The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The management of diabetes in children and adolescents (individuals <18 years of age) cannot simply be derived from care routinely provided to adults with diabetes. The epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric diabetes are often different from those of adult diabetes. There are also differences in recommended care for children and adolescents with type 1 diabetes, type 2 diabetes, and other forms of pediatric diabetes. This section is divided into two major parts: the first part addresses care for children and adolescents with type 1 diabetes, and the second part addresses care for children and adolescents with type 2 diabetes. Monogenic diabetes (neonatal diabetes and maturity-onset diabetes of the young [MODY]) and cystic fibrosis–related diabetes, which are often present in youth, are discussed in Section 2, “Diagnosis and Classification of Diabetes.” Table 14.1A  and Table 14.1B  provide an overview of the recommendations for screening and treatment of complications and related conditions in pediatric type 1 diabetes and type 2 diabetes, respectively. In addition to comprehensive diabetes care, youth with diabetes should receive age-appropriate and developmentally appropriate pediatric care, including immunizations as recommended by the Centers for Disease Control and Prevention (CDC) (1). To ensure continuity of care as an adolescent with diabetes becomes an adult, guidance is provided at the end of this section on the transition from pediatric to adult diabetes care.

Table 14.1A

Recommendations for screening and treatment of complications and related conditions in pediatric type 1 diabetes

Thyroid diseaseCeliac diseaseHypertensionNephropathyRetinopathyNeuropathyDyslipidemia
Corresponding recommendations 14.28 and 14.29 14.30–14.32 14.33–14.36 14.42 and 14.43 14.44–14.46 14.47 14.37–14.41 
Method Thyroid-stimulating hormone; consider antithyroglobulin and antithyroid peroxidase antibodies IgA tTG if total IgA normal; IgG tTG and deamidated gliadin antibodies if IgA deficient Blood pressure monitoring Albumin-to-creatinine ratio; random sample acceptable initially Dilated fundoscopy or retinal photography Foot exam with foot pulses, pinprick, 10-g monofilament sensation tests, vibration, and ankle reflexes Lipid profile, nonfasting acceptable initially 
When to start Soon after diagnosis Soon after diagnosis At diagnosis Puberty or ≥10 years old, whichever is earlier, and diabetes duration of 5 years Puberty or ≥11 years old, whichever is earlier, and diabetes duration of 3–5 years Puberty or ≥10 years old, whichever is earlier, and diabetes duration of 5 years Soon after diagnosis; preferably after glycemia has improved and ≥2 years old 
Follow-up frequency Every 1–2 years if thyroid antibodies negative; more often if symptoms develop or presence of thyroid antibodies Within 2 years and then at 5 years after diagnosis; sooner if symptoms develop Every visit If normal, annually; if abnormal, repeat with confirmation in two of three samples over 6 months If normal, every 2 years; consider less frequently (every 4 years) if A1C <8% and eye professional agrees If normal, annually If LDL <100 mg/dL, repeat at 9–11 years old; then, if <100 mg/dL, every 3 years 
Goal NA NA <90th percentile for age, sex, and height; if ≥13 years old, <120/80 mmHg Albumin-to-creatinine ratio <30 mg/g No retinopathy No neuropathy LDL <100 mg/dL 
Treatment Appropriate treatment of underlying thyroid disorder After confirmation, start gluten-free diet Lifestyle modification for elevated blood pressure (90th to <95th percentile for age, sex, and height or, if ≥13 years old, 120–129/<80 mmHg); lifestyle modification and ACE inhibitor or ARB* for hypertension (≥95th percentile for age, sex, and height or, if ≥13 years old, ≥130/80 mmHg) Optimize glycemia and blood pressure; ACE inhibitor* if albumin-to-creatinine ratio is elevated in two of three samples over 6 months Optimize glycemia; treatment per ophthalmology Optimize glycemia; referral to neurology If abnormal, optimize glycemia and medical nutrition therapy; if after 6 months LDL >160 mg/dL or >130 mg/dL with cardiovascular risk factor(s), initiate statin therapy (for those aged >10 years)* 
Thyroid diseaseCeliac diseaseHypertensionNephropathyRetinopathyNeuropathyDyslipidemia
Corresponding recommendations 14.28 and 14.29 14.30–14.32 14.33–14.36 14.42 and 14.43 14.44–14.46 14.47 14.37–14.41 
Method Thyroid-stimulating hormone; consider antithyroglobulin and antithyroid peroxidase antibodies IgA tTG if total IgA normal; IgG tTG and deamidated gliadin antibodies if IgA deficient Blood pressure monitoring Albumin-to-creatinine ratio; random sample acceptable initially Dilated fundoscopy or retinal photography Foot exam with foot pulses, pinprick, 10-g monofilament sensation tests, vibration, and ankle reflexes Lipid profile, nonfasting acceptable initially 
When to start Soon after diagnosis Soon after diagnosis At diagnosis Puberty or ≥10 years old, whichever is earlier, and diabetes duration of 5 years Puberty or ≥11 years old, whichever is earlier, and diabetes duration of 3–5 years Puberty or ≥10 years old, whichever is earlier, and diabetes duration of 5 years Soon after diagnosis; preferably after glycemia has improved and ≥2 years old 
Follow-up frequency Every 1–2 years if thyroid antibodies negative; more often if symptoms develop or presence of thyroid antibodies Within 2 years and then at 5 years after diagnosis; sooner if symptoms develop Every visit If normal, annually; if abnormal, repeat with confirmation in two of three samples over 6 months If normal, every 2 years; consider less frequently (every 4 years) if A1C <8% and eye professional agrees If normal, annually If LDL <100 mg/dL, repeat at 9–11 years old; then, if <100 mg/dL, every 3 years 
Goal NA NA <90th percentile for age, sex, and height; if ≥13 years old, <120/80 mmHg Albumin-to-creatinine ratio <30 mg/g No retinopathy No neuropathy LDL <100 mg/dL 
Treatment Appropriate treatment of underlying thyroid disorder After confirmation, start gluten-free diet Lifestyle modification for elevated blood pressure (90th to <95th percentile for age, sex, and height or, if ≥13 years old, 120–129/<80 mmHg); lifestyle modification and ACE inhibitor or ARB* for hypertension (≥95th percentile for age, sex, and height or, if ≥13 years old, ≥130/80 mmHg) Optimize glycemia and blood pressure; ACE inhibitor* if albumin-to-creatinine ratio is elevated in two of three samples over 6 months Optimize glycemia; treatment per ophthalmology Optimize glycemia; referral to neurology If abnormal, optimize glycemia and medical nutrition therapy; if after 6 months LDL >160 mg/dL or >130 mg/dL with cardiovascular risk factor(s), initiate statin therapy (for those aged >10 years)* 

ARB, angiotensin receptor blocker; NA, not applicable; tTG, tissue transglutaminase.

*

Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and medication should be avoided in individuals of childbearing age who are not using reliable contraception.

Table 14.1B

Recommendations for screening and treatment of complications and related conditions in pediatric type 2 diabetes

HypertensionNephropathyNeuropathyRetinopathyDyslipidemiaNonalcoholic fatty liver diseaseObstructive sleep apneaPolycystic ovarian syndrome (for adolescent femaleindividuals)
Corresponding recommendations 14.74–14.77 14.78–14.83 14.84 and 14.85 14.86–14.89 14.96–14.100 14.90 and 14.91 14.92 14.93 and 14.94 
Method Blood pressure monitoring Albumin-to- creatinine ratio; random sample acceptable initially Foot exam with foot pulses, pinprick, 10-g monofilament sensation tests, vibration, and ankle reflexes Dilated fundoscopy Lipid profile AST and ALT measurement Screening for symptoms Screening for symptoms; laboratory evaluation if positive symptoms 
When to start At diagnosis At diagnosis At diagnosis At/soon after diagnosis Soon after diagnosis, preferably after glycemia has improved At diagnosis At diagnosis At diagnosis 
Follow-up frequency Every visit If normal, annually; if abnormal, repeat with confirmation in two of three samples over 6 months If normal, annually If normal, annually Annually Annually Every visit Every visit 
Goal <90th percentile for age, sex, and height; if ≥13 years old, <130/80 mmHg <30 mg/g No neuropathy No retinopathy LDL <100 mg/dL, HDL >35 mg/dL, triglycerides <150 mg/dL NA NA NA 
Treatment Lifestyle modification for elevated blood pressure (90th to <95th percentile for age, sex, and height or, if ≥13 years old, 120–129/<80 mmHg); lifestyle modification and ACE inhibitor or ARB* for hypertension (≥95th percentile for age, sex, and height or, if ≥13 years, ≥130/80 mmHg) Optimize glycemia and blood pressure; ACE inhibitor* if albumin-to-creatinine ratio is elevated in two of three samples over 6 months Optimize glycemia; referral to neurology Optimize glycemia; treatment per ophthalmology If abnormal, optimize glycemia and medical nutrition therapy; if LDL >130 mg/dL after 6 months, initiate statin therapy (for those aged >10 years)*; if triglycerides >400 mg/dL fasting or >1,000 mg/dL nonfasting, begin fibrate Refer to gastroenterology for persistently elevated or worsening transaminases If positive symptoms, refer to sleep specialist and polysomnogram If no contraindications, oral contraceptive pills; medical nutrition therapy; metformin 
HypertensionNephropathyNeuropathyRetinopathyDyslipidemiaNonalcoholic fatty liver diseaseObstructive sleep apneaPolycystic ovarian syndrome (for adolescent femaleindividuals)
Corresponding recommendations 14.74–14.77 14.78–14.83 14.84 and 14.85 14.86–14.89 14.96–14.100 14.90 and 14.91 14.92 14.93 and 14.94 
Method Blood pressure monitoring Albumin-to- creatinine ratio; random sample acceptable initially Foot exam with foot pulses, pinprick, 10-g monofilament sensation tests, vibration, and ankle reflexes Dilated fundoscopy Lipid profile AST and ALT measurement Screening for symptoms Screening for symptoms; laboratory evaluation if positive symptoms 
When to start At diagnosis At diagnosis At diagnosis At/soon after diagnosis Soon after diagnosis, preferably after glycemia has improved At diagnosis At diagnosis At diagnosis 
Follow-up frequency Every visit If normal, annually; if abnormal, repeat with confirmation in two of three samples over 6 months If normal, annually If normal, annually Annually Annually Every visit Every visit 
Goal <90th percentile for age, sex, and height; if ≥13 years old, <130/80 mmHg <30 mg/g No neuropathy No retinopathy LDL <100 mg/dL, HDL >35 mg/dL, triglycerides <150 mg/dL NA NA NA 
Treatment Lifestyle modification for elevated blood pressure (90th to <95th percentile for age, sex, and height or, if ≥13 years old, 120–129/<80 mmHg); lifestyle modification and ACE inhibitor or ARB* for hypertension (≥95th percentile for age, sex, and height or, if ≥13 years, ≥130/80 mmHg) Optimize glycemia and blood pressure; ACE inhibitor* if albumin-to-creatinine ratio is elevated in two of three samples over 6 months Optimize glycemia; referral to neurology Optimize glycemia; treatment per ophthalmology If abnormal, optimize glycemia and medical nutrition therapy; if LDL >130 mg/dL after 6 months, initiate statin therapy (for those aged >10 years)*; if triglycerides >400 mg/dL fasting or >1,000 mg/dL nonfasting, begin fibrate Refer to gastroenterology for persistently elevated or worsening transaminases If positive symptoms, refer to sleep specialist and polysomnogram If no contraindications, oral contraceptive pills; medical nutrition therapy; metformin 

ARB, angiotensin receptor blocker; NA, not applicable; tTG, tissue transglutaminase.

*

Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and medication should be avoided in individuals of childbearing age who are not using reliable contraception.

Due to the nature of pediatric clinical research, the recommendations for children and adolescents with diabetes are less likely to be based on clinical trial evidence. However, expert opinion and a review of available and relevant experimental data are summarized in the American Diabetes Association (ADA) position statements “Type 1 Diabetes in Children and Adolescents” (2) and “Evaluation and Management of Youth-Onset Type 2 Diabetes” (3). Finally, other sections in the Standards of Care may have recommendations that apply to youth with diabetes and are referenced in the narrative of this section.

Type 1 diabetes is the most common form of diabetes in youth (4), although data suggest that it accounts for a large proportion of cases diagnosed in adult life (5). The health care professional must consider the unique aspects of care and management of children and adolescents with type 1 diabetes, such as changes in insulin sensitivity related to physical growth and sexual maturation, ability to provide self-care, supervision in the childcare and school environment, neurological vulnerability to hypoglycemia and hyperglycemia in young children, and possible adverse neurocognitive effects of diabetic ketoacidosis (DKA) (6,7). Attention to family dynamics, developmental stages, and physiologic differences related to sexual maturity is essential in developing and implementing an optimal diabetes treatment plan (8).

An interprofessional team trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families should provide diabetes-specific care for this population. It is essential that diabetes self-management education and support, medical nutrition therapy, and psychosocial/behavioral support be provided at diagnosis and regularly thereafter in a developmentally appropriate format that builds on prior knowledge by a team of health care professionals experienced with the biological, educational, nutritional, behavioral, and emotional needs of the growing child and family. The diabetes team, taking into consideration the youth’s developmental and psychosocial needs, should ask about and discuss diabetes management responsibilities with youth and parents/caregivers on an ongoing basis.

Diabetes Self-Management Education and Support

Recommendation

  • 14.1 Youth with type 1 diabetes and their parents/caregivers (for individuals aged <18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B

Self-management in pediatric diabetes involves both the youth and their parents/adult caregivers. No matter how sound the medical plan is, it can only be effective if the family and/or affected individuals are able to implement it. Family involvement is a vital component of optimal diabetes management throughout childhood and adolescence. As parents/caregivers are critical to diabetes self-management in youth, diabetes care requires an approach that places the youth and their parents/caregivers at the center of the care model. The pediatric diabetes care team must be capable of evaluating the educational, behavioral, emotional, and psychosocial factors that impact the implementation of a treatment plan and must work with the youth and family to overcome barriers or redefine goals as appropriate. Diabetes self-management education and support requires periodic reassessment, especially as the youth grows, develops, and acquires the need and desire for greater independent self-care skills. The pediatric diabetes team should work with the youth and their parents/caregivers to ensure there is not a premature transfer of self-management tasks to the youth during this time. In addition, it is necessary to assess the educational needs and skills of, and provide training to, daycare workers, school nurses, and school personnel who are responsible for the care and supervision of the child with diabetes (2,9,10).

Nutrition Therapy

Recommendations

  • 14.2 Individualized medical nutrition therapy is recommended for youth with type 1 diabetes as an essential component of the overall treatment plan. A

  • 14.3 Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, is a key component to optimizing glycemic management. B

  • 14.4 Meal composition impacts postprandial glucose excursions. Education on the impact of high-fat and high-protein meals and the adjustment of insulin dosing is necessary. A

  • 14.5 Comprehensive nutrition education at diagnosis, with at least annual updates and as needed, by an experienced registered dietitian nutritionist is recommended to assess caloric and nutrition intake in relation to weight status and cardiovascular disease risk factors and to inform macronutrient choices. E

Nutrition management should be individualized: family habits, food preferences, religious or cultural needs, finances, schedules, physical activity, and the youth’s and family’s abilities in numeracy, literacy, and self-management should be considered. Visits with a registered dietitian nutritionist should include assessment for changes in food preferences over time, access to food, growth, and development, weight status, cardiovascular risk, and potential for disordered eating. Following recommended nutrition plans is associated with better glycemic outcomes in youth with type 1 diabetes (11).

Although carbohydrate content is the primary variable for calculation of meal insulin dose, it is well known that meals with higher content of fat and protein can cause early hypoglycemia and delayed postprandial excursion. Some adjustments in insulin dosing, including an increase in the calculated dose as well as a split dose, will improve postprandial glucose management (1228).

Physical Activity and Exercise

Recommendations

  • 14.6 Physical activity is recommended for all youth with type 1 diabetes with the goal of 60 min of moderate- to vigorous-intensity aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week. C

  • 14.7 Frequent glucose monitoring before, during, and after exercise, via blood glucose meter or continuous glucose monitoring (CGM), is important to prevent, detect, and treat hypoglycemia and hyperglycemia associated with exercise. C

  • 14.8 Youth and their parents/caregivers should receive education on goals and management of glycemia before, during, and after physical activity, individualized according to the type and intensity of the planned physical activity. E

  • 14.9 Youth and their parents/caregivers should be educated on strategies to prevent hypoglycemia during, after, and overnight following physical activity and exercise, which may include reducing prandial insulin dosing for the meal/snack preceding (and, if needed, following) exercise, reducing basal insulin doses, increasing carbohydrate intake, eating bedtime snacks, and/or using CGM. Treatment for hypoglycemia should be accessible before, during, and after engaging in activity. C

Physical activity and structured exercise positively impact metabolic and psychological health in children with type 1 diabetes (29). While it affects insulin sensitivity, physical fitness, strength building, weight management, social interaction, mood, self-esteem building, and the creation of healthful habits for adulthood, it also has the potential to cause both hypoglycemia and hyperglycemia.

See below for strategies to mitigate hypoglycemia risk and minimize hyperglycemia associated with exercise. For an in-depth discussion, see reviews and guidelines (3032).

Overall, it is recommended that youth participate in 60 min of moderate-intensity (e.g., brisk walking or dancing) to vigorous-intensity (e.g., running or jumping rope) aerobic activity daily, including resistance and flexibility training (33). Although uncommon in the pediatric population, youth should be medically evaluated for comorbid conditions or diabetes complications that may restrict participation in an exercise program. As hyperglycemia can occur before, during, and after physical activity, it is important to ensure that the elevated glucose level is not related to insulin deficiency that would lead to worsening hyperglycemia with exercise and ketosis risk. Intense activity should be postponed with marked hyperglycemia (glucose ≥350 mg/dL [≥19.4 mmol/L]), moderate to large urine ketones, and/or β-hydroxybutyrate (B-OHB) >1.5 mmol/L. Caution may be needed when B-OHB levels are ≥0.6 mmol/L (11,30).

The prevention and treatment of hypoglycemia associated with physical activity include decreasing the prandial insulin for the meal/snack before exercise and/or increasing food intake. Youth on insulin pumps without automated insulin delivery (AID) can lower basal rates by ∼10–50% or more or suspend for 1–2 h during exercise (34). Decreasing basal rates or long-acting insulin doses by ∼20% after exercise may reduce delayed exercise-induced hypoglycemia (35). Accessible rapid-acting carbohydrates and frequent blood glucose monitoring before, during, and after exercise, with or without continuous glucose monitoring (CGM), maximize safety with exercise. The use of AID systems may improve time in range (TIR) (70–180 mg/dL) during exercise, and youth can use brand-specific settings that are more conservative or increase the glycemic goal to prevent hypoglycemia (36).

Blood glucose goals prior to physical activity and exercise should be 126–180 mg/dL (7.0–10.0 mmol/L) but should be individualized based on the type, intensity, and duration of activity (30,32). Consider additional carbohydrate intake during and/or after exercise, depending on the duration and intensity of physical activity, to prevent hypoglycemia. For low- to moderate-intensity aerobic activities (30–60 min), and if the youth is fasting, 10–15 g of carbohydrate may prevent hypoglycemia (32). After insulin boluses (relative hyperinsulinemia), consider 0.5–1.0 g of carbohydrates/kg per hour of exercise (∼30–60 g), which is similar to carbohydrate requirements to optimize performance in athletes without type 1 diabetes (3739).

In addition, obesity is as common in youth with type 1 diabetes as in those without diabetes. It is associated with a higher frequency of cardiovascular risk factors, and it disproportionately affects racial/ethnic minorities in the U.S. (4044). Therefore, diabetes health care professionals should monitor weight status and encourage a healthy eating pattern, physical activity, and healthy weight as key components of pediatric type 1 diabetes care.

School and Child Care

As a large portion of a youth’s day is spent in school and/or day care, training of school or day care personnel to provide care in accordance with the child’s individualized diabetes medical management plan is essential for optimal diabetes management and safe access to all school or day care–sponsored opportunities (10,45,46). In addition, federal and state laws require schools, day care facilities, and other entities to provide needed diabetes care to enable the child to safely access the school or day care environment. Refer to the ADA position statements “Diabetes Care in the School Setting” (10) and “Care of Young Children With Diabetes in the Childcare and Community Setting” (46) and the ADA’s Safe at School website (diabetes.org/resources/know-your-rights/safe-at-school-state-laws) for additional details.

Psychosocial Care

Recommendations

  • 14.10 At diagnosis and during routine follow-up care, screen youth with type 1 diabetes for psychosocial concerns (e.g., diabetes distress, depressive symptoms, and disordered eating), family factors, and behavioral health concerns that could impact diabetes management with age-appropriate standardized and validated tools. Refer to a qualified behavioral health professional, preferably experienced in childhood diabetes, when indicated. B

  • 14.11 Behavioral health professionals should be considered integral members of the pediatric diabetes interprofessional team. E

  • 14.12 Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature or unsupportive transfer of diabetes care responsibility to the youth can contribute to diabetes distress, lower engagement in diabetes self-management behaviors, and deterioration in glycemia. A

  • 14.13 Health care professionals should screen for food security, housing stability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. E

  • 14.14 Health care professionals should consider asking youth and their parents/caregivers about social adjustment (peer relationships) and school performance to determine whether further intervention is needed. B

  • 14.15 Offer adolescents time by themselves with their health care professional(s) starting at age 12 years or when developmentally appropriate. E

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

Rapid and dynamic cognitive, developmental, and emotional changes occur during childhood, adolescence, and emerging adulthood. Diabetes management during childhood and adolescence places substantial burdens on the youth and family, necessitating ongoing assessment of psychosocial status, social determinants of health, and diabetes distress in the youth and the parents/caregivers during routine diabetes visits (4755). It is important to consider the impact of diabetes on quality of life as well as the development of behavioral health problems related to diabetes distress, fear of hypoglycemia (and hyperglycemia), symptoms of anxiety, disordered eating behaviors and eating disorders, and symptoms of depression (50,56). Consider screening youth for diabetes distress, generally starting at 7 or 8 years of age (56), using validated tools for youth and their parents/caregivers (57). Consider screening for depression and disordered eating behaviors using available screening tools (58,59). Early detection of depression, anxiety, disordered eating, and learning disabilities can facilitate effective treatment options and help minimize adverse effects on diabetes management and disease outcomes (50,56). When psychological symptoms are identified, referral to a behavioral health professional, ideally with experience in pediatric diabetes, may be warranted. Such professionals can provide individualized, evidence-based behavioral health care services, including cognitive-behavioral, mindfulness-based, and other interventions (60), to improve psychosocial functioning in youth with type 1 diabetes (6163).

The complexities of diabetes management require ongoing parental involvement in care throughout childhood and adolescence. Developmentally appropriate, supportive family teamwork between the growing youth and parent can help maintain engagement in self-management behaviors and reduce deterioration in glycemia (64,65). It is appropriate to inquire about diabetes-specific family relationships, including family teamwork and conflict, during visits; health care professionals can both help families negotiate a plan and refer to an appropriate behavioral health professional for more in-depth support (66). Such professionals can conduct further assessment and deliver evidence-based behavioral interventions to support developmentally appropriate, collaborative family involvement in diabetes self-management (61,63). Monitoring of social adjustment (peer relationships) and school performance can facilitate both well-being and academic achievement (67). Diabetes management and glycemic levels may be related to academic progress and students’ functioning in the school setting, which highlights the need for appropriate accommodations and access to diabetes-related support in school (68).

Shared decision-making with youth regarding the adoption of management plan components and self-management behaviors can improve diabetes self-efficacy, participation in diabetes care, and metabolic outcomes (41,69). Although cognitive abilities vary, the ethical position often adopted is the “mature minor rule,” whereby children after age 12 or 13 years who appear to be “mature” have the right to consent or withhold consent to general medical treatment, except in cases in which refusal would significantly endanger health (70).

Beginning at the onset of puberty or at diagnosis of diabetes, all individuals with childbearing potential should receive education about the risks of fetal malformations associated with elevated A1C and the use of effective contraception to prevent unplanned pregnancy. Preconception counseling using developmentally appropriate educational and behavioral strategies enables individuals of childbearing potential to make well-informed decisions (71). Preconception counseling resources tailored for adolescents are available at no cost through the ADA (72). Refer to the ADA position statement “Psychosocial Care for People With Diabetes” for further details (56).

Youth with type 1 diabetes have an increased risk of disordered eating behavior as well as clinical eating disorders, with serious short-term and long-term negative effects on diabetes outcomes and health in general. It is important to recognize the unique and dangerous disordered eating behavior of insulin omission for weight management in type 1 diabetes (73) using tools such as the Diabetes Eating Problems Survey-Revised (DEPS-R) to allow for early diagnosis and intervention (59,7476). Given the complexity of treating disordered eating behaviors, collaboration between the diabetes health care team and a behavioral health professional, ideally with expertise in disordered eating behaviors and diabetes, is recommended.

The presence of a behavioral health professional on pediatric interprofessional teams highlights the importance of attending to the psychosocial issues of diabetes. These psychosocial factors are significantly related to self-management difficulties, elevated A1C, reduced quality of life, and higher rates of acute and chronic diabetes complications.

Glycemic Monitoring, Insulin Delivery, and Goals

Recommendations

  • 14.17 All youth with type 1 diabetes should monitor glucose levels multiple times daily (up to 6–10 times/day by blood glucose meter or CGM), including prior to meals and snacks, at bedtime, and as needed for safety in specific situations such as physical activity, driving, or the presence of symptoms of hypoglycemia. B

  • 14.18 Real-time CGM A or intermittently scanned CGM E should be offered for diabetes management at diagnosis or as soon as possible in youth with diabetes on multiple daily injections or insulin pump therapy who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs.

  • 14.19 Automated insulin delivery (AID) systems should be offered for diabetes management to youth with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A

  • 14.20 Insulin pump therapy alone should be offered for diabetes management to youth on multiple daily injections with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers) if unable to use AID systems. The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A

  • 14.21 Students must be supported at school in the use of diabetes technology, including continuous glucose monitors, insulin pumps, connected insulin pens, and AID systems as prescribed by their diabetes care team. E

  • 14.22 A1C goals must be individualized and reassessed over time. An A1C of <7% (<53 mmol/mol) is appropriate for many children and adolescents. B

  • 14.23 Less stringent A1C goals (such as <7.5% [<58 mmol/mol]) may be appropriate for youth who cannot articulate symptoms of hypoglycemia; have hypoglycemia unawareness; lack access to analog insulins, advanced insulin delivery technology, and/or CGM; cannot check blood glucose regularly; or have nonglycemic factors that increase A1C (e.g., high glycators). B

  • 14.24 Even less stringent A1C goals (such as <8% [<64 mmol/mol]) may be appropriate for individuals with a history of severe hypoglycemia, limited life expectancy, or where the harms of treatment are greater than the benefits. B

  • 14.25 Health care professionals may reasonably suggest more stringent A1C goals (such as <6.5% [<48 mmol/mol]) for selected individuals if they can be achieved without significant hypoglycemia, negative impacts on well-being, or undue burden of care or in those who have nonglycemic factors that decrease A1C (e.g., lower erythrocyte life span). Lower goals may also be appropriate during the honeymoon phase. B

  • 14.26 CGM metrics derived from continuous glucose monitor use over the most recent 14 days (or longer for youth with more glycemic variability), including time in range (70–180 mg/dL [3.9–10.0 mmol/L]), time below range (<70 mg/dL [<3.9 mmol/L] and <54 mg/dL [<3.0 mmol/L]), and time above range (>180 mg/dL [>10.0 mmol/L] and >250 mg/dL [>13.9 mmol/L]), are recommended to be used in conjunction with A1C whenever possible. E

Current standards for diabetes management reflect the need to minimize hyperglycemia as safely as possible. The Diabetes Control and Complications Trial (DCCT), which did not enroll children <13 years of age, demonstrated that near normalization of blood glucose levels was more difficult to achieve in adolescents than in adults. Nevertheless, the increased use of basal-bolus plans, insulin pumps, frequent blood glucose monitoring, CGM, AID systems, goal setting, and improved patient education has been associated with more children and adolescents reaching the blood glucose goals recommended by the ADA (7779), particularly in families in which both the parents/caregivers and the child with diabetes participate jointly to perform the required diabetes-related tasks.

Lower A1C in adolescence and young adulthood is associated with a lower risk and rate of microvascular and macrovascular complications (8083) and demonstrates the effects of metabolic memory (8487).

In addition, type 1 diabetes can be associated with adverse effects on cognition during childhood and adolescence (6,8890), and neurocognitive imaging differences related to hyperglycemia in children provide another motivation for achieving glycemic goals (6). DKA has been shown to cause adverse effects on brain development and function. Additional factors (9194) that contribute to adverse effects on brain development and function include young age, severe hypoglycemia at <6 years of age, and chronic hyperglycemia (95,96). However, meticulous use of therapeutic modalities such as rapid- and long-acting insulin analogs, technological advances (e.g., CGM, sensor-augmented pump therapy, and AID systems), and intensive self-management education now make it more feasible to achieve glycemic goals while reducing the incidence of severe hypoglycemia (97120). Please refer to Section 7, “Diabetes Technology,” for more information on technology to support people with diabetes.

In selecting individualized glycemic goals, the long-term health benefits of achieving a lower A1C should be balanced against the risks of hypoglycemia and the developmental burdens of intensive treatment plans in youth (121). Recent data with newer devices and insulins indicate that the risk of hypoglycemia with lower A1C is less than it was before (122131). Some data suggest that there could be a threshold where lower A1C is associated with more hypoglycemia (132,133); however, the confidence intervals were large, suggesting great variability. In addition, achieving lower A1C levels is likely facilitated by setting lower A1C goals (134,135). Lower goals may be possible during the honeymoon phase of type 1 diabetes. Special consideration should be given to the risk of hypoglycemia in young children (aged <6 years) who are often unable to recognize, articulate, and/or manage hypoglycemia. However, registry data indicate that A1C goals can be achieved in children, including those aged <6 years, without increased risk of severe hypoglycemia (123,134). Recent data have demonstrated that the use of real-time CGM lowered A1C and increased TIR in adolescents and young adults and, in children aged <8 years old, was associated with a lower risk of hypoglycemia (136,137). Please refer to Section 6, “Glycemic Goals and Hypoglycemia,” for more information on glycemic assessment.

A strong relationship exists between the frequency of blood glucose monitoring and glycemic management (118120, 138144). Glucose levels for all children and adolescents with type 1 diabetes should be monitored multiple times daily by blood glucose monitoring and/or CGM. Recent data on children and adults suggest that use of CGM soon after type 1 diabetes diagnosis is associated with improved A1C (104,105,145). In the U.S., real-time CGM is approved for nonadjunctive use in children aged 2 years and older and intermittently scanned CGM is approved for nonadjunctive use in children aged 4 years and older. Parents/caregivers and youth should be offered initial and ongoing education and support for CGM use. Behavioral support may further improve ongoing CGM use (137). Metrics derived from CGM include percent time in target range, below target range, and above target range (146). While studies indicate a relationship between TIR and A1C (147,148), it is still uncertain what the ideal goal TIR should be for children, and further studies are needed. Please refer to Section 7, “Diabetes Technology,” for more information on the use of blood glucose meters, CGM, and insulin pumps. More information on insulin injection technique can be found in Section 9, “Pharmacologic Approaches to Glycemic Treatment.”

Key Concepts in Setting Glycemic Goals

  • Glycemic goals should be individualized, and lower goals may be reasonable based on a benefit–risk assessment.

  • Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness.

  • Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to assess preprandial insulin doses in those on basal-bolus or pump plans.

Autoimmune Conditions

Recommendation

  • 14.27 Assess for additional autoimmune conditions soon after the diagnosis of type 1 diabetes and if symptoms develop. B

Because of the increased frequency of other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction and celiac disease should be considered (149153). Periodic screening in asymptomatic individuals has been recommended, but the optimal frequency of screening is unclear.

Although much less common than thyroid dysfunction and celiac disease, other autoimmune conditions, such as Addison disease (primary adrenal insufficiency), autoimmune hepatitis, autoimmune gastritis, dermatomyositis, and myasthenia gravis, occur more commonly in the population with type 1 diabetes than in the general pediatric population and should be assessed and monitored as clinically indicated. In addition, relatives of youth with type 1 diabetes should be offered testing for islet autoantibodies through research studies (e.g., TrialNet) and national programs for early diagnosis of preclinical type 1 diabetes (stages 1 and 2).

Thyroid Disease

Recommendations

  • 14.28 Consider testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. B

  • 14.29 Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or soon after optimizing glycemia. If normal, suggest rechecking every 1–2 years or sooner if the youth has positive thyroid antibodies or develops symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability. B

Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17–30% of individuals with type 1 diabetes (150,154,155). At the time of diagnosis, ∼25% of children with type 1 diabetes have thyroid autoantibodies (156), the presence of which is predictive of thyroid dysfunction—most commonly hypothyroidism, although hyperthyroidism occurs in ∼0.5% of people with type 1 diabetes (157,158). For thyroid autoantibodies, a study from Sweden indicated that antithyroid peroxidase antibodies were more predictive than antithyroglobulin antibodies in multivariate analysis (159). Thyroid function tests may be misleading (euthyroid sick syndrome) if performed at the time of diagnosis owing to the effect of previous hyperglycemia, ketosis or ketoacidosis, weight loss, etc. Therefore, if performed at diagnosis and slightly abnormal, thyroid function tests should be repeated soon after a period of metabolic stability and achievement of glycemic goals. Subclinical hypothyroidism may be associated with an increased risk of symptomatic hypoglycemia (160) and a reduced linear growth rate. Hyperthyroidism alters glucose metabolism and usually causes deterioration of glycemia.

Celiac Disease

Recommendations

  • 14.30 Screen youth with type 1 diabetes for celiac disease by measuring IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or IgG tTG and deamidated gliadin antibodies if IgA is deficient. B

  • 14.31 Repeat screening for celiac disease within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in youth who have symptoms or a first-degree relative with celiac disease. B

  • 14.32 Individuals with confirmed celiac disease should be placed on a gluten-free diet for treatment and to avoid complications. Youth and their caregivers should also have a consultation with a registered dietitian nutritionist experienced in managing both diabetes and celiac disease. B

Celiac disease is an immune-mediated disorder that occurs with increased frequency in people with type 1 diabetes (1.6–16.4% of individuals compared with 0.3–1% in the general population) (149,152,153,161165). Screening people with type 1 diabetes for celiac disease is further justified by its association with osteoporosis, iron deficiency, growth failure, and potential increased risk of retinopathy and albuminuria (166169).

Screening for celiac disease includes measuring serum levels of IgA and tissue transglutaminase (tTG) IgA antibodies, or, with IgA deficiency, screening can include measuring tTG IgG antibodies or deamidated gliadin peptide IgG antibodies. Because most cases of celiac disease are diagnosed within the first 5 years after the diagnosis of type 1 diabetes, screening should be considered at the time of diagnosis and repeated at 2 and then 5 years (163) or if clinical symptoms indicate, such as poor growth or increased hypoglycemia (164,166).

Although celiac disease can be diagnosed more than 10 years after diabetes diagnosis, there are insufficient data after 5 years to determine the optimal screening frequency. Measurement of tTG antibody should be considered at other times in individuals with symptoms suggestive of celiac disease (163). Monitoring for symptoms should include an assessment of linear growth and weight gain (164,166). A small bowel biopsy in antibody-positive children is recommended to confirm the diagnosis (170). European guidelines on screening for celiac disease in children (not specific to children with type 1 diabetes) suggest that biopsy may not be necessary in symptomatic children with high antibody titers (i.e., greater than 10 times the upper limit of normal) provided that further testing is performed (verification of endomysial antibody positivity on a separate blood sample) (171). Whether this approach may be appropriate for asymptomatic children in high-risk groups remains an open question, though evidence is emerging (172). It is also advisable to check for celiac disease–associated HLA types in individuals who are diagnosed without a small intestinal biopsy. In symptomatic children with type 1 diabetes and confirmed celiac disease, gluten-free diets reduce symptoms and rates of hypoglycemia (173). The challenging dietary restrictions associated with having both type 1 diabetes and celiac disease place a significant burden on individuals. Therefore, a biopsy to confirm the diagnosis of celiac disease is recommended, especially in asymptomatic children, before establishing a diagnosis of celiac disease (171) and endorsing significant dietary changes. A gluten-free diet was beneficial in asymptomatic adults with positive antibodies confirmed by biopsy (174).

Management of Cardiovascular Risk Factors

Hypertension Screening

Recommendation

  • 14.33 Blood pressure should be measured at every routine visit. In youth with high blood pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13 years, blood pressure ≥120/80 mmHg) on three separate measurements, ambulatory blood pressure monitoring should be strongly considered. B

Hypertension Treatment

Recommendations

  • 14.34 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C

  • 14.35 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and ACE inhibitors and angiotensin receptor blockers should be avoided in individuals of childbearing age who are not using reliable contraception. B

  • 14.36 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C

Blood pressure measurements should be performed using the appropriate size cuff with the youth seated and relaxed. Elevated blood pressure should be confirmed on at least three separate days, and ambulatory blood pressure monitoring should be considered. Evaluation should proceed as clinically indicated (175,176). Treatment is generally initiated with an ACE inhibitor, but an angiotensin receptor blocker can be used if the ACE inhibitor is not tolerated (e.g., due to cough) (177).

