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Pediatric Outpatient Management of Type 1 Diabetes

Pediatric Outpatient Management of Type 1 Diabetes - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related


Key Recommendations for Outpatient Management of Type 1 Diabetes Mellitus in Children
Screening in Children Diagnosis
Blood glucose rather than A1C should be used to diagnose the acute onset of type 1
diabetes in individuals with symptoms of hyperglycemia. (grade E)
Type 1 Diabetes is defined by the presence of 1 or more autoimmune Markers.
ξ GAD 65
ξ IA-2
ξ IA-2B
ξ ZnT8
ξA1C: > 6.5%
ξFasting plasma glucose*: > 126 mg/dL (*Fasting is defined as no caloric intake for > 8 hrs.)
ξRandom plasma glucose: > 200 mg/dL
When to
Test
Risk Factors:
ξ Symptoms of Hyperglycemia
o Polyuria
o Polydipsia
ξ Presence of autoantibodies
Tests
Plasma glucose
Hemoglobin A1C
Urinalysis
Autoimmune Markers
ξ GAD 65
ξ IA-2
ξ IA-2B
ξ ZnT8
MANAGEMENT
Lifestyle
Interventions
Nutrition Physical Activity
All patients with type 1 diabetes need to be evaluated by a registered
dietitian with expertise in addressing the nutritional needs of children with
Type 1 diabetes. (ADA Grade A)
Individualized eating plan and education.
Children with diabetes should be encouraged to engage in at
least 60 minutes of daily physical activity (vigorous-intensity
aerobic activity, bone/muscle-strengthening 3 days/week).
(ADA Grade B)
All patients should be encouraged to reduce sedentary time,
particularly by breaking up extended amounts of time (> 90
min.) spent sitting. (ADA Grade B)
Pharmacologic
Interventions
ξ Multiple Daily Injections: Including Basal and Prandial Insulin or Continuous subcutaneous insulin infusion (grade A)
ξ Use Rapid-acting insulin to reduce hypoglycemia risk (grade A)
ξ Match prandial insulin doses to carbohydrate intake, premeal blood glucose levels and anticipated physical activity (grade A)
References:
Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017; 40 (Suppl 1).
Kroenke, K & Spitzer, R. The PHQ-9: A New Depression Diagnostic and Severity Measure – 2002. Psychiatric Annals. Sep 2002: 32 (9).
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Monitoring
BLOOD GLUCOSE CONTROL
Test Frequency Notes
Blood Glucose
ξCheck blood
glucose levels
fasting, pre-
meal and at
bedtime until at
target level
ξAt diagnosis
ξReview self-monitored blood
glucose (SMBG) at each visit
ξGoal: 90-130 mg/dL pre-meals and 90-150 mg/dL at bedtime (individualize goals for
children < 6 years of age and/or hypoglycemia unawareness)
Hemoglobin A1C ξA1C ξAt diagnosis
ξReview A1C every 3 months
ξHemoglobin A1C goal < 7.5 % (< 7 % is reasonable if it can be achieved without
excessive hypoglycemia)
ξLong term benefits of achieving lower A1C should be balanced against the risks of
hypoglycemia and developmental burdens of intensive regimens in children and
youth.
AUTOIMMUNE CONDITIONS
Thyroid Disease
TPO antibodies
TSH
ξConsider testing antithyroid
peroxidase and antithyroglobulin
antibodies soon after
diagnosis.(grade E)
ξMeasure TSH at diagnosis and
after glucose control has been
established.
ξRecheck TSH every 1-2 years
thereafter and sooner if patient
develops symptoms of thyroid
disorder.
ξ Thyroid disease occurs in 17-30% of patients with Type 1 Diabetes
ξ 25% of children with type 1 diabetes will have thyroid antibodies at the time of
diagnosis
ξ Thyroid function tests at diagnosis may be misleading (euthyroid sick
syndrome)
Celiac Disease TTG and IgA
ξScreen tissue transglutaminase
and IgA levels soon after the
diagnosis (grade E)
ξ 1.6 % - 16.4 % of patients with type 1 diabetes will also be diagnosed with
celiac disease.
ξ Most cases of celiac disease are diagnosed within the first 5 years after the
diagnosis of type 1 diabetes. Consider repeat TTG and IgA at 2 years and 5
years after diagnosis and with symptoms
ξ If elevated a GI consult and small bowel biopsy is recommended to confirm
diagnosis
ξ In symptomatic children with confirmed celiac disease, gluten-free diets reduce
symptoms of rates of hypoglycemia.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

