Funded out Association’s general revenues and does not use industry support. Funded out Association’s general revenues and does not use industry support

Recommendations less likely to be based on clinical trial evidence.

Youth w/ T1DM & parents/caregivers should receive culturally sensitive & developmentally appropriate individualized DSME and DSMS according to national standards at diagnosis and routinely thereafter. B

• Youth w/ T1DM & parents/caregivers should receive culturally sensitive & developmentally appropriate individualized DSME and DSMS according to national standards at diagnosis and routinely thereafter. B

At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact adherence to diabetes mgmt. Provide referrals to trained mental health professionals, preferably experienced in childhood diabetes. E

• At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact adherence to diabetes mgmt. Provide referrals to trained mental health professionals, preferably experienced in childhood diabetes. E

Encourage family involvement in diabetes mgmt. tasks for children & adolescents, as premature transfer of diabetes care can result in nonadherence and deterioration in glycemic control. B

• Encourage family involvement in diabetes mgmt. tasks for children & adolescents, as premature transfer of diabetes care can result in nonadherence and deterioration in glycemic control. B

• Mental health professionals should be considered integral members of the pediatric diabetes multidisciplinary team. E

Providers should assess children’s and adolescents’ diabetes distress, social adjustment (peer relationships), and school performance to determine whether further intervention is needed. B

• Providers should assess children’s and adolescents’ diabetes distress, social adjustment (peer relationships), and school performance to determine whether further intervention is needed. B

• In youth and families with behavioral self-care difficulties, repeated hospitalizations for diabetic ketoacidosis, or significant distress, consider referral to a mental health provider for evaluation and treatment. E

Adolescents should have time by themselves with their care provider(s) starting at age 12 years. E

• Adolescents should have time by themselves with their care provider(s) starting at age 12 years. E

• Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential. A

An A1C goal of <7.5% is recommended across all pediatric age-groups. E

• An A1C goal of <7.5% is recommended across all pediatric age-groups. E

Assess for the presence of autoimmune conditions associated with type 1 diabetes soon after the diagnosis and if symptoms develop. E

• Assess for the presence of autoimmune conditions associated with type 1 diabetes soon after the diagnosis and if symptoms develop. E

Consider testing children with T1DM for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. E

• Consider testing children with T1DM for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. E

• Measure thyroid stimulating hormone concentrations soon after diagnosis of T1DM & glucose control has been established. If normal, consider rechecking every 1-2 yrs or sooner if patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variation. E

Consider screening individuals with T1DM for celiac disease soon after the diagnosis of diabetes. E

• Consider screening individuals with T1DM for celiac disease soon after the diagnosis of diabetes. E

• Consider screening in individuals who have a first degree relative with celiac disease, growth failure, weight loss, failure to gain weight, diarrhea, flatulence, abdominal pain, or signs of malabsorption, or in children with frequent unexplained hypoglycemia or deterioration in glycemic control. E

Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B

• Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B

Screening:

• Screening:

• Measure BP at each routine visit. Children found to have high-normal blood pressure (SBP or DBP ≥90th percentile for age, sex, and height) or hypertension (SBP or DBP ≥95th percentile for age, sex, and height) should have blood pressure confirmed on three separate days. B

Treatment:

• Treatment:

• Initial treatment of high-normal BP (SBP or DBP consistently ≥90th percentile for age, sex, and height) includes dietary modification and increased exercise, if appropriate, aimed at weight control. If target blood pressure is not reached with 3–6 months of initiating lifestyle intervention, consider pharmacological treatment. E

• In addition to lifestyle modification, pharmacological treatment of HTN should be considered as soon as HTN is confirmed. E

Treatment (2):

• Treatment (2):

• Consider ACE inhibitors or ARBs for the initial pharmacological treatment of HTN, following reproductive counseling due to the potential teratogenic effects of both drug classes. E

• The goal of treatment is blood pressure consistently <90th percentile for age, sex, and height. E

Testing:

• Testing:

• Obtain a fasting lipid profile in children ≥10 years of age soon after the diagnosis (after glucose control has been established). E

• If lipids are abnormal, annual monitoring is reasonable. If LDL values are <100 mg/dL, a lipid profile every 3-5 years is reasonable. E

Treatment:

• Treatment:

• Initial therapy: Optimize glucose control & MNT using a Step 2 American Heart Association diet to decrease the amount of saturated fat in the diet. B

• After age 10, addition of a statin is suggested in patients who, despite MNT & lifestyle changes, continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more CVD risk factors. E

• Goal of therapy is LDL <100 mg/dL. E

Elicit a smoking history at initial and follow-up diabetes visits and discourage smoking in youth who do not smoke and encourage smoking cessation in those who do. B

• Elicit a smoking history at initial and follow-up diabetes visits and discourage smoking in youth who do not smoke and encourage smoking cessation in those who do. B

Screening:

• Screening:

• Annual screening for albuminuria with a random spot urine sample for albumin-to-creatinine ratio (UACR), should be considered once the child has had diabetes for 5 years. B

• Estimate glomerular filtration rate at initial evaluation and then based on age, diabetes duration & treatment. E

Treatment:

• Treatment:

• Consider an ACE inhibitor, titrated to normalization of albumin excretion, when elevated UACR (>30 mg/g) is documented with at least 2 of 3 urine samples. Obtain these over a 6-month interval following efforts to improve glycemic control and normalize blood pressure. C

An initial dilated & comprehensive eye exam is recommended at age ≥10 years or after puberty has started, whichever is earlier, once the youth has had diabetes for 3–5 years. B

• An initial dilated & comprehensive eye exam is recommended at age ≥10 years or after puberty has started, whichever is earlier, once the youth has had diabetes for 3–5 years. B

• After the initial exam, annual follow-up is recommended. Less frequent exams, every 2 years, may be acceptable on the advice of an eye care professional. E

Consider an annual comprehensive foot exam at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. E

• Consider an annual comprehensive foot exam at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. E

Distinguishing between type 1 and type 2 can be challenging.

• Distinguishing between type 1 and type 2 can be challenging.

• Diabetes-associated autoantibodies and ketosis may be present in patients with features of type 2 such as obesity and acanthosis nigricans.

• Accurate diagnosis is critical.

Comorbidities may be present at time of diagnosis.

• Comorbidities may be present at time of diagnosis.

• At diagnosis, perform:

• BP measurement
• Fasting lipid panel
• Assessment for albumin excretion
• Dilated eye exam

• Other screening & treatment recommendations similar to T1DM.

Additional problems may include:

• Additional problems may include:

• PCOS
• Sleep apnea
• Hepatic steatosis
• Orthopedic complications
• Psychosocial concerns

• ADA consensus report on Type 2 Diabetes in Children & Adolescents

• AAP Clinical Practice Guideline

Health care providers and families should begin to prepare youth in early to mid-adolescence and, at the latest, at least 1 year before the transition to adult health care. E

• Health care providers and families should begin to prepare youth in early to mid-adolescence and, at the latest, at least 1 year before the transition to adult health care. E

• Both pediatricians and adult health care providers should assist in providing support and links to resources for the teen and emerging adult. B

Early & ongoing attention should be given to comprehensive coordinated planning for seamless transition of all youth to adult health care.

• Early & ongoing attention should be given to comprehensive coordinated planning for seamless transition of all youth to adult health care.

• Association position statement, “Diabetes Care for Emerging Adults”

• NDEP: http://ndep.nih.gov/transitions

• Endocrine Society: www.endocrine.org

Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential. A

• Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential. A

• Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A

Provide preconception counseling that addresses the importance of glycemic control as close to normal as safely possible, ideally <6.5%, to reduce the risk of congenital anomalies. B

• Provide preconception counseling that addresses the importance of glycemic control as close to normal as safely possible, ideally <6.5%, to reduce the risk of congenital anomalies. B

Women w/ preexisting type 1 or type 2 diabetes who are pregnant or planning to become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye exams should occur before pregnancy or in the first trimester & then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B

• Women w/ preexisting type 1 or type 2 diabetes who are pregnant or planning to become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye exams should occur before pregnancy or in the first trimester & then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B

Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets. A

• Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets. A

• Insulin is the preferred medication for treating hyperglycemia in GDM, as it does not cross the placenta. Metformin and glyburide may be used but both, particularly metformin, cross the placenta. All oral agents lack long-term safety data. A

Metformin, when used to treat polycystic ovary syndrome and induce ovulation, need not be continued once pregnancy has been confirmed. A

• Metformin, when used to treat polycystic ovary syndrome and induce ovulation, need not be continued once pregnancy has been confirmed. A

Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B

• Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B

• Fasting and postprandial SMBG are recommended in both GDM and preexisting diabetes in pregnancy to achieve glycemic control. Some women with preexisting diabetes should also test blood glucose preprandially. B

Due to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. A1C target in pregnancy is 6 – 6.5% (42–48mmol/mol); <6% (42 mmol/mol) may be optimal if achievable without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B

• Due to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. A1C target in pregnancy is 6 – 6.5% (42–48mmol/mol); <6% (42 mmol/mol) may be optimal if achievable without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B

• In pregnant patients with diabetes and hypertension, BP targets 120-160/80-105 are suggested. E

For women with gestational diabetes or preexisting type 1 or type 2 diabetes in pregnancy, the following targets are recommended:

• For women with gestational diabetes or preexisting type 1 or type 2 diabetes in pregnancy, the following targets are recommended:

• Fasting ≤95 mg/dL (5.3 mmol/L) and either
• One-hour postprandial ≤140 mg/dL (7.8 mmol/L) or
• Two-hour postprandial ≤120 mg/dL (6.7 mmol/L)

Perform an A1C for all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. B

• Perform an A1C for all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. B

• Insulin therapy for should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL. Then a target glucose of 140–180 mg/dL is recommended for the majority of critically ill A and noncritically ill patients. C

More stringent goals, such as <140 mg/dL mmol/L) may be appropriate for selected critically ill patients, if achievable without significant hypoglycemia. C

• More stringent goals, such as <140 mg/dL mmol/L) may be appropriate for selected critically ill patients, if achievable without significant hypoglycemia. C

• Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the infusion rate based on glycemic fluctuations and insulin dose. E

Basal insulin or basal + bolus correction regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional & correction components is the preferred treatment for noncritically ill patients with good nutritional intake. A

• Basal insulin or basal + bolus correction regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional & correction components is the preferred treatment for noncritically ill patients with good nutritional intake. A

• The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A

A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. E

• A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. E

• A plan for preventing and treating hypoglycemia should be established for each patient. E

• Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E

A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E

• A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E

The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C

• The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C

• There should be a structured discharge plan tailored to the individual patient. B

ADA publishes evidence-based advocacy statements on issues including:

• ADA publishes evidence-based advocacy statements on issues including:

• Diabetes and employment
• Diabetes and driving
• Diabetes management in schools, child care programs, and correctional institutions.

• These are important tools in educating:

• Schools
• Employers
• Licensing agencies
• Policy makers
• Professional.diabetes.org/SOC