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Overview of the management of type 1 diabetes mellitus in children and adolescents

Overview of the management of type 1 diabetes mellitus in children and adolescents
Authors:
Lynne L Levitsky, MD
Madhusmita Misra, MD, MPH
Section Editor:
Joseph I Wolfsdorf, MD, BCh
Deputy Editor:
Alison G Hoppin, MD
Literature review current through: Dec 2022. | This topic last updated: Aug 16, 2022.

INTRODUCTION — Type 1 diabetes mellitus (T1DM), one of the most common chronic diseases in childhood, is caused by insulin deficiency resulting from the destruction of insulin-producing pancreatic beta cells. (See "Pathogenesis of type 1 diabetes mellitus".)

There are unique challenges in caring for children and adolescents with T1DM that differentiate pediatric from adult care. These include the obvious differences in the size of the patients, developmental issues such as the unpredictability of a toddler's dietary intake and activity level and inability to communicate symptoms of hypoglycemia, and medical issues such as the increased risk of hypoglycemia and diabetic ketoacidosis (DKA). Because of these considerations, the management of a child with T1DM must take into account the age and developmental maturity of the child.

Most children with T1DM present relatively early with the classic signs and symptoms of hyperglycemia and deficient insulin release, including polyuria and polydipsia, sometimes associated with polyphagia and weight loss. Approximately 30 percent of children present with severe insulin deficiency and DKA [1,2]. The topic below provides an overview of the management of T1DM in children who are not in DKA. Details of insulin therapy, including regimens, pumps, and blood glucose monitoring, are presented separately. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)

Other aspects of childhood-onset T1DM are discussed separately:

Routine management:

(See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents".)

(See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)

(See "Complications and screening in children and adolescents with type 1 diabetes mellitus".)

(See "Management of exercise for children and adolescents with type 1 diabetes mellitus".)

(See "Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel".)

Prevention and management of acute glycemic emergencies:

(See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus".)

(See "Diabetic ketoacidosis in children: Clinical features and diagnosis".)

(See "Diabetic ketoacidosis in children: Treatment and complications".)

(See "Diabetic ketoacidosis in children: Cerebral injury (cerebral edema)".)

OVERVIEW OF DIABETES EDUCATION

Goals — Successful management of children with diabetes includes [3-5]:

Balance the goal of strict glycemic control, which reduces the risk of long-term sequelae of chronic hyperglycemia, against the goal of avoiding severe hypoglycemia. Severe hypoglycemia can occur more frequently in the setting of stricter control, but newer technologies mitigate this risk to variable degrees. Targeted glycemic goals define what is thought to be the best balance between these long- and short-term complications. (See 'Overview of insulin therapy' below.)

Set realistic goals for each child and family. The patient's age and developmental status and the level of family involvement are important factors in establishing a practical management plan that can be implemented by the patient and family/caregivers. (See 'Age-based care' below.)

Train the patient and family/caregivers in diabetes self-management techniques to maintain blood glucose within a target range and to recognize and treat hypoglycemia. (See "Self-management education for the child with diabetes mellitus".)

Maintain normal growth, development, and emotional maturation and support increasing independence and self-care of diabetes as the child grows older.

Initial diabetes education and self-care training provided by a multidisciplinary team effectively permits the patient and family to acquire the knowledge and skills needed for care [5]. Team members should include an endocrinologist, nurse educator, dietitian, and mental health professional who can provide pediatric-specific education and care. Comprehensive management by a pediatric diabetes team reduces the number of hospitalizations and emergency room visits and is cost-effective [6].

Training and care of the patient and family/caregivers is divided into two management phases [3]. In the initial phase, treatment with insulin is initiated and the patient and family/caregivers are taught the most essential skills to safely manage diabetes. In the second phase, the family is given further education and support to optimize glycemic control and long-term management.

Initial management — The initial phase begins at the time of diagnosis. In these first few days, the family begins to understand the disease process and is trained to successfully measure blood glucose concentrations, administer insulin, recognize and treat hypoglycemia, and measure blood or urine ketone concentrations (table 1).

Basic understanding – The diabetes team teaches the patient and family the cause and treatment of T1DM, how to maintain a daily schedule and record of blood glucose test results, how to administer insulin, and the timing and carbohydrate content of meals and snacks.

Blood glucose testing – Families/caregivers must master blood glucose testing. A variety of easy-to-use blood glucose meters are available for this purpose. The parents or caregivers are instructed on the frequency and timing of blood glucose testing, depending upon the needs of their child.

Insulin administration – Training includes teaching the family and caregivers about the different types of prescribed insulin, how to measure and inject insulin, and how to rotate injection sites. Family members and caregivers must learn about the duration and action of the various types of insulin prescribed for the child, and how to adjust the insulin dose based upon blood glucose concentrations and carbohydrate intake. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)

In our practice, we encourage the parents to administer the first injection. Although this requires additional assistance and fairly directive behavior on the part of the clinician, we find that it facilitates the learning process. Because most parents are frightened about administering an injection to their child, their ability to learn is limited until they have administered the first injection. We also find it useful to have the parents administer a saline injection to themselves so that they realize the discomfort is minimal.