CARDIOVASCULAR RISK FACTORS
Tobacco Use Interview
patient/parent ξEvery visit (ADA Grade B)
ξ Discourage smoking in youth who do not smoke and encourage smoking
cessation in those who do.
ξ Consider secondhand smoke exposure and use of e-cigarettes
Hypertension Blood pressure ξEvery visit (ADA Grade B)
ξGoal: < 90th percentile for age, sex and height (ADA Grade B)
ξConfirm BP on 3 separate days.
ξConsider Nephrology consult.
ξInitial treatment of high/normal BP is diet and exercise. If target BP is not reached
within 3-6 months , pharmacologic treatment should be considered.(ADA Grade E)
ξIf HTN >95% tile is confirmed pharmacologic treatment is advised immediately in
addition to lifestyle modifications.
ξConsider ACE Inhibitor following appropriate reproductive counseling. (ADA Grade E)
Dyslipidemia Fasting lipid profile
(ADA Grade E)
ξAge 10
ξFor children with significant
family history of CVD, start at
age 2.
ξIf abnormal, repeat annually
(ADA Grade E)
ξIf LDL values are <100 mg/dL,
repeat every 3-5 years (ADA
Grade E)
ξ14-45% of children with type 1 diabetes have two or more CVD risk factors and
prevalence increases with age, with girls having a higher risk burden than boys.
ξInitial therapy consists of optimizing glucose control and medical nutrition therapy with
a registered dietician. (ADA Grade B)
ξIf patient 10 years old and LDL > 160 mg/dL after 6 months or LDL > 130 mg/dL and
one or more CVD risk factors, consider statins with goal of LDL < 100 mg/dL,
following reproductive education and implementation of effective birth control.
(ADA Grade E).
ξConsider Pediatric Preventive Cardiology Clinic consult.
MICROVASCULAR COMPLICATIONS
Retinopathy Dilated eye exam
ξAge 10 or after puberty has
started, once the youth has had
diabetes for 3-5 years.
ξAnnually thereafter (ADA Grade E)
Less frequent examinations (i.e., every 2 years) may be acceptable on the advice of an
eye care professional. (ADA Grade E)
Nephropathy
Random urine
sample for
microalbumin/
creatinine ratio
(UACR)
Creatinine
clearance/estimat
ed glomerular
filtration rate
ξAnnual urine screen (UACR)
once child has diabetes for 5
yrs. (ADA Grade B)
ξEstimate glomerular filtration
rate at initial evaluation and then
based on age, diabetes
duration, and treatment.
ξIf initial positive screen, repeat on separate occasion
ξWhen persistently elevated ratio (>30 mg/d) is documented in 2-3 urine samples:
treatment with an ACE inhibitor should be considered following appropriate
reproductive counseling. (ADA Grade C)
ξConsider Nephrology consult.
Neuropathy Comprehensive
foot exam.
ξAnnually, starting at Age 10,
once the youth has had type 1
diabetes for 5 years.
ξComprehensive exam includes: inspection, palpation of pulses, reflexes,
proprioception, vibration and monofilament sensation and assessment of pain
symptoms.
ξInclude Foot Care Education
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

QUALITY OF LIFE
Self-Management
Education and
Support
ξDSME/DSMS ξAt diagnosis (B)
ξWith Routine Visits (B)
ξCulturally sensitive
ξDevelopmentally appropriate
ξFor both the patient and the caregivers
School and
childcare
ξInterview
parent/child
ξWith Routine Visits ξAssess the educational needs and skills of day care providers, school nurses or other
school personnel who participate I the care of the young child with diabetes.
Psychosocial
Issues:
ξ Depression
ξ Symptoms of
disordered
eating
ξInterview
patient/parent
ξConsider
screening for
diabetes distress
starting at 7-8
years of age.
ξDepression
Screen (PHQ-2,
with follow-up for
children > 12 yrs.)
ξConsider
screening for
disordered eating
ξAt diagnosis (ADA Grade E)
ξEvery visit (ADA Grade E)
ξAssess psychosocial issues and family stresses that could impact diabetes
management and provide appropriate referrals to trained mental health professionals,
preferably experienced in childhood diabetes. ( grade E)
ξProvide developmentally appropriate family involvement in diabetes self-management
tasks in children and adolescents. (grade B)
ξMental health professionals should be considered integral part of pediatric
multidisciplinary team. (grade E)
ξYouth and families with behavioral self-care difficulties, repeated hospitalizations for
DKA, significant family distress, consider referral to mental health provider for
evaluation and treatment.
ξAdolescents should have time by themselves with their care provider starting at age
12. (grade E)
ξStarting at puberty, preconception counseling should be incorporated into routine
diabetes care for all girls of childbearing potential. (grade A)
ξPositive screen on PHQ-2 (> 3 points)
ξFurther assessment using PHQ-A or PHQ-9 (> 10 points)
Transition from
Pediatric to Adult
Care
ξPrepare youth for
transition
ξEarly-mid adolescence and at
the least 1 year before transition
to adult health care (grade E)
ξBoth pediatric and adult HCP should provide support and links to resources for teen
and emerging adult
ξRefer to UW Health Transition of Pediatric Patients with Special Health Care Needs to
Adult Health Care – Adult/Pediatric – Ambulatory Clinical Practice Guideline
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org