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Dyslipidemia
- When the patient is 10 or older, obtain a fasting lipid profile as soon as glycemic control has been established.
- Therapy goal is a low-density lipoprotein (LDL) cholesterol value of 100 mg/dL (2.6 mmol/L).
- If LDL cholesterol values are within the accepted risk level (100 mg/dL [2.6 mmol/L]), repeating a lipid profile every 3 to 5 years is reasonable.
- If lipids are abnormal, initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association diet that restricts saturated fat to 7% of total calories and dietary cholesterol to 200 mg/d. This is safe and does not interfere with normal growth and development.
- After age 10, consider adding a statin in patients who continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130mg/dL (3.4 mmol/L[HAS1] ) and one or more CVD risk factors despite medical nutrition therapy and lifestyle changes for 6 months, following reproductive counseling because of the potential teratogenic effects of statins.
- Get a smoking history at the initial and at follow-up visits.
- Discourage smoking in patient who do not smoke, and encourage patients who do smoke to quit.
Autoimmune Conditions
“Assess for additional autoimmune conditions soon after the diagnosis of type 1 diabetes and if symptoms develop,” the guideline authors advised.1
Thyroid Disease
- Soon after diagnosis, consider testing children with T1D for antithyroid peroxidase and antithyroglobulin antibodies.
- Measure thyroid-stimulating hormone concentrations at diagnosis when the patient is clinically stable, or soon after glycemic control has been established.
- If normal, suggest rechecking every 1 to 2 years or sooner if the patient develops signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability.
Celiac Disease
- Soon after diagnosis of diabetes, screen children with T1D for celiac disease by measuring immunoglobulin A (IgA) tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, or IgG to tTG and deamidated gliadin antibodies if IgA is deficient.
- Repeat this screening within 2 years of initial screening and again at 5 years. Consider more frequent screening in children who have symptoms of or a first-degree relative with celiac disease.
- Patients with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian who is experienced in managing both diabetes and celiac disease.
Transitioning From Pediatric to Adult Care
“Pediatric diabetes providers should begin to prepare youth for transition in early adolescence, and at the latest, at least 1 year before the transition to adult health care,” the guideline authors wrote. “Both pediatric and adult diabetes care providers should provide support and resources for transitioning young adults.”1
Conclusion
These guidelines emphasize that providers should encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, and note that prematurely transferring diabetes care from the pediatric to the adult care setting may result in poor self-management behaviors and deterioration in glycemic control.
The guideline authors also noted that although technological advances are credited with providing advances in research, treatment, and management of T1D, more pediatric studies are needed to address the unique characteristics of T1D during each developmental stage from childhood to adolescence to adulthood.
“While we are still uncovering the complex markers and potential triggers for type 1 diabetes in youth, these guidelines represent our commitment to personalized care to meet the unique needs of each individual living with diabetes,” said ADA’s chief scientific, medical and mission officer William T. Cefalu, MD. “We also encourage rapid diagnosis and treatment and whole-family care, given the 24/7 burdens of diabetes management in children, in the hopes of yielding improved short- and long-term health outcomes and quality of life.”2
Future updates to pediatric care will be published in the ADA’s annual Standards of Medical Care in Diabetes.
References
- Chiang JL, Maahs DM, Garvey KC, et al. Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association [published online July 18, 2018]. Diabetes Care. doi:10.2337/dci18-0023
- American Diabetes Association® issues new position statement on care for pediatric patients with type 1 diabetes [press release]. ADA. Published August 9, 2018. www.diabetes.org/newsroom/press-releases/2018/position-statement-care-pediatric-patients-type-1-diabetes.html. Accessed August 9, 2018.