Hypoglycemia – Families and caregivers are taught to recognize the signs and symptoms of hypoglycemia. Detection of hypoglycemia is particularly difficult in the nonverbal young child and infant in whom the signs of hypoglycemia are nonspecific. Parents are trained to check a blood glucose level and, if this is too low, to intervene with dietary measures and/or glucagon. (See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus" and 'Age-based care' below.)

Ketosis – Families and caregivers are taught to check urine for ketones or measure blood beta-hydroxybutyrate concentration at times of illness and/or in the setting of significant or prolonged hyperglycemia (eg, if two consecutive blood glucose readings are greater than 250 mg/dL [13.9 mmol/L]) [7]. This is especially important in young children, insulin pump users, or those with a history of diabetic ketoacidosis (DKA). (See "Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel" and "Diabetic ketoacidosis in children: Clinical features and diagnosis".)

Care setting – The initial educational and care phase may occur either in the inpatient or ambulatory setting. Most institutions have moved from prolonged inpatient admissions for newly diagnosed patients to either short hospitalizations, day hospital settings, or exclusively ambulatory management. Patient outcome is similar with outpatient and inpatient management, regardless of the length of inpatient hospitalization, and health care costs are much less with day hospital or outpatient treatment [8-12]. Accordingly, we initiate the care of most newly diagnosed children with T1DM without DKA in the outpatient setting. A multidisciplinary team provides close follow-up (daily phone contact and ambulatory visits as necessary), comprehensive education, and an individualized management plan for the child and their family.

Supervision – Once the family and diabetes clinicians are comfortable with the family's ability to manage the child's diabetes at home, plans should be made to return the child to school or the daycare center, as appropriate. If the child will require insulin at school or daycare, a responsible individual must be identified and trained in basic diabetes management skills. Supervising adults should be taught to detect and respond to hypoglycemia. (See "Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel", section on 'School and daycare'.)

Patients with diabetes should wear a medical emergency bracelet/necklace to enable suitable intervention by emergency personnel should an emergency situation arise (ie, hypoglycemia or DKA). MedicAlert provides an excellent resource.

Ongoing management — After the initial phase, the diabetes team continues to provide care, teaching, and support to the child and family. Sessions with individual team members (endocrinologist, nurse educator, dietitian, and mental health professional) allow more in-depth education and care directed toward the goal of maintaining excellent glucose control. (See "Self-management education for the child with diabetes mellitus".)

During these sessions, the concepts that are required for glycemic control are taught and reinforced. These include the interaction of insulin, diet, and exercise on blood glucose concentrations. A management regimen specific for each patient is designed to achieve the best possible glucose control. In addition, the clinician should explain that strict glycemic control helps to prevent long-term sequelae of T1DM; this discussion should be repeated and reinforced as often as necessary, particularly if glycemic control is suboptimal.

Providing age-appropriate psychosocial support for the patient and family by a proficient mental health professional improves adherence to the management plan [5]. (See 'Psychosocial issues' below.)

As the child grows older, education and training are directed toward increased autonomy and self-management for the patient. (See 'Age-based care' below.)

Printed literature and websites available for patient and family education are valuable supplements to the teaching provided by the diabetes team (table 2).

OVERVIEW OF INSULIN THERAPY — Insulin administration is the core treatment for all patients with T1DM. To be safe and effective, insulin therapy must be tailored to the individual patient and adjusted based on blood glucose testing.

Key steps include:

Monitoring glycemic control

Glycated hemoglobin (A1C) – A1C is monitored intermittently (typically, every three months) as an index of long-term glycemic control.

Blood glucose – Frequent monitoring of blood glucose is performed several times daily to detect short-term glycemic excursions. This can be done with a home glucose meter using fingerstick sampling or a device for continuous glucose monitoring. These data are used to adjust insulin dosing.

In those using a continuous glucose monitor, "time in range" (time in the target glucose range of 70 to 180 mg/dL [3.9 to 10 mmol/L]) over a 14-day period is increasingly being used as a measure of diabetes control in children, adolescents, and adults and correlates well with long-term microvascular complications. The target glucose range could be set narrower (such as 70 to 140 mg/dL) if tighter glucose control is desired. Time in range correlates well with A1C, and continuous glucose monitor downloads now provide an estimated A1C level (referred to as the glucose management indicator) based on the 14-day continuous glucose monitor output. In addition, daily glycemic variability is a valuable tool for monitoring glycemic control, also available in the continuous glucose monitor downloads.

