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New ADA position statement stresses differences between pediatric, adult management of type 1 diabetes

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August 9, 2018

Desmond Schatz
Desmond Schatz

Type 1 diabetes management for children and adolescents must not be extrapolated from adult diabetes care, and providers should consider a child’s evolving developmental stages in creating an adaptive care plan to best suit his or her changing needs, according to a position statement released today by the American Diabetes Association.

“There have been tremendous strides in the management of children and adolescents with type 1 diabetes and tremendous technology advances as we push toward the holy grail of a true artificial pancreas,” Desmond Schatz, MD, an author of the updated position statement and 2016 president of medicine and science for the ADA, told Endocrine Today. “But type 1 diabetes remains a challenge. There are more and more cases occurring each year and with the demands on physicians and on patients overall, it is important that we put guidelines forward for the optimal management of all youth with type 1 diabetes.”

In an update of the ADA’s original position statement published in 2005, Schatz and colleagues emphasized the importance of adapting type 1 diabetes care to a child’s needs and circumstances, with an emphasis on timely guidance and care coordination to allow an eventual seamless transition from adolescence to young adulthood for both the child with type 1 diabetes and his or her family. The statement highlights the importance of type 1 staging, proper screening and testing, blood glucose management, recommendations regarding adjunctive therapies and lifestyle management, as well as the management of complications and comorbidities in children.

“Children are not young adults,” Schatz, also professor, associate chairman of pediatrics and medical director of the Diabetes Institute at the University of Florida College of Medicine, said in an interview. “They have unique challenges and developmental phases, challenges of growth, challenges of puberty and challenges related to the [young adult] transition, as well as challenges related to independence and paying for care. The medical community needs to be aware of these challenges, particularly at a time when it’s not easy. We as a health care team need to support children and their families through all phases of vulnerability.”

Glucose management in children

Most children with type 1 diabetes should be treated with an intensive insulin regimen via either multiple daily injection therapy of prandial and basal insulin or continuous insulin pump therapy, according to the statement. Continuous glucose monitoring should be considered in all children and adolescents with type 1 diabetes regardless of insulin delivery method to help improve glycemic profile. Automated insulin delivery systems “appear to improve glycemic control” and reduce hypoglycemia in children and should be considered in pediatric patients with type 1 diabetes, according to the researchers.

 

In children, lifestyle management should include healthful approaches to nutrition and exercise, including individualized medical nutrition therapy as an essential component of an overall treatment plan, comprehensive nutrition education and a physical activity goal of 60 minutes of moderate- to vigorous-intensity aerobic activity daily. Psychosocial issues and family stresses should be assessed at diagnosis and during routine follow-up care, with appropriate referrals to trained mental health professionals, preferably experienced in childhood diabetes.

“Certainly, there is an emphasis on better glucose control,” Schatz said. “Type 1 diabetes is a disease that is heterogeneous that requires personal attention. Utilizing resources of technology, of physicians, educators, nutritionists, exercise physiologists, psychologists and social workers, where needed, enables patients to achieve the best possible outcomes with individualized goals.”

Adolescent years

Adolescence is a time that can disrupt diabetes care and communication between family members, youth and providers, the researchers noted, adding that cognitive development and medical decision-making skills will affect a wide variety of risk-taking behaviors. The statement includes a recommendation for a thorough, age-appropriate psychosocial evaluation and review of the adolescent medical regimen to suggest targets for modification to facilitate self-management and well-being.

“That is a particularly vulnerable time, particularly for adolescents,” Schatz said. “The kids become more independent. You’re seeking to empower more kids and transfer care to them. It’s so important, and that’s why I believe in engaging the child as soon as possible. It’s all very well my telling you, as a parent, what you need to do. It’s so important we empower children to make good decisions, by educating them about the disease.”

Research needed

New research and technological advances have increased understanding of type 1 diabetes, but studies have yet to accomplish the goal of preventing and preserving beta-cell function, the statement notes.

“Management of type 1 diabetes in youth remains imperfect, requiring unending vigilance and behavioral intervention,” the researchers wrote. “While it is burdensome to all affected individuals and their families, it is particularly challenging to those with limited resources and skills.”

The researchers wrote that ongoing research is required to better understand the complexities involving epidemiology, pathophysiology, complications and quality of life and to improve long-term outcomes associated with the disease in pediatric patients.

The position statement was published online in Diabetes Care.by Regina Schaffer

For more information:

Desmond Schatz, MD, can be reached at the University of Florida College of Medicine, Box 100296, Gainesville, FL 32610; email: schatda@peds.ufl.edu.

Disclosures: Schatz reported he has served on the external advisory board for Sankyo and has served as a consultant for and received a TrialNet grant from Sanofi. Please see the study for the other authors’ relevant financial disclosures.