Guideline 10: Nutrition Therapy
- Individualized nutrition therapy is recommended.
- Monitoring carbohydrate intake is critical to achieving glycemic control.
- Comprehensive nutrition education is recommended at diagnosis with annual updates.
Guideline 11: Physical Activity and Exercise
- Exercise is recommended for all youths with T1D, with a goal of moderate- to vigorous-intensity daily aerobic activity and vigorous muscle- and bone-strengthening exercise 3 days/week.
- Educate youths about the prevention of possible hypoglycemia during and after exercise, including ensuring a blood glucose level of 90 to 250 mg/dL (5 to 13 mmol/L), and having carbohydrates available to eat during exercise.
Guideline 12: Behavioral Aspects and Self-Management
- Address possible psychological issues such as, anxiety, depression, and/or diabetes-related distress, and refer patients to an appropriate mental health professional.
- Consider family dynamics and issues that could be affecting care.
- Encourage age-related involvement in diabetes treatment.
- Assess whether the patient can comprehend the potential health consequences of their behavior.
- Offer adolescents time alone with clinicians, generally starting at approximately age 12.
- Consider screening for disordered or disrupted eating behaviors.
Guideline 13: Complications and Comorbidities
Acute complications can include:
- Educate patients and caregivers annually on diabetic keto acidosis (DKA).
- Patients must have an uninterrupted supply of insulin and medical support.
- Hospitals must have pediatric-specific protocols for DKA treatment.
- Ask about symptomatic or asymptomatic hypoglycemia at each encounter.
- 15g of glucose is recommended to treat hypoglycemia (<70 mg/dL [3.9 mmol/L]). Repeat treatment if blood glucose does not return to normal after 15 minutes. Consider a meal or snack once blood glucose returns to normal to reduce the chance of repeat hypoglycemia.
- Prescribe glucagon and instruct caregivers and family members on its administration.
- Re-evaluate the treatment regimen if the patient is unable to sense hypoglycemia or has had 1 or more severe episodes.
- Patients with hypoglycemia unawareness or an episode of severe hypoglycemia should raise their blood glucose targets for at least several weeks to attempt to partially reverse hypoglycemia unawareness and reduce the risk for future episodes.
Microvascular complications can include:
- At age 10 or after puberty is reached, an initial dilated and comprehensive eye examination is recommended after the patient has had diabetes for 3 to 5 years.
- After initial examination, annual routine follow-up is recommended. Examinations every 2 years may be acceptable based on an eye care professional’s advice and on the individual risk level.
Diabetic Kidney Disease (DKD)
- Screen patients annually for albuminuria, with a random spot check (morning sample preferred) of albumin-to-creatinine ratio at puberty or after the patient has had diabetes for 5 years.
- If elevated urinary albumin-to-creatinine ratio (.30 mg/g) is documented (2 of 3 urine samples obtained over a 6-month interval) following efforts to improve glycemic control and normalize blood pressure, an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) may be considered.
- Once the patient has had diabetes for 5 years, an annual comprehensive foot exam at the start of puberty or age 10 should be considered.
- Check blood pressure at each visit.
- The treatment goal is blood pressure consistently <90th percentile for age, sex, and height.
- Initial treatment for high blood pressure should include dietary modification and increased exercise. Consider pharmacologic treatment if the target blood pressure is not reached within 3 to 6 months of lifestyle intervention.
- Also consider pharmacologic intervention if hypertension is confirmed (systolic blood pressure or diastolic blood pressure consistently at the 95th percentile for age, sex, and height).
- ACE inhibitors or ARBs should be considered for the initial pharmacologic treatment of hypertension following reproductive counseling (due to the potential teratogenic effects of both drug classes).