Targets for glycemic control

A target A1C of <7 percent (53 mmol/mol) is recommended for most children, adolescents, and adults who have access to comprehensive diabetes care [5,13]. This target should be tailored to the individual patient. Less-stringent goals (eg, A1C <7.5 percent) may be appropriate for younger patients or those with special risk factors for hypoglycemia. Even less-stringent A1C goals (such as <8 percent) may be appropriate if there is a history of severe hypoglycemia, limited life expectancy, or extensive comorbid conditions. More-stringent goals (eg, A1C <6.5 percent) may be appropriate for some other patients if they can be achieved without significant hypoglycemia or undue burden of care, or in the honeymoon phase of T1DM.

General targets for blood glucose are approximately 80 to 130 mg/dL (4.4 to 7.2 mmol/L) before meals and 80 to 140 mg/dL (4.4 to 7.8 mmol/L) at bedtime and overnight.

For individuals using a continuous glucose monitor, American Diabetes Association guidelines recommend the following targets [14]:

-Time with blood glucose 70 to 180 mg/dL (3.9 to 10 mmol/L), known as "time in range" – At least 70 percent (approximately 17 hours/day)

-Time with blood glucose <70 mg/dL (3.9 mmol/L) – Less than 4 percent (<1 hour/day)

-Time with blood glucose >180 mg/dL (10 mmol/L) – Less than 25 percent (<6 hours/day)

-Time with blood glucose >250 mg/dL (13.9 mmol/L) – Less than 5 percent (<1 hour/day)

Less stringent targets may be necessary in younger children.

Insulin regimen – Designing an insulin regimen to maintain blood glucose in a target range and anticipating the effects of meals, exercise, and fasting on glycemic excursions.

Insulin administration – Selecting an approach to insulin administration, which may include multiple daily injections or continuous subcutaneous insulin infusion (an insulin pump, with or without integrated continuous glucose sensors and automated dose adjustments ["closed-loop systems"])

Insulin dose adjustments

Adjustments to bolus doses of insulin in response to deviations from the target range, amount of carbohydrates to be consumed, or exercise

Adjustments in basal insulin, usually guided by overnight/fasting glucose profiles

Adjustments to the overall regimen to achieve targets for glycemic control (A1C and "time in range")

Each of these steps is discussed in detail in a separate topic review. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)

AGE-BASED CARE — The management plan for childhood-onset T1DM depends on the child's age, cognitive ability, and emotional maturity, which affect his or her ability to communicate symptoms and participate in self-management (table 3).

Recommended targets for glycemic control are now the same for all pediatric age groups, recognizing that both hypoglycemia and hyperglycemia can have adverse effects on neurologic development. However, the goals should be individualized based on the characteristics of the individual patient and this may include considerations related to the child's age and developmental stage. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Target for hemoglobin A1c'.)

The following discussion regarding age-based management is compatible with the American Diabetes Association guidelines for the care of children and adolescents with T1DM [5].

Infants — Infants (younger than one year of age) with diabetes have the highest risk of severe hypoglycemia compared with older children [15,16]. Hypoglycemia is difficult to detect because infants are unable to communicate their symptoms and clinical signs are nonspecific (eg, poor feeding, lethargy, jitteriness, hypotonia).

Infants with severe hypoglycemia can present with seizures or coma, which may have permanent neurologic sequelae. In addition, repeated, prolonged episodes of hypoglycemia as well as persistent hyperglycemia may have deleterious effects on brain development and learning, especially in children younger than five years of age [17-20]. Clinical experience with modern management methods suggests that more-stringent glycated hemoglobin (A1C) targets improve glycemic control without significantly increasing the risk for severe hypoglycemia [4,13]. As a result, usual targets for glycemic control in infants and young children are now similar to those for older age groups, in which equal value is placed on avoiding both hypo- and hyperglycemia. However, less-stringent A1C targets may be appropriate in some cases. (See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus" and "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Target for hemoglobin A1c'.)

The frequent feeding schedule of infancy makes it challenging to develop a management plan that avoids episodes of hypoglycemia but provides sufficient glycemic control. In addition, caregivers may experience emotional stress and other challenges because of the burden of managing T1DM in an infant and may benefit from extra support and guidance [4].

Toddlers — The issues regarding the care of toddlers (one to three years of age) are similar to those in infants. The parents or caregivers must learn to manage diabetes and be responsible for the daily care of the child. Avoiding hypoglycemia can be challenging because of the erratic food intake and activity levels of toddlers. This problem can be addressed by frequent blood glucose monitoring (or use of continuous glucose monitoring) and use of an insulin pump or other flexible dosing systems.

Symptoms of hypoglycemia may be difficult to recognize in a toddler. In some cases, the altered behavior caused by hypoglycemia may resemble developmentally normal episodes of oppositional behavior and temper tantrums. Caregivers must learn to measure blood glucose in response to these symptoms rather than ignoring a temper tantrum.

Preschool and early school-aged children — For preschool and early school-aged children (three to seven years of age), a parent or other caregiver must still provide most of the daily diabetes care. However, some children can begin to participate in their own care by testing their blood glucose or preparing materials. Often, such mastery behaviors are short-lived as the children rapidly become bored and wish to forgo such responsibilities. It is important to understand that this behavior is normal and age-appropriate. At this age, the child should participate in their diabetes care only under direct supervision by a parent or caregiver.

