11. Children and Adolescents
Type 1 Diabetes
Three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age. The provider must consider the unique aspects of care and management of children and adolescents with type 1 diabetes, such as changes in insulin sensitivity related to physical growth and sexual maturation, ability to provide self-care, supervision in the child care and school environment, and neurological vulnerability to hypoglycemia and hyperglycemia in young children, as well as possible adverse neurocognitive effects of diabetic ketoacidosis (1,2). Attention to family dynamics, developmental stages, and physiological differences related to sexual maturity are all essential in developing and implementing an optimal diabetes regimen (3). Due to the paucity of clinical research in children, the recommendations for children and adolescents are less likely to be based on clinical trial evidence. However, expert opinion and a review of available and relevant experimental data are summarized in the American Diabetes Association (ADA) position statement “Care of Children and Adolescents With Type 1 Diabetes” (4) and have been updated in the ADA position statement “Type 1 Diabetes Through the Life Span” (5).
A multidisciplinary team of specialists trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families should provide care for this population. It is essential that diabetes self-management education (DSME) and support (DSMS), medical nutrition therapy, and psychosocial support be provided at diagnosis and regularly thereafter by individuals experienced with the educational, nutritional, behavioral, and emotional needs of the growing child and family. The appropriate balance between adult supervision and independent self-care should be defined at the first interaction and reevaluated at subsequent clinic visits. The balance between adult supervision and independent self-care will evolve as the adolescent gradually becomes an emerging young adult.
Diabetes Self-management Education and Support
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 at diagnosis and routinely thereafter. B
No matter how sound the medical regimen, it can only be effective if the family and/or affected individuals are able to implement it. Family involvement is a vital component of optimal diabetes management throughout childhood and adolescence. Health care providers (the diabetes care team) who care for children and adolescents must be capable of evaluating the educational, behavioral, emotional, and psychosocial factors that impact implementation of a treatment plan and must work with the individual and family to overcome barriers or redefine goals as appropriate. DSME and DSMS require periodic reassessment, especially as the youth grows, develops, and acquires the need for greater independent self-care skills. In addition, it is necessary to assess the educational needs and skills of day care providers, school nurses, or other school personnel who participate in the care of the young child with diabetes (6).
School and Child Care
As a large portion of a child’s day is spent in school, close communication with and the cooperation of school or day care personnel are essential for optimal diabetes management, safety, and maximal academic opportunities. Refer to the ADA position statements “Diabetes Care in the School Setting” (7) and “Care of Young Children With Diabetes in the Child Care Setting” (8) for additional details.
At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact adherence to diabetes management and provide appropriate referrals to trained mental health professionals, preferably experienced in childhood diabetes. E
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. B
Consider mental health professionals as integral members of the pediatric diabetes multidisciplinary team. E
Diabetes management throughout childhood and adolescence places substantial burdens on the youth and family, necessitating ongoing assessment of psychosocial issues and distress during routine diabetes visits (9–11). Further, the complexities of diabetes management require ongoing parental involvement in care throughout childhood with developmentally appropriate family teamwork between the growing child/teen and parent in order to maintain adherence and to prevent deterioration in glycemic control (12,13). As diabetes-specific family conflict is related to poorer adherence and glycemic control, it is appropriate to inquire about such conflict during visits and to either help to negotiate a plan for resolution or refer to an appropriate mental health specialist (14).
Screening for psychosocial distress and mental health problems is an important component of ongoing care. It is important to consider the impact of diabetes on quality of life as well as the development of mental health problems related to diabetes distress, fear of hypoglycemia (and hyperglycemia), symptoms of anxiety, disordered eating behaviors as well as eating disorders, and symptoms of depression (15). Consider screening for depression and disordered eating behaviors using available screening tools (9,16), and, with respect to disordered eating, it is important to recognize the unique and dangerous disordered eating behavior of insulin omission for weight control in type 1 diabetes (17). The presence of a mental health professional on pediatric multidisciplinary teams highlights the importance of attending to the psychosocial issues of diabetes. These psychosocial factors are significantly related to nonadherence, suboptimal glycemic control, reduced quality of life, and higher rates of acute and chronic diabetes complications.
An A1C goal of <7.5% (58 mmol/mol) is recommended across all pediatric age-groups. E
Current standards for diabetes management reflect the need to lower glucose as safely as possible. This should be done with stepwise goals. Special consideration should be given to the risk of hypoglycemia in young children (aged <6 years) who are often unable to recognize, articulate, and/or manage their hypoglycemic symptoms. This “hypoglycemia unawareness” should be considered when establishing individualized glycemic targets.
Although it was previously thought that young children were at risk for cognitive impairment after episodes of severe hypoglycemia, current data have not confirmed this notion (18–20). Furthermore, new therapeutic modalities, such as rapid- and long-acting insulin analogs, technological advances (e.g., continuous glucose monitors, low glucose suspend insulin pumps), and education may mitigate the incidence of severe hypoglycemia (21).
The Diabetes Control and Complications Trial (DCCT) demonstrated that near-normalization of blood glucose levels was more difficult to achieve in adolescents than in adults. Nevertheless, the increased use of basal–bolus regimens, insulin pumps, frequent blood glucose monitoring, goal setting, and improved patient education in youth from infancy through adolescence have been associated with more children reaching the blood glucose targets set by the ADA (7,22–25) in those families in which both the parents and the child with diabetes participate jointly to perform the required diabetes-related tasks. Furthermore, studies documenting neurocognitive imaging differences related to hyperglycemia in children provide another compelling motivation for lowering glycemic targets (1).
In selecting glycemic goals, the long-term health benefits of achieving a lower A1C should be balanced against the risks of hypoglycemia and the developmental burdens of intensive regimens in children and youth. In addition, achieving lower A1C levels is more likely to be related to setting lower A1C targets (26,27). A1C goals are presented in Table 11.1.
Assess for the presence of additional autoimmune conditions soon after the diagnosis and if symptoms develop. E
Because of the increased frequency of other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction and celiac disease should be considered. Periodic screening in asymptomatic individuals has been recommended, but the optimal frequency and benefit of screening are unclear.
Although much less common than celiac disease and thyroid dysfunction, other autoimmune conditions, such as Addison disease (primary adrenal insufficiency), autoimmune hepatitis, autoimmune gastritis, dermatomyositis, and myasthenia gravis, occur more commonly in the population with type 1 diabetes than in the general pediatric population and should be assessed and monitored as clinically indicated.
Consider testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after the diagnosis. E
Measure thyroid-stimulating hormone concentrations soon after the diagnosis of type 1 diabetes and after glucose 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. E
Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17–30% of patients with type 1 diabetes (28). At the time of diagnosis, about 25% of children with type 1 diabetes have thyroid autoantibodies (29); their presence is predictive of thyroid dysfunction—most commonly hypothyroidism, although hyperthyroidism occurs in ∼0.5% of cases (30,31). Thyroid function tests may be misleading (euthyroid sick syndrome) if performed at time of diagnosis owing to the effect of previous hyperglycemia, ketosis or ketoacidosis, weight loss, etc. Therefore, thyroid function tests should be performed soon after a period of metabolic stability and good glycemic control. Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia (32) and reduced linear growth rate. Hyperthyroidism alters glucose metabolism and usually causes deterioration of metabolic control.
Consider screening children with type 1 diabetes for celiac disease by measuring either tissue transglutaminase or deamidated gliadin antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes. E
Consider screening in children who have a first-degree relative with celiac disease, growth failure, weight loss, failure to gain weight, diarrhea, flatulence, abdominal pain, or signs of malabsorption or in children with frequent unexplained hypoglycemia or deterioration in glycemic control. E
Children with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B
Testing for celiac disease includes measuring serum levels of IgA and antitissue transglutaminase antibodies, or, with IgA deficiency, screening can include measuring IgG tissue transglutaminase antibodies or IgG deamidated gliadin peptide antibodies. Because most cases of celiac disease are diagnosed within the first 5 years after the diagnosis of type 1 diabetes, screening should be considered at the time of diagnosis and repeated within 2 and 5 years thereafter.
Although celiac disease can be diagnosed more than 10 years after diabetes diagnosis, there are insufficient data after 5 years to determine the optimal screening frequency. Testing for antitissue transglutaminase antibody should be considered at other times in patients with symptoms suggestive of celiac disease (35). A small-bowel biopsy in antibody-positive children is recommended to confirm the diagnosis (36). European guidelines on screening for celiac disease in children (not specific to children with type 1 diabetes) suggest that biopsy may not be necessary in symptomatic children with high antibody titers (i.e., greater than 10 times the upper limit of normal) provided that further testing is performed (verification of endomysial antibody positivity on a separate blood sample). It is also advisable to check for HLA types in patients who are diagnosed without a small intestinal biopsy. Asymptomatic at-risk children should have an intestinal biopsy (37).
In symptomatic children with type 1 diabetes and confirmed celiac disease, gluten-free diets reduce symptoms and rates of hypoglycemia (38). The challenging dietary restrictions associated with having both type 1 diabetes and celiac disease place a significant burden on individuals. Therefore, we recommend a biopsy to confirm the diagnosis of celiac disease, especially in asymptomatic children, before endorsing significant dietary changes.
Management of Cardiovascular Risk Factors
Blood pressure should be measured at each routine visit. Children found to have high-normal blood pressure (systolic blood pressure or diastolic blood pressure ≥90th percentile for age, sex, and height) or hypertension (systolic blood pressure or diastolic blood pressure ≥95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days. B
Initial treatment of high-normal blood pressure (systolic blood pressure or diastolic blood pressure consistently ≥90th percentile for age, sex, and height) includes dietary modification and increased exercise, if appropriate, aimed at weight control. If target blood pressure is not reached with 3–6 months of initiating lifestyle intervention, pharmacological treatment should be considered. E
In addition to lifestyle modification, pharmacological treatment of hypertension (systolic blood pressure or diastolic blood pressure consistently ≥95th percentile for age, sex, and height) should be considered as soon as hypertension is confirmed. E
ACE inhibitors or angiotensin receptor blockers should be considered for the initial pharmacological treatment of hypertension, following reproductive counseling due to the potential teratogenic effects of both drug classes. E
The goal of treatment is blood pressure consistently <90th percentile for age, sex, and height. E
Blood pressure measurements should be determined using the appropriate size cuff with the child seated and relaxed. Hypertension should be confirmed on at least 3 separate days. Evaluation should proceed as clinically indicated. Treatment is generally initiated with an ACE inhibitor, but an angiotensin receptor blocker can be used if the ACE inhibitor is not tolerated (e.g., due to cough). Normal blood pressure levels for age, sex, and height and appropriate methods for measurement are available online at www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf (39).
Obtain a fasting lipid profile in children ≥10 years of age soon after the diagnosis (after glucose control has been established). E
If lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values are within the accepted risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3–5 years is reasonable. E
Initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association diet to decrease the amount of saturated fat in the diet. B
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 LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors. E
The goal of therapy is an LDL cholesterol value <100 mg/dL (2.6 mmol/L). E
Population-based studies estimate that 14–45% of children with type 1 diabetes have two or more cardiovascular disease (CVD) risk factors (40–42), and the prevalence of CVD risk factors increases with age (42), with girls having a higher risk burden than boys (41).
The atherosclerotic process begins in childhood, and although CVD events are not expected to occur during childhood, observations using a variety of methodologies show that youth with type 1 diabetes may have subclinical CVD abnormalities within the first decade of diagnosis (43–45). Studies of carotid intima-media thickness have yielded inconsistent results (39).
Pediatric lipid guidelines provide some guidance relevant to children with type 1 diabetes (46–48); however, there are few studies on modifying lipid levels in children with type 1 diabetes. A 6-month trial of dietary counseling produced a significant improvement in lipid levels (49); likewise, a lifestyle intervention trial with 6 months of exercise in adolescents demonstrated improvement in lipid levels (50).
Although intervention data are sparse, the American Heart Association (AHA) categorizes children with type 1 diabetes in the highest tier for cardiovascular risk and recommends both lifestyle and pharmacological treatment for those with elevated LDL cholesterol levels (48,51). Initial therapy should be with a Step 2 AHA diet, which restricts saturated fat to 7% of total calories and restricts dietary cholesterol to 200 mg/day. Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and development (52).
For children with a significant family history of CVD, the National Heart, Lung, and Blood Institute recommends obtaining a fasting lipid panel beginning at 2 years of age (46). Abnormal results from a random lipid panel should be confirmed with a fasting lipid panel. Data from the SEARCH for Diabetes in Youth (SEARCH) study show that improved glucose control over a 2-year period is associated with a more favorable lipid profile; however, improved glycemic control alone will not normalize lipids in youth with type 1 diabetes and dyslipidemia (53).
Neither long-term safety nor cardiovascular outcome efficacy of statin therapy has been established for children; however, studies have shown short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels in familial hypercholesterolemia or severe hyperlipidemia, improving endothelial function, and causing regression of carotid intimal thickening (54,55). Statins are not approved for patients aged <10 years, and statin treatment should generally not be used in children with type 1 diabetes before this age. Statins are category X in pregnancy; therefore, pregnancy prevention is of paramount importance for postpubertal girls (see Section 12 “Management of Diabetes in Pregnancy” for more information).
Elicit a smoking history at initial and follow-up diabetes visits and discourage smoking in youth who do not smoke and encourage smoking cessation in those who do smoke. B
The adverse health effects of smoking are well recognized with respect to future cancer and CVD risk. In youth with diabetes, it is important to avoid additional CVD risk factors. Smoking increases the risk of onset of albuminuria; therefore, smoking avoidance is important to prevent both microvascular and macrovascular complications (46,56). Discouraging cigarette smoking, including e-cigarettes, is an important part of routine diabetes care. In younger children, it is important to assess exposure to cigarette smoke in the home due to the adverse effects of secondhand smoke and to discourage youth from ever smoking if exposed to smokers in childhood.
Annual screening for albuminuria with a random spot urine sample for albumin–to–creatinine ratio should be considered once the child has had diabetes for 5 years. B
Estimate glomerular filtration rate at initial evaluation and then based on age, diabetes duration, and treatment. E
Treatment with an ACE inhibitor, titrated to normalization of albumin excretion, should be considered when elevated urinary albumin–to–creatinine ratio (>30 mg/g) is documented with at least two of three urine samples. These should be obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure. B
Data from 7,549 participants <20 years of age in the T1D Exchange clinic registry emphasize the importance of good glycemic and blood pressure control, particularly as diabetes duration increases, in order to reduce the risk of nephropathy. The data also underscore the importance of routine screening to ensure early diagnosis and timely treatment of albuminuria (57). An estimation of glomerular filtration rate (GFR), calculated using GFR estimating equations from the serum creatinine, height, age, and sex (58), should be determined at baseline and repeated as indicated based on clinical status, age, diabetes duration, and therapies. Estimated GFR is calculated from a serum creatinine measurement using an estimating equation. This is not a recommendation to perform a measurement of creatinine clearance (involves timed urine collection) every year. There are ongoing clinical trials assessing the efficacy of early treatment of persistent albuminuria with ACE inhibitors (59).
An initial dilated and comprehensive eye examination is recommended at age ≥10 years or after puberty has started, whichever is earlier, once the youth has had diabetes for 3–5 years. B
After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations, every 2 years, may be acceptable on the advice of an eye care professional. E
Although retinopathy (like albuminuria) most commonly occurs after the onset of puberty and after 5–10 years of diabetes duration (60), it has been reported in prepubertal children and with diabetes duration of only 1–2 years. Referrals should be made to eye care professionals with expertise in diabetic retinopathy and experience in counseling the pediatric patient and family on the importance of early prevention and intervention.
Consider an annual comprehensive foot exam for the child at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. E
Neuropathy rarely occurs in prepubertal children or after only 1–2 years of diabetes (60). A comprehensive foot exam, including inspection, palpation of dorsalis pedis and posterior tibial pulses, assessment of the patellar and Achilles reflexes, and determination of proprioception, vibration, and monofilament sensation, should be performed annually along with assessment of symptoms of neuropathic pain. Foot inspection can be performed at each visit to educate youth regarding the importance of foot care.
Type 2 Diabetes
For information on testing for type 2 diabetes and prediabetes in children and adolescents, please refer to Section 2 “Classification and Diagnosis of Diabetes.”
The Centers for Disease Control and Prevention recently published projections for type 2 diabetes prevalence using the SEARCH database. Assuming a 2.3% annual increase, the prevalence of type 2 diabetes in those under 20 years of age will quadruple in 40 years (61,62). Given the current obesity epidemic, distinguishing between type 1 and type 2 diabetes in children can be difficult. For example, excessive weight is common in children with type 1 diabetes (63). Furthermore, diabetes-associated autoantibodies and ketosis may be present in patients with features of type 2 diabetes (including obesity and acanthosis nigricans) (64). Nevertheless, accurate diagnosis is critical as treatment regimens, educational approaches, dietary advice, and outcomes differ markedly between the two diagnoses.
The general treatment goals for type 2 diabetes are the same as those for type 1 diabetes. A multidisciplinary diabetes team, including a physician, diabetes nurse educator, registered dietitian, and behavioral specialist or social worker, is essential. In addition to blood glucose control, treatment must include management of comorbidities such as obesity, dyslipidemia, hypertension, and albumin levels from the outset.
Presentation with ketosis or ketoacidosis requires a period of insulin therapy until fasting and postprandial glycemia have been restored to normal or near-normal. Metformin therapy may be used as an adjunct after resolution of ketosis/ketoacidosis. Initial treatment should also be with insulin when the distinction between type 1 diabetes and type 2 diabetes is unclear and in patients who have random blood glucose concentrations ≥250 mg/dL (13.9 mmol/L) and/or A1C >9% (75 mmol/mol) (65).
Patients and their families must prioritize lifestyle modifications such as eating a balanced diet, maintaining a healthy weight, and exercising regularly. A family-centered approach to nutrition and lifestyle modification is essential in children with type 2 diabetes. Nutrition recommendations should be culturally appropriate and sensitive to family resources (see Section 3 “Foundations of Care and Comprehensive Medical Evaluation”).
When insulin treatment is not required, initiation of metformin, currently the only oral hypoglycemic agent specifically approved for use in children with type 2 diabetes, is recommended. However, the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study found that metformin alone provided durable glycemic control (A1C ≤8% [64 mmol/mol] for 6 months) in approximately half of the subjects (66), suggesting that many youth with type 2 diabetes are likely to require combination treatment within a few years of diagnosis.
Comorbidities may already be present at the time of diagnosis in youth with type 2 diabetes (67). Therefore, blood pressure measurement, a fasting lipid panel, assessment for albumin excretion, and a dilated eye examination should be performed at diagnosis. Thereafter, screening guidelines and treatment recommendations for hypertension, dyslipidemia, albumin excretion, and retinopathy are similar to those for youth with type 1 diabetes. Additional problems that may need to be addressed include polycystic ovary disease and other comorbidities associated with pediatric obesity, such as sleep apnea, hepatic steatosis, orthopedic complications, and psychosocial concerns. The ADA consensus report “Type 2 Diabetes in Children and Adolescents” (68) and a more recent American Academy of Pediatrics clinical practice guideline (69) provide guidance on the prevention, screening, and treatment of type 2 diabetes and its comorbidities in children and adolescents.
Transition From Pediatric to Adult Care
Health care providers and families should begin to prepare youth in early to mid-adolescence and, at the latest, at least 1 year before the transition to adult health care. E
Both pediatricians and adult health care providers should assist in providing support and links to resources for the teen and emerging adult. B
Care and close supervision of diabetes management are increasingly shifted from parents and other adults to the youth with diabetes throughout childhood and adolescence. The shift from pediatrics to adult health care providers, however, often occurs abruptly as the older teen enters the next developmental stage referred to as emerging adulthood (70), which is a critical period for young people who have diabetes. During this period of major life transitions, youth begin to move out of their parents’ home and must become fully responsible for their diabetes care. Their new responsibilities include self-management of their diabetes, making medical appointments, and financing health care, once they are no longer covered by their parents’ health insurance plan (ongoing coverage until age 26 years is possible with recent U.S. health care reform). In addition to lapses in health care, this is also a period associated with deterioration in glycemic control; increased occurrence of acute complications; psychosocial, emotional, and behavioral challenges; and the emergence of chronic complications (71–74).
Although scientific evidence is limited, it is clear that comprehensive and coordinated planning that begins in early adolescence, or at least 1 year before the date of transition, is necessary to facilitate a seamless transition from pediatric to adult health care (71,72). A comprehensive discussion regarding the challenges faced during this period, including specific recommendations, is found in the ADA position statement “Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems” (72).
The National Diabetes Education Program (NDEP) has materials available to facilitate the transition process (http://ndep.nih.gov/transitions), and the Endocrine Society in collaboration with the ADA and other organizations has developed transition tools for clinicians and youth and families (http://www.endo-society.org/clinicalpractice/transition_of_care.cfm).
Suggested citation: American Diabetes Association. Children and adolescents. Sec. 11. In Standards of Medical Care in Diabetes—2016. Diabetes Care 2016;39(Suppl. 1):S86–S93
- © 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.