ADA Releases Updated Guidelines for Managing Pediatric Type 1 Diabetes

The American Diabetes Association (ADA) has issued updated guidelines on managing type 1 diabetes (T1D) in children and adolescents. The guidelines are available online and will be published in the September 2018 print issue of Diabetes Care.¹

A team of 8 pediatric diabetes experts created these guidelines and recommendations based on more than 190 research studies and consensus reports. Because large randomized pediatric control studies are difficult to recruit for and complete, it is much more difficult to gather robust evidence for T1D in children and adolescents than in adults. Most recommendations for children and adolescents with T1D come from supportive evidence from cohort/registry studies, expert consensus, or clinical experience. This is, therefore, the first updated ADA pediatric T1D position statement since 2005.

One of the main takeaways from the new guidelines is a paradigm for thinking about treating children with T1D. “It is critical for us to remember that children are not little adults. Thus, pediatric-onset diabetes is different from adult-onset diabetes due to its distinct epidemiology, pathophysiology, developmental considerations, and response to therapy,” said senior guideline author Desmond Schatz, MD, professor of pediatrics and medical director of the Diabetes Center, and director of the Clinical Research Center within the Clinical and Translational Science Institute at the University of Florida, Gainesville, and the ADA’s 2016 president of Science and Medicine. “Clinicians must be mindful of a child’s current and evolving developmental stages and must adapt care plans, particularly during the adolescent years, in order to maximize glycemic control and appropriately support the needs of both the patient and their family.”²

Guideline 1: Diagnosing Diabetes at Stages 1, 2, and 3

Stage 1

B cell autoimmunity is evidenced by two or more islet autoantibodies with normoglycemia; this stage is presymptomatic

Diagnostic criteria: ≥2 autoantibodies; no impaired glucose tolerance or impaired fasting glucose

Stage 2

B -cell autoimmunity with dysglycemia is present; this stage is presymptomatic

Diagnostic criteria: ≥2 autoantibodies; dysglycemia: impaired fasting glucose and/or impaired glucose tolerance; fasting plasma glucose (FPG) 100-125 mg/dL (5.6-6.9 mmol/L); 2-hour plasma glucose (2-h PG) 140-199 mg/dL (7.8-11.0 mmol/L); hemoglobin A1c (HbA1c) 5.7-6.4% (39-47 mmol/mol) or ≥10% increase in A1c

Stage 3

New-onset hyperglycemia; symptomatic

Diagnostic criteria: clinical symptoms; diabetes according to standard criteria

In addition:

• Blood glucose, rather than A1c, should be used to diagnose acute onset of T1D in individuals with symptoms of hyperglycemia.
• Clinical diagnostic criteria are the same for type 1 and type 2 diabetes (T2D).
• A glucose tolerance test is not usually required except in atypical cases or early in the disease process when plasma glucose values may be normal or only mildly abnormal and the diagnosis may be uncertain.
• Because the metabolic state of untreated children with T1D can deteriorate rapidly, a definitive diagnosis should be made immediately.