Managing type 1 diabetes in adolescents and kids : New position statement by ADA

The American Diabetes Association (ADA) has released a new position statement for the management of type 1 diabetes in adolescents and children.

The recommendations are published in the journal Diabetes Care.

KEY RECOMMENDATIONS:

Diagnosis

• Diagnosis of T1D should be pursued expeditiously.


• A pediatric endocrinologist should be consulted before making a diagnosis of type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in the setting of acute illness and in the absence of classic symptoms.


• Distinguishing between type 1, type 2, monogenic , and other forms of diabetes is based on history, patient characteristics, and laboratory tests, including an islet autoantibody panel.

BLOOD GLUCOSE MANAGEMENT: MONITORING AND TREATMENT

Insulin

• Most children with type 1 diabetes should be treated with intensive insulin regimens via either multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion.

Assessment of Glycemic Control

• A1C should be measured in all children and adolescents with type 1 diabetes at 3-month intervals to assess their overall glycemic control.


• An A1C target of <7.5% should be considered in children and adolescents with type 1 diabetes but should be individualized based on the needs and situation of the patient and family.


• With increasing use of CGM devices, outcomes other than A1C, such as time with glucose in target range and frequency of hypoglycemia, should be considered in the overall assessment of glycemic control.

Blood Glucose Monitoring

• All children and adolescents with type 1 diabetes should have blood glucose levels monitored multiple times daily (up to 6–10 times/day), including premeal and pre-bedtime, and as needed for safety in specific situations such as exercise, driving, illness, or the presence of symptoms of hypoglycemia.

Blood/Urinary Ketone Monitoring

• Blood or urine ketone levels should be monitored in children with type 1 diabetes in the setting of prolonged/severe hyperglycemia or acute illness to determine if the adjustment to treatment or referral to urgent care is needed.

CGM

• CGM should be considered in all children and adolescents with type 1 diabetes, whether using injections or insulin pump therapy, as an additional tool to help improve glycemic control. Benefits of CGM correlate with adherence to ongoing use of the device.

Automated Insulin Delivery

• Automated insulin delivery systems appear to improve glycemic control and reduce hypoglycemia in children and should be considered in pediatric patients with type 1 diabetes.

Adjunctive Therapies

• There is insufficient evidence to support the routine use of adjunctive medical therapies in children with type 1 diabetes.

Nutrition Therapy

• Individualized medical nutrition therapy is recommended for children and adolescents with type 1 diabetes as an essential component of the overall treatment plan.


• Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, is key to achieving optimal glycemic control.


• Comprehensive nutrition education at diagnosis, with annual updates, by an experienced registered dietitian, is recommended to assess caloric and nutrition intake in relation to weight status and CVD risk factors and to inform macronutrient choices.

Physical Activity and Exercise

• Exercise is recommended for all youth with type 1 diabetes with the goal of 60 min of moderate- to vigorous-intensity aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week.


• Education about prevention and management of potential hypoglycemia during and after exercise is essential, including pre-exercise glucose levels of 90–250 mg/dL (5–13 mmol/L) and accessible carbohydrates, individualized according to the type/intensity of the planned physical activity.


• Strategies to prevent hypoglycemia during exercise, after exercise, and overnight following exercise include reducing prandial insulin dosing for the meal/snack preceding exercise, increasing carbohydrate intake, eating bedtime snacks, using CGM, and/or reducing basal insulin doses.


• Frequent glucose monitoring before, during, and after exercise, with or without CGM use, is important to prevent, detect, and treat hypoglycemia and hyperglycemia with exercise.

BEHAVIORAL ASPECTS OF SELF-MANAGEMENT

• At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact diabetes management and provide appropriate referrals to trained mental health professionals, preferably experienced in childhood diabetes.


• Providers should consider asking youth and their parents about social adjustment (peer relationships) and school performance to determine whether further evaluation is needed.


• Assess youth with diabetes for generic and diabetes-related distress, generally starting at 7–8 years of age.


• Providers should encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child may result in poor self-management behaviors and deterioration in glycemic control.


• Consider including children in consent processes as early as cognitive development indicates an understanding of health consequences of behavior.


• Offer adolescents time by themselves with their care provider(s) starting at age 12 years, or when developmentally appropriate.


• Consider screening for disordered or disrupted eating behaviors using validated screening measures when hyperglycemia and/or weight loss are unexplained based on self-reported behaviors related to medication dosing, meal plan, and physical activity. In addition, a review of the medical regimen is recommended to identify potential treatment-related effects on hunger/caloric intake.

Diabetic Ketoacidosis (DKA)

• Individuals and caregivers of individuals with type 1 diabetes should be educated annually on DKA prevention, including sick-day management, the importance of insulin administration, and glucose and ketone level monitoring.


• 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 DKA.


• Patients and families with type 1 diabetes should have continual access to medical support to assist with sick-day management.


• Standard pediatric-specific protocols for DKA treatment should be available in emergency departments and hospitals.

Hypoglycemia

• Individuals with type 1 diabetes, or their caregivers, should be asked about symptomatic and asymptomatic hypoglycemia at each encounter.


• Glucose (15 g) is the preferred treatment for the conscious individual with hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]), although any form of carbohydrate may be used. If the SMBG result 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once blood glucose concentration returns to normal, the individual should consider a meal or snack and/or reduce insulin to prevent hypoglycemia recurrence.


• Glucagon should be prescribed for all individuals with type 1 diabetes. Caregivers or family members of these individuals should be instructed in its administration.


• Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger a re-evaluation of the treatment regimen.


• Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to avoid further hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce the risk of future episodes.

Diabetic Kidney Disease (DKD)

• Annual screening for albuminuria with a random (morning sample preferred to avoid effects of exercise) spot urine sample for albumin-to-creatinine ratio should be considered at puberty or at age >10 years, whichever is earlier, once the child has had diabetes for 5 years.


• An ACE inhibitor or an angiotensin receptor blocker (ARB), titrated to normalization of albumin excretion, may be considered when the elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented (two of three urine samples obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure).

For further reference follow the link: https://doi.org/10.2337/dci18-0023