Type 1 Diabetes in Children and Adolescents

Type 1 Diabetes in Children and Adolescents

Y L N 2018 Clinical Practice Guidelines O E S U Children Type 1 Diabetes in L A N O and Adolescents S R E Chapter 34 P Diane K. Wherrett MD FRCPC, Cline Huot MD MSc FRCPC, Laurent Legault MD FRCPC, Josephine Ho MD MSc FRCPC, Meranda Nakhla MD MSc FRCPC, Elizabeth Rosolowsky MD MPH FAAP FRCPC Disclaimer All Content contained on this slide deck is the property of Diabetes Canada, its content suppliers or its licensors as the case may be, and is protected by Canadian and international copyright, trademark, and other applicable laws. Diabetes Canada grants personal, limited, revocable, non-transferable and non-exclusive license to access and read content in this slide deck for personal, non-commercial and not-for-profit use only. The slide deck is made available for lawful, personal use only and not for commercial use.

S R PE S U L A ON Y L N O E The unauthorized reproduction, distribution of this copyrighted work is not permitted. For permission to use this slide deck for commercial or any use other than personal, please contact [email protected] 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Key Changes 2018 New recommendation on Y A1C target of < 7.5% for all children and L N O

adolescents <18 years ofEage S U Use of a psychosocialL risk index aid to identify A children and adolescents at high risk of poor N O S glycemic control R PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Overview Education Complications Glycemic targets Immunization LY Insulin therapy Smoking S Hypoglycemia

Comorbidities DKA Transition to Adult care N O E U L Glucose monitoringNA Sexual Health O S Nutrition Psychology R E P PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Introduction Diabetes mellitus is the most common endocrine disease and one ofLYthe most N O common chronic conditions E in children

S U L other types of Type 2 diabetes and A N O S diabetes, including genetic defects of beta R PE cell function, such as maturity-onset diabetes of the young, are being increasingly recognized in children and should be considered when clinical presentation is atypical for type 1 diabetes PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Education Key Message Education, from diagnosis onwards, is Yof issues L complex, touching on a range N O E medical and social. Therefore it is best done S U

L team trained in by a interprofessional A N O pediatric diabetes RS PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Education Key Message Children with new-onset type 1 diabetes and their families require intensive diabetes Y pediatric L education by an interprofessional N O diabetes health-care (DHC) E team. S U include: Education topics should L A

N and treatment of Prevention, detection O S hypoglycemia R E P Insulin action and administration Dosage adjustment Blood glucose and ketone testing Sick-day management Prevention of DKA Nutrition and exercise DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Education Key Message Anticipatory guidance and healthy behaviour counselling should be part of routine care during critical developmental Y L N beginning transitions (e.g. school entry, O E S high school). U

L A should regularly Health-care providers N O S initiate discussions with children and their R E P families about School Substance use Diabetes camp Psychological issues Fear of hypoglycemia Driving Career choices PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 1 Delivery of Care 1. All children with diabetes should Yhave access L team that N to an experienced pediatric DHC O E

includes either a pediatric endocrinologist or S U L pediatrician with diabetes expertise, dietician, A N diabetes nurse educator, social worker and O S Rprofessional for specialized care mental health E P starting at diagnosis [Grade D, Level 4] DHC, diabetes health-care PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 2 Delivery of Care 2. Children with new-onset type L1Y diabetes N receive their O who are medically stable should E S initial education and management in an U

L A provided that outpatient setting, N O S appropriate personnel and daily R E P with a DHC team are available communication [Grade B, Level 1A] DHC, diabetes health-care PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Transition to Adult Care Change of physician or DHC team can have major impact on disease management and Y L metabolic control N O E S have no medical 25% to 65% of young adults U L A follow-up during the

transition N O S Those with noER follow-up are more likely to P experience hospitalization for DKA during this period Organized transition services may decrease the rate of loss of follow-up DHC, diabetes health-care; DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 3 Delivery of Care 3. To ensure ongoing and adequate diabetes Y L care, adolescents should receive care from a N O E specialized program aimed at creating a S U L well-prepared and supported transition to

A N O adult care that is initiated early and includes S R E a transition coordinator; patient P reminders; and support and education promoting autonomy and self-care management skills [Grade C, Level 3] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents 2018 Glycemic Targets Key Message New single target of 7.5% for all children Y L N Achieving adult targets forOmetabolic E S control is not always U indicated and may be

L A unsafe for some N children O S ER AchievingPtargets may require much work on the part of family and DHC team to find the right insulin approach DHC, diabetes health-care PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Glycemic Targets Clinical judgement is required tailor goals to the patient Y L Episodes of frequent or severe Nhypoglycemia O Epoorer cognitive S have been associated with U L A function in some follow-up studies N Oresearch suggests that

S Know your goals R E P glycemic targets by patients and knowledge of parents, and consistent target setting by the DHC team, was associated with improved metabolic control DHC, diabetes health-care PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents 2018 Glycemic Targets Age (years ) A1C (%) FPG / premeal PG (mmol/L) 2-hour pc PG (mmol/L) <18

7.5 % 4.0-8.0 5.0 10.0 S R PE S U L A ON Considerations Y L N O E Caution is required to minimize severe or excessive hypoglycemia. Consider preprandial targets of 6.010.0 mmol/L as well as higher A1C targets in children and adolescents who have had

severe or excessive hypoglycemia or have hypoglycemia unawareness *Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available A1C ; glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucose; PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 4 2018 Glycemic Targets 4. Children and adolescents <18 years of age Y L should aim for an A1C targetN<7.5% [Grade D, O Consensus] E S U Attempts should be made to safely reach the L A recommended glycemic target, while minimizing the N O recurrent hypoglycemia. risk for severeSor

Treatment P targets ER should be tailored to each child, taking into consideration individual risk factors for hypoglycemia [Grade D, Consensus] In children <6 years of age, particular care to minimize hypoglycemia is recommended because of the potential association in this age group between severe hypoglycemia and later cognitive impairment [Grade D, Level 4] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Chronic Poor Metabolic Control Diabetes control may worsen Yduring L N adolescence, possibly dueOto the following E S factors: LU A N Adolescent adjustment issues O S R Psychosocial PE distress Intentional insulin omission

Physiologic insulin resistance PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 5 Glycemic Targets 5. Children with persistently poor glycemic Y L Nshould be control (e.g., A1C >10.0%) O E tool by a assessed with a validated S U L specialized pediatric DHC team for A N O comprehensiveSinterdisciplinary assessment R E and referred P for psychosocial support as indicated [Grade D, Consensus]. Intensive family and individualized psychological interventions aimed at improving glycemic control should be considered to improve chronically poor metabolic control [Grade A,

DHC, diabetes health-care Level 1A] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Insulin Therapy Key Message It is reasonable to start with a basic insulin Y per day) but a L regimen (e.g. minimum 3 injections N O Eindicated if success more intensive approach is S U L not achieved despite NAgood effort PE O S R PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Types of insulin in Type 1 Diabetes

Insulin Type (trade name) Onset Peak Duration 10 - 15 min 10 - 15 min 10 - 15 min 1 - 1.5 h 1 - 1.5 h 1-2h Y L N O E 3-5h 3-5h 3.5 - 4.75 h 2-3h 6.5 h 1-3h 5-8h Up to 18 h

90 min Not applicable Up to 24 h (glargine 24 h, detemir 16 - 24 h) Bolus (prandial) Insulins Rapid-acting insulin analogues (clear): Insulin aspart (NovoRapid) Insulin glulisine (Apidra) Insulin lispro (Humalog) Short-acting insulins (clear): Insulin regular (Humulin-R) Insulin regular (NovolingeToronto) S R E P Intermediate-acting insulins (cloudy): Basal Insulins Insulin NPH (Humulin-N) Insulin NPH (Novolinge NPH) Long-acting basal insulin analogues (clear) Insulin detemir (Levemir) Insulin glargine (Lantus/Basaglar) S

U 30 Lmin A ON PERSONAL USE ONLY Types of insulin Insulin type (trade name) Onset Peak Duration Rapid-acting insulin analogues (clear) Insulin aspart (NovoRapid) Insulin glulisine (Apidra) Insulin lispro (Humalog) U-100 U-200 Faster-acting insulin aspart (Fiasp) 920min 1015min 1015min 4min 11.5h 11.5h 12h 0.5-1.5h 35h 3.55h

34.75h 3-5h Short-acting insulins (clear) Insulin regular (Humulin-R, Novolin ge Toronto) Insulin regular U-500 (Entuzity (U-500) 30min 15min BOLUS (prandial or mealtime) insulins BASAL insulins Intermediate-acting (cloudy) Insulin neutral protamine Hagedorn (Humulin N, Novolin ge NPH) Long-acting insulin (clear) Insulin detemir (Levemir) Insulin glargine U-100 (Lantus) Insulin glargine U-300 (Toujeo) Insulin glargine biosimilar (Basaglar) Insulin degludec U-100, U-200 (Tresiba) PE RS S U L A 90min ON 13h

Y L N O E 23h 4-8h 6.5h 17-24h 58h Up to 18h Not applicable U-100 glargine 24h, detemir 1624h U-300 glargine >30h degludec 42h PREMIXED insulins Premixed regular insulin NPH (cloudy) Humulin 30/70 Novolin ge 30/70, 40/60, 50/50 A single vial or cartridge contains a fixed ratio of insulin (% of rapid-acting or short-acting insulin to % of intermediate-acting insulin) Premixed insulin analogues (cloudy) Biphasic insulin aspart (NovoMix 30) Insulin lispro/lispro protamine (Humalog Mix25 and Mix50) PERSONAL USE ONLY

Serum Insulin Level S R PE S U L A ON Y L N O E Time Human Basal Analogue Basal Human Bolus Analogue Bolus PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Insulin Therapy Key Message Insulin is the mainstay of medical management Y

L N EO S The choice of insulin regimen U depends on L many factors: ONA S R Childs ageE P Duration of diabetes Family lifestyle Socioeconomic factors Family, patient, and physician preferences PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Insulin Therapy Starting regimen should comprise: Y L N O E 2 daily bolus injections S

U L A N O 1 basal insulin RS injection PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Insulin Therapy If initial regimen fails to meet glycemic Y targets, more intensive management may L N O be required: E S U Three methods of intensive L diabetes A Nbe used at any age: O

management can S R Similar regimen PE with more frequent injections basal bolus regimens using long and rapid acting insulin analogues continuous subcutaneous insulin infusion (CSII, insulin pump therapy) PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 6 Insulin Therapy 6. Children with new-onset diabetes Y should be L N started on boluses of rapid-acting insulin O Ebasal insulin (e.g. analogues combined with S U L intermediate-actingAinsulin or long-acting N basal insulin analogue) using an O S R regimen that best addresses

individualized E P the practical issues of daily life [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 7 Insulin Therapy 7. Insulin therapy should be assessed at each clinical encounter to ensure it still enables the child to meet A1C targets, minimizes the risk of hypoglycemia and allows exibility in carbohydrate intake, daily schedule and activities [Grade D, Consensus]. If these goals are not being met, an intensied diabetes management approach (including increased education, monitoring and contact with diabetes team) should be used [Grade A, Level 1 for adolescents; Grade D, Consensus for younger children], and treatment options may include the following: S R PE S U L A ON

Y L N O E Increased frequency of injections Change in the type of basal and/or bolus insulin Change to CSII therapy [Grade D, Consensus] [Grade B, Level 2, for adolescents; Grade D, Consensus, for younger children] [Grade C, Level 3] CSII, continuous subcutaneous insulin infusion PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Glucose Monitoring Self-monitoring of blood glucose is an Y type 1 L essential part of management of

N O diabetes SE U L Subcutaneous continuous A glucose sensors N O asymptomatic S allow detection of R E P and hyperglycemia hypoglycemia Subcutaneous continuous glucose sensors may have a beneficial role in children and adolescents but evidence is not as strong as in adults PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Nutrition All children with type 1 diabetes should receive counselling from a registered dietitian Y L N experienced in pediatric diabetes

O E S U Children with diabetes should follow a healthy L A N diet as recommended for children without O S ER diabetes inPEating Well with Canadas Food Guide There is no evidence that one form of nutrition therapy is superior to another in attaining age-appropriate glycemic targets PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Nutrition Use of insulin to carbohydrate ratios may be beneficial but is not required Y L N The effect of protein and E fatOon glucose S

U absorption must alsoLbe considered A N O should be individualized Nutrition therapy S R E P childs nutritional needs, eating (based on the habits, lifestyle, ability, and interest) and must ensure normal growth and development without compromising glycemic control PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Hypoglycemia Key Message All families should understand the Y L N importance of hypoglycemiaO(severity and E S frequency) along with treatment and follow U L A up strategies N

PE O S R PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Hypoglycemia Key Message Hypoglycemia is a major obstacle for children with type 1 diabetes and can affect their Y L N ability to achieve glycemic targets O E S U Significant risk of hypoglycemia often L A N necessitates less Ostringent glycemic goals, S

ER younger children particularlyPfor There is no evidence in children that one insulin regimen or mode of administration is superior to another for reducing non-severe hypoglycemia PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Examples of Carbohydrate for Treatment of Mild to Moderate Hypoglycemia Patient Weight <15 kg 15 to 30 Y L kg N >30 kg 10 g 15 g 2 or 3 3 85 ml 4 5

125 ml O E S Amount of 5gU L carbohydrate A Carbohydrate Source ON Glucose tablet (4 g)RS 1 Dextrose tablet (3 2 PEg) Apple or orange juice; 40 ml regular soft drink; sweet beverage (cocktails) PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Hypoglycemia Key Message Frequent use of continuous glucose monitoring in a clinical care setting may Y L reduce episodes of hypoglycemia N

O E S In children, the use of mini-doses of U L A glucagon has been shown to be useful in the N O of mild or impending S home management R E P associated with inability or hypoglycemia refusal to take oral carbohydrate Dose = 10 mcg x (years of age) Dose range 20 150 mcg PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Severe Hypoglycemia Age 5 yrs 0.5 mg glucagon SC or IM Y L Age >5 yrs 1 mg glucagonNSC or IM O E

S U L A N should be contacted Diabetes care team O S R following a Psevere hypoglycemic event E Consider reducing insulin doses in short term to avoid repeat event PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 8 Treatment of Hypoglycemia Y of 8. In children, the use of mini-doses L N age with O glucagon (10 mcg per year of E S minimum dose 20 mcgUand maximum dose L A 150 mcg) should be

considered in the home N O S management Rof mild or impending E P hypoglycemia associated with inability or refusal to take oral carbohydrate [Grade D, Level 4] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 9 Treatment of Hypoglycemia 9. In the home situation, severe Lhypoglycemia Y Nyears of age in an unconscious child >5 O E S should be treated with U 1 mg glucagon L A subcutaneously orNintramuscularly. In children O a dose of 0.5 mg glucagon S <5 years of age, R E P

should be given. The episode should be discussed with the DHC team as soon as possible and consideration given to reducing insulin doses for the next 24 hours to prevent further severe hypoglycemia [Grade D, Consensus] DHC, diabetes health-care PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 10 Treatment of Hypoglycemia Y be given 10. Dextrose 0.5 to 1 g/kg should L N to treat severe O intravenously over 1-3 minutes E S hypoglycemia with unconsciousness when U L intravenous access NAis available [Grade D, Consensus] PE O S

R PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 11 2018 Physical Activity Y 11. Regular physical activity 3 times per L N O week for 60 minutes each time should be E encouraged for all children US with diabetes [Grade A, Level 1] S R PE L A ON PERSONAL USE ONLY

2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Diabetes Ketoacidosis DKA is the leading cause of morbidity and mortality in children with diabetes Y L N Strategies are required to prevent the O E S development of DKA U L A N In new-onset diabetes, DKA can be prevented O S R through earlier PE recognition and initiation of insulin therapy Caution is necessary in management of pediatric DKA due to increase risk of cerebral edema DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents

Diabetes Ketoacidosis Failing to take insulin or poor sick day management Y L N O E Diabetic ketoacidosis US L A Risk factors areSthe ON following: R control or previous episodes of DKA E Children with poor P Peripubertal and adolescent girls Children on pumps or long-acting insulin analogs Children with psychiatric disorders, and those with difficult family circumstances DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Diabetes Ketoacidosis: PREVENTION Y

The frequency of DKA in established L N O diabetes can be decreased E with education, S U and family behavioural intervention, L A N Oas access to 24-hour support, as well S R E P telephone services for parents of children with diabetes DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Management of DKA: Cerebral Edema 0.5 to 1.0% of pediatric cases are complicated Y L N by cerebral edema which is O

associated with E S U significant morbidity L (21-35%) and mortality A N (21-24%) O S R Do NOT administer hypotonic uid rapidly PE Do NOT give IV insulin bolus Start IV insulin infusion 1 hour AFTER uid resuscitation has begun PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Risk Factors for Developing Cerebral Edema

Younger age (<5 years) Y New-onset diabetes L N O High initial serum urea E S U or arterial carbon Low initial partial pressure L A dioxide (pCO2) N O S R Rapid administration of hypotonic uids E P IV bolus of insulin Early IV insulin infusion (within 1st hour of uids) Failure of serum sodium to rise during treatment Use of bicarbonate PERSONAL USE ONLY 2018 Managemen

t of DKA in Children or Adolescents S R PE S U L A ON Y L N O E PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Management of DKA in Children or Adolescents S R PE S U L A

ON 2018 Y L N O E PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Management of DKA in 2018 Children or Adolescents S R PE S U L A ON Y L N O E PERSONAL USE ONLY

2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Management of DKA in Children or Adolescents S R PE S U L A ON 2018 Y L N O E PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 12 Diabetic Ketoacidosis 12. To prevent DKA in children with diabetes: Y Targeted public awareness campaigns L should be N

considered to educate parents,O other caregivers E S providers about the (e.g., teachers), and healthcare U L [Grade C, Level 3] early symptoms of diabetes A N Immediate assessment of ketone and acid-base O S Rbe done in any child presenting with status should E new onset P diabetes [Grade D, Consensus] Comprehensive education and support services [Grade C, Level 3], as well as 24-hour telephone services [Grade C, Level 3], should be available for families of children with diabetes DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 13 Diabetic Ketoacidosis 13. DKA in children should be treated Y according L N [Grade D, to pediatric-specic protocols

O E Consensus]. If appropriate S expertise/facilities are U Lthere should be not available locally, A N immediate consultation with a centre O S R in pediatric diabetes [Grade D, with expertise E P Consensus] DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 14 Diabetic Ketoacidosis Y 14. In children in DKA, rapid administration of L ONavoided [Grade hypotonic uids shouldEbe S

D, Level 4]. Circulatory compromise should be U L A treated with only enough isotonic uids to N O S correct circulatory inadequacy [Grade D, R E Consensus]. P Replacement of uid decit should be extended over a 48-hour period with regular reassessments of uid status [Grade D, Level 4] DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 15 Diabetic Ketoacidosis 15. In children in DKA, an intravenous Y insulin L N bolus should not be givenO[Grade D, E S

Consensus]. The insulin U infusion should not L A be started for atNleast 1 hour after O starting uidRS replacement therapy [Grade D, PE Level 4]. An intravenous infusion of short-acting insulin should be used at an initial dose of 0.05 to 0.1 units/kg/h, depending on the clinical situation [Grade A, Level 1A] DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 16 2018 Diabetic Ketoacidosis 16. In children in DKA, once blood Lglucose Y N reaches 17.0 mmol/L, intravenous O E S dextrose should be started to prevent U

L A hypoglycemia. TheNdextrose infusion should be Othan reducing insulin, to S increased, rather R E P decreases in glucose. The insulin prevent rapid infusion should be maintained until pH normalizes and ketones have mostly cleared [Grade D, Consensus] DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 17-18 2018 Diabetic Ketoacidosis 17.In children in DKA, administration Y of sodium L N bicarbonate should be avoided except in O E extreme circulatory compromise, as this may S

U contribute to cerebral ALedema [Grade D, Level 4] N O S R E 18.In children P in DKA, either mannitol or hypertonic saline may be used in the treatment of cerebral edema [Grade D, Level 4] DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Diabetes Complications Key Messages Nephropathy, retinopathy, neuropathy and Y L N hypertension are rare in pediatric diabetes O L A ON

E S U Screening efforts S should focus most R E P attention on post-pubertal patients with longer duration and poorer control of their diabetes PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Nephropathy Prepubertal children, and those in the first Y L 5 years of diabetes, should be considered N O at very low risk for microalbuminuria SE U L A N O S

R A first morning PE urine albumin to creatinine ratio (ACR) has high sensitivity and specificity for the detection of microalbuminuria (MAU) PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Nephropathy A random ACR may be compromised in adolescents due to their higher Yfrequency of L N O exercise-induced proteinuria and benign E S U postural proteinuria L A N O S R Abnormal random ACRs (>2.5 mg/mmol) PE require confirmation with a first morning

ACR or timed urine overnight collection as abnormal ACR frequently normalize spontaneously ACR, albumin to creatinine ratio PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Nephropathy Treatment is indicated only for those adolescents with persistent albuminuria LY N O There are no long-term intervention studies E S U L assessing the effectiveness of ACE inhibitors A N O or angiotensin receptor blockers in delaying S R E progressionPto overt nephropathy in adolescents with microalbuminuria Therefore, treatment guidelines are based on adult data

ACE, angiotensin converting enzyme PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Retinopathy Retinopathy is rare in prepubertal children with type 1 diabetes and in postpubertal Y L adolescents with good metabolic ON control Age 15 yrs + DM of 5 years S R E P If DM 5-10 yrs + normal eye exam + good glycemic control L A ON E S U Begin annual screening

Screen every 2 years DM, diabetes mellitus PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Neuropathy Neuropathy is mostly subclinical in children Y L Vibration and monofilament testing have N O E S specificity in suboptimal sensitivity U and L A adolescents, persistence of abnormalities is N O S R finding an inconsistent E P The only treatment modality for children

and adolescents is intensified diabetes management to achieve and maintain glycemic targets PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Dyslipidemia Most children with type 1 diabetes should be considered at low risk for vascular disease Y L N associated with dyslipidemia. The exceptions O E S are those with: LU A Longer duration ofNdisease O S Microvascular ERcomplications P CV risk factors, including: Smoking Hypertension Obesity

Family history of premature CVD CV, cardiovasulcar; CVD, cardiovascular disease PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Dyslipidemia Begin screening at: 12 years of age Y L Nrisk factors <12 years of age with specific O E S U 5 years Repeat screening every L A N O only rarely been studied Statin therapy Shas R E specificallyPin children with diabetes No evidence linking specific LDL-C cutoffs in children with diabetes with long-term outcomes PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Hypertension

Up to 16% of adolescents with type 1 diabetes have hypertension NLY O E Screen blood pressure Uat S least twice a year L A Role of ambulatory N blood pressure O S R monitoring PinE routine care remains uncertain Treat according to the guidelines for children without diabetes PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Screening for Complications Complication Nephropathy Retinopathy Neuropathy Indications & intervals for screening Yearly screening commencing at 12 years

of age in those with duration of type 1 diabetes 5 years Screening method First morning (preferred) or random urine ACR Abnormal ACR requires confirmation at least 1 month later with a first morning ACR, and if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate Repeated sampling should be done ever y 34 months over a 6-12-month period to demonstrate persistence Y L N O Yearly screening commencing at 15 yrs of 7-standard field, stereoscopic-colour fundus photography E age with duration of DM 5 yrs with interpretation by a trained reader (gold standard); or S Screening interval can increase to 2 yrs if U Direct ophthalmoscopy or indirect slit-lamp fundoscopy good glycemic control, duration of diabetes through dilated pupil; or L A Digital fundus photography < 10 yrs, and no retinopathy at initial N assessment O

S R E P with poor Postpubertal adolescents Question and examine for symptoms of numbness, pain, metabolic control should be screened yearly cramps and paresthesia, as well as sensation, vibration sense, after 5 years duration of DM light touch & ankle reflexes Dyslipidemia Delay screening post-diabetes diagnosis Fasting or non-fastingTC, HDL-C, TG, LDL-C until metabolic control has stabilized Screen at 12 years of age or <12 years of age with BMI > 97th percentile, family history of hyperlipidemia or premature CVD Hyper tension Screen all children with type 1 diabetes at Use appropriate cuff size least twice a year PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 19 Microvascular Complications 19. Children 12 years with diabetes duration > 5 years should be screened annually for CKDLY with a rst N morning urine ACR (preferred) O

[Grade B, Level 2] or a E random ACR [Grade D, Consensus]. S Abnormal results U L B, Level 2] at least 1 month should be confirmed [Grade A N ACR and, if abnormal, followed later with a first morning O S or 24-hour split urine collections for R by timed, overnight E P albumin excretion rate [Grade D, Consensus]. Albuminuria (ACR >2.5 mg/mmol; AER >20 mcg/min) should not be diagnosed unless it is persistent, as demonstrated by 2 consecutive first morning ACR or timed collections obtained at 3- to 4-month intervals over a 6- to 12month period [Grade D, Consensus] ACR, albumin to creatinine ratio; AER, albumin excretion rate; CKD, chronic kidney disease PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 20 Microvascular Complications Y 20. Children 12 years with persistent L N per adult O

albuminuria should be treated E S guidelines (see Chronic U Kidney Disease in Diabetes L A chapter) [Grade D, Consensus] N O S R PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 21 Microvascular Complications 21. Children 15 years with 5 years diabetes Y L N duration should be annuallyOscreened and E by an expert S evaluated for retinopathy U L professional [GradeNC,ALevel 3]. The screening O interval can be increased

to every 2 years S R E type 1 diabetes who have in children P with good glycemic control, duration of diabetes <10 years and no signicant retinopathy (as determined by an expert professional) [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 22 Microvascular Complications Y duration 22. Children 15 years with 5 years L Nshould be O and poor metabolic control E S questioned about symptoms of numbness, U L Aparesthesia, and pain, cramps and N O S

examined for R skin sensation, vibration E P touch and ankle reexes sense, light [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 25 Comorbid Conditions and Other Complications Y L N O who are <12 25. Children with type 1 diabetes E S years of age should beUscreened for L A have other risk factors, dyslipidemia if they N O S such as obesity R (body mass index >97th E P

percentile for age and gender) and/or a family history of dyslipidemia or premature CVD. Routine screening for dyslipidemia should begin at 12 years of age, with repeat screening after 5 years [Grade D, Consensus] CVD, cardiovascular disease PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 26 Comorbid Conditions and Other Complications Y L N in children 26. Once dyslipidemia is diagnosed O E S with type 1 diabetes, the dyslipidemia should U L A be monitored regularly and efforts should N O metabolic control and S be made to improve R E

P promote healthy behaviours. While it can be treated effectively with statins, a specific cutoff to initiate treatment is yet to be determined in this age category [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendations 27-28 Comorbid Conditions and Other Complications 27.All children with type 1 diabetesLYshould be Nat least twice screened for hypertension O E S annually [Grade D, Consensus] U L A ON 28.Children with type S 1 diabetes and BP R readings persistently above the 95th PE percentile for age should receive healthy behaviour counselling, including weight loss if overweight [Grade D, Level 4]. If BP remains

elevated, treatment should be initiated based on recommendations for children without BP, blood pressure diabetes [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Comorbid Conditions / Considerations Immunization Smoking S U L A ON Y L N O E Contraception / S Sexual health counseling R PE Psychological / Psychiatric Eating disorders

PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Immunizations There is no evidence supporting increased Y morbidity or mortality from inuenza in L N O children with type 1 diabetes SE U L The managementNof A type 1 diabetes can be O S complicated by illness R PE For this reason, parents may choose to immunize their children PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Smoking Smoking prevention/cessation should be

Y emphasized throughout childhood and L N O adolescence. E S R PE S U L A ON PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Contraception / Sexual Health Counseling Adolescents with diabetes should receive Y regular counselling about sexualLhealth and N O contraception E S

U Pregnancy in adolescent females with type 1 L A metabolic control may N diabetes with suboptimal O S result in higher Rrisks of maternal and fetal E P complications than in older women with type 1 diabetes Oral contraceptives, intrauterine devices and barrier methods can be used safely in the vast majority of adolescents PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendations 29 Comorbid Conditions and Other Complications Y L N O be offered to 29.Inuenza vaccination should E Sa way to prevent an children with diabetes as

U L A intercurrent illnessNthat could complicate O S diabetes management [Grade D, Consensus] R E P PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendations 30-31 Comorbid Conditions and Other Complications Y L N O and 30. Formal smoking prevention E S cessation counselingUshould be part of L A for children with diabetes management N O S

diabetes [Grade R D, Consensus] E P 31. Adolescents should be regularly counseled around alcohol and substance use [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 32 Comorbid Conditions and Other Complications Y L N O 1 diabetes 32. Adolescent females with type E S on contraception should receive counseling U L A and sexual health in order to prevent N O S unplanned pregnancy [Grade D, Level 4]

R E P PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Psychological Issues For children, and particularly adolescents, Y L there is a need to identify psychological N O Ediabetes and to disorders associated with S U L intervene early toNminimize the impact over A SO the course ofRdevelopment. PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Psychological / Psychiatric Risks Children and adolescents with diabetes

Y L have significant risks for psychological N O problems: SE U L A N O Depression Anxiety S R Eating disorders PE Externalizing disorders The risks increase exponentially during adolescence PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Psychological / Psychiatric Risks Psychological disorders predict poor diabetes

Y L Nconsequently, management and control and O E S negative medical outcomes U L A N Conversely, as glycemic control worsens, the O S R probability of PEpsychological problems increases Presence of psychological symptoms and diabetes problems in children and adolescents are often strongly affected by caregiver/family distress PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Eating Disorders 10% of adolescent females with type 1 diabetes meet the Diagnostic L and Y Statistical N Edition) Manual of Mental DisordersO(4th

E S criteria for eating disorders compared to 4% U L A peers without of their age-matched N O S diabetes ER P Eating disorders are associated with poor metabolic control and earlier onset and more rapid progression of microvascular complications PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Eating Disorders Eating disorders should be suspected in those adolescent and young adults who are Y L N metabolic unable to achieve and maintain O E S

targets, especially when U insulin omission is L suspected. NA O S R E P It is important to identify individuals with eating disorders because different management strategies are required to optimize metabolic control and prevent microvascular complications PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 23 Comorbid Conditions and Other Complications Y L N O diabetes, 23. Children and adolescentsEwith Sshould be screened along with their families, U L A

regularly for psychosocial or psychological N O S disorders [Grade R D, Consensus] and should be E P referred to an expert in mental health and/or psychosocial issues for intervention when required [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 24 Comorbid Conditions and Other Complications Y L N O 24. Adolescents with type 1 diabetes should be E Snonjudgmental regularly screened using U L A questions about weight and body image

N O S concerns, dieting, R binge eating and insulin E P weight loss [Grade D, Consensus] omission for PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Comorbid Conditions Key Messages Always consider the possibility of Y L N autoimmune thyroid and adrenal disease, O E S U and celiac disease, Lparticularly when A N there are suggestive signs or symptoms O S

R PE PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Autoimmune Thyroid Disease Autoimmune Thyroid Disease (AITD) occurs in 15 to 30% of individuals with Y type 1 L N O diabetes E S U Risk for AITD during the first decade of diabetes L A N is directly related to the presence or absence of O S R thyroid antibodies PE Hypothyroidism is most likely to develop in girls at puberty

Early detection and treatment of hypothyroidism will prevent growth failure and symptoms of hypothyroidism PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Autoimmune Thyroid Disease Hyperthyroidism also occurs more Ytype 1 L frequently in association with N O diabetes than in the general population SE S R PE U L A N O PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Primary Adrenal Insufficiency

Primary adrenal insufficiency is rare, Y even in those with type 1 diabetes L N O E S U L A is required in those Targeted screening N O S with unexplained recurrent R E P hypoglycemia and decreasing insulin requirements PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Celiac Disease Celiac disease can be identified in 4 to 9% of children with type 1 diabetes Y L

N 60% to 70% of these children, the disease is O E S asymptomatic U L A There is good evidence N that treatment of O S celiac disease with a R classic or atypical PE gluten-free diet improves: Intestinal and extra-intestinal symptoms Prevents the long-term sequelae of untreated disease PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Celiac Disease No evidence that: Y Untreated asymptomatic celiac disease L is

N O associated with short- or long-term health risks E S U A gluten-free diet improves health in these L individuals NA PE O S R Universal screening for and treatment of asymptomatic celiac disease remains controversial PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Condition Screening for Comorbid Frequency Indications for screening Screening test Conditions All children with type 1

Autoimmune thyroid disease diabetes Positive thyroid antibodies, thyroid symptoms or goiter Primary adrenal insufficiency Celiac disease Serum TSH level + thyroperoxidase antibodies Y L N O E Serum TSH level + thyroperoxidase antibodies (if previously negative) S U Unexplained recurrent L 8 AM serum cortisol A hypoglycemia and + serum sodium and N decreasing insulin O

potassium S requirements R PE Recurrent gastrointestinal symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic control Tissue transglutaminase + immunoglobulin A levels At diagnosis and every 2 years thereafter Every 612 months As clinically indicated As clinically indicated PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 33 Comorbid Conditions and Other Complications LY have anti33. Children with type 1 diabetesNwho Obe considered

thyroid antibodies should E S U high risk for autoimmune thyroid disease L A [Grade C, Level 3]. Children with type 1 diabetes N O S should be screened at diabetes diagnosis R E P screening every 2 years using a with repeat serum thyroid- stimulating hormone and thyroid peroxidase antibodies [Grade D, Consensus]. More frequent screening is indicated in the presence of positive antithyroid antibodies, thyroid symptoms or goiter [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Recommendation 34 Comorbid Conditions and Other Complications LY symptoms 34. Children with type 1 diabetesNand O

of classic or atypical celiac disease should E S U undergo celiac screening [Grade D, Consensus] L A treated with a gluten-free and, if confirmed,Nbe O S diet to improve R symptoms [Grade D, Level 4] and E P long-term sequelae of untreated prevent the classic celiac disease [Grade D, Level 4]. Discussion of the pros and cons of screening and treatment of asymptomatic celiac disease should take place with children and adolescents with type 1 diabetes and their families [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Summary Guidelines for children and adolescents differ from those of adults in a number Y of ways: L

Less aggressive A1C target acceptable ON in children E Less intensive screening for complications of diabetes in US L A the younger years due N to lower incidence O DKA management given cerebral S Greater caution around R E P edema risk Greater awareness of unique psychosocial needs as children progress through developmental stages DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents Key Messages 2018

Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and LY likelihood of initiation of treatment to reduceNthe O diabetic ketoacidosis E S U L Management of pediatric DKA differs from DKA A Nthe increased risk for in adults because of O S R cerebral edema. PE Pediatric protocols should be used Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 34. Type 1 Diabetes in Children & Adolescents 2018 Key Messages for People with

Children and Adolescents with Type 1 Diabetes When a child is diagnosed with type Y 1 diabetes, L Nmore important O the role of a caregiver becomes E S than ever. Family life andUdaily routines may L A seem more complicated in the beginning but, N O S over time, and with R the support of your diabetes E P improve. You will discover that team, these will your child can have a healthy and fulfilling life with diabetes PERSONAL USE ONLY Visit guidelines.diabetes.ca S R PE S

U L A ON Y L N O E PERSONAL USE ONLY Or download the App S R PE S U L A ON Y L N O E PERSONAL USE ONLY Diabetes Canada Clinical Practice Guidelines

LY www.guidelines.diabetes.ca forNhealth-care providers EO S U L A ON 1-800-BANTING (226-8464) S R E P www.diabetes.ca for people with diabetes PERSONAL USE ONLY

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