ADA Releases Updated Guidelines for Managing Pediatric Type 1 Diabetes

Guideline 2: Screening and Testing for Type 1 Diabetes in Asymptomatic Children

“Screening for type 1 diabetes in asymptomatic children with a panel of autoantibodies is currently recommended only in the setting of research studies in first-degree family members of a proband with type 1 diabetes,” the guideline authors wrote. “The incidental discovery of hyperglycemia without classic symptoms does not necessarily indicate new-onset diabetes, especially in young children with an acute illness who may experience ‘stress hyperglycemia.’ The risk of eventually developing diabetes, however, may be increased in some children with incidental or stress hyperglycemia, especially those with immunological, metabolic, or genetic markers for type 1 diabetes, and consultation with a pediatric endocrinologist is indicated.”¹

•  In an asymptomatic child or adolescent, an FPG ≥126 mg/dL (7 mmol/L), 2-h PG ≥200 mg/dL (11.1 mmol/L), or A1c ≥6.5% should be repeated on a separate day to confirm the diagnosis. The ADA recommends that the same test be repeated without delay using a new blood sample.
• Diagnosis is confirmed if 2 different tests, such as A1c and FPG, are both above the diagnostic threshold. If they are different, repeat the test that had results above the diagnostic cut.
• Typical symptoms of diabetes and a random PG ≥200 mg/dL (11.1 mmol/L) does not require further testing to diagnose diabetes.
• There is still debate over whether the same A1c threshold should be used to diagnose diabetes in children and adults.

Guideline 3: Distinguishing Between Diabetes Types

“One often correctly assumes a diagnosis of type 1 diabetes in the slender pre-pubertal child with classic symptoms and without a family history suggestive of a monogenic form of diabetes,” the guideline authors wrote. “However, observational studies show increasing numbers of overweight and obese children and adolescents with type 1 diabetes, similar to the general population,” they noted.¹

• Monogenic diabetes, which accounts for 1.2% to 4% of pediatric diabetes, is frequently misdiagnosed as T1D and inappropriately treated with insulin.
• Clinicians should be aware of the possibility of mature-onset diabetes in the young (MODY), particularly in antibody-negative youths with diabetes and neonatal diabetes, particularly in children diagnosed with diabetes in the first 6 months of life.
• Diagnosis of MODY or neonatal diabetes has important implications for treatment, as well as other affected family members. Although it is still undergoing validation, an online probability calculator from diabetes.genes.org (www.diabetesgenes.org/content/modyprobability-calculator) can help determine who would benefit from genetic testing.

Guideline 4: Blood Glucose Management: Monitoring and Treatment

• Most children with T1D should be treated with intensive insulin regimens, either with multiple daily injections of prandial insulin and basal insulin or by continuous subcutaneous insulin infusion.
• A1c should be measured in all youths with T1D at 3-month intervals to assess overall glycemic control.
• An A1c target of <7.5% should be considered but this should be individualized based on the patient’s and family’s needs.
• Outcomes other than A1c should be considered, such as time with glucose in target range and frequency of hypoglycemia, given the increasing use of continuous glucose monitoring (CGM) devices.

Guideline 5: Frequency of Monitoring

• All youths with T1D should monitor their glucose levels 6 to 10 times a day, including pre-meals, pre-bedtime, and to assess safety in situations such as during exercise, driving, illness, or when experiencing symptoms of hypoglycemia.
• In prolonged or severe hyperglycemia, blood or urine ketone levels should be monitored to determine whether a treatment adjustment or referral to urgent care is needed.

Guideline 6: Continuous Glucose Monitoring (CGM)

• CGM should be considered in all youths with T1D, whether using injections or insulin pump therapy. The benefits of CGM correlate with adherence to device use.

Guideline 7: Automated Insulin Delivery

• Automated insulin delivery systems should be considered in youths with T1D, as they appear to improve glycemic control and reduce hypoglycemia.

Guideline 8: Adjunctive Therapies

• There is insufficient evidence to support routine use of adjunctive medical therapies in pediatric patients with T1D (such as metformin or pramlintide).

Guideline 9: Adequate Reimbursement for Diabetes Supplies and Medications

The guideline authors noted that there are improved outcomes in patients when the numerous supplies and devices needed to optimize management of T1D are adequately reimbursed. This is especially true in pediatric populations.