| Evaluation | Purpose | Initiate screening | Repeat at least | Abnormal result | Usual treatment |
| Hypoglycemia assessment | Ask about episodes of hypoglycemia and associated symptoms, and review records of blood glucose monitoring. Evaluate for hypoglycemia unawareness. | After diagnosis of diabetes. | Every 3 months. | Frequent episodes of hypoglycemia (blood glucose level <70 mg/dL), especially with hypoglycemia unawareness. | Review insulin and monitoring regimen, and educate regarding prevention of and response to hypoglycemia. Consider continuous glucose monitoring and automated insulin delivery systems. |
| Psychosocial assessment | Screen for depression, family conflict, risk-taking behaviors, or other psychosocial dysfunction. Offer time alone with clinician, starting at age 12 years when developmentally appropriate. In older children and adolescents, screen for eating disorders, and provide anticipatory counseling and screen for smoking and use of e-cigarettes. | At diagnosis of diabetes. Assess for psychosocial and diabetes-related stress starting at 7 to 8 years of age. Screen for eating disorders starting at 10 to 12 years of age. | Every 3 months. | Clinical symptoms of depression, eating disorder, or psychosocial dysfunction. | Refer to mental health professional. For youth who smoke or use e-cigarettes (vaping nicotine), provide counseling and/or referral for cessation assistance. Preconception counseling for girls of childbearing potential starting at puberty. |
| Smoking | Ask about use or experimentation with tobacco products including vaping (e-cigarettes). | At initial diabetes visit. | Every 3 months. | History of smoking or vaping. | Discourage smoking and vaping. If there is a history of smoking or vaping, encourage cessation. |
| BP | Screen for hypertension. | At diagnosis of diabetes. | Every 3 months. | Elevated BP (prehypertension)[1,2]:
| Nonpharmacologic intervention (diet and exercise, with weight reduction if appropriate). Initiate pharmacologic intervention (ACE inhibitor or ARB) if BP remains in prehypertensive range despite intervention for 3 to 6 months*. |
Hypertension[1]:
| In addition to nonpharmacologic intervention, initiate pharmacologic intervention (ACE inhibitor or ARB)*[3]. | ||||
| Foot examination with testing for vibration (tuning fork) and pressure (10 g monofilament) | Screen for polyneuropathy. | Age ≥10 years (or onset of puberty, if earlier) and if the youth has had diabetes for ≥5 years. | Annually. | Inspection, palpation of dorsalis pedis and posterior tibial pulses, assessment of vibration, proprioception and 10 g monofilament sensation. | Optimize glycemic control with blood glucose monitoring and insulin administration (refer to topic text). |
| Urine albumin:creatinine ratio (spot specimen) | Screen for nephropathy. | Age ≥10 years (or onset of puberty, if earlier) and if the youth has had diabetes for ≥5 years. | Annually. | >30 mg albumin/g creatinine (in at least 2 of 3 urine samples over a 6-month interval, following efforts to improve glycemic control and normalize BP)¶. | ACE inhibitor or ARB*. |
| A1C | Glycemic control. | At diagnosis of diabetes. | Every 3 months. | Goal A1C <7% for most children and adolescentsΔ[2]. | Optimize glycemic control with blood glucose monitoring and insulin administration (refer to topic text). |
| Lipid profile | Screen for dyslipidemia. | At diagnosis of diabetes, once initial glycemic control is achieved and age ≥2 years◊. If sample was nonfasting (random) and results abnormal, confirm with a fasting lipid panel. | If initial LDL ≤100, initiate serial testing at age 9 to 11 years and repeat every 3 years if normal. Repeat annually if LDL is abnormal or if glycemic control is poor. | LDL ≥100 mg/dL. | Nonpharmacologic intervention: optimize glycemic control; exercise and diet to limit dietary cholesterol (≤200 mg/day) and saturated fat (≤7% of total calories) and maintain healthy body weight. |
| LDL ≥130 to 159 mg/dL. | Pharmacologic intervention (statins) for children ≥10 years if any CVD risk factors are present (obesity, tobacco use, family history of early CVD), if nonpharmacologic intervention is not successful, and after reproductive counseling. Aim for LDL ≤100 mg/dL. | ||||
| LDL ≥160 mg/dL. | Pharmacologic intervention (statins) for children ≥10 years, if nonpharmacologic intervention is not successful, and after reproductive counseling. Aim for LDL ≤100 mg/dL. | ||||
| TSH | Screen for hypothyroidism caused by autoimmune thyroiditis. | At diagnosis of diabetes, after patient is clinically stable or soon after glycemic control is established◊. | Every 1 to 2 years, or if symptoms of hypothyroidism develop, or if anti-thyroid antibodies are present. | Elevated TSH. | Treatment with levothyroxine as needed. |
| tTG, IgA | Screen for celiac disease. | At diagnosis of diabetes. | Repeat within 2 years of diagnosis, then after 5 years, or if gastrointestinal symptoms develop, and more frequently if a first-degree relative has celiac disease§. | Positive results of antibody test. | Evaluate further with upper endoscopy, before beginning a gluten-free diet. |
| Dilated eye examination | Screen for retinopathy. | Age ≥11 years (or onset of puberty, if earlier), and the child has had diabetes for 3 to 5 years. | Repeat every 2 years. May be done less frequently based on risk factor assessment (including A1C ≤8%) and advice of an eye care professional. | Background, preproliferative, or proliferative retinopathy. | Optimizing glycemic control may reverse background retinopathy; laser therapy for more advanced disease. |
BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; A1C: hemoglobin A1c (glycated hemoglobin); LDL: low-density lipoprotein; CVD: cardiovascular disease; TSH: thyroid-stimulating hormone; tTG: tissue transglutaminase; IgA: immunoglobulin A; ADA: American Diabetes Association; TPO: thyroid peroxidase.
* ACE inhibitors (eg, lisinopril or enalapril) and ARBs have teratogenic potential, so appropriate reproductive counseling should be given to young women. Aim for BP consistently <90th percentile for age, sex, and height.
¶ Transient albuminuria is common in children. Abnormal results should be confirmed on at least 2 occasions, ruling out orthostatic albuminuria, or with a 24-hour urine collection.
Δ More or less stringent goals may be appropriate for individual patients, depending on their personal history of severe hyperglycemia, severe hypoglycemia, and hypoglycemia unawareness.
◊ Glycemic control should be established before performing the lipid profile or thyroid screening. The ADA suggests that antibodies to TPO and thyroglobulin should be measured at diagnosis.
§ More frequent screening for celiac disease may be appropriate for children who have a first-degree relative with celiac disease. Measurement of tTg is sufficient if IgA is normal. Antibody testing is only valid if performed on a gluten-containing diet.