As children enter daycare or school, childcare providers and school nurses must be involved in their diabetes care. Some parents or primary caregivers may have difficulty sharing care with others, including the patient. Continued support by the diabetes care team is important to facilitate this transition. In the United States, children younger than six years may be eligible to receive supplemental Social Security income to help their parents with the economic impact of diabetes management in the young child [21]. (See "Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel", section on 'School and daycare'.)

School-aged children — For school-aged children (8 to 11 years of age), optimal care consists of shared responsibility, so that the child begins to assume some of the daily management of their diabetes but has close adult supervision and support [5]. The child can learn to administer the routine insulin injections but still needs assistance and supervision for all management decisions that are not routine. All glucose testing and insulin administration should be under adult supervision. Children who make an early transition to independent self-management with minimal or no adult supervision tend to have poorer glycemic control [22-24].

The diagnosis of diabetes has a psychological impact on children, which may be manifested by depression and anxiety [25,26]. Children may also have difficulty with social interactions because of the perception that they are different from their peers. The family and diabetes team should encourage participation in school activities to develop normal peer relationships and ensure regular school attendance [27]. Attendance at diabetes camp also may help children better adjust to their diagnosis [28,29]. A diabetes camp can also help familiarize children with alternate methods for glucose monitoring and insulin administration, such as continuous glucose monitoring systems and insulin pumps, and the peer-interactive environment may help to engage patients with these technologies.

Screening for behavioral disturbances and discussion of psychosocial issues should be included in the routine medical care for a child with diabetes. Children who are at risk for these problems may benefit from mental health evaluation and support, which may include the parents or other family members [4]. The family and clinicians should also be alert for the possibility of developing cognitive deficits and learning difficulties, so that appropriate resources care to be provided if needed [30]. This is particularly important for children who are at increased risk of cognitive deficits because they developed diabetes at a very young age or have poor glycemic control, frequent episodes of hypoglycemia, and/or longer duration of the disease. (See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus", section on 'Neurologic sequelae'.)

Adolescents — Adolescence naturally is a time of increasing independence and self-assertiveness but also of risk-taking. Worsening of glycemic control is common, in part because insulin resistance and insulin requirements increase during puberty [31]. Therefore, determining the appropriate extent of adult involvement can be challenging [32]. Although adolescents can be responsible for the daily management of their diabetes, those who have minimal or no adult supervision tend to have poor glycemic control [4], and shared management between the adolescent and their parents or caregivers is associated with better glycemic control [33]. On the other hand, excessive involvement by the parent or caregivers and parent-child conflict over daily management sometimes leads to poor control [34-36]. Similarly, depressed mood in the adolescent (even if mild) can interfere with family involvement and diabetes control [37].

Family-focused teamwork, which includes developing shared parent-child responsibility and strategies to avoid conflict, improves the care of the older child or adolescent with diabetes [31]. This was illustrated in a controlled trial of family-focused teamwork compared with standard multidisciplinary diabetes care in children who ranged from 8 to 17 years of age [38]. Family-focused care, which included establishing a responsibility-sharing plan at the end of each office visit and active family discussion, increased family involvement and resulted in better glycemic control (adjusted A1C 8.8 versus 9.3 percent). This approach allows the care team to develop a shared responsibility plan that is appropriate for the patient based upon their cognitive, physical, and psychosocial maturity.

Other issues for the adolescent patient with diabetes include [39]:

Driving – Adolescents with diabetes should be taught to test blood glucose levels before driving. Patients may not be aware of the risks of driving when they are hypoglycemic, as shown by data in adult patients [40]. It is essential that adolescents understand the risks of driving while hypoglycemic and that they carry carbohydrate snacks with them at all times. If the blood glucose test before driving is in the hypoglycemic range, they should take a carbohydrate snack and recheck their blood glucose to confirm normalization before driving.

Risky behavior – Adolescence is also a time period that is characterized by experimentation with risky behaviors, such as alcohol and drug use and unprotected sexual intercourse.

Alcohol intake can be associated with severe hypoglycemia. Adolescents should be aware of this risk, routinely assessed for alcohol use, and counseled if appropriate. If they are unwilling to abstain from alcohol, they should limit their intake (eg, no more than one standard drink per day), ingest it with food, and use blood glucose monitoring to assess any immediate or delayed effects of alcohol on blood glucose levels.

Smoking is an important risk factor for long-term diabetic complications. Counseling to prevent smoking initiation (or to support smoking cessation if appropriate) should be an important part of ongoing care [5]. Use of e-cigarettes (vaping) also should be specifically discouraged. (See "Prevention of smoking and vaping initiation in children and adolescents" and "Management of smoking and vaping cessation in adolescents" and "Vaping and e-cigarettes".)

Before initiating sexual activity, adolescent girls should be given preconception counseling that includes the risks of diabetes complications to themselves and, potentially, the fetus [7]. Use of contraception should be reviewed and encouraged [41]. (See "Pregestational (preexisting) diabetes: Preconception counseling, evaluation, and management".)

Depression – Adolescent patients with T1DM have a threefold increased risk of psychiatric disorders, primarily depression. Children with diabetes should be screened annually for depression, especially during adolescence [4,31]. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus", section on 'Depression'.)

Eating disorders – Adolescents with T1DM, and especially girls, also have an increased risk for eating disorders. These may take the form of inappropriate fasting, bulimia, or intentional underdosing of insulin for weight control (sometimes known as "diabulimia"). Children should be screened for disordered eating beginning at 10 to 12 years of age, and symptoms of disordered eating and the possibility of intentional insulin misuse should be specifically investigated [5,31,42]. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus", section on 'Eating disorders'.)

Transition into adult care — As the adolescent approaches adulthood, there should be an orderly transition to independent self-management with support from the family and diabetes care team [4,5,31,39].

Each of the following issues should be monitored during and after the transition to adult care as well as during adolescence (see 'Adolescents' above):

Driving, including monitoring for and managing hypoglycemia before driving

Alcohol, including the adverse effects of alcohol on glycemic control and risks of acute hypoglycemia

Smoking, including prevention of initiation and education about the adverse effects of tobacco on the vascular complications of diabetes

Risk for eating disorders, including intentional insulin misuse

Contraception and education to minimize the maternal and fetal risks during pregnancy [41]

Additional issues that may arise during the transition include:

Expectation of greater autonomy in the adult diabetes clinic

Decreased contact with diabetes clinicians after transition to an adult program, with fragmented care, deterioration of self-care behaviors, poorer glycemic control, and a higher rate of hospitalization [43-45]

Possibility of discontinuation of insurance coverage, which warrants education regarding insurance options and maintenance of coverage

Strategies to facilitate a transition to adult health care include preparation for the transition while in the pediatric setting, longer or more frequent initial adult care visits, use of a transition coordinator, or transition to a clinic designed for young adults [39]. The Pediatric Endocrine Society has developed a Transition Toolkit to facilitate transition from pediatric to adult care, including a checklist for the pediatric provider and a clinical summary of key health information to be transferred.

OTHER MANAGEMENT ISSUES — Other issues that need to be addressed in the management of children and adolescents with T1DM include nutrition, exercise, and psychosocial factors that may affect glycemic control.

Nutrition — Meal planning must be individualized to accommodate the child's food preferences, cultural eating patterns, and schedules. Young children often have variable food intake and picky eating habits, requiring adjustments to the insulin dose [46]. Insulin pumps facilitate variable dosing regimens and may be particularly useful for this age group.

Many patients experience weight loss when diabetes is first diagnosed. The lost weight is generally regained during the first few weeks of therapy due to insulin administration, hydration, and adequate energy intake. During this time of increased consumption, children often require large amounts of insulin to control their blood glucose levels. After the weight loss is corrected, ongoing assessment of growth (eg, weight, height, body mass index) is necessary to monitor adequacy of dietary intake and glycemic control [47].

A small number of patients have adopted very low-carbohydrate diets, which may improve glycemic control; however, their sustainability in children and adolescents, effects on physical growth and development, and long-term safety and efficacy have not been evaluated [48].

Excellent glycemic control is necessary for normal growth and development [49]. Excess insulin administration, or failure to reduce insulin dose post-puberty or after initial regain of weight, may lead to excessive weight gain as the child attempts to treat hypoglycemia by overeating. If the child becomes overweight, caloric intake or insulin administration may need to be reduced [4].

Consultation with a registered dietitian with experience in pediatric nutrition and diabetes is an important component of diabetes care [4]. The dietitian provides instruction regarding the effect of food on blood glucose concentration, a diet that ensures adequate nutritional intake, and information regarding carbohydrate counting. Mastery of carbohydrate counting and understanding the glycemic effects of different kinds of carbohydrates are especially important in patients on an intensive regimen, who need to adjust premeal insulin boluses based upon the anticipated glycemic effect of consumed carbohydrates. The glycemic effect also depends on the balance of carbohydrates, fats, and proteins in a given meal. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Calculate prandial insulin'.)

Nutrition management, including consistency of carbohydrate intake, carbohydrate counting, and glycemic content and index, is discussed in greater detail separately. (See "Nutritional considerations in type 1 diabetes mellitus".)

Exercise — Regular exercise has important health and social benefits for children and adolescents with T1DM and should be encouraged. Exercise also presents several important challenges, which require careful management. In patients with diabetes, the intensity and duration of exercise affect the physiologic response and risk for hypoglycemia. Hypoglycemia can occur during or immediately after exercise or be delayed by several hours. The physiologic response to exercise also depends upon the plasma insulin concentration at the time of exercise. Conversely, exercise can trigger hyperglycemia under certain circumstances. (See "Management of exercise for children and adolescents with type 1 diabetes mellitus", section on 'Clinical consequences'.)

Children who participate in sport activities require increased monitoring of blood glucose (before, after, and at regular intervals during prolonged strenuous activity) and appropriate adjustment of insulin dosing. School personnel and coaches need to recognize symptoms of and be able to treat hypoglycemia. At the beginning of a new exercise regimen (eg, a new sports season), insulin requirements often decrease, particularly during and after exercise. Frequent blood glucose monitoring during the 12 hours after physical activity should be performed to guide insulin dose adjustment during this period. Afternoon or evening exercise may cause hypoglycemia later that night. Therefore, it is prudent for patients to check blood glucose during the overnight period after strenuous exercise. (See "Management of exercise for children and adolescents with type 1 diabetes mellitus".)

Psychosocial issues — We suggest routinely assessing for depression, anxiety, school absences, family conflict, and other mental health challenges during most routine visits for diabetes care. This is especially important for children 10 years and older and for those who are not adhering to the diabetes management regimen. Patients with symptoms of depression or other concerns should be referred for evaluation by a mental health specialist. (See 'Referrals' below.)

Diabetes has a psychological impact on the patient and family, as do other chronic diseases. Depression and anxiety are common in older children and adolescents with diabetes and in their parents or caregivers [25,26,50,51]; adolescents are at risk for an eating disorder. In older children and adolescents, family conflict arises over the level of adult involvement in the care of the patient, during a normal developmental period of increasing independence and self-assertiveness. These psychological issues lead to poorer glycemic control and an increased risk of hospitalization and episodes of diabetic ketoacidosis (DKA) [52-55]. (See 'Adolescents' above and "Complications and screening in children and adolescents with type 1 diabetes mellitus", section on 'Psychiatric disorders'.)

In addition, socioeconomic factors such as single-parent families, poor socioeconomic status, and chronic physical or mental health problems in a parent or other close family member are associated with poorer diabetes control and increased hospitalizations [4,52,56-59]. As an example, one study from New Zealand reported that Maori or Pacific ethnicity and social deprivation are independent predictors of poor metabolic control in T1DM [60].

Comprehensive management of diabetes that addresses these psychosocial issues can improve glycemic control and reduce hospitalization even in the high-risk adolescent. In two controlled studies, structured psychoeducational support significantly improved glycemic control and reduced hospital admission rates in adolescents with previously poorly controlled diabetes [61,62]. Additionally, psychological screening of newly diagnosed patients with T1DM may help identify families at risk for poor adherence and poor diabetes control [63]. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus", section on 'Psychiatric disorders'.)

Factors associated with better health-related quality of life in children and adolescents with diabetes include later age at onset, fewer hyperglycemic episodes, lower glycated hemoglobin (A1C), older age, and male sex [64].

Parental and caregiver involvement — Several studies have examined the role of the family's attitudes and support systems in determining the quality of diabetes management:

Stressors and support systems for parents – Parental fatigue ("burn out") can increase the risk for poor glycemic control, and predictors of burn out in a parent include low self-esteem, inadequate social support, lack of leisure time, and financial concerns [65].

Parenting style – One study reported that diabetes control in children is optimized by an authoritative parenting style, in which the parents set clear and consistent expectations but are also responsive to the child's opinions and needs [66]. Similarly, adolescents who perceive greater sharing of responsibility for diabetes care with their caregivers are more likely to engage in better management of diabetes [67]. One study reported an improvement in A1C levels and an improvement in quality-of-life responses in adolescents with T1DM who chose to participate in clinician-moderated chat sessions [68].

Immunizations — Patients with diabetes should be given the following immunizations:

All standard childhood immunizations on a standard schedule. (See "Standard immunizations for children and adolescents: Overview", section on 'Infants and children'.)

Annual influenza vaccine (also recommended for all individuals six months of age and older). Children with diabetes should receive the inactivated (injectable) vaccine rather than the live attenuated (intranasal) form of the vaccine. (See "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups' and "Seasonal influenza in children: Prevention with vaccines", section on 'Choice of vaccine'.)

Pneumococcal vaccine. Children with diabetes should receive the pneumococcal conjugate vaccine, which is recommended for all children. They should also be given the pneumococcal polysaccharide vaccine because they are considered to be at high risk for invasive pneumococcal disease. (See "Pneumococcal vaccination in children" and "Pneumococcal vaccination in children", section on 'Immunization of high-risk children and adolescents'.)

There is no evidence for an association between immunizations and the development of T1DM. (See "Autism spectrum disorder and chronic disease: No evidence for vaccines or thimerosal as a contributing factor", section on 'Type 1 diabetes mellitus' and "Pathogenesis of type 1 diabetes mellitus".)

FOLLOW-UP — The frequency of follow-up visits is tailored to the needs of the child and family. Frequent visits (eg, every two to four weeks) are needed during the initial educational phase, when the patient and family require intensive training in self-care management, and during periods when adjustment of glycemic control and insulin dose are problematic. More frequent visits are also necessary when major changes in insulin regimen are made (eg, commencing insulin pump therapy).

Once the family has demonstrated mastery of diabetes management and a stable management plan is established, we recommend follow-up at least every three months to review glycemic control and adjust management as needed [4]. However, families must learn how to perform interim adjustments and to contact the diabetes team for assistance in adjustment of insulin dosing between visits.

Routine monitoring — Routine follow-up should be performed at least four times a year and includes the following (table 4) [5]:

Physical examination

Height and weight – Monitor for normal growth, with vigilance for weight gain that is either insufficient or excessive.

Blood pressure – Screen for hypertension using age-specific standards.

Pubertal assessment – Identify the patient's stage of puberty to anticipate changes in insulin requirements; insulin resistance and insulin requirements increase in early puberty.

Thyroid – Check for thyroid enlargement to screen for autoimmune hypothyroidism, a condition associated with T1DM. (See "Associated autoimmune diseases in children and adolescents with type 1 diabetes mellitus", section on 'Autoimmune thyroiditis'.)

Skin – Examine the child's usual insulin injection sites for evidence of lipohypertrophy or atrophy that can alter insulin absorption rates. Also, examine the sites used for blood glucose monitoring to make sure that there is no skin irritation.

Eyes – A general eye examination is an appropriate part of the routine evaluation. However, a funduscopic examination without dilation of the pupils is of little value as a screen for retinopathy because diabetic retinopathy usually starts at the periphery of the retina. Therefore, patients should have regularly scheduled dilated funduscopic examinations starting at 11 years of age once they have had diabetes for three to five years, as discussed below. (See 'Referrals' below.)

Extremities – A foot examination should be performed annually in children ≥10 years of age. As the disease duration increases, extremity examination for evidence of limited joint mobility (sclerodactyly, joint or finger stiffness) or peripheral neuropathy (feet). (See "Overview of the musculoskeletal complications of diabetes mellitus" and "Screening for diabetic polyneuropathy".)

Laboratory evaluation — Laboratory evaluation includes evaluation of glycemic control and screening for long-term sequelae. Recommended schedules for laboratory monitoring are outlined in the table (table 4):

Glycated hemoglobin (A1C)

Urine albumin-to-creatinine ratio in a spot specimen

Tissue transglutaminase (tTG)

Lipid profile

Thyroid-stimulating hormone (TSH)

Details about the screening for these and other complications and associated conditions (eg, nephropathy, retinopathy, celiac disease, dyslipidemia, autoimmune thyroiditis) are discussed in separate topic reviews. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus" and "Associated autoimmune diseases in children and adolescents with type 1 diabetes mellitus".)

Referrals — Referrals include:

Nutrition therapy by registered dietitian.

Initial screening for mental health issues is appropriately performed by a member of the diabetes management team. Patients with significant depression, difficulty adhering to the diabetes regimen, or other mental health concerns should be referred for evaluation by a mental health specialist.

Dilated ophthalmologic evaluation for retinopathy for children ≥11 years of age (or at onset of puberty if earlier), once the youth has had diabetes for three to five years. This examination generally should be repeated every two years; less frequent examinations may be acceptable if recommended by the child's eye care professional [5].

Patients with diabetes are at increased risk for gum disease. Good oral health and regular visits to the dentist are advised.

Special situations — Special situations such as illness, school and camp, travel, and medical and dental procedures (eg, endoscopy, surgery), which require adjusting diabetes management, are discussed in detail separately. (See "Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel".)

INVESTIGATIONAL THERAPIES FOR TYPE 1 DIABETES — The following aspects of T1DM are important subjects of investigation but are not yet incorporated into routine clinical care of children:

Diabetes prevention – A number of attempts to use immune modulation early in the course of T1DM have been reported, but long-term success is elusive as yet. These include trials of a vaccine against glutamic acid decarboxylase (GAD), rituximab, teplizumab, and other immunomodulators for patients with newly diagnosed diabetes, the details of which are described separately. (See "Prevention of type 1 diabetes mellitus", section on 'Immunomodulators'.)

Artificial pancreas – "Hybrid closed-loop" insulin pump devices, which deliver insulin based on real-time glucose concentrations and are controlled by a computer-driven algorithm, are commercially available; these systems require manual input for meal carbohydrates. More advanced closed-loop systems are in development. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Closed-loop insulin pumps' and "Continuous subcutaneous insulin infusion (insulin pump)", section on 'Types of insulin pumps'.)

Adjunctive therapies – Supplementing insulin therapy with agents like metformin, amylin analogs (pramlintide), and glucagon-like peptide 1 (GLP-1) receptor agonists (eg, exenatide) has been studied in adults with T1DM, but the safety and efficacy of these agents has not been established [4]. Among these adjunctive therapies, pramlintide is the most promising, based on studies in adults, but requires careful management to avoid severe hypoglycemia. (See "Management of blood glucose in adults with type 1 diabetes mellitus", section on 'Adjunctive therapy not recommended'.)

The use of metformin as an adjunct to insulin therapy has been suggested as a means of improving diabetes control and alleviating weight gain in T1DM. In a trial in adolescents with T1DM and overweight randomly assigned to metformin or placebo as an adjunct to insulin treatment, use of metformin did not improve glycemic control at six months and increased adverse gastrointestinal symptoms [69]. However, the group receiving metformin had a lower mean total daily insulin dose and less weight gain during the trial (mean weight gain 0 kg in the metformin group, compared with 2 kg in the control group). Furthermore, 24 percent of participants in the metformin group, compared with only 7 percent of those in the placebo group, were able to reduce their body mass index by at least 10 percent. This study does not support prescribing metformin as adjunctive therapy for adolescents with overweight to improve glycemic control, but it suggests that metformin may help some patients to lose weight.

Transplantation – Techniques for pancreas or islet cell transplantation for patients with T1DM continue to evolve. Pancreas transplantation is limited to adults with serious progressive complications of diabetes in whom the quality of life is unacceptable, including those with end-stage kidney disease who require a kidney transplant. Clinical and experimental experience is discussed in a separate topic review. (See "Pancreas and islet transplantation in diabetes mellitus".)

INFORMATION RESOURCES — Useful resources for patients, families/caregivers, and school personnel include the following (table 2):

American Diabetes Association – Internet resource for patients, families, and providers, including guidance for diabetes care tasks at school

Children with Diabetes – Internet community and resource, including guidance for completing plans for school management (known as 504 plans in the United States)

Juvenile Diabetes Research Foundation – Internet resource that includes guidance for management of many special situations, such as school, travel, and medical insurance

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diabetes mellitus in children" and "Society guideline links: Hyperglycemic emergencies".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Type 1 diabetes (The Basics)" and "Patient education: My child has diabetes: How will we manage? (The Basics)" and "Patient education: Controlling blood sugar in children with diabetes (The Basics)" and "Patient education: Carb counting for children with diabetes (The Basics)" and "Patient education: Managing diabetes in school (The Basics)" and "Patient education: Giving your child insulin (The Basics)" and "Patient education: Checking your child's blood sugar level (The Basics)" and "Patient education: Should I switch to an insulin pump? (The Basics)")

Beyond the Basics topics (see "Patient education: Type 1 diabetes: Overview (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Diabetes education – Optimal management of a child with type 1 diabetes mellitus (T1DM) is defined by the implementation of a care plan that maintains glucose control as near to normal as safely possible, balancing the risks of long-term sequelae and hypoglycemia. This requires comprehensive case management and intensive training of the patient, family, and other caregivers. (See 'Goals' above.)

Diabetes education and self-management training by a pediatric diabetes multidisciplinary team provides the ideal setting to acquire the knowledge and skills needed for care. Training is divided into initial and ongoing management phases:

In the initial phase, the team teaches the family about the disease process and skills required for daily care (administering insulin, blood glucose monitoring, testing for urine ketones, and recognizing and treating hypoglycemia) (table 1). (See 'Initial management' above.)

In the ongoing phase, the care and training required for optimal glycemic control are reviewed. (See 'Ongoing management' above.)

Approach to insulin therapy – A target glycated hemoglobin (A1C) of <7 percent (53 mmol/mol) is recommended for most children, adolescents, and adults who have access to comprehensive diabetes care. However, glycemic targets should be further tailored to the individual patient; less-stringent goals may be appropriate for individual patients. Insulin therapy is tailored to the individual patient, and the dose is adjusted as needed to maintain blood glucose in the target range. Insulin may be administered as multiple daily injections or a continuous subcutaneous insulin infusion (insulin pump, with or without integrated continuous glucose sensors and automated dose adjustments ["closed-loop systems"]). (See 'Overview of insulin therapy' above and "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)

Age-based care – Specific challenges with diabetes management arise in each age group, and these should be anticipated and addressed with the child and family (table 3). (See 'Age-based care' above.)

Nutrition and exercise – Detailed plans to ensure good glycemic control with healthy nutrition and exercise should be developed for each patient, in consultation with a registered dietitian. Exercise acutely alters insulin requirements and requires careful management to avoid hypoglycemia. (See 'Nutrition' above and 'Exercise' above.)

Psychosocial support – Patients with diabetes and their families are at increased risk for psychological disorders such as depression and anxiety, which result in poor glycemic control. Addressing these psychosocial issues improves glycemic control. (See 'Psychosocial issues' above.)

Follow-up – The frequency of follow-up visits is tailored to the needs of the child and family. Visits are more frequent during the initial educational phase and also if glycemic control is problematic. Ongoing visits allow for continued family education and monitoring for complications of diabetes, including screening for retinopathy, nephropathy, hypertension, and dyslipidemia (table 4). (See 'Follow-up' above.)

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Topic 5817 Version 67.0

References