Dyslipidemia Screening

Recommendations

  • 14.37 Initial lipid profile should be performed soon after diagnosis, preferably after glycemia has improved and age is ≥2 years. If initial LDL cholesterol is ≤100 mg/dL (≤2.6 mmol/L), subsequent testing should be performed at 9–11 years of age. B Initial testing may be done with a nonfasting lipid level with confirmatory testing with a fasting lipid panel.

  • 14.38 If LDL cholesterol values are within the accepted risk level (<100 mg/dL [<2.6 mmol/L]), a lipid profile repeated every 3 years is reasonable. E

Dyslipidemia Treatment
Recommendations

  • 14.39 If lipids are abnormal, initial therapy should consist of optimizing glycemia and medical nutrition therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats. A

  • 14.40 After the age of 10 years, addition of a statin may be considered in youth with type 1 diabetes who, despite medical nutrition therapy and 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 cardiovascular disease risk factors. E Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and statins should be avoided in individuals of childbearing age who are not using reliable contraception. B

  • 14.41 The goal of therapy is an LDL cholesterol value <100 mg/dL (<2.6 mmol/L). E

Population-based studies estimate that 14–45% of children with type 1 diabetes have two or more atherosclerotic cardiovascular disease (ASCVD) risk factors (178180), and the prevalence of cardiovascular disease (CVD) risk factors increase with age (180) and among racial/ethnic minorities (40), with girls having a higher risk burden than boys (179).

Pathophysiology.

The atherosclerotic process begins in childhood, and although ASCVD events are not expected to occur during childhood, observations using a variety of methodologies show that youth with type 1 diabetes may have subclinical CVD within the first decade of diagnosis (181183). Studies of carotid intima media thickness have yielded inconsistent results (176,177).

Screening.

Diabetes predisposes to the development of accelerated arteriosclerosis. Lipid evaluation for these individuals contributes to risk assessment and identifies an important proportion of those with dyslipidemia. Therefore, initial screening should be done soon after diagnosis. If the initial screen is normal, subsequent screening may be done at 9–11 years of age, which is a stable time for lipid assessment in children (184). Children with a primary lipid disorder (e.g., familial hyperlipidemia) should be referred to a lipid specialist. Non-HDL cholesterol level has been identified as a significant predictor of the presence of atherosclerosis—as powerful as any other lipoprotein cholesterol measure in children and adolescents. For both children and adults, non-HDL cholesterol level seems to be more predictive of persistent dyslipidemia and, therefore, atherosclerosis and future events than total cholesterol, LDL cholesterol, or HDL cholesterol levels alone. A major advantage (185) of non-HDL cholesterol is that it can be accurately calculated in a nonfasting state and therefore is practical to obtain in clinical practice as a screening test (186). Youth with type 1 diabetes have a high prevalence of lipid abnormalities (178,185).

Even if normal, screening should be repeated within 3 years, as A1C and other cardiovascular risk factors can change dramatically during adolescence (187).

Treatment.

Pediatric lipid guidelines provide some guidance relevant to children with type 1 diabetes and secondary dyslipidemia (176,184,188,189); however, there are few studies on modifying lipid levels in children with type 1 diabetes. A 6-month trial of dietary counseling produced a significant improvement in lipid levels (190); likewise, a lifestyle intervention trial with 6 months of exercise in adolescents demonstrated improvement in lipid levels (191). Data from the SEARCH for Diabetes in Youth (SEARCH) study show that improved glucose over a 2-year period is associated with a more favorable lipid profile; however, improved glycemia alone will not normalize lipids in youth with type 1 diabetes and dyslipidemia (187).

Although intervention data are sparse, the American Heart Association categorizes children with type 1 diabetes in the highest tier for cardiovascular risk and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cholesterol levels (189,192). Initial therapy should include a nutrition plan that restricts saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day (184). Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and development (193).

Neither long-term safety nor cardiovascular outcome efficacy of statin therapy has been established for children; however, studies have shown short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels in familial hypercholesterolemia or severe hyperlipidemia, improving endothelial function and causing regression of carotid intimal thickening (194,195). Statins are not approved for children aged <10 years, and statin treatment should generally not be used in children with type 1 diabetes before this age. Statins are contraindicated in pregnancy; therefore, the prevention of unplanned pregnancies is of paramount importance. Statins should be avoided in individuals of childbearing age who are not using reliable contraception (see Section 15, “Management of Diabetes in Pregnancy,” for more information). The multicenter, randomized, placebo-controlled Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) provides safety data on pharmacologic treatment with an ACE inhibitor and statin in adolescents with type 1 diabetes (176).

Microvascular Complications

Nephropathy Screening

Recommendation

  • 14.42 Annual screening for albuminuria with a random (morning sample preferred to avoid effects of exercise) spot urine sample for albumin-to-creatinine ratio should be considered at puberty or at age >10 years, whichever is earlier, once the youth has had diabetes for 5 years. B

Nephropathy Treatment

Recommendation

  • 14.43 An ACE inhibitor or an angiotensin receptor blocker, titrated to normalization of albumin excretion, may be considered when elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented (two of three urine samples obtained over a 6-month interval following efforts to improve glycemia and normalize blood pressure). E Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and ACE inhibitors and angiotensin receptor blockers should be avoided in individuals of childbearing age who are not using reliable contraception. B

Data from 7,549 participants <20 years of age in the T1D Exchange clinic registry emphasize the importance of meeting glycemic and blood pressure goals, particularly as diabetes duration increases, in order to reduce the risk of diabetic kidney disease. The data also underscore the importance of routine screening to ensure early diagnosis and timely treatment of albuminuria (196). An estimation of glomerular filtration rate (GFR), calculated using GFR estimating equations from the serum creatinine, height, age, and sex (197), should be considered at baseline and repeated as indicated based on clinical status, age, diabetes duration, and therapies. Improved methods are needed to screen for early GFR loss since estimated GFR is inaccurate at GFR >60 mL/min/1.73 m2 (197,198). The AdDIT study in adolescents with type 1 diabetes demonstrated the safety of ACE inhibitor treatment, but the treatment did not change the albumin-to-creatinine ratio over the course of the study (176).

Retinopathy

Recommendations

  • 14.44 An initial dilated and comprehensive eye examination is recommended once youth have had type 1 diabetes for 3–5 years, provided they are aged ≥11 years or puberty has started, whichever is earlier. B

  • 14.45 After the initial examination, repeat dilated and comprehensive eye examination every 2 years. Less frequent examinations, every 4 years, may be acceptable on the advice of an eye care professional and based on risk factor assessment, including a history of A1C <8%. B

  • 14.46 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E

Retinopathy (like albuminuria) most commonly occurs after the onset of puberty and after 5–10 years of diabetes duration (199). It is currently recognized that there is a low risk of development of vision-threatening retinal lesions prior to 12 years of age (200,201). A 2019 publication based on the follow-up of the DCCT adolescent cohort supports a lower frequency of eye examinations than previously recommended, particularly in adolescents with A1C closer to the goal range (202,203). Referrals should be made to eye care professionals with expertise in diabetic retinopathy and experience in counseling pediatric patients and families on the importance of prevention, early detection, and intervention.

Neuropathy

Recommendation

  • 14.47 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. The examination should include inspection, assessment of foot pulses, pinprick, and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. B

Diabetic neuropathy rarely occurs in prepubertal children or after only 1–2 years of diabetes (199), although data suggest a prevalence of distal peripheral neuropathy of 7% in 1,734 youth with type 1 diabetes and association with the presence of CVD risk factors (204,205). A comprehensive foot exam, including inspection, palpation of dorsalis pedis and posterior tibial pulses, and determination of proprioception, vibration, and monofilament sensation, should be performed annually along with an assessment of symptoms of neuropathic pain (205). Foot inspection can be performed at each visit to educate youth regarding the importance of foot care (see Section 12, “Retinopathy, Neuropathy, and Foot Care”).

For information on risk-based screening for type 2 diabetes and prediabetes in youth, please refer to Section 2, “Diagnosis and Classification of Diabetes.” For additional support for these recommendations, see the ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (3).

The prevalence of type 2 diabetes in youth has continued to increase over the past 20 years (4). The CDC published projections for type 2 diabetes prevalence using the SEARCH database; assuming a 2.3% annual increase, the prevalence in those under 20 years of age will quadruple in 40 years (206,207).

Evidence suggests that type 2 diabetes in youth is different not only from type 1 diabetes but also from type 2 diabetes in adults and has unique features, such as a more rapidly progressive decline in β-cell function and accelerated development of diabetes complications (3,208). Long-term follow-up data from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study showed that a majority of individuals with type 2 diabetes diagnosed as youth had microvascular complications by young adulthood (209). Type 2 diabetes disproportionately impacts youth of ethnic and racial minorities and can occur in complex psychosocial and cultural environments, which may make it difficult to sustain healthy lifestyle changes and self-management behaviors (41,210213). Additional risk factors associated with type 2 diabetes in youth include adiposity, family history of diabetes, female sex, and low socioeconomic status (208).

As with type 1 diabetes, youth with type 2 diabetes spend much of the day in school. Therefore, close communication with and the cooperation of school personnel are essential for optimal diabetes management, safety, and maximal academic opportunities.

Screening and Diagnosis

Recommendations

  • 14.48 Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or ≥10 years of age, whichever occurs earlier, in youth with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more additional risk factors for diabetes (see Table 2.5 for evidence grading of other risk factors).

  • 14.49 If screening is normal, repeat screening at a minimum of 3-year intervals, E or more frequently if BMI is increasing. C

  • 14.50 Fasting plasma glucose, 2-h plasma glucose during a 75-g oral glucose tolerance test, and A1C can be used to test for prediabetes or diabetes in children and adolescents. B

  • 14.51 Children and adolescents with overweight or obesity in whom the diagnosis of type 2 diabetes is being considered should have a panel of pancreatic autoantibodies tested to exclude the possibility of autoimmune type 1 diabetes. B

In the last decade, the incidence and prevalence of type 2 diabetes in adolescents has increased dramatically, especially in racial and ethnic minority populations (184,214). A few studies suggest oral glucose tolerance tests or fasting plasma glucose values as more suitable diagnostic tests than A1C in the pediatric population, especially among certain ethnicities (215), although fasting glucose alone may overdiagnose diabetes in children (216,217). In addition, many of these studies do not recognize that diabetes diagnostic criteria are based on long-term health outcomes, and validations are not currently available in the pediatric population (218). An analysis of National Health and Nutrition Examination Survey (NHANES) data suggests using A1C for screening of high-risk youth (219).

The ADA acknowledges the limited data supporting A1C for diagnosing type 2 diabetes in children and adolescents. Although A1C is not recommended for diagnosis of diabetes in children with cystic fibrosis or symptoms suggestive of acute onset of type 1 diabetes, and only A1C assays without interference are appropriate for children with hemoglobinopathies, the ADA continues to recommend A1C for diagnosis of type 2 diabetes in this population (214,215).

Diagnostic Challenges

Given the current obesity epidemic, distinguishing between type 1 and type 2 diabetes in children can be difficult. Overweight and obesity are common in children with type 1 diabetes (42), and diabetes-associated autoantibodies and ketosis may be present in pediatric individuals with clinical features of type 2 diabetes (including obesity and acanthosis nigricans) (216). The presence of islet autoantibodies has been associated with faster progression to insulin deficiency (216). At the onset, DKA occurs in ∼6% of youth aged 10–19 years with type 2 diabetes (220). Although uncommon, type 2 diabetes has been observed in prepubertal children under the age of 10 years, and thus it should be part of the differential in children with suggestive symptoms (221). Finally, obesity contributes to the development of type 1 diabetes in some individuals (222), which further blurs the lines between diabetes types. However, accurate diagnosis is critical, as treatment plans, educational approaches, dietary advice, and outcomes differ markedly between individuals with the two diagnoses. The significant diagnostic difficulties posed by MODY are discussed in Section 2, “Diagnosis and Classification of Diabetes.” In addition, there are rare and atypical diabetes cases that represent a challenge for clinicians and researchers.

Management

Lifestyle Management

Recommendations

  • 14.52 All youth with type 2 diabetes and their families should receive comprehensive diabetes self-management education and support that is specific to youth with type 2 diabetes and is culturally appropriate. B

  • 14.53 Youth with overweight/obesity and type 2 diabetes and their families should be provided with developmentally and culturally appropriate comprehensive lifestyle programs that are integrated with diabetes management to achieve at least a 7–10% decrease in excess weight. C

  • 14.54 Given the necessity of long-term weight management for youth with type 2 diabetes, lifestyle intervention should be based on a chronic care model and offered in the context of diabetes care. E

  • 14.55 Youth with prediabetes and type 2 diabetes, like all children and adolescents, should be encouraged to participate in at least 60 min of moderate to vigorous physical activity daily (with muscle and bone strength training at least 3 days/week) B and to decrease sedentary behavior. C

  • 14.56 Nutrition for youth with prediabetes and type 2 diabetes, like for all children and adolescents, should focus on healthy eating patterns that emphasize consumption of nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages. B

Glycemic Goals

Recommendations

  • 14.57 Blood glucose monitoring should be individualized, taking into consideration the pharmacologic treatment of the youth with type 2 diabetes. E

  • 14.58 Real-time CGM or intermittently scanned CGM should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or insulin pumps who are capable of using the device safely (either by themselves or with a caregiver). The choice of device should be made based on an individual’s and family’s circumstances, desires, and needs. E

  • 14.59 Glycemic status should be assessed at least every 3 months. E

  • 14.60 A reasonable A1C goal for most children and adolescents with type 2 diabetes is <7% (<53 mmol/mol). More stringent A1C goals (such as <6.5% [<48 mmol/mol]) may be appropriate for selected individuals if they can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate individuals might include those with a short duration of diabetes and lesser degrees of β-cell dysfunction and individuals treated with lifestyle or metformin only who achieve significant weight improvement. E

  • 14.61 Less stringent A1C goals (such as 7.5% [58 mmol/mol]) may be appropriate if there is an increased risk of hypoglycemia. E

  • 14.62 A1C goals for individuals on insulin should be individualized, taking into account the relatively low rates of hypoglycemia in youth-onset type 2 diabetes. E

Pharmacologic Management

Recommendations

  • 14.63 Initiate pharmacologic therapy, in addition to behavioral counseling for healthful nutrition and physical activity changes, at diagnosis of type 2 diabetes. A

  • 14.64 In individuals with incidentally diagnosed or metabolically stable diabetes (A1C <8.5% [<69 mmol/mol] and asymptomatic), metformin is the initial pharmacologic treatment of choice if renal function is normal. A

  • 14.65 Youth with marked hyperglycemia (blood glucose ≥250 mg/dL [≥13.9 mmol/L], A1C ≥8.5% [≥69 mmol/mol]) without acidosis at diagnosis who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss should be treated initially with long-acting insulin while metformin is initiated and titrated. B

  • 14.66 In individuals with ketosis/ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct the hyperglycemia and the metabolic derangement. Once acidosis is resolved, metformin should be initiated while subcutaneous insulin therapy is continued. A

  • 14.67 In individuals presenting with severe hyperglycemia (blood glucose ≥600 mg/dL [≥33.3 mmol/L]), consider assessment for hyperglycemic hyperosmolar nonketotic syndrome. A

  • 14.68 If glycemic goals are no longer met with metformin (with or without long-acting insulin), glucagon-like peptide 1 (GLP-1) receptor agonist therapy and/or empagliflozin should be considered in children 10 years of age or older. A

  • 14.69 When choosing glucose-lowering or other medications for youth with overweight or obesity and type 2 diabetes, consider medication-taking behavior and the medications’ effect on weight. E

  • 14.70 For youth not meeting glycemic goals, maximize noninsulin therapies (metformin, a GLP-1 receptor agonist, and empagliflozin) before initiating and/or intensifying insulin therapy plan. E

  • 14.71 In individuals initially treated with insulin and metformin and/or other glucose lowering medications who are meeting glucose goals based on blood glucose monitoring or CGM, insulin can be tapered over 2–6 weeks by decreasing the insulin dose 10–30% every few days. B

Treatment of youth-onset type 2 diabetes should include lifestyle management, diabetes self-management education and support, and pharmacologic treatment. Initial treatment of youth with obesity and diabetes must take into account that diabetes type is often uncertain in the first few weeks of treatment due to overlap in presentation and that a substantial percentage of youth with type 2 diabetes will present with clinically significant ketoacidosis (223). Therefore, initial therapy should address the hyperglycemia and associated metabolic derangements irrespective of ultimate diabetes type, with adjustment of therapy once metabolic compensation has been established and subsequent information, such as islet autoantibody results, becomes available. Figure 14.1  provides an approach to the initial treatment of new-onset diabetes in youth with overweight or obesity with clinical suspicion of type 2 diabetes.

Figure 14.1

Management of new-onset diabetes in youth with overweight or obesity with clinical suspicion of type 2 diabetes. A1C 8.5% = 69 mmol/mol. Adapted from the ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (3). BGM, blood glucose monitoring; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; GLP-1, glucagon-like peptide 1; HHNK, hyperosmolar hyperglycemic nonketotic syndrome; i.v., intravenous; MDI, multiple daily injections; SGLT2, sodium–glucose cotransporter 2.

Figure 14.1

Management of new-onset diabetes in youth with overweight or obesity with clinical suspicion of type 2 diabetes. A1C 8.5% = 69 mmol/mol. Adapted from the ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (3). BGM, blood glucose monitoring; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; GLP-1, glucagon-like peptide 1; HHNK, hyperosmolar hyperglycemic nonketotic syndrome; i.v., intravenous; MDI, multiple daily injections; SGLT2, sodium–glucose cotransporter 2.

Close modal

Glycemic goals should be individualized, taking into consideration the long-term health benefits of more stringent goals and risk for adverse effects, such as hypoglycemia. A lower A1C goal in youth with type 2 diabetes when compared with those recommended in type 1 diabetes is justified by a lower risk of hypoglycemia and higher risk of complications (209,224227).

Self-management in pediatric diabetes involves both the youth and their parents/adult caregivers. Individuals and their families should receive education and support for healthful nutrition and physical activity, such as a balanced meal plan, achieving and maintaining a healthy weight, and regular physical activity. Youth with type 2 diabetes and comorbidities, including nephropathy, should continue to have age-appropriate protein intake (228). Physical activity should include aerobic, muscle-strengthening, and bone-strengthening activities (33). A family-centered approach to nutrition and lifestyle modification is essential in children and adolescents with type 2 diabetes, and nutrition recommendations should be culturally appropriate and sensitive to family resources (see Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes”). Given the complex social and environmental context surrounding youth with type 2 diabetes, individual-level lifestyle interventions may not be sufficient to address the complex interplay of family dynamics, behavioral health, community readiness, and the broader environmental system (3).

An interprofessional diabetes team, including a physician, diabetes care and education specialist, registered dietitian nutritionist, and psychologist or social worker, is essential. In addition to achieving glycemic goals and self-management education (229231), initial treatment must include management of comorbidities such as obesity, dyslipidemia, hypertension, and microvascular complications.

Current pharmacologic treatment options for youth-onset type 2 diabetes are limited to four approved drug classes: insulin, metformin, glucagon-like peptide 1 (GLP-1) receptor agonists, and sodium–glucose cotransporter 2 inhibitors (specifically empagliflozin). Presentation with ketoacidosis or marked ketosis requires a period of insulin therapy until fasting and postprandial glycemia have been restored to normal or near-normal levels. Insulin pump therapy may be considered as an option for those on long-term multiple daily injections who are able to safely manage the device. Initial treatment should also be with insulin when the distinction between type 1 diabetes and type 2 diabetes is unclear and in individuals who have random blood glucose concentrations ≥250 mg/dL (≥13.9 mmol/L) and/or A1C ≥8.5% (≥69 mmol/mol) (232). Metformin therapy should be added after resolution of ketosis/ketoacidosis.

When initial insulin treatment is not required, initiation of metformin is recommended. The TODAY study found that metformin alone provided durable glycemic control (A1C ≤8% [≤64 mmol/mol] for 6 months) in approximately half of the subjects (233). The Restoring Insulin Secretion (RISE) Consortium study did not demonstrate differences in measures of glucose or β-cell function preservation between metformin and insulin, but there was more weight gain with insulin (234).

To date, the TODAY study is the only trial combining lifestyle and metformin therapy in youth with type 2 diabetes; the combination did not perform better than metformin alone in achieving durable glycemic levels (233).

Randomized controlled trials in youth have shown that GLP-1 receptor agonists are safe and effective for decreasing A1C (235239). Use of GLP-1 receptor agonists can increase the frequency of gastrointestinal side effects and should not be used in individuals with a family history of medullary thyroid cancer.

In a recent multicenter double-blind, placebo-controlled trial, 158 children with type 2 diabetes aged between 10 and 17 years were randomized to 10 mg empagliflozin, 5 mg linagliptin, or placebo. There was a significant reduction in the primary outcome (A1C): −0.84% from baseline in the empagliflozin group compared with the placebo group (P = 0.012). There were no episodes of severe hypoglycemia during the study (240).

Blood glucose monitoring plans should be individualized, taking into consideration the pharmacologic treatment of the person. Although data on CGM in youth with type 2 diabetes are sparse (241), CGM could be considered in individuals requiring frequent blood glucose monitoring for diabetes management.

Metabolic Surgery

Recommendations

  • 14.72 Metabolic surgery may be considered for the treatment of adolescents with type 2 diabetes who have class 2 obesity or higher (BMI >35 kg/m2 or 120% of 95th percentile for age and sex, whichever is lower) and who have elevated A1C and/or serious comorbidities despite lifestyle and pharmacologic intervention. A

  • 14.73 Metabolic surgery should be performed only by an experienced surgeon working as part of a well-organized and engaged interprofessional team, including a surgeon, endocrinologist, registered dietitian nutritionist, behavioral health specialist, and nurse. A

The results of weight loss and lifestyle interventions for obesity in children and adolescents have been disappointing, and treatment options as adjuncts to lifestyle therapy are limited. Recent U.S. Food and Drug Administration–approved medications for youth ages 12 and older include phentermine and topiramate extended-release capsules and GLP-1 receptor agonists (242245). Over the last decade, weight loss surgery has been increasingly performed in adolescents with obesity. Small retrospective analyses and a prospective multicenter, nonrandomized study suggest that bariatric or metabolic surgery have benefits in adolescents with obesity and type 2 diabetes similar to those observed in adults. Teenagers experience similar degrees of weight loss, diabetes remission, and improvement of cardiometabolic risk factors for at least 3 years after surgery (246). A secondary data analysis from the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and TODAY studies suggests surgical treatment of adolescents with severe obesity and type 2 diabetes is associated with improved glycemia (247); however, no randomized trials have yet compared the effectiveness and safety of surgery to those of conventional treatment options in adolescents (248). The guidelines used as an indication for metabolic surgery in adolescents generally include class 2 obesity or higher (BMI >35 kg/m2 or 120% of 95th percentile for age and sex, whichever is lower, with comorbidities) or BMI >40 kg/m2 with or without comorbidities (249261). A number of groups, including the Pediatric Bariatric Study Group and Teen-LABS study, have demonstrated the effectiveness of metabolic surgery in adolescents (253259).

Prevention and Management of Diabetes Complications

Hypertension

Recommendations

  • 14.74 Blood pressure should be measured at every clinic visit. In youth with high blood pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥120/80 mmHg) on three separate measurements, ambulatory blood pressure monitoring should be strongly considered. B

  • 14.75 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C

  • 14.76 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and ACE inhibitors and angiotensin receptor blockers should be avoided in individuals of childbearing age who are not using reliable contraception. B

  • 14.77 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C

Nephropathy

Recommendations

  • 14.78 Protein intake should be at the recommended daily allowance of 0.85–1.2 g/kg/day (according to age). E

  • 14.79 Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and annually thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on two of three samples. B

  • 14.80 Estimated glomerular filtration rate (GFR) should be determined at the time of diagnosis and annually thereafter. E

  • 14.81 In youth with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) and is strongly recommended for those with urinary albumin-to-creatinine ratio >300 mg/g creatinine and/or estimated GFR <60 mL/min/1.73 m2. E Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and ACE inhibitors and angiotensin receptor blockers should be avoided in individuals of childbearing age who are not using reliable contraception. B

  • 14.82 For youth with nephropathy, continue monitoring (yearly and/or as indicated by urinary albumin-to-creatinine ratio and estimated GFR) to detect disease progression. E

  • 14.83 Referral to nephrology is recommended in case of uncertainty of etiology, worsening urinary albumin-to-creatinine ratio, or decrease in estimated GFR. E

Neuropathy

Recommendations

  • 14.84 Youth with type 2 diabetes should be screened for the presence of neuropathy by foot examination at diagnosis and annually. The examination should include inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. C

  • 14.85 Prevention of neuropathy should focus on achieving glycemic goals. C

Retinopathy

Recommendations

  • 14.86 Screening for retinopathy should be performed by dilated fundoscopy at or soon after diagnosis and annually thereafter. C

  • 14.87 Optimizing glycemia is recommended to decrease the risk or slow the progression of retinopathy. B

  • 14.88 Less frequent examination (every 2 years) may be considered if achieving glycemic goals and a normal eye exam. C

  • 14.89 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E

Nonalcoholic Fatty Liver Disease

Recommendations

  • 14.90 Evaluation of youth with type 2 diabetes for nonalcoholic fatty liver disease (by measuring AST and ALT) should be done at diagnosis and annually thereafter. B

  • 14.91 Referral to gastroenterology should be considered for persistently elevated or worsening transaminases. B

Obstructive Sleep Apnea

Recommendation

  • 14.92 Screening for symptoms of sleep apnea should be done at each visit, and referral to a pediatric sleep specialist for evaluation and a polysomnogram, if indicated, is recommended. Obstructive sleep apnea should be treated when documented. B

Polycystic Ovary Syndrome

Recommendations

  • 14.93 Evaluate for polycystic ovary syndrome in female adolescents with type 2 diabetes, including laboratory studies, when indicated. B

  • 14.94 Metformin, in addition to lifestyle modification, is likely to improve the menstrual cyclicity and hyperandrogenism in female individuals with type 2 diabetes. E

Cardiovascular Disease

Recommendation

  • 14.95 Intensive lifestyle interventions focusing on weight loss, dyslipidemia, hypertension, and dysglycemia are important to prevent overt macrovascular disease in early adulthood. E

Dyslipidemia

Recommendations

  • 14.96 Lipid screening should be performed initially after optimizing glycemia and annually thereafter. B

  • 14.97 Optimal goals are LDL cholesterol <100 mg/dL (<2.6 mmol/L), HDL cholesterol >35 mg/dL (>0.91 mmol/L), and triglycerides <150 mg/dL (<1.7 mmol/L). E

  • 14.98 If lipids are abnormal, initial therapy should consist of optimizing glycemia and medical nutritional therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats for elevated LDL. For elevated triglycerides, medical nutrition therapy should also focus on decreasing simple sugar intake and increasing dietary n-3 fatty acids in addition to the above changes. A

  • 14.99 If LDL cholesterol remains >130 mg/dL (>3.4 mmol/L) after 6 months of dietary intervention, initiate therapy with statin, with a goal of LDL <100 mg/dL (<2.6 mmol/L). Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and statins should be avoided in individuals of childbearing age who are not using reliable contraception. B

  • 14.100 If triglycerides are >400 mg/dL (>4.7 mmol/L) fasting or >1,000 mg/dL (>11.6 mmol/L) nonfasting, optimize glycemia and begin fibrate, with a goal of <400 mg/dL (<4.7 mmol/L) fasting to reduce risk for pancreatitis. C

Cardiac Function Testing

Recommendation

  • 14.101 Routine screening for heart disease with electrocardiogram, echocardiogram, or stress testing is not recommended in asymptomatic youth with type 2 diabetes. B

Comorbidities may already be present at the time of diagnosis of type 2 diabetes in youth (208,262). Therefore, blood pressure measurement, a fasting lipid panel, assessment of random urine albumin-to-creatinine ratio, and a dilated eye examination should be performed at diagnosis. Additional medical conditions that may need to be addressed include polycystic ovary disease and other comorbidities associated with pediatric obesity, such as sleep apnea, hepatic steatosis, orthopedic complications, and psychosocial concerns. The ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (3) provides guidance on the prevention, screening, and treatment of type 2 diabetes and its comorbidities in children and adolescents.

Youth-onset type 2 diabetes is associated with significant microvascular and macrovascular risk burden and a substantial increase in the risk of cardiovascular morbidity and mortality at an earlier age than in those diagnosed later in life (209,263). The higher complication risk in earlier-onset type 2 diabetes is likely related to prolonged lifetime exposure to hyperglycemia and other atherogenic risk factors, including insulin resistance, dyslipidemia, hypertension, and chronic inflammation. There is a low risk of hypoglycemia in youth with type 2 diabetes, even if they are being treated with insulin (264), and there are high rates of complications (224227). These diabetes comorbidities also appear to be higher than in youth with type 1 diabetes despite shorter diabetes duration and lower A1C (262). In addition, the progression of vascular abnormalities appears to be more pronounced in youth-onset type 2 diabetes than with type 1 diabetes of similar duration, including ischemic heart disease and stroke (263).

In youth with type 2 diabetes and polycystic ovary syndrome, oral contraceptives are appropriate agents.

Psychosocial Factors

Recommendations

  • 14.102 Health care professionals should screen for food insecurity, housing instability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. E

  • 14.103 Use age-appropriate standardized and validated tools to screen for diabetes distress, depressive symptoms, and behavioral health in youth with type 2 diabetes, with attention to symptoms of depression and disordered eating, and refer to a qualified behavioral health professional when indicated. B

  • 14.104 Starting at puberty, preconception counseling should be incorporated into routine diabetes clinic visits for all individuals of childbearing potential because of the adverse pregnancy outcomes in this population. A

  • 14.105 Adolescents and young adults should be screened for tobacco/nicotine, electronic cigarettes, substance use, and alcohol use at diagnosis and regularly thereafter. C

Most youth with type 2 diabetes come from racial/ethnic minority groups, have low socioeconomic status, and often experience multiple psychosocial stressors (41,56,212,213). Consideration of the sociocultural context and efforts to personalize diabetes management are of critical importance to minimize barriers to care, enhance participation, and maximize response to treatment.

Evidence about psychiatric disorders and symptoms in youth with type 2 diabetes is limited (265269), but given the sociocultural context for many youth and the medical burden and obesity associated with type 2 diabetes, ongoing surveillance of behavioral health is indicated. Symptoms of depression and disordered eating are common and associated with higher A1C (53,266,270,271). Early detection of psychological and behavioral concerns can facilitate effective treatment options to improve psychosocial well-being and support diabetes (56). When psychological symptoms are identified, referral to a behavioral health professional, ideally with experience in pediatric diabetes, may be warranted. Although far less research has been done on psychological and behavioral interventions for youth with type 2 diabetes than for youth with type 1 diabetes, behavioral professionals can provide behavioral health care services to support youth with type 2 diabetes (6163). Many of the medications prescribed for diabetes and psychiatric disorders are associated with weight gain and can increase concerns about eating, body shape, and weight (272,273).

The TODAY study documented high rates of maternal complications during pregnancy and low rates of preconception counseling and contraception use (274). Preconception counseling tailored for adolescents with diabetes (including type 2 diabetes) has sustained behavioral benefits (71).

Tobacco and Electronic Cigarettes

Recommendations

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

  • 14.107 Electronic cigarette use should be discouraged. A

The adverse health effects of smoking and use of tobacco products are well recognized with respect to future cancer and CVD risk. Despite this, smoking rates are significantly higher among youth with diabetes than among youth without diabetes (275,276). In youth with diabetes, it is important to avoid additional CVD risk factors. Smoking increases the risk of the onset of albuminuria; therefore, smoking avoidance is important to prevent both microvascular and macrovascular complications (184,277). Discouraging use of tobacco products, including electronic cigarettes (278,279), is an important part of routine diabetes care. Individuals with diabetes should be advised to avoid vaping and using electronic cigarettes, either as a way to stop smoking tobacco or as a recreational drug. In younger children, it is important to assess exposure to cigarette smoke in the home because of the adverse effects of secondhand smoke and to discourage youth from ever smoking. See Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,” for more information about smoking, tobacco, and electronic cigarettes in people with diabetes.

As alcohol use has implications for glycemic management and safety in youth and young adults with diabetes, efforts are warranted to reduce alcohol use and increase education about the risks of alcohol use and strategies to minimize risks. A psychoeducational intervention for adolescents with chronic medical conditions, including type 1 diabetes, has demonstrated benefits for knowledge, perceived benefits, and reduced use (280).

Recommendations

  • 14.108 Pediatric diabetes care teams should implement transition preparation programs for youth beginning in early adolescence and, at the latest, at least 1 year before the anticipated transfer from pediatric to adult health care. E

  • 14.109 Interprofessional adult and pediatric health care teams should provide support and resources for adolescents, young adults, and their families prior to and during the transition process from pediatric to adult health care. E

  • 14.110 Pediatric diabetes specialists should partner with youth with diabetes and their caregivers to decide on the timing of transfer to an adult diabetes specialist. E

Care and close supervision of diabetes management are increasingly shifted from parents and other adults to the youth with type 1 or type 2 diabetes throughout childhood and adolescence. The shift from pediatric to adult health care professionals, however, often occurs abruptly as the older teen enters the next developmental stage, referred to as emerging adulthood (281), which is a critical period for young people who have diabetes. During this period of major life transitions, youth may begin to move out of their parents’ or caregivers' homes and become increasingly responsible for their diabetes care. Their new responsibilities include self-management of their diabetes, making medical appointments, and financing health care once they are no longer covered by their parents’ health insurance plans (ongoing coverage until age 26 years is currently available under provisions of the U.S. Affordable Care Act). In addition to lapses in health care, this is also a period associated with deterioration in glycemic stability; increased occurrence of acute complications; psychosocial, emotional, and behavioral challenges; and the emergence of chronic complications (282287). The transfer period from pediatric to adult care is prone to fragmentation in health care delivery, which may adversely impact health care quality, cost, and outcomes (288). Worsening diabetes health outcomes during the transition to adult care and early adulthood have been documented (289,290).

It is clear that comprehensive and coordinated planning that begins in early adolescence is necessary to facilitate a seamless transition from pediatric to adult health care (282,283,291,292). Research on effective interventions to promote successful transition to adult care is limited, although there are promising developments that may improve attendance at follow-up appointments and lower hospitalizations (293). Use of transition coordinators, technology to support communication with young adults, and other interventions may be useful in addressing the identified needs and preferences of young adults for transition (294) and in supporting successful establishment in adult care settings (295300). Given the behavioral, psychosocial, and developmental factors that relate to this transition, diabetes care teams addressing transition should include physicians, certified diabetes care and education specialists, nurses, behavioral health professionals, nutritionists, and social workers (61,301). Resources to enhance social/peer support during the transition process may also be valuable (302). A comprehensive discussion regarding the challenges faced during this period, including specific recommendations, is found in the ADA position statement “Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems” (283).

The Endocrine Society, in collaboration with the ADA and other organizations, has developed transition tools for clinicians and youth and families (292).

*

A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc24-SINT.

Duality of interest information for each author is available at https://doi.org/10.2337/dc24-SDIS.

