13. Children and Adolescents:Standards of Medical Care inDiabetes22020Diabetes Care 2020;43(Suppl. 1):S163–S182 | https://doi.org/10.2337/dc20-S013

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes the ADA’s current clinical practice recommendations and is intended to providethe components of diabetes care, general treatment goals and guidelines, and toolsto evaluate quality of care. Members of the ADA Professional Practice Committee, amultidisciplinaryexpert committee (https://doi.org/10.2337/dc20-SPPC), are responsiblefor updating the Standards of Care annually, or more frequently as warranted. For adetailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to theStandardsofCareIntroduction(https://doi.org/10.2337/dc20-SINT).Readerswhowishtocomment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Themanagementofdiabetes in childrenandadolescents cannot simplybederived fromcare routinely provided to adults with diabetes. The epidemiology, pathophysiology,developmental considerations, and response to therapy in pediatric-onset diabetesare different from adult diabetes. There are also differences in recommended carefor children and adolescents with type 1 as opposed to type 2 diabetes. This sectionfirstaddressescareforchildrenandadolescentswith type1diabetesandnextaddressescare for children and adolescents with type 2 diabetes. Figure 13.1 provides guidanceon managing new-onset diabetes in youth with overweight or obesity before type 1or type 2 diabetes is diagnosed and so applies to all youth with overweight or obesity.Lastly, guidance is provided in this section on transition of care from pediatric toadult providers to ensure that the continuum of care is appropriate as the childwithdiabetesdevelops intoadulthood.Due to thenatureof clinical research inchildren,the recommendations for children and adolescents with diabetes are less likelyto be based on clinical trial evidence. However, expert opinion and a review ofavailable and relevant experimental data are summarized in the American DiabetesAssociation (ADA) position statements “Type 1 Diabetes in Children and Adoles-cents” (1) and “Evaluation and Management of Youth-Onset Type 2 Diabetes” (2).TheADAconsensus report “Youth-Onset Type2DiabetesConsensusReport: CurrentStatus, Challenges, and Priorities” (3) characterizes type 2 diabetes in children and evalu-ates treatment options but also discusses knowledge gaps and recruitmentchallenges in clinical and translational research in youth-onset type 2 diabetes.Monogenic diabetes (neonatal diabetes and maturity-onset diabetes in the young[MODY]), which often present in youth, are discussed in section 2 “Classification andDiagnosis of Diabetes” (https://doi.org/10.2337/dc20-S002).

TYPE 1 DIABETES

Type 1 diabetes is the most common form of diabetes in youth (4), althoughrecent data suggest that it may account for a large proportion of cases diagnosed in

Suggested citation: American Diabetes Associa-tion. 13. Children and adolescents: Standards ofMedical Care in Diabetesd2020. Diabetes Care2020;43(Suppl. 1):S163–S182

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American Diabetes Association

Diabetes Care Volume 43, Supplement 1, January 2020 S163

13.CHILD

REN

ANDADOLESC

ENTS

adult life (5). The provider must considerthe unique aspects of care and manage-ment of children and adolescents withtype 1 diabetes, such as changes in insu-lin sensitivity related to physical growthand sexual maturation, ability to pro-vide self-care, supervision in the childcareand school environment, neurologicalvulnerability to hypoglycemia and hy-perglycemia in young children, and pos-sible adverse neurocognitive effectsofdiabetic ketoacidosis (DKA) (6,7). Atten-tion to family dynamics, developmentalstages, and physiologic differences re-lated to sexual maturity is essential indeveloping and implementing an optimaldiabetes treatment plan (8).A multidisciplinary team of special-

ists trained in pediatric diabetes man-agement and sensitive to the challengesof children and adolescents with type1 diabetes and their families shouldprovide care for this population. It isessential that diabetes self-managementeducation and support, medical nutri-tion therapy, and psychosocial supportbe provided at diagnosis and regularlythereafter in a developmentally appro-priate format that builds on prior knowl-edge by individuals experienced with thebiological, educational, nutritional, be-havioral, and emotional needs of thegrowing child and family. The appropri-ate balance between adult supervisionand independent self-care should be de-fined at the first interaction and reeval-uated at subsequent visits, with theexpectation that it will evolve as theadolescent gradually becomes an emerg-ing young adult.

Diabetes Self-Management Educationand Support

Recommendation

13.1 Youth with type 1 diabetes andparents/caregivers (for patientsaged,18 years) should receiveculturally sensitive and develop-mentally appropriate individual-ized diabetes self-managementeducationandsupportaccordingto national standards at diagno-sis and routinely thereafter. B

No matter how sound the medical reg-imen, it can only be effective if thefamily and/or affected individuals areable to implement it. Family involve-ment is a vital component of optimal

diabetes management throughout child-hood and adolescence. Health careproviders in the diabetes care teamwho care for children and adolescentsmust be capable of evaluating the edu-cational, behavioral, emotional, andpsychosocial factors that impact imple-mentation of a treatment plan and mustwork with the individual and family toovercome barriers or redefine goals asappropriate. Diabetes self-managementeducation and support requires peri-odic reassessment, especially as theyouth grows, develops, and acquires theneed for greater independent self-careskills. In addition, it is necessary to as-sess the educational needs and skills ofday careproviders, schoolnurses, orotherschool personnel who participate in thecare of the child with diabetes (9).

Nutrition Therapy

Recommendations

13.2 Individualized medical nutritiontherapy is recommended forchildren and adolescents withtype 1 diabetes as an essentialcomponent of the overall treat-ment plan. A

13.3 Monitoring carbohydrate in-take, whether by carbohydratecounting or experience-basedestimation, is key to achievingoptimal glycemic control. B

13.4 Comprehensive nutrition edu-cation at diagnosis, with annualupdates, by an experienced reg-istered dietitian nutritionist isrecommended to assess caloricand nutrition intake in relationto weight status and cardiovas-cular disease risk factors and toinformmacronutrient choices. E

Dietary management should be individ-ualized: family habits, food preferences,religious or cultural needs, finances,schedules, physical activity, and the pa-tient’s and family’s abilities in numeracy,literacy, and self-management should beconsidered. Visits with a registered di-etitian nutritionist should include assess-ment for changes in food preferencesover time, access to food, growth anddevelopment, weight status, cardiovas-cular risk, and potential for eating dis-orders. Dietary adherence is associatedwith better glycemic control in youthwith type 1 diabetes (10).

Physical Activity and Exercise

Recommendations

13.5 Exercise is recommended for allyouth with type 1 diabetes withthe goal of 60 min of moderate-to-vigorous intensity aerobicactivity daily, with vigorousmuscle-strengthening and bone-strengthening activities at least3 days per week. C

13.6 Education about frequent pat-terns of glycemia during andafter exercise, which may in-clude initial transient hyperglyce-mia followed by hypoglycemia,is essential. Families shouldalso receive education on pre-vention and management ofhypoglycemia during and afterexercise, including ensuringpatients have a preexercise glu-cose level of 90–250 mg/dL (5.0–13.9 mmol/L) and accessiblecarbohydrates before engagingin activity, individualized accord-ing to the type/intensity of theplanned physical activity. E

13.7 Patients should be educated onstrategies to prevent hypoglyce-mia during exercise, after exercise,and overnight following exercise,which may include reducing pran-dial insulin dosing for the meal/snack preceding (and, if needed,following) exercise, reducing basalinsulin doses, increasing carbohy-drate intake, eating bedtimesnacks, and/or using continuousglucose monitoring. C

13.8 Frequent glucose monitoringbefore, during, and after exer-cise, with or without use ofcontinuous glucose monitoring,is important to prevent, detect,and treat hypoglycemia and hy-perglycemia with exercise. C

Exercisepositivelyaffects insulin sensitivity,physical fitness, strength building, weightmanagement, social interaction, mood,self-esteem building, and creation ofhealthful habits for adulthood, but italso has the potential to cause bothhypoglycemia and hyperglycemia.

See below for strategies to mitigatehypoglycemia risk and minimize hyper-glycemia with exercise. For an in-depthdiscussion, see recently published re-views and guidelines (11–13).

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Overall, it is recommended thatyouth with type 1 diabetes participatein60minofmoderate (e.g., briskwalking,dancing) to vigorous (e.g., running, jump-ing rope) intensity aerobic activity daily,including resistance and flexibility train-ing (14). Although uncommon in thepediatric population, patients shouldbe medically evaluated for comorbidconditions or diabetes complicationsthat may restrict participation in anexercise program. As hyperglycemia canoccur before, during, and after physi-cal activity, it is important to ensurethat the elevated glucose level is notrelated to insulin deficiency that wouldlead to worsening hyperglycemia withexercise and ketosis risk. Intense activ-ity should be postponed with markedhyperglycemia (glucose $350 mg/dL[19.4 mmol/L]), moderate to large urineketones, and/or b-hydroxybutyrate(B-OHB) .1.5 mmol/L. Caution maybe needed when B-OHB levels are$0.6 mmol/L (10,11).The prevention and treatment of

hypoglycemia associated with physicalactivity include decreasing the pran-dial insulin for the meal/snack beforeexercise and/or increasing food intake.Patients on insulin pumps can lowerbasal rates by ;10–50% or more orsuspend for 1–2 h during exercise (15).Decreasing basal rates or long-actinginsulin doses by ;20% after exercisemay reduce delayed exercise-induced hy-poglycemia (16). Accessible rapid-actingcarbohydrates and frequent blood glu-cose monitoring before, during, andafter exercise, with or without contin-uous glucose monitoring, maximizesafety with exercise.Blood glucose targets prior to exercise

should be 90–250 mg/dL (5.0–13.9mmol/L). Consider additional carbo-hydrate intake during and/or afterexercise, depending on the durationand intensity of physical activity, toprevent hypoglycemia. For low-to-moderate intensity aerobic activities(30–60 min), and if the patient isfasting, 10–15 g of carbohydratemay prevent hypoglycemia (17). Afterinsulin boluses (relative hyperinsuli-nemia), consider 0.5–1.0 g of carbohy-drates/kg per hour of exercise (;30–60 g), which is similar to carbohydraterequirements to optimize performancein athletes without type 1 diabetes(18–20).

In addition, obesity is as common inchildren and adolescents with type 1diabetes as in those without diabetes.It is associated with higher frequency ofcardiovascular risk factors, and it dispro-portionately affects racial/ethnic minor-ities in the U.S. (21–25). Therefore,diabetes care providers should monitorweight status and encourage a healthydiet, exercise, and healthy weight as keycomponents of pediatric type 1 diabetescare.

School and Child CareAs a large portion of a child’s day is spentin school, close communication with andthe cooperation of school or day carepersonnel are essential for optimal di-abetes management, safety, and maxi-mal academic opportunities. Refer to theADA position statements “Diabetes Carein the School Setting” (26) and “Care ofYoung Children With Diabetes in theChild Care Setting” (27) for additionaldetails.

Psychosocial Issues

Recommendations

13.9 At diagnosis and during rou-tine follow-up care, assess psy-chosocial issues and familystresses that could impact di-abetes management and pro-vide appropriate referrals totrained mental health profes-sionals, preferably experi-enced in childhood diabetes. E

13.10 Mental health professionalsshould be considered inte-gral members of the pediat-ric diabetes multidisciplinaryteam. E

13.11 Encourage developmentallyappropriate family involve-ment in diabetesmanagementtasks for children and adoles-cents, recognizing that prema-ture transfer of diabetes careto the child can result in di-abetes burnout nonadherenceand deterioration in glycemiccontrol. A

13.12 Providers should considerasking youth and their par-ents about social adjustment(peer relationships) and schoolperformance to determinewhether further interventionis needed. B

13.13 Assess youth with diabetes forpsychosocial and diabetes-related distress, generally start-ing at 7–8 years of age. B

13.14 Offer adolescents time bythemselves with their careprovider(s) starting at age 12years, or when developmen-tally appropriate. E

13.15 Starting at puberty, precon-ception counseling should beincorporated into routine di-abetes care for all girls of child-bearing potential. A

13.16 Begin screening youth withtype 1 diabetes for eating dis-orders between 10 and 12years of age. The Diabetes Eat-ing Problems Survey-Revised(DEPS-R) is a reliable, valid,and brief screening tool foridentifying disturbed eatingbehavior. B

Rapid and dynamic cognitive, develop-mental, and emotional changes occurduring childhood, adolescence, andemerging adulthood. Diabetes manage-ment during childhood and adolescenceplaces substantial burdens on the youthand family, necessitating ongoing as-sessment of psychosocial status anddiabetes distress in the patient andthe caregiver during routine diabetesvisits (28–34). It is important to considerthe impact of diabetes on quality of lifeas well as the development of mentalhealth problems related to diabetesdistress, fear of hypoglycemia (and hy-perglycemia), symptoms of anxiety, dis-ordered eating behaviors and eatingdisorders, and symptoms of depression(35). Consider assessing youth for di-abetes distress, generally starting at 7 or8 years of age (36). Consider screeningfor depression and disordered eatingbehaviors using available screeningtools (28,37). Early detection of depres-sion, anxiety, eating disorders, andlearning disabilities can facilitate ef-fective treatment options and helpminimize adverse effects on diabetesmanagement and disease outcomes(33,36). There are validated tools,such as the Problem Areas in Diabetes-Teen (PAID-T) and Parent (P-PAID-Teen)(34), that can be used in assessing di-abetes-specific distress in youth start-ing at age 12 years and in their parent

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caregivers. Furthermore, the complex-ities of diabetes management requireongoing parental involvement in carethroughout childhood with develop-mentally appropriate family teamworkbetween the growing child/teen andparent in order to maintain adherenceand to prevent deterioration in glycemiccontrol (38,39). As diabetes-specificfamily conflict is related to pooreradherence and glycemic control, it isappropriate to inquire about suchconflict during visits and to eitherhelp to negotiate a plan for resolutionor refer to an appropriate mentalhealth specialist (40). Monitoring ofsocial adjustment (peer relationships)and school performance can facili-tate both well-being and academicachievement (41). Suboptimal glyce-mic control is a risk factor for under-performance at school and increasedabsenteeism (42).Shared decision-making with youth

regarding the adoption of regimen com-ponents and self-management behav-iors can improve diabetes self-efficacy,adherence, and metabolic outcomes(22,43). Although cognitive abilitiesvary, the ethical position often adoptedis the “mature minor rule,” wherebychildren after age 12 or 13 years whoappear to be “mature” have the right toconsent or withhold consent to generalmedical treatment, except in cases inwhich refusal would significantly endan-ger health (44).Beginning at the onset of puberty or at

diagnosis of diabetes, all adolescent girlsand women with childbearing potentialshould receive education about the risksof malformations associated with poormetabolic control and the use of effectivecontraception to prevent unplanned preg-nancy. Preconception counseling usingdevelopmentally appropriate educa-tional tools enables adolescent girlsto make well-informed decisions (45).Preconception counseling resources tai-lored for adolescents are available at nocost through the ADA (46). Refer to theADApositionstatement“PsychosocialCarefor People With Diabetes” for further de-tails (36).Youth with type 1 diabetes have an

increased risk of disordered eating be-havior as well as clinical eating disorderswith serious short-term and long-termnegative effects on diabetes outcomesand health in general. It is important to

recognize the unique and dangerousdisordered eating behavior of insulinomission for weight control in type 1diabetes (47) using tools such as the Di-abetes Eating Problems Survey-Revised(DEPS-R) to allow for early diagnosisand intervention (37,48–50).

The presence of a mental health pro-fessional on pediatric multidisciplinaryteams highlights the importance of at-tending to the psychosocial issues ofdiabetes. These psychosocial factorsare significantly related to self-manage-ment difficulties, suboptimal glycemiccontrol, reduced quality of life, andhigher rates of acute and chronic di-abetes complications.

Glycemic Control

Recommendations

13.17 The majority of children andadolescents with type 1 diabe-tes should be treated withintensive insulin regimens,either via multiple daily injec-tions or continuous subcuta-neous insulin infusion. A

13.18 All children and adolescentswith type 1 diabetes shouldself-monitorglucose levelsmul-tiple times daily (up to 6–10times/day), including premeal,prebedtime, and as needed forsafety in specific situations suchas exercise, driving, or the pres-ence of symptoms of hypogly-cemia. B

13.19 Continuous glucose monitor-ing (CGM) should be consid-ered in all children andadolescents with type 1 diabe-tes, whether using injectionsor continuous subcutaneousinsulin infusion, as an addi-tional tool to help improveglucose control. Benefits ofCGMcorrelatewith adherenceto ongoing use of the device. B

13.20 Automated insulin deliverysystems appear to improveglycemic control and reducehypoglycemia in children andshould be considered in chil-dren with type 1 diabetes. B

13.21 A1C goals must be individual-ized and reassessed over time.AnA1Cof,7% (53mmol/mol)is appropriate for many chil-dren. B

13.22 Less-stringent A1C goals (suchas,7.5% [58mmol/mol])maybe appropriate for patientswho cannot articulate symp-toms of hypoglycemia; havehypoglycemia unawareness;lack access to analog insulins,advanced insulin delivery tech-nology, and/or continuous glu-cose monitors; cannot checkblood glucose regularly; orhave nonglycemic factors thatincrease A1C (e.g., high glyca-tors). B

13.23 Even less-stringent A1C goals(such as,8% [64 mmol/mol])may be appropriate for pa-tients with a history of severehypoglycemia, limited life ex-pectancy, or extensive comor-bid conditions. B

13.24 Providers may reasonably sug-gest more-stringent A1C goals(such as ,6.5% [48 mmol/mol]) for selected individ-ual patients if they can beachieved without significanthypoglycemia, negative im-pacts on well-being, or undueburden of care, or in thosewho have nonglycemic factorsthat decrease A1C (e.g., lowererythrocyte life span). Lowertargets may also be appropri-ate during the honeymoonphase. B

Current standards for diabetes man-agement reflect the need to lower glu-cose as safely as possible. This should bedone with stepwise goals. When estab-lishing individualized glycemic targets,special consideration should be givento the risk of hypoglycemia in youngchildren (aged ,6 years) who are oftenunable to recognize, articulate, and/ormanage hypoglycemia. However, regis-try data indicate that A1C targets can beachieved in children, including those,6years, without increased risk of severehypoglycemia (51,52). Recent data havedemonstrated that the use of continuousglucose monitors lowered A1C andincreased time in range in adolescentsand young adults, and, in children ,8years old, was associated with lower riskof hypoglycemia (53,54). Please refer toSection 7 “Diabetes Technology” (https://doi.org/10.2337/dc20-S007) for more

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information on the use of blood glucosemeters, continuousglucosemonitors, andinsulin pumps. More information on in-sulin injection technique can be foundin Section 9 “Pharmacologic Approachesto Glycemic Treatment (https://doi.org/10.2337/dc20-S009).”The Diabetes Control and Complica-

tions Trial (DCCT), which did not enrollchildren,13 years of age, demonstratedthat near normalization of blood glucoselevels was more difficult to achieve inadolescents than in adults. Nevertheless,the increased use of basal-bolus regi-mens, insulin pumps, frequent bloodglucose monitoring, goal setting, andimproved patient education in youthfrom infancy through adolescence hasbeen associated with more childrenreaching the blood glucose targets rec-ommended by ADA (55–58), particularlyin patients of families in which both theparents and the child with diabetes par-ticipate jointly to perform the requireddiabetes-related tasks. Furthermore,studies documenting neurocognitiveimaging differences related to hy-perglycemia in children provide an-other motivation for lowering glycemictargets (6).Lower A1C in adolescence and young

adulthood is associated with lower riskand rate of microvascular and macro-vascular complications, as shown in stud-ies in youth (59–62) and in studies thatinclude youth and adults and demon-strate the effects of metabolic memory(63–66).In addition, type 1 diabetes can be

associated with adverse effects on cog-nition during childhood and adoles-cence (6,67,68). DKA has been shownto cause adverse effects on brain de-velopment and function. Additional fac-tors (69–72) that contribute to adverseeffects on brain development and func-tion include young age, severe hypo-glycemia at,6 years of age, and chronichyperglycemia (73,74). However, me-ticulous use of new therapeutic modal-ities such as rapid- and long-actinginsulin analogs, technological advances(e.g., continuous glucosemonitors, low-glucose suspend insulin pumps, andautomated insulin delivery systems), andintensive self-management educationnow make it more feasible to achieveexcellent glycemic control while reduc-ing the incidence of severe hypoglyce-mia (75–84). Intermittently scanned

continuous glucose monitors are notcurrently approved for use in childrenand adolescents. A strong relationshipexists between frequency of blood glu-cose monitoring and glycemic stability(77–86). Recent data with newer devi-ces and insulins indicate that the risk ofhypoglycemia with lower A1C is less thanit was before (52,76,87–94). Some datasuggest that there could be a thresholdwhere lower A1C is associatedwithmorehypoglycemia (95,96); however, the con-fidence intervals were large, suggestinggreat variability.

In selecting glycemic targets, thelong-term health benefits of achieving alower A1C should be balanced againstthe risks of hypoglycemia and the de-velopmental burdens of intensive regi-mens in children and youth. In addition,achieving lower A1C levels is likely fa-cilitated by setting lower A1C targets(51,97). Lower goals may be possibleduring the “honeymoon” phase of type 1diabetes.

Key Concepts in Setting GlycemicTargetsc Targets should be individualized, and

lower targetsmaybe reasonable basedon a benefit-risk assessment.

c Blood glucose targets should bemodified in children with frequenthypoglycemia or hypoglycemia un-awareness.

c Postprandial blood glucose valuesshould be measured when there isa discrepancy between preprandialblood glucose values and A1C levelsand to assess preprandial insulindoses in those on basal-bolus or pumpregimens.

Autoimmune Conditions

Recommendation

13.25 Assess for additional autoim-mune conditions soon afterthe diagnosis of type 1 diabe-tes and if symptomsdevelop.B

Because of the increased frequency ofother autoimmune diseases in type 1diabetes, screening for thyroid dysfunc-tion and celiac disease should be con-sidered (98–102). Periodic screening inasymptomatic individuals has been rec-ommended, but the optimal frequencyof screening is unclear.

Although much less common thanthyroid dysfunction and celiac disease,

other autoimmune conditions, such asAddison disease (primary adrenal insuf-ficiency), autoimmune hepatitis, autoim-mune gastritis, dermatomyositis, andmyasthenia gravis, occur more com-monly in the population with type 1diabetes than in the general pediatricpopulation and should be assessed andmonitored as clinically indicated. In ad-dition, relatives of patients should beoffered testing for islet autoantibodiesthrough research studies (e.g., TrialNet)for early diagnosis of preclinical type 1diabetes (stages 1 and 2).

Thyroid Disease

Recommendations

13.26 Consider testing children withtype 1 diabetes for antithyroidperoxidase and antithyroglob-ulin antibodