- Evidence from a well-conducted prospective cohort study or registry
- Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies, including:
- Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
- Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
- Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E
Expert consensus or clinical experience