Suggested citation: American Diabetes Association Professional Practice Committee. 14. Children and adolescents: Standards of Care in Diabetes—2024. Diabetes Care 2024;47(Suppl. 1):S258–S281

1.
Centers for Disease Control and Prevention
.
Vaccines Site: Healthcare Providers/Professionals, 2021
.
Accessed 21 August 2023. Available from https://www.cdc.gov/vaccines/hcp/index.html
.
2.
Chiang
JL
,
Maahs
DM
,
Garvey
KC
, et al
.
Type 1 diabetes in children and adolescents: a position statement by the American Diabetes Association
.
Diabetes Care
2018
;
41
:
2026
2044
3.
Arslanian
S
,
Bacha
F
,
Grey
M
,
Marcus
MD
,
White
NH
,
Zeitler
P
.
Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association
.
Diabetes Care
2018
;
41
:
2648
2668
4.
Lawrence
JM
,
Divers
J
,
Isom
S
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017
.
JAMA
2021
;
326
:
717
727
5.
Thomas
NJ
,
Jones
SE
,
Weedon
MN
,
Shields
BM
,
Oram
RA
,
Hattersley
AT
.
Frequency and phenotype of type 1 diabetes in the first six decades of life: a cross-sectional, genetically stratified survival analysis from UK Biobank
.
Lancet Diabetes Endocrinol
2018
;
6
:
122
129
6.
Barnea-Goraly
N
,
Raman
M
,
Mazaika
P
, et al.;
Diabetes Research in Children Network (DirecNet)
.
Alterations in white matter structure in young children with type 1 diabetes
.
Diabetes Care
2014
;
37
:
332
340
7.
Cameron
FJ
,
Scratch
SE
,
Nadebaum
C
, et al.;
DKA Brain Injury Study Group
.
Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children
.
Diabetes Care
2014
;
37
:
1554
1562
8.
Markowitz
JT
,
Garvey
KC
,
Laffel
LM
.
Developmental changes in the roles of patients and families in type 1 diabetes management
.
Curr Diabetes Rev
2015
;
11
:
231
238
9.
Driscoll
KA
,
Volkening
LK
,
Haro
H
, et al
.
Are children with type 1 diabetes safe at school? Examining parent perceptions
.
Pediatr Diabetes
2015
;
16
:
613
620
10.
Jackson
CC
,
Albanese-O’Neill
A
,
Butler
KL
, et al
.
Diabetes care in the school setting: a position statement of the American Diabetes Association
.
Diabetes Care
2015
;
38
:
1958
1963
11.
Mehta
SN
,
Volkening
LK
,
Anderson
BJ
, et al.;
Family Management of Childhood Diabetes Study Steering Committee
.
Dietary behaviors predict glycemic control in youth with type 1 diabetes
.
Diabetes Care
2008
;
31
:
1318
1320
12.
Bell
KJ
,
Smart
CE
,
Steil
GM
,
Brand-Miller
JC
,
King
B
,
Wolpert
HA
.
Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era
.
Diabetes Care
2015
;
38
:
1008
1015
13.
Smith
TA
,
Marlow
AA
,
King
BR
,
Smart
CE
.
Insulin strategies for dietary fat and protein in type 1 diabetes: a systematic review
.
Diabet Med
2021
;
38
:
e14641
14.
Paterson
MA
,
Smart
CEM
,
Lopez
PE
, et al
.
Increasing the protein quantity in a meal results in dose-dependent effects on postprandial glucose levels in individuals with type 1 diabetes mellitus
.
Diabet Med
2017
;
34
:
851
854
15.
Paterson
MA
,
King
BR
,
Smart
CEM
,
Smith
T
,
Rafferty
J
,
Lopez
PE
.
Impact of dietary protein on postprandial glycaemic control and insulin requirements in type 1 diabetes: a systematic review
.
Diabet Med
2019
;
36
:
1585
1599
16.
Reddy
M
,
Jugnee
N
,
El Laboudi
A
,
Spanudakis
E
,
Anantharaja
S
,
Oliver
N
.
A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia
.
Diabet Med
2018
;
35
:
483
490
17.
Smith
TA
,
Blowes
AA
,
King
BR
,
Howley
PP
,
Smart
CE
.
Families’ reports of problematic foods, management strategies and continuous glucose monitoring in type 1 diabetes: a cross-sectional study
.
Nutr Diet
2021
;
78
:
449
457
18.
Bao
J
,
Gilbertson
HR
,
Gray
R
, et al
.
Improving the estimation of mealtime insulin dose in adults with type 1 diabetes: the Normal Insulin Demand for Dose Adjustment (NIDDA) study
.
Diabetes Care
2011
;
34
:
2146
2151
19.
Kordonouri
O
,
Hartmann
R
,
Remus
K
,
Bläsig
S
,
Sadeghian
E
,
Danne
T
.
Benefit of supplementary fat plus protein counting as compared with conventional carbohydrate counting for insulin bolus calculation in children with pump therapy
.
Pediatr Diabetes
2012
;
13
:
540
544
20.
Lundgren
M
,
Sahlin
Å
,
Svensson
C
, et al.;
DiPiS study group
.
Reduced morbidity at diagnosis and improved glycemic control in children previously enrolled in DiPiS follow-up
.
Pediatr Diabetes
2014
;
15
:
494
501
21.
Bell
KJ
,
Gray
R
,
Munns
D
, et al
.
Clinical application of the food insulin index for mealtime insulin dosing in adults with type 1 diabetes: a randomized controlled trial
.
Diabetes Technol Ther
2016
;
18
:
218
225
22.
Bell
KJ
,
Gray
R
,
Munns
D
, et al
.
Estimating insulin demand for protein-containing foods using the food insulin index
.
Eur J Clin Nutr
2014
;
68
:
1055
1059
23.
Lopez
PE
,
Evans
M
,
King
BR
, et al
.
A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with type 1 diabetes
.
Diabet Med
2018
;
35
:
1440
1447
24.
Paterson
MA
,
Smart
CE
,
Lopez
PE
, et al
.
Influence of dietary protein on postprandial blood glucose levels in individuals with type 1 diabetes mellitus using intensive insulin therapy
.
Diabet Med
2016
;
33
:
592
598
25.
Furthner
D
,
Lukas
A
,
Schneider
AM
, et al
.
The role of protein and fat intake on insulin therapy in glycaemic control of paediatric type 1 diabetes: a systematic review and research gaps
.
Nutrients
2021
;
13
:
3558
26.
Smith
TA
,
Smart
CE
,
Fuery
MEJ
, et al
.
In children and young people with type 1 diabetes using pump therapy, an additional 40% of the insulin dose for a high-fat, high-protein breakfast improves postprandial glycaemic excursions: a cross-over trial
.
Diabet Med
2021
;
38
:
e14511
27.
Smith
TA
,
Smart
CE
,
Howley
PP
,
Lopez
PE
,
King
BR
.
For a high fat, high protein breakfast, preprandial administration of 125% of the insulin dose improves postprandial glycaemic excursions in people with type 1 diabetes using multiple daily injections: a cross-over trial
.
Diabet Med
2021
;
38
:
e14512
28.
Kaya
N
,
Kurtoğlu
S
,
Gökmen Özel
H
.
Does meal-time insulin dosing based on fat-protein counting give positive results in postprandial glycaemic profile after a high protein-fat meal in adolescents with type 1 diabetes: a randomised controlled trial
.
J Hum Nutr Diet
2020
;
33
:
396
403
29.
Absil
H
,
Baudet
L
,
Robert
A
,
Lysy
PA
.
Benefits of physical activity in children and adolescents with type 1 diabetes: a systematic review
.
Diabetes Res Clin Pract
2019
;
156
:
107810
30.
Riddell
MC
,
Gallen
IW
,
Smart
CE
, et al
.
Exercise management in type 1 diabetes: a consensus statement
.
Lancet Diabetes Endocrinol
2017
;
5
:
377
390
31.
Colberg
SR
,
Sigal
RJ
,
Yardley
JE
, et al
.
Physical activity/exercise and diabetes: a position statement of the American Diabetes Association
.
Diabetes Care
2016
;
39
:
2065
2079
32.
Moser
O
,
Riddell
MC
,
Eckstein
ML
, et al
.
Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA)
.
Diabetologia
2020
;
63
:
2501
2520
33.
U.S. Department of Health and Human Services
.
Physical Activity Guidelines for Americans
.
34.
Tsalikian
E
,
Kollman
C
,
Tamborlane
WB
, et al.;
Diabetes Research in Children Network (DirecNet) Study Group
.
Prevention of hypoglycemia during exercise in children with type 1 diabetes by suspending basal insulin
.
Diabetes Care
2006
;
29
:
2200
2204
35.
Taplin
CE
,
Cobry
E
,
Messer
L
,
McFann
K
,
Chase
HP
,
Fiallo-Scharer
R
.
Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes
.
J Pediatr
2010
;
157
:
784
788.e1
36.
Eckstein
ML
,
Weilguni
B
,
Tauschmann
M
, et al
.
Time in range for closed-loop systems versus standard of care during physical exercise in people with type 1 diabetes: a systematic review and meta-analysis
.
J Clin Med
2021
;
10
:
10
37.
Francescato
MP
,
Stel
G
,
Stenner
E
,
Geat
M
.
Prolonged exercise in type 1 diabetes: performance of a customizable algorithm to estimate the carbohydrate supplements to minimize glycemic imbalances
.
PLoS One
2015
;
10
:
e0125220
38.
Baker
LB
,
Rollo
I
,
Stein
KW
,
Jeukendrup
AE
.
Acute effects of carbohydrate supplementation on intermittent sports performance
.
Nutrients
2015
;
7
:
5733
5763
39.
Adolfsson
P
,
Mattsson
S
,
Jendle
J
.
Evaluation of glucose control when a new strategy of increased carbohydrate supply is implemented during prolonged physical exercise in type 1 diabetes
.
Eur J Appl Physiol
2015
;
115
:
2599
2607
40.
Redondo
MJ
,
Libman
I
,
Cheng
P
, et al.;
Pediatric Diabetes Consortium
.
Racial/ethnic minority youth with recent-onset type 1 diabetes have poor prognostic factors
.
Diabetes Care
2018
;
41
:
1017
1024
41.
Liu
LL
,
Lawrence
JM
,
Davis
C
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth study
.
Pediatr Diabetes
2010
;
11
:
4
11
42.
DuBose
SN
,
Hermann
JM
,
Tamborlane
WV
, et al
.
Obesity in youth with type 1 diabetes in Germany, Austria, and the United States
.
J Pediatr
2015
;
167
:
627
632.e1
4
43.
Corbin
KD
,
Driscoll
KA
,
Pratley
RE
,
Smith
SR
,
Maahs
DM
;
Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON)
.
Obesity in type 1 diabetes: pathophysiology, clinical impact, and mechanisms
.
Endocr Rev
2018
;
39
:
629
663
44.
Redondo
MJ
,
Foster
NC
,
Libman
IM
, et al
.
Prevalence of cardiovascular risk factors in youth with type 1 diabetes and elevated body mass index
.
Acta Diabetol
2016
;
53
:
271
277
45.
American Association of Diabetes Educators
.
Management of children with diabetes in the school setting
.
Diabetes Educ
2000
;
26
:
32
35
46.
March
C
,
Serman
J
,
Bannuru
RR
, et al
.
Care of young children with diabetes in the childcare and community setting: a statement of the American Diabetes Association
.
Diabetes Care
2023
;
46
:
2102
2111
47.
Hood
KK
,
Beavers
DP
,
Yi-Frazier
J
, et al
.
Psychosocial burden and glycemic control during the first 6 years of diabetes: results from the SEARCH for Diabetes in Youth study
.
J Adolesc Health
2014
;
55
:
498
504
48.
Hagger
V
,
Hendrieckx
C
,
Sturt
J
,
Skinner
TC
,
Speight
J
.
Diabetes distress among adolescents with type 1 diabetes: a systematic review
.
Curr Diab Rep
2016
;
16
:
9
49.
Anderson
BJ
,
Laffel
LM
,
Domenger
C
, et al
.
Factors associated with diabetes-specific health-related quality of life in youth with type 1 diabetes: the Global TEENs Study
.
Diabetes Care
2017
;
40
:
1002
1009
50.
Hilliard
ME
,
De Wit
M
,
Wasserman
RM
, et al
.
Screening and support for emotional burdens of youth with type 1 diabetes: strategies for diabetes care providers
.
Pediatr Diabetes
2018
;
19
:
534
543
51.
Iturralde
E
,
Rausch
JR
,
Weissberg-Benchell
J
,
Hood
KK
.
Diabetes-related emotional distress over time
.
Pediatrics
2019
;
143
:
e20183011
52.
Hill-Briggs
F
,
Adler
NE
,
Berkowitz
SA
, et al
.
Social determinants of health and diabetes: a scientific review
.
Diabetes Care
2020
;
44
:
258
279
53.
Monaghan
M
,
Mara
CA
,
Kichler
JC
, et al
.
Multisite examination of depression screening scores and correlates among adolescents and young adults with type 2 diabetes
.
Can J Diabetes
2021
;
45
:
411
416
54.
Mulvaney
SA
,
Mara
CA
,
Kichler
JC
, et al
.
A retrospective multisite examination of depression screening practices, scores, and correlates in pediatric diabetes care
.
Transl Behav Med
2021
;
11
:
122
131
55.
Rechenberg
K
,
Koerner
R
.
Cognitive behavioral therapy in adolescents with type 1 diabetes: an integrative review
.
J Pediatr Nurs
2021
;
60
:
190
197
56.
Young-Hyman
D
,
de Groot
M
,
Hill-Briggs
F
,
Gonzalez
JS
,
Hood
K
,
Peyrot
M
.
Psychosocial care for people with diabetes: a position statement of the American Diabetes Association
.
Diabetes Care
2016
;
39
:
2126
2140
57.
Evans
MA
,
Weil
LEG
,
Shapiro
JB
, et al
.
Psychometric properties of the parent and child problem areas in diabetes measures
.
J Pediatr Psychol
2019
;
44
:
703
713
58.
Corathers
SD
,
Kichler
J
,
Jones
NH
, et al
.
Improving depression screening for adolescents with type 1 diabetes
.
Pediatrics
2013
;
132
:
e1395
e1402
59.
Pursey
KM
,
Hart
M
,
Jenkins
L
,
McEvoy
M
,
Smart
CE
.
Screening and identification of disordered eating in people with type 1 diabetes: a systematic review
.
J Diabetes Complications
2020
;
34
:
107522
60.
Inverso
H
,
Moore
HR
,
Lupini
F
, et al
.
Mindfulness-based interventions: focus on pediatric type 1 and type 2 diabetes
.
Curr Diab Rep
2022
;
22
:
493
500
61.
Kichler
JC
,
Harris
MA
,
Weissberg-Benchell
J
.
Contemporary roles of the pediatric psychologist in diabetes care
.
Curr Diabetes Rev
2015
;
11
:
210
221
62.
Winkley
K
,
Upsher
R
,
Stahl
D
, et al
.
Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review
.
Health Technol Assess
2020
;
24
:
1
232
63.
Hilliard
ME
,
Powell
PW
,
Anderson
BJ
.
Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families
.
Am Psychol
2016
;
71
:
590
601
64.
Katz
ML
,
Volkening
LK
,
Butler
DA
,
Anderson
BJ
,
Laffel
LM
.
Family-based psychoeducation and Care Ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial
.
Pediatr Diabetes
2014
;
15
:
142
150
65.
Laffel
LM
,
Vangsness
L
,
Connell
A
,
Goebel-Fabbri
A
,
Butler
D
,
Anderson
BJ
.
Impact of ambulatory, family-focused teamwork intervention on glycemic control in youth with type 1 diabetes
.
J Pediatr
2003
;
142
:
409
416
66.
Anderson
BJ
,
Vangsness
L
,
Connell
A
,
Butler
D
,
Goebel-Fabbri
A
,
Laffel
LM
.
Family conflict, adherence, and glycaemic control in youth with short duration Type 1 diabetes
.
Diabet Med
2002
;
19
:
635
642
67.
Helgeson
VS
,
Palladino
DK
.
Implications of psychosocial factors for diabetes outcomes among children with type 1 diabetes: a review
.
Soc Personal Psychol Compass
2012
;
6
:
228
242
68.
Kucera
M
,
Sullivan
AL
.
The educational implications of type I diabetes mellitus: a review of research and recommendations for school psychological practice
.
Psychol Sch
2011
;
48
:
587
603
69.
Kuther
TL
.
Medical decision-making and minors: issues of consent and assent
.
Adolescence
2003
;
38
:
343
358
70.
Coleman
DL
,
Rosoff
PM
.
The legal authority of mature minors to consent to general medical treatment
.
Pediatrics
2013
;
131
:
786
793
71.
Charron-Prochownik
D
,
Sereika
SM
,
Becker
D
, et al
.
Long-term effects of the booster-enhanced READY-Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes
.
Diabetes Care
2013
;
36
:
3870
3874
72.
American Diabetes Association
.
Diabetes and Reproductive Health for Girls
.
2016
.
73.
Wisting
L
,
Frøisland
DH
,
Skrivarhaug
T
,
Dahl-Jørgensen
K
,
O
.
Disturbed eating behavior and omission of insulin in adolescents receiving intensified insulin treatment: a nationwide population-based study
.
Diabetes Care
2013
;
36
:
3382
3387
74.
Goebel-Fabbri
AE
.
Disturbed eating behaviors and eating disorders in type 1 diabetes: clinical significance and treatment recommendations
.
Curr Diab Rep
2009
;
9
:
133
139
75.
Atik Altınok
Y
,
Özgür
S
,
Meseri
R
,
Özen
S
,
Darcan
Ş
,
Gökşen
D
.
Reliability and validity of the diabetes eating problem survey in turkish children and adolescents with type 1 diabetes mellitus
.
J Clin Res Pediatr Endocrinol
2017
;
9
:
323
328
76.
Saßmann
H
,
Albrecht
C
,
Busse-Widmann
P
, et al
.
Psychometric properties of the German version of the Diabetes Eating Problem Survey-Revised: additional benefit of disease-specific screening in adolescents with type 1 diabetes
.
Diabet Med
2015
;
32
:
1641
1647
77.
Gerhardsson
P
,
Schwandt
A
,
Witsch
M
, et al
.
The SWEET project 10-year benchmarking in 19 countries worldwide is associated with improved HbA1c and increased use of diabetes technology in youth with type 1 diabetes
.
Diabetes Technol Ther
2021
;
23
:
491
499
78.
Cameron
FJ
,
de Beaufort
C
,
Aanstoot
HJ
, et al.;
Hvidoere International Study Group
.
Lessons from the Hvidoere International Study Group on childhood diabetes: be dogmatic about outcome and flexible in approach
.
Pediatr Diabetes
2013
;
14
:
473
480
79.
Miller
KM
,
Beck
RW
,
Foster
NC
,
Maahs
DM
.
HbA1c levels in type 1 diabetes from early childhood to older adults: a deeper dive into the influence of technology and socioeconomic status on HbA1c in the T1D Exchange Clinic Registry findings
.
Diabetes Technol Ther
2020
;
22
:
645
650
80.
Diabetes Control and Complications Trial Research Group
.
Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial
.
J Pediatr
1994
;
125
:
177
188
81.
White
NH
,
Cleary
PA
,
Dahms
W
,
Goldstein
D
,
Malone
J
;
Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group
.
Beneficial effects of intensive therapy of diabetes during adolescence: outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT)
.
J Pediatr
2001
;
139
:
804
812
82.
Samuelsson
U
,
Steineck
I
,
Gubbjornsdottir
S
.
A high mean-HbA1c value 3-15 months after diagnosis of type 1 diabetes in childhood is related to metabolic control, macroalbuminuria, and retinopathy in early adulthood—a pilot study using two nation-wide population based quality registries
.
Pediatr Diabetes
2014
;
15
:
229
235
83.
Carlsen
S
,
Skrivarhaug
T
,
Thue
G
, et al
.
Glycemic control and complications in patients with type 1 diabetes—a registry-based longitudinal study of adolescents and young adults
.
Pediatr Diabetes
2017
;
18
:
188
195
84.
Genuth
SM
,
Backlund
JY
,
Bayless
M
, et al.;
DCCT/EDIC Research Group
.
Effects of prior intensive versus conventional therapy and history of glycemia on cardiac function in type 1 diabetes in the DCCT/EDIC
.
Diabetes
2013
;
62
:
3561
3569
85.
Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group
.
Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study
.
JAMA
2003
;
290
:
2159
2167
86.
Gubitosi-Klug
RA
,
Sun
W
,
Cleary
PA
, et al.;
Writing Team for the DCCT/EDIC Research Group
.
Effects of prior intensive insulin therapy and risk factors on patient-reported visual function outcomes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort
.
JAMA Ophthalmol
2016
;
134
:
137
145
87.
Orchard
TJ
,
Nathan
DM
,
Zinman
B
, et al.;
Writing Group for the DCCT/EDIC Research Group
.
Association between 7 years of intensive treatment of type 1 diabetes and long-term mortality
.
JAMA
2015
;
313
:
45
53
88.
Foland-Ross
LC
,
Reiss
AL
,
Mazaika
PK
, et al.;
Diabetes Research in Children Network (DirecNet)
.
Longitudinal assessment of hippocampus structure in children with type 1 diabetes
.
Pediatr Diabetes
2018
;
19
:
1116
1123
89.
Mauras
N
,
Mazaika
P
,
Buckingham
B
, et al.;
Diabetes Research in Children Network (DirecNet)
.
Longitudinal assessment of neuroanatomical and cognitive differences in young children with type 1 diabetes: association with hyperglycemia
.
Diabetes
2015
;
64
:
1770
1779
90.
Foland-Ross
LC
,
Tong
G
,
Mauras
N
, et al.;
Diabetes Research in Children Network (DirecNet)
.
Brain function differences in children with type 1 diabetes: a functional MRI study of working memory
.
Diabetes
2020
;
69
:
1770
1778
91.
Pourabbasi
A
,
Tehrani-Doost
M
,
Qavam
SE
,
Arzaghi
SM
,
Larijani
B
.
Association of diabetes mellitus and structural changes in the central nervous system in children and adolescents: a systematic review
.
J Diabetes Metab Disord
2017
;
16
:
10
92.
Perantie
DC
,
Wu
J
,
Koller
JM
, et al
.
Regional brain volume differences associated with hyperglycemia and severe hypoglycemia in youth with type 1 diabetes
.
Diabetes Care
2007
;
30
:
2331
2337
93.
Arbelaez
AM
,
Semenkovich
K
,
Hershey
T
.
Glycemic extremes in youth with T1DM: the structural and functional integrity of the developing brain
.
Pediatr Diabetes
2013
;
14
:
541
553
94.
Broadley
MM
,
White
MJ
,
Andrew
B
.
A systematic review and meta-analysis of executive function performance in type 1 diabetes mellitus
.
Psychosom Med
2017
;
79
:
684
696
95.
Ryan
CM
.
Why is cognitive dysfunction associated with the development of diabetes early in life? The diathesis hypothesis
.
Pediatr Diabetes
2006
;
7
:
289
297
96.
Mauras
N
,
Buckingham
B
,
White
NH
, et al.;
Diabetes Research in Children Network (DirecNet)
.
Impact of type 1 diabetes in the developing brain in children: a longitudinal study
.
Diabetes Care
2021
;
44
:
983
992
97.
Campbell
MS
,
Schatz
DA
,
Chen
V
, et al.;
T1D Exchange Clinic Network
.
A contrast between children and adolescents with excellent and poor control: the T1D Exchange clinic registry experience
.
Pediatr Diabetes
2014
;
15
:
110
117
98.
Brown
SA
,
Kovatchev
BP
,
Raghinaru
D
, et al.;
iDCL Trial Research Group
.
Six-month randomized, multicenter trial of closed-loop control in type 1 diabetes
.
N Engl J Med
2019
;
381
:
1707
1717
99.
Bergenstal
RM
,
Nimri
R
,
Beck
RW
, et al.;
FLAIR Study Group
.
A comparison of two hybrid closed-loop systems in adolescents and young adults with type 1 diabetes (FLAIR): a multicentre, randomised, crossover trial
.
Lancet
2021
;
397
:
208
219
100.
Breton
MD
,
Kanapka
LG
,
Beck
RW
, et al.;
iDCL Trial Research Group
.
A randomized trial of closed-loop control in children with type 1 diabetes
.
N Engl J Med
2020
;
383
:
836
845
101.
Dorando
E
,
Haak
T
,
Pieper
D
.
Correction: Continuous glucose monitoring for glycemic control in children and adolescents diagnosed with diabetes type 1: a systematic review and meta-analysis
.
Exp Clin Endocrinol Diabetes
2022
;
130
:
e1
e3
102.
Brown
SA
,
Forlenza
GP
,
Bode
BW
, et al.;
Omnipod 5 Research Group
.
Multicenter trial of a tubeless, on-body automated insulin delivery system with customizable glycemic targets in pediatric and adult participants with type 1 diabetes
.
Diabetes Care
2021
;
44
:
1630
1640
103.
Carlson
AL
,
Sherr
JL
,
Shulman
DI
, et al
.
Safety and glycemic outcomes during the MiniMed advanced hybrid closed-loop system pivotal trial in adolescents and adults with type 1 diabetes
.
Diabetes Technol Ther
2022
;
24
:
178
189
104.
Prahalad
P
,
Ding
VY
,
Zaharieva
DP
, et al
.
Teamwork, targets, technology, and tight control in newly diagnosed type 1 diabetes: the Pilot 4T study
.
J Clin Endocrinol Metab
2022
;
107
:
998
1008
105.
Champakanath
A
,
Akturk
HK
,
Alonso
GT
,
Snell-Bergeon
JK
,
Shah
VN
.
Continuous glucose monitoring initiation within first year of type 1 diabetes diagnosis is associated with improved glycemic outcomes: 7-year follow-up study
.
Diabetes Care
2022
;
45
:
750
753
106.
Johnson
SR
,
Holmes-Walker
DJ
,
Chee
M
, et al.;
ADDN Study Group
.
Universal subsidized continuous glucose monitoring funding for young people with type 1 diabetes: uptake and outcomes over 2 years, a population-based study
.
Diabetes Care
2022
;
45
:
391
397
107.
Rose
S
,
Styles
SE
,
Wiltshire
EJ
, et al
.
Use of intermittently scanned continuous glucose monitoring in young people with high-risk type 1 diabetes—extension phase outcomes following a 6-month randomized control trial
.
Diabet Med
2022
;
39
:
e14756
108.
Beato-Víbora
PI
,
Gallego-Gamero
F
,
Ambrojo-López
A
,
Gil-Poch
E
,
Martín-Romo
I
,
Arroyo-Díez
FJ
.
Rapid improvement in time in range after the implementation of an advanced hybrid closed-loop system in adolescents and adults with type 1 diabetes
.
Diabetes Technol Ther
2021
;
23
:
609
615
109.
Breton
MD
,
Kovatchev
BP
.
One year real-world use of the Control-IQ advanced hybrid closed-loop technology
.
Diabetes Technol Ther
2021
;
23
:
601
608
110.
Forlenza
GP
,
Ekhlaspour
L
,
DiMeglio
LA
, et al
.
Glycemic outcomes of children 2-6 years of age with type 1 diabetes during the pediatric MiniMed 670G system trial
.
Pediatr Diabetes
2022
;
23
:
324
329
111.
Messer
LH
,
Berget
C
,
Pyle
L
, et al
.
Real-world use of a new hybrid closed loop improves glycemic control in youth with type 1 diabetes
.
Diabetes Technol Ther
2021
;
23
:
837
843
112.
Varimo
T
,
Pulkkinen
MA
,
Hakonen
E
,
Hero
M
,
Miettinen
PJ
,
Tuomaala
AK
.
First year on commercial hybrid closed-loop system-experience on 111 children and adolescents with type 1 diabetes
.
Pediatr Diabetes
2021
;
22
:
909
915
113.
Ware
J
,
Allen
JM
,
Boughton
CK
, et al.;
KidsAP Consortium
.
Randomized trial of closed-loop control in very young children with type 1 diabetes
.
N Engl J Med
2022
;
386
:
209
219
114.
Isganaitis
E
,
Raghinaru
D
,
Ambler-Osborn
L
, et al.;
iDCL Trial Research Group
.
Closed-loop insulin therapy improves glycemic control in adolescents and young adults: outcomes from the International Diabetes Closed-Loop Trial
.
Diabetes Technol Ther
2021
;
23
:
342
349
115.
Schoelwer
MJ
,
Kanapka
LG
,
Wadwa
RP
, et al.;
iDCL Trial Research Group
.
Predictors of time-in-range (70-180 mg/dL) achieved using a closed-loop control system
.
Diabetes Technol Ther
2021
;
23
:
475
481
116.
Sherr
JL
,
Bode
BW
,
Forlenza
GP
, et al.;
Omnipod 5 in Preschoolers Study Group
.
Safety and glycemic outcomes with a tubeless automated insulin delivery system in very young children with type 1 diabetes: a single-arm multicenter clinical trial
.
Diabetes Care
2022
;
45
:
1907
1910
117.
Marigliano
M
,
Eckert
AJ
,
Guness
PK
, et al.;
SWEET Study Group
.
Association of the use of diabetes technology with HbA1c and BMI-SDS in an international cohort of children and adolescents with type 1 diabetes: the SWEET project experience
.
Pediatr Diabetes
2021
;
22
:
1120
1128
118.
Bergenstal
RM
,
Garg
S
,
Weinzimer
SA
, et al
.
Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes
.
JAMA
2016
;
316
:
1407
1408
119.
Thabit
H
,
Tauschmann
M
,
Allen
JM
, et al
.
Home use of an artificial beta cell in type 1 diabetes
.
N Engl J Med
2015
;
373
:
2129
2140
120.
Kovatchev
B
,
Cheng
P
,
Anderson
SM
, et al
.
Feasibility of long-term closed-loop control: a multicenter 6-month trial of 24/7 automated insulin delivery
.
Diabetes Technol Ther
2017
;
19
:
18
24
121.
Redondo
MJ
,
Libman
I
,
Maahs
DM
, et al
.
The evolution of hemoglobin A1c targets for youth with type 1 diabetes: rationale and supporting evidence
.
Diabetes Care
2021
;
44
:
301
312
122.
Cooper
MN
,
O’Connell
SM
,
Davis
EA
,
Jones
TW
.
A population-based study of risk factors for severe hypoglycaemia in a contemporary cohort of childhood-onset type 1 diabetes
.
Diabetologia
2013
;
56
:
2164
2170
123.
Haynes
A
,
Hermann
JM
,
Miller
KM
, et al.;
T1D Exchange, WACDD and DPV registries
.
Severe hypoglycemia rates are not associated with HbA1c: a cross-sectional analysis of 3 contemporary pediatric diabetes registry databases
.
Pediatr Diabetes
2017
;
18
:
643
650
124.
Haynes
A
,
Hermann
JM
,
Clapin
H
, et al.;
WACDD and DPV registries
.
Decreasing trends in mean HbA1c are not associated with increasing rates of severe hypoglycemia in children: a longitudinal analysis of two contemporary population-based pediatric type 1 diabetes registries from Australia and Germany/Austria between 1995 and 2016
.
Diabetes Care
2019
;
42
:
1630
1636
125.
Fredheim
S
,
Johansen
A
,
Thorsen
SU
, et al.;
Danish Society for Diabetes in Childhood and Adolescence
.
Nationwide reduction in the frequency of severe hypoglycemia by half
.
Acta Diabetol
2015
;
52
:
591
599
126.
Birkebaek
NH
,
Drivvoll
AK
,
Aakeson
K
, et al
.
Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008-2012: association with hemoglobin A1c and treatment modality
.
BMJ Open Diabetes Res Care
2017
;
5
:
e000377
127.
Ly
TT
,
Nicholas
JA
,
Retterath
A
,
Lim
EM
,
Davis
EA
,
Jones
TW
.
Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trial
.
JAMA
2013
;
310
:
1240
1247
128.
Downie
E
,
Craig
ME
,
Hing
S
,
Cusumano
J
,
Chan
AK
,
Donaghue
KC
.
Continued reduction in the prevalence of retinopathy in adolescents with type 1 diabetes: role of insulin therapy and glycemic control
.
Diabetes Care
2011
;
34
:
2368
2373
129.
Karges
B
,
Rosenbauer
J
,
Kapellen
T
, et al
.
Hemoglobin A1c levels and risk of severe hypoglycemia in children and young adults with type 1 diabetes from Germany and Austria: a trend analysis in a cohort of 37,539 patients between 1995 and 2012
.
PLoS Med
2014
;
11
:
e1001742
130.
Johnson
SR
,
Cooper
MN
,
Jones
TW
,
Davis
EA
.
Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study
.
Diabetologia
2013
;
56
:
2392
2400
131.
Karges
B
,
Kapellen
T
,
Wagner
VM
, et al.;
DPV Initiative
.
Glycated hemoglobin A1c as a risk factor for severe hypoglycemia in pediatric type 1 diabetes
.
Pediatr Diabetes
2017
;
18
:
51
58
132.
Saydah
S
,
Imperatore
G
,
Divers
J
, et al
.
Occurrence of severe hypoglycaemic events among US youth and young adults with type 1 or type 2 diabetes
.
Endocrinol Diabetes Metab
2019
;
2
:
e00057
133.
Ishtiak-Ahmed
K
,
Carstensen
B
,
Pedersen-Bjergaard
U
,
Jørgensen
ME
.
Incidence trends and predictors of hospitalization for hypoglycemia in 17,230 adult patients with type 1 diabetes: a Danish Register linkage cohort study
.
Diabetes Care
2017
;
40
:
226
232
134.
Maahs
DM
,
Hermann
JM
,
DuBose
SN
, et al.;
DPV Initiative
;
T1D Exchange Clinic Network
.
Contrasting the clinical care and outcomes of 2,622 children with type 1 diabetes less than 6 years of age in the United States T1D Exchange and German/Austrian DPV registries
.
Diabetologia
2014
;
57
:
1578
1585
135.
Swift
PG
,
Skinner
TC
,
de Beaufort
CE
, et al.;
Hvidoere Study Group on Childhood Diabetes
.
Target setting in intensive insulin management is associated with metabolic control: the Hvidoere childhood diabetes study group centre differences study 2005
.
Pediatr Diabetes
2010
;
11
:
271
278
136.
Laffel
LM
,
Kanapka
LG
,
Beck
RW
, et al.;
CGM Intervention in Teens and Young Adults with T1D (CITY) Study Group
;
CDE10
.
Effect of continuous glucose monitoring on glycemic control in adolescents and young adults with type 1 diabetes: a randomized clinical trial
.
JAMA
2020
;
323
:
2388
2396
137.
Strategies to Enhance New CGM Use in Early Childhood (SENCE) Study Group
.
A randomized clinical trial assessing continuous glucose monitoring (CGM) use with standardized education with or without a family behavioral intervention compared with fingerstick blood glucose monitoring in very young children with type 1 diabetes
.
Diabetes Care
2021
;
44
:
464
472
138.
Bergenstal
RM
,
Klonoff
DC
,
Garg
SK
, et al.;
ASPIRE In-Home Study Group
.
Threshold-based insulin-pump interruption for reduction of hypoglycemia
.
N Engl J Med
2013
;
369
:
224
232
139.
Abraham
MB
,
Davey
R
,
O’Grady
MJ
, et al
.
Effectiveness of a predictive algorithm in the prevention of exercise-induced hypoglycemia in type 1 diabetes
.
Diabetes Technol Ther
2016
;
18
:
543
550
140.
Buckingham
BA
,
Bailey
TS
,
Christiansen
M
, et al
.
Evaluation of a predictive low-glucose management system in-clinic
.
Diabetes Technol Ther
2017
;
19
:
288
292
141.
Nimri
R
,
Muller
I
,
Atlas
E
, et al
.
MD-Logic overnight control for 6 weeks of home use in patients with type 1 diabetes: randomized crossover trial
.
Diabetes Care
2014
;
37
:
3025
3032
142.
El-Khatib
FH
,
Balliro
C
,
Hillard
MA
, et al
.
Home use of a bihormonal bionic pancreas versus insulin pump therapy in adults with type 1 diabetes: a multicentre randomised crossover trial
.
Lancet
2017
;
389
:
369
380
143.
Levine
BS
,
Anderson
BJ
,
Butler
DA
,
Antisdel
JE
,
Brackett
J
,
Laffel
LM
.
Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes
.
J Pediatr
2001
;
139
:
197
203
144.
Miller
KM
,
Beck
RW
,
Bergenstal
RM
, et al.;
T1D Exchange Clinic Network
.
Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D exchange clinic registry participants
.
Diabetes Care
2013
;
36
:
2009
2014
145.
Patton
SR
,
Noser
AE
,
Youngkin
EM
,
Majidi
S
,
Clements
MA
.
Early initiation of diabetes devices relates to improved glycemic control in children with recent-onset type 1 diabetes mellitus
.
Diabetes Technol Ther
2019
;
21
:
379
384
146.
Battelino
T
,
Danne
T
,
Bergenstal
RM
, et al
.
Clinical targets for continuous glucose monitoring data interpretation: recommendations from the International Consensus on Time in Range
.
Diabetes Care
2019
;
42
:
1593
1603
147.
Vigersky
RA
,
McMahon
C
.
The relationship of hemoglobin A1C to time-in-range in patients with diabetes
.
Diabetes Technol Ther
2019
;
21
:
81
85
148.
Petersson
J
,
Åkesson
K
,
Sundberg
F
,
Särnblad
S
.
Translating glycated hemoglobin A1c into time spent in glucose target range: a multicenter study
.
Pediatr Diabetes
2019
;
20
:
339
344
149.
Warncke
K
,
Fröhlich-Reiterer
EE
,
Thon
A
,
Hofer
SE
,
Wiemann
D
;
DPV Initiative of the German Working Group for Pediatric Diabetology
;
German BMBF Competence Network for Diabetes Mellitus
.
Polyendocrinopathy in children, adolescents, and young adults with type 1 diabetes: a multicenter analysis of 28,671 patients from the German/Austrian DPV-Wiss database
.
Diabetes Care
2010
;
33
:
2010
2012
150.
Nederstigt
C
,
Uitbeijerse
BS
,
Janssen
LGM
,
Corssmit
EPM
,
de Koning
EJP
,
Dekkers
OM
.
Associated auto-immune disease in type 1 diabetes patients: a systematic review and meta-analysis
.
Eur J Endocrinol
2019
;
180
:
135
144
151.
Kozhakhmetova
A
,
Wyatt
RC
,
Caygill
C
, et al
.
A quarter of patients with type 1 diabetes have co-existing non-islet autoimmunity: the findings of a UK population-based family study
.
Clin Exp Immunol
2018
;
192
:
251
258
152.
Hughes
JW
,
Riddlesworth
TD
,
DiMeglio
LA
,
Miller
KM
,
Rickels
MR
;
T1D Exchange Clinic Network
.
Autoimmune diseases in children and adults with type 1 diabetes from the T1D Exchange Clinic Registry
.
J Clin Endocrinol Metab
2016
;
101
:
4931
4937
153.
Kahaly
GJ
,
Hansen
MP
.
Type 1 diabetes associated autoimmunity
.
Autoimmun Rev
2016
;
15
:
644
648
154.
Roldán
MB
,
Alonso
M
,
Barrio
R
.
Thyroid autoimmunity in children and adolescents with type 1 diabetes mellitus
.
Diabetes Nutr Metab
1999
;
12
:
27
31
155.
Shun
CB
,
Donaghue
KC
,
Phelan
H
,
Twigg
SM
,
Craig
ME
.
Thyroid autoimmunity in type 1 diabetes: systematic review and meta-analysis
.
Diabet Med
2014
;
31
:
126
135
156.
Triolo
TM
,
Armstrong
TK
,
McFann
K
, et al
.
Additional autoimmune disease found in 33% of patients at type 1 diabetes onset
.
Diabetes Care
2011
;
34
:
1211
1213
157.
Kordonouri
O
,
Deiss
D
,
Danne
T
,
Dorow
A
,
Bassir
C
,
Grüters-Kieslich
A
.
Predictivity of thyroid autoantibodies for the development of thyroid disorders in children and adolescents with type 1 diabetes
.
Diabet Med
2002
;
19
:
518
521
158.
Dost
A
,
Rohrer
TR
,
Fröhlich-Reiterer
E
, et al.;
DPV Initiative and the German Competence Network Diabetes Mellitus
.
Hyperthyroidism in 276 children and adolescents with type 1 diabetes from Germany and Austria
.
Horm Res Paediatr
2015
;
84
:
190
198
159.
Jonsdottir
B
,
Larsson
C
,
Carlsson
A
, et al.;
Better Diabetes Diagnosis Study Group
.
Thyroid and islet autoantibodies predict autoimmune thyroid disease at type 1 diabetes diagnosis
.
J Clin Endocrinol Metab
2017
;
102
:
1277
1285
160.
Mohn
A
,
Di Michele
S
,
Di Luzio
R
,
Tumini
S
,
Chiarelli
F
.
The effect of subclinical hypothyroidism on metabolic control in children and adolescents with type 1 diabetes mellitus
.
Diabet Med
2002
;
19
:
70
73
161.
Holmes
GK
.
Screening for coeliac disease in type 1 diabetes
.
Arch Dis Child
2002
;
87
:
495
498
162.
Rewers
M
,
Liu
E
,
Simmons
J
,
Redondo
MJ
,
Hoffenberg
EJ
.
Celiac disease associated with type 1 diabetes mellitus
.
Endocrinol Metab Clin North Am
2004
;
33
:
197
214
,
xi
163.
Pham-Short
A
,
Donaghue
KC
,
Ambler
G
,
Phelan
H
,
Twigg
S
,
Craig
ME
.
Screening for celiac disease in type 1 diabetes: a systematic review
.
Pediatrics
2015
;
136
:
e170
e176
164.
Craig
ME
,
Prinz
N
,
Boyle
CT
, et al.;
Australasian Diabetes Data Network (ADDN)
;
T1D Exchange Clinic Network (T1DX)
;
National Paediatric Diabetes Audit (NPDA) and the Royal College of Paediatrics and Child Health
;
Prospective Diabetes Follow-up Registry (DPV) initiative
.
Prevalence of celiac disease in 52,721 youth with type 1 diabetes: international comparison across three continents
.
Diabetes Care
2017
;
40
:
1034
1040
165.
Cerutti
F
,
Bruno
G
,
Chiarelli
F
,
Lorini
R
,
Meschi
F
;
Diabetes Study Group of the Italian Society of Pediatric Endocrinology and Diabetology
.
Younger age at onset and sex predict celiac disease in children and adolescents with type 1 diabetes: an Italian multicenter study
.
Diabetes Care
2004
;
27
:
1294
1298
166.
Simmons
JH
,
Foster
NC
,
Riddlesworth
TD
, et al.;
T1D Exchange Clinic Network
.
Sex- and age-dependent effects of celiac disease on growth and weight gain in children with type 1 diabetes: analysis of the Type 1 Diabetes Exchange clinic registry
.
Pediatr Diabetes
2018
;
19
:
741
748
167.
Margoni
D
,
Chouliaras
G
,
Duscas
G
, et al
.
Bone health in children with celiac disease assessed by dual x-ray absorptiometry: effect of gluten-free diet and predictive value of serum biochemical indices
.
J Pediatr Gastroenterol Nutr
2012
;
54
:
680
684
168.
Rohrer
TR
,
Wolf
J
,
Liptay
S
, et al.;
DPV Initiative and the German BMBF Competence Network Diabetes Mellitus
.
Microvascular complications in childhood-onset type 1 diabetes and celiac disease: a multicenter longitudinal analysis of 56,514 patients from the German-Austrian DPV database
.
Diabetes Care
2015
;
38
:
801
807
169.
Mollazadegan
K
,
Kugelberg
M
,
Montgomery
SM
,
Sanders
DS
,
Ludvigsson
J
,
Ludvigsson
JF
.
A population-based study of the risk of diabetic retinopathy in patients with type 1 diabetes and celiac disease
.
Diabetes Care
2013
;
36
:
316
321
170.
Rubio-Tapia
A
,
Hill
ID
,
Kelly
CP
,
Calderwood
AH
;
American College of Gastroenterology
.
ACG clinical guidelines: diagnosis and management of celiac disease
.
Am J Gastroenterol
2013
;
108
:
656
676
171.
Husby
S
,
Koletzko
S
,
Korponay-Szabó
IR
, et al.;
ESPGHAN Working Group on Coeliac Disease Diagnosis
;
ESPGHAN Gastroenterology Committee
;
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition
.
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease
.
J Pediatr Gastroenterol Nutr
2012
;
54
:
136
160
172.
Paul
SP
,
Sandhu
BK
,
Spray
CH
,
Basude
D
,
Ramani
P
.
Evidence supporting serology-based pathway for diagnosing celiac disease in asymptomatic children from high-risk groups
.
J Pediatr Gastroenterol Nutr
2018
;
66
:
641
644
173.
Abid
N
,
McGlone
O
,
Cardwell
C
,
McCallion
W
,
Carson
D
.
Clinical and metabolic effects of gluten free diet in children with type 1 diabetes and coeliac disease
.
Pediatr Diabetes
2011
;
12
:
322
325
174.
Kurppa
K
,
Paavola
A
,
Collin
P
, et al
.
Benefits of a gluten-free diet for asymptomatic patients with serologic markers of celiac disease
.
Gastroenterology
2014
;
147
:
610
617.e1
175.
Flynn
JT
,
Kaelber
DC
,
Baker-Smith
CM
, et al.;
Subcommittee on Screening and Management of High Blood Pressure in Children
.
Clinical practice guideline for screening and management of high blood pressure in children and adolescents
.
Pediatrics
2017
;
140
:
e20171904
176.
Marcovecchio
ML
,
Chiesa
ST
,
Bond
S
, et al.;
AdDIT Study Group
.
ACE inhibitors and statins in adolescents with type 1 diabetes
.
N Engl J Med
2017
;
377
:
1733
1745
177.
de Ferranti
SD
,
de Boer
IH
,
Fonseca
V
, et al
.
Type 1 diabetes mellitus and cardiovascular disease: a scientific statement from the American Heart Association and American Diabetes Association
.
Diabetes Care
2014
;
37
:
2843
2863
178.
Rodriguez
BL
,
Fujimoto
WY
,
Mayer-Davis
EJ
, et al
.
Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with diabetes: the SEARCH for diabetes in youth study
.
Diabetes Care
2006
;
29
:
1891
1896
179.
Margeirsdottir
HD
,
Larsen
JR
,
Brunborg
C
,
Overby
NC
;
Norwegian Study Group for Childhood Diabetes
.
High prevalence of cardiovascular risk factors in children and adolescents with type 1 diabetes: a population-based study
.
Diabetologia
2008
;
51
:
554
561
180.
Schwab
KO
,
Doerfer
J
,
Hecker
W
, et al.;
DPV Initiative of the German Working Group for Pediatric Diabetology
.
Spectrum and prevalence of atherogenic risk factors in 27,358 children, adolescents, and young adults with type 1 diabetes: cross-sectional data from the German diabetes documentation and quality management system (DPV)
.
Diabetes Care
2006
;
29
:
218
225
181.
Singh
TP
,
Groehn
H
,
Kazmers
A
.
Vascular function and carotid intimal-medial thickness in children with insulin-dependent diabetes mellitus
.
J Am Coll Cardiol
2003
;
41
:
661
665
182.
Haller
MJ
,
Stein
J
,
Shuster
J
, et al
.
Peripheral artery tonometry demonstrates altered endothelial function in children with type 1 diabetes
.
Pediatr Diabetes
2007
;
8
:
193
198
183.
Urbina
EM
,
Wadwa
RP
,
Davis
C
, et al
.
Prevalence of increased arterial stiffness in children with type 1 diabetes mellitus differs by measurement site and sex: the SEARCH for Diabetes in Youth Study
.
J Pediatr
2010
;
156
:
731
737.e731
184.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents
;
National Heart, Lung, and Blood Institute
.
Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report
.
Pediatrics
2011
;
128
(
Suppl. 5
):
S213
S256
185.
Kershnar
AK
,
Daniels
SR
,
Imperatore
G
, et al
.
Lipid abnormalities are prevalent in youth with type 1 and type 2 diabetes: the SEARCH for Diabetes in Youth Study
.
J Pediatr
2006
;
149
:
314
319
186.
Blaha
MJ
,
Blumenthal
RS
,
Brinton
EA
;
National Lipid Association Taskforce on Non-HDL Cholesterol
.
The importance of non-HDL cholesterol reporting in lipid management
.
J Clin Lipidol
2008
;
2
:
267
273
187.
Maahs
DM
,
Dabelea
D
,
D’Agostino
RB
Jr
, et al.;
SEARCH for Diabetes in Youth Study
.
Glucose control predicts 2-year change in lipid profile in youth with type 1 diabetes
.
J Pediatr
2013
;
162
:
101
107.e1
188.
Daniels
SR
;
Committee on Nutrition
.
Lipid screening and cardiovascular health in childhood
.
Pediatrics
2008
;
122
:
198
208
189.
Kavey
RE
,
Allada
V
,
Daniels
SR
, et al.;
American Heart Association Expert Panel on Population and Prevention Science
;
American Heart Association Council on Cardiovascular Disease in the Young
;
American Heart Association Council on Epidemiology and Prevention
;
American Heart Association Council on Nutrition, Physical Activity and Metabolism
;
American Heart Association Council on High Blood Pressure Research
;
American Heart Association Council on Cardiovascular Nursing
;
American Heart Association Council on the Kidney in Heart Disease
;
Interdisciplinary Working Group on Quality of Care and Outcomes Research
.
Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics
.
Circulation
2006
;
114
:
2710
2738
190.
Cadario
F
,
Prodam
F
,
Pasqualicchio
S
, et al
.
Lipid profile and nutritional intake in children and adolescents with type 1 diabetes improve after a structured dietician training to a Mediterranean-style diet
.
J Endocrinol Invest
2012
;
35
:
160
168
191.
Salem
MA
,
AboElAsrar
MA
,
Elbarbary
NS
,
ElHilaly
RA
,
Refaat
YM
.
Is exercise a therapeutic tool for improvement of cardiovascular risk factors in adolescents with type 1 diabetes mellitus? A randomised controlled trial
.
Diabetol Metab Syndr
2010
;
2
:
47
192.
McCrindle
BW
,
Urbina
EM
,
Dennison
BA
, et al.;
American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee
;
American Heart Association Council of Cardiovascular Disease in the Young
;
American Heart Association Council on Cardiovascular Nursing
.
Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing
.
Circulation
2007
;
115
:
1948
1967
193.
Salo
P
,
Viikari
J
,
Hämäläinen
M
, et al
.
Serum cholesterol ester fatty acids in 7- and 13-month-old children in a prospective randomized trial of a low-saturated fat, low-cholesterol diet: the STRIP baby project. Special Turku Coronary Risk Factor Intervention Project for Children
.
Acta Paediatr
1999
;
88
:
505
512
194.
McCrindle
BW
,
Ose
L
,
Marais
AD
.
Efficacy and safety of atorvastatin in children and adolescents with familial hypercholesterolemia or severe hyperlipidemia: a multicenter, randomized, placebo-controlled trial
.
J Pediatr
2003
;
143
:
74
80
195.
Wiegman
A
,
Hutten
BA
,
de Groot
E
, et al
.
Efficacy and safety of statin therapy in children with familial hypercholesterolemia: a randomized controlled trial
.
JAMA
2004
;
292
:
331
337
196.
Daniels
M
,
DuBose
SN
,
Maahs
DM
, et al.;
T1D Exchange Clinic Network
.
Factors associated with microalbuminuria in 7,549 children and adolescents with type 1 diabetes in the T1D Exchange clinic registry
.
Diabetes Care
2013
;
36
:
2639
2645
197.
Schwartz
GJ
,
Work
DF
.
Measurement and estimation of GFR in children and adolescents
.
Clin J Am Soc Nephrol
2009
;
4
:
1832
1843
198.
Inker
LA
,
Schmid
CH
,
Tighiouart
H
, et al.;
CKD-EPI Investigators
.
Estimating glomerular filtration rate from serum creatinine and cystatin C
.
N Engl J Med
2012
;
367
:
20
29
199.
Cho
YH
,
Craig
ME
,
Hing
S
, et al
.
Microvascular complications assessment in adolescents with 2- to 5-yr duration of type 1 diabetes from 1990 to 2006
.
Pediatr Diabetes
2011
;
12
:
682
689
200.
Scanlon
PH
,
Stratton
IM
,
Bachmann
MO
,
Jones
C
;
Four Nations Diabetic Retinopathy Screening Study Group
.
Risk of diabetic retinopathy at first screen in children at 12 and 13 years of age
.
Diabet Med
2016
;
33
:
1655
1658
201.
Beauchamp
G
,
Boyle
CT
,
Tamborlane
WV
, et al.;
T1D Exchange Clinic Network
.
Treatable diabetic retinopathy is extremely rare among pediatric T1D Exchange clinic registry participants
.
Diabetes Care
2016
;
39
:
e218
e219
202.
Nathan
DM
,
Bebu
I
,
Hainsworth
D
, et al.;
DCCT/EDIC Research Group
.
Frequency of evidence-based screening for retinopathy in type 1 diabetes
.
N Engl J Med
2017
;
376
:
1507
1516
203.
Gubitosi-Klug
RA
,
Bebu
I
,
White
NH
, et al.;
Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group
.
Screening eye exams in youth with type 1 diabetes under 18 years of age: once may be enough?
Pediatr Diabetes
2019
;
20
:
743
749
204.
Jaiswal
M
,
Divers
J
,
Dabelea
D
, et al
.
Prevalence of and risk factors for diabetic peripheral neuropathy in youth with type 1 and type 2 diabetes: SEARCH for Diabetes in Youth Study
.
Diabetes Care
2017
;
40
:
1226
1232
205.
Pop-Busui
R
,
Boulton
AJ
,
Feldman
EL
, et al
.
Diabetic neuropathy: a position statement by the American Diabetes Association
.
Diabetes Care
2017
;
40
:
136
154
206.
Imperatore
G
,
Boyle
JP
,
Thompson
TJ
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Projections of type 1 and type 2 diabetes burden in the U.S. population aged <20 years through 2050: dynamic modeling of incidence, mortality, and population growth
.
Diabetes Care
2012
;
35
:
2515
2520
207.
Pettitt
DJ
,
Talton
J
,
Dabelea
D
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study
.
Diabetes Care
2014
;
37
:
402
408
208.
Copeland
KC
,
Zeitler
P
,
Geffner
M
, et al.;
TODAY Study Group
.
Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline
.
J Clin Endocrinol Metab
2011
;
96
:
159
167
209.
Bjornstad
P
,
Drews
KL
,
Caprio
S
, et al.;
TODAY Study Group
.
Long-term complications in youth-onset type 2 diabetes
.
N Engl J Med
2021
;
385
:
416
426
210.
Arslanian
SA
.
Metabolic differences between Caucasian and African-American children and the relationship to type 2 diabetes mellitus
.
J Pediatr Endocrinol Metab
2002
;
15
(
Suppl. 1
):
509
517
211.
Naughton
MJ
,
Ruggiero
AM
,
Lawrence
JM
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Health-related quality of life of children and adolescents with type 1 or type 2 diabetes mellitus: SEARCH for Diabetes in Youth Study
.
Arch Pediatr Adolesc Med
2008
;
162
:
649
657
212.
Wadden
TA
,
Webb
VL
,
Moran
CH
,
Bailer
BA
.
Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy
.
Circulation
2012
;
125
:
1157
1170
213.
Whalen
DJ
,
Belden
AC
,
Tillman
R
,
Barch
DM
,
Luby
JL
.
Early adversity, psychopathology, and latent class profiles of global physical health from preschool through early adolescence
.
Psychosom Med
2016
;
78
:
1008
1018
214.
Dabelea
D
,
Mayer-Davis
EJ
,
Saydah
S
, et al.;
SEARCH for Diabetes in Youth Study
.
Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009
.
JAMA
2014
;
311
:
1778
1786
215.
Buse
JB
,
Kaufman
FR
,
Linder
B
,
Hirst
K
,
El Ghormli
L
;
HEALTHY Study Group
.
Diabetes screening with hemoglobin A(1c) versus fasting plasma glucose in a multiethnic middle-school cohort
.
Diabetes Care
2013
;
36
:
429
435
216.
Klingensmith
GJ
,
Pyle
L
,
Arslanian
S
, et al.;
TODAY Study Group
.
The presence of GAD and IA-2 antibodies in youth with a type 2 diabetes phenotype: results from the TODAY study
.
Diabetes Care
2010
;
33
:
1970
1975
217.
Hannon
TS
,
Arslanian
SA
.
The changing face of diabetes in youth: lessons learned from studies of type 2 diabetes
.
Ann N Y Acad Sci
2015
;
1353
:
113
137
218.
Kapadia
C
;
Drugs and Therapeutics Committee of the Pediatric Endocrine Society
.
Hemoglobin A1c measurement for the diagnosis of type 2 diabetes in children
.
Int J Pediatr Endocrinol
2012
;
2012
:
31
219.
Wallace
AS
,
Wang
D
,
Shin
JI
,
Selvin
E
.
Screening and diagnosis of prediabetes and diabetes in US children and adolescents
.
Pediatrics
2020
;
146
:
e20200265
220.
Dabelea
D
,
Rewers
A
,
Stafford
JM
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study
.
Pediatrics
2014
;
133
:
e938
e945
221.
Hutchins
J
,
Barajas
RA
,
Hale
D
,
Escaname
E
,
Lynch
J
.
Type 2 diabetes in a 5-year-old and single center experience of type 2 diabetes in youth under 10
.
Pediatr Diabetes
2017
;
18
:
674
677
222.
Ferrara
CT
,
Geyer
SM
,
Liu
YF
, et al.;
Type 1 Diabetes TrialNet Study Group
.
Excess BMI in childhood: a modifiable risk factor for type 1 diabetes development?
Diabetes Care
2017
;
40
:
698
701
223.
Pinhas-Hamiel
O
,
Dolan
LM
,
Zeitler
PS
.
Diabetic ketoacidosis among obese African-American adolescents with NIDDM
.
Diabetes Care
1997
;
20
:
484
486
224.
TODAY Study Group
.
Safety and tolerability of the treatment of youth-onset type 2 diabetes: the TODAY experience
.
Diabetes Care
2013
;
36
:
1765
1771
225.
TODAY Study Group
.
Retinopathy in youth with type 2 diabetes participating in the TODAY clinical trial
.
Diabetes Care
2013
;
36
:
1772
1774
226.
TODAY Study Group
.
Lipid and inflammatory cardiovascular risk worsens over 3 years in youth with type 2 diabetes: the TODAY clinical trial
.
Diabetes Care
2013
;
36
:
1758
1764
227.
TODAY Study Group
.
Rapid rise in hypertension and nephropathy in youth with type 2 diabetes: the TODAY clinical trial
.
Diabetes Care
2013
;
36
:
1735
1741
228.
Hudson
JL
,
Baum
JI
,
Diaz
EC
,
Børsheim
E
.
Dietary protein requirements in children: methods for consideration
.
Nutrients
2021
;
13
:
1554
229.
Grey
M
,
Schreiner
B
,
Pyle
L
.
Development of a diabetes education program for youth with type 2 diabetes
.
Diabetes Educ
2009
;
35
:
108
116
230.
American Diabetes Association
.
Be Healthy Today; Be Healthy For Life
.
Arlington, VA, American Diabetes Association. Accessed 1 October 2023. Available from http://main.diabetes.org/dorg/PDFs/Type-2-Diabetes-in-Youth/Type-2-Diabetes-in-Youth.pdf
231.
Atkinson
A
,
Radjenovic
D
.
Meeting quality standards for self-management education in pediatric type 2 diabetes
.
Diabetes Spectr
2007
;
20
:
40
46
232.
Copeland
KC
,
Silverstein
J
,
Moore
KR
, et al.;
American Academy of Pediatrics
.
Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents
.
Pediatrics
2013
;
131
:
364
382
233.
Zeitler
P
,
Hirst
K
,
Pyle
L
, et al.;
TODAY Study Group
.
A clinical trial to maintain glycemic control in youth with type 2 diabetes
.
N Engl J Med
2012
;
366
:
2247
2256
234.
RISE Consortium
.
Impact of insulin and metformin versus metformin alone on β-cell function in youth with impaired glucose tolerance or recently diagnosed type 2 diabetes
.
Diabetes Care
2018
;
41
:
1717
1725
235.
Tamborlane
WV
,
Barrientos-Pérez
M
,
Fainberg
U
, et al.;
Ellipse Trial Investigators
.
Liraglutide in children and adolescents with type 2 diabetes
.
N Engl J Med
2019
;
381
:
637
646
236.
U.S. Food and Drug Administration
.
FDA approves treatment for pediatric patients with type 2 diabetes - drug information update
.
2021
.
237.
U.S. Food and Drug Administration
.
FDA approves new treatment for pediatric patients with type 2 diabetes
.
2019
.
238.
Tamborlane
WV
,
Bishai
R
,
Geller
D
, et al
.
Once-weekly exenatide in youth with type 2 diabetes
.
Diabetes Care
2022
;
45
:
1833
1840
239.
Arslanian
SA
,
Hannon
T
,
Zeitler
P
, et al.;
AWARD-PEDS Investigators
.
Once-weekly dulaglutide for the treatment of youths with type 2 diabetes
.
N Engl J Med
2022
;
387
:
433
443
240.
Laffel
LM
,
Danne
T
,
Klingensmith
GJ
, et al.;
DINAMO Study Group
.
Efficacy and safety of the SGLT2 inhibitor empagliflozin versus placebo and the DPP-4 inhibitor linagliptin versus placebo in young people with type 2 diabetes (DINAMO): a multicentre, randomised, double-blind, parallel group, phase 3 trial
.
Lancet Diabetes Endocrinol
2023
;
11
:
169
181
241.
Chan
CL
.
Use of continuous glucose monitoring in youth-onset type 2 diabetes
.
Curr Diab Rep
2017
;
17
:
66
242.
Weghuber
D
,
Kelly
AS
,
Arslanian
S
.
Once-weekly semaglutide in adolescents with obesity. Reply
.
N Engl J Med
2023
;
388
:
1146
243.
Kelly
AS
,
Auerbach
P
,
Barrientos-Perez
M
, et al.;
NN8022-4180 Trial Investigators
.
A randomized, controlled trial of liraglutide for adolescents with obesity
.
N Engl J Med
2020
;
382
:
2117
2128
244.
U.S. Food and Drug Administration
.
FDA approves weight management drug for patients aged 12 and older
.
2021
.
245.
U.S. Food and Drug Administration
.
FDA approves treatment for chronic weight management in pediatric patients aged 12 years and older
.
2022
.
246.
Inge
TH
,
Courcoulas
AP
,
Jenkins
TM
, et al.;
Teen-LABS Consortium
.
Weight loss and health status 3 years after bariatric surgery in adolescents
.
N Engl J Med
2016
;
374
:
113
123
247.
Inge
TH
,
Laffel
LM
,
Jenkins
TM
, et al.;
Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) Consortia
.
Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents
.
JAMA Pediatr
2018
;
172
:
452
460
248.
Rubino
F
,
Nathan
DM
,
Eckel
RH
, et al.;
Delegates of the 2nd Diabetes Surgery Summit
.
Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by International Diabetes Organizations
.
Diabetes Care
2016
;
39
:
861
877
249.
Pratt
JS
,
Lenders
CM
,
Dionne
EA
, et al
.
Best practice updates for pediatric/adolescent weight loss surgery
.
Obesity (Silver Spring)
2009
;
17
:
901
910
250.
Dolan
K
,
Creighton
L
,
Hopkins
G
,
Fielding
G
.
Laparoscopic gastric banding in morbidly obese adolescents
.
Obes Surg
2003
;
13
:
101
104
251.
Sugerman
HJ
,
Sugerman
EL
,
DeMaria
EJ
, et al
.
Bariatric surgery for severely obese adolescents
.
J Gastrointest Surg
2003
;
7
:
102
108
252.
Inge
TH
,
Garcia
V
,
Daniels
S
, et al
.
A multidisciplinary approach to the adolescent bariatric surgical patient
.
J Pediatr Surg
2004
;
39
:
442
447
253.
Lawson
ML
,
Kirk
S
,
Mitchell
T
, et al.;
Pediatric Bariatric Study Group
.
One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group
.
J Pediatr Surg
2006
;
41
:
137
143
254.
Inge
TH
,
Zeller
M
,
Harmon
C
, et al
.
Teen-Longitudinal Assessment of Bariatric Surgery: methodological features of the first prospective multicenter study of adolescent bariatric surgery
.
J Pediatr Surg
2007
;
42
:
1969
1971
255.
Ells
LJ
,
Mead
E
,
Atkinson
G
, et al
.
Surgery for the treatment of obesity in children and adolescents
.
Cochrane Database Syst Rev
2015
:
CD011740
256.
Michalsky
MP
,
Inge
TH
,
Simmons
M
, et al.;
Teen-LABS Consortium
.
Cardiovascular risk factors in severely obese adolescents: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study
.
JAMA Pediatr
2015
;
169
:
438
444
257.
Zeinoddini
A
,
Heidari
R
,
Talebpour
M
.
Laparoscopic gastric plication in morbidly obese adolescents: a prospective study
.
Surg Obes Relat Dis
2014
;
10
:
1135
1139
258.
Göthberg
G
,
Gronowitz
E
,
Flodmark
CE
, et al
.
Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity—surgical aspects and clinical outcome
.
Semin Pediatr Surg
2014
;
23
:
11
16
259.
Inge
TH
,
Prigeon
RL
,
Elder
DA
, et al
.
Insulin sensitivity and β-cell function improve after gastric bypass in severely obese adolescents
.
J Pediatr
2015
;
167
:
1042
1048.e1
260.
Styne
DM
,
Arslanian
SA
,
Connor
EL
, et al
.
Pediatric obesity-assessment, treatment, and prevention: an Endocrine Society clinical practice guideline
.
J Clin Endocrinol Metab
2017
;
102
:
709
757
261.
Hampl
SE
,
Hassink
SG
,
Skinner
AC
, et al
.
Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity
.
Pediatrics
2023
;
151
:
e2022060640
262.
Eppens
MC
,
Craig
ME
,
Cusumano
J
, et al
.
Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes
.
Diabetes Care
2006
;
29
:
1300
1306
263.
Song
SH
,
Hardisty
CA
.
Early onset type 2 diabetes mellitus: a harbinger for complications in later years—clinical observation from a secondary care cohort
.
QJM
2009
;
102
:
799
806
264.
Zeitler
P
,
Fu
J
,
Tandon
N
, et al.;
International Society for Pediatric and Adolescent Diabetes
.
ISPAD clinical practice consensus guidelines 2014. Type 2 diabetes in the child and adolescent
.
Pediatr Diabetes
2014
;
15
(
Suppl. 20
):
26
46
265.
Cefalu
WT
.
“TODAY” reflects on the changing “faces” of type 2 diabetes
.
Diabetes Care
2013
;
36
:
1732
1734
266.
Lawrence
JM
,
Standiford
DA
,
Loots
B
, et al.;
SEARCH for Diabetes in Youth Study
.
Prevalence and correlates of depressed mood among youth with diabetes: the SEARCH for Diabetes in Youth study
.
Pediatrics
2006
;
117
:
1348
1358
267.
Levitt Katz
LE
,
Swami
S
,
Abraham
M
, et al
.
Neuropsychiatric disorders at the presentation of type 2 diabetes mellitus in children
.
Pediatr Diabetes
2005
;
6
:
84
89
268.
Lewis-Fernández
R
,
Rotheram-Borus
MJ
,
Betts
VT
, et al
.
Rethinking funding priorities in mental health research
.
Br J Psychiatry
2016
;
208
:
507
509
269.
Reinehr
T
.
Type 2 diabetes mellitus in children and adolescents
.
World J Diabetes
2013
;
4
:
270
281
270.
Pinhas-Hamiel
O
,
Hamiel
U
,
Levy-Shraga
Y
.
Eating disorders in adolescents with type 1 diabetes: challenges in diagnosis and treatment
.
World J Diabetes
2015
;
6
:
517
526
271.
McVoy
M
,
Hardin
H
,
Fulchiero
E
, et al
.
Mental health comorbidity and youth onset type 2 diabetes: a systematic review of the literature
.
Int J Psychiatry Med
2023
;
58
:
37
55
272.
Shelton
RC
.
Depression, antidepressants, and weight gain in children
.
Obesity (Silver Spring)
2016
;
24
:
2450
273.
Baeza
I
,
Vigo
L
,
de la Serna
E
, et al
.
The effects of antipsychotics on weight gain, weight-related hormones and homocysteine in children and adolescents: a 1-year follow-up study
.
Eur Child Adolesc Psychiatry
2017
;
26
:
35
46
274.
TODAY Study Group
.
Pregnancy outcomes in young women with youth-onset type 2 diabetes followed in the TODAY study
.
Diabetes Care
2021
;
45
:
1038
1045
275.
Karter
AJ
,
Stevens
MR
,
Gregg
EW
, et al
.
Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study
.
Am J Public Health
2008
;
98
:
365
370
276.
Reynolds
K
,
Liese
AD
,
Anderson
AM
, et al
.
Prevalence of tobacco use and association between cardiometabolic risk factors and cigarette smoking in youth with type 1 or type 2 diabetes mellitus
.
J Pediatr
2011
;
158
:
594
601.e1
277.
Scott
LJ
,
Warram
JH
,
Hanna
LS
,
Laffel
LM
,
Ryan
L
,
Krolewski
AS
.
A nonlinear effect of hyperglycemia and current cigarette smoking are major determinants of the onset of microalbuminuria in type 1 diabetes
.
Diabetes
2001
;
50
:
2842
2849
278.
Chaffee
BW
,
Watkins
SL
,
Glantz
SA
.
Electronic cigarette use and progression from experimentation to established smoking
.
Pediatrics
2018
;
141
:
e20173594
279.
Audrain-McGovern
J
,
Stone
MD
,
Barrington-Trimis
J
,
Unger
JB
,
Leventhal
AM
.
Adolescent E-cigarette, hookah, and conventional cigarette use and subsequent marijuana use
.
Pediatrics
2018
;
142
:
e20173616
280.
Weitzman
ER
,
Wisk
LE
,
Minegishi
M
, et al
.
Effects of a patient-centered intervention to reduce alcohol use among youth with chronic medical conditions
.
J Adolesc Health
2022
;
71
(
4S
):
S24
S33
281.
Arnett
JJ
.
Emerging adulthood. A theory of development from the late teens through the twenties
.
Am Psychol
2000
;
55
:
469
480
282.
Weissberg-Benchell
J
,
Wolpert
H
,
Anderson
BJ
.
Transitioning from pediatric to adult care: a new approach to the post-adolescent young person with type 1 diabetes
.
Diabetes Care
2007
;
30
:
2441
2446
283.
Peters
A
,
Laffel
L
;
American Diabetes Association Transitions Working Group
.
Diabetes care for emerging adults: recommendations for transition from pediatric to adult diabetes care systems: a position statement of the American Diabetes Association, with representation by the American College of Osteopathic Family Physicians, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Osteopathic Association, the Centers for Disease Control and Prevention, Children with Diabetes, The Endocrine Society, the International Society for Pediatric and Adolescent Diabetes, Juvenile Diabetes Research Foundation International, the National Diabetes Education Program, and the Pediatric Endocrine Society (formerly Lawson Wilkins Pediatric Endocrine Society)
.
Diabetes Care
2011
;
34
:
2477
2485
284.
Bryden
KS
,
Peveler
RC
,
Stein
A
,
Neil
A
,
Mayou
RA
,
Dunger
DB
.
Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study
.
Diabetes Care
2001
;
24
:
1536
1540
285.
Kapellen
TM
,
Müther
S
,
Schwandt
A
, et al.;
DPV initiative and the Competence Network Diabetes Mellitus funded by the German Federal Ministry of Education and Research
.
Transition to adult diabetes care in Germany—high risk for acute complications and declining metabolic control during the transition phase
.
Pediatr Diabetes
2018
;
19
:
1094
1099
286.
Agarwal
S
,
Raymond
JK
,
Isom
S
, et al
.
Transfer from paediatric to adult care for young adults with type 2 diabetes: the SEARCH for Diabetes in Youth Study
.
Diabet Med
2018
;
35
:
504
512
287.
Laing
SP
,
Jones
ME
,
Swerdlow
AJ
,
Burden
AC
,
Gatling
W
.
Psychosocial and socioeconomic risk factors for premature death in young people with type 1 diabetes
.
Diabetes Care
2005
;
28
:
1618
1623
288.
Mays
JA
,
Jackson
KL
,
Derby
TA
, et al
.
An evaluation of recurrent diabetic ketoacidosis, fragmentation of care, and mortality across Chicago, Illinois
.
Diabetes Care
2016
;
39
:
1671
1676
289.
Lotstein
DS
,
Seid
M
,
Klingensmith
G
, et al.;
SEARCH for Diabetes in Youth Study Group
.
Transition from pediatric to adult care for youth diagnosed with type 1 diabetes in adolescence
.
Pediatrics
2013
;
131
:
e1062
e1070
290.
Lyons
SK
,
Becker
DJ
,
Helgeson
VS
.
Transfer from pediatric to adult health care: effects on diabetes outcomes
.
Pediatr Diabetes
2014
;
15
:
10
17
291.
Garvey
KC
,
Foster
NC
,
Agarwal
S
, et al
.
Health care transition preparation and experiences in a U.S. national sample of young adults with type 1 diabetes
.
Diabetes Care
2017
;
40
:
317
324
292.
The Endocrine Society
.
Transitions of Care
.
Accessed 1 October 2023. Available from https://www.endocrine.org/improving-practice/transitions#t1d
293.
D’Amico
RP
,
Pian
TM
,
Buschur
EO
.
Transition from pediatric to adult care for individuals with type 1 diabetes: opportunities and challenges
.
Endocr Pract
2023
;
29
:
279
285
294.
Xie
LF
,
Housni
A
,
Nakhla
M
, et al
.
Adaptation of an adult web application for type 1 diabetes self-management to youth using the behavior change wheel to tailor the needs of health care transition: qualitative interview study
.
JMIR Diabetes
2023
;
8
:
e42564
295.
Butalia
S
,
Crawford
SG
,
McGuire
KA
,
Dyjur
DK
,
Mercer
JR
,
Pacaud
D
.
Improved transition to adult care in youth with type 1 diabetes: a pragmatic clinical trial
.
Diabetologia
2021
;
64
:
758
766
296.
Reid
MW
,
Krishnan
S
,
Berget
C
, et al
.
CoYoT1 clinic: home telemedicine increases young adult engagement in diabetes care
.
Diabetes Technol Ther
2018
;
20
:
370
379
297.
Spaic
T
,
Robinson
T
,
Goldbloom
E
, et al.;
JDRF Canadian Clinical Trial CCTN1102 Study Group
.
Closing the gap: results of the multicenter Canadian randomized controlled trial of structured transition in young adults with type 1 diabetes
.
Diabetes Care
2019
;
42
:
1018
1026
298.
White
M
,
O’Connell
MA
,
Cameron
FJ
.
Clinic attendance and disengagement of young adults with type 1 diabetes after transition of care from paediatric to adult services (TrACeD): a randomised, open-label, controlled trial
.
Lancet Child Adolesc Health
2017
;
1
:
274
283
299.
Schultz
AT
,
Smaldone
A
.
Components of interventions that improve transitions to adult care for adolescents with type 1 diabetes
.
J Adolesc Health
2017
;
60
:
133
146
300.
Sequeira
PA
,
Pyatak
EA
,
Weigensberg
MJ
, et al
.
Let’s empower and prepare (LEAP): evaluation of a structured transition program for young adults with type 1 diabetes
.
Diabetes Care
2015
;
38
:
1412
1419
301.
Monaghan
M
,
Baumann
K
.
Type 1 diabetes: addressing the transition from pediatric to adult-oriented health care
.
Res Rep Endocr Disord
2016
;
6
:
31
40
302.
Carreon
SA
,
Duran
B
,
Tang
TS
, et al
.
Here for you: a review of social support research in young adults with diabetes
.
Diabetes Spectr
2021
;
34
:
363
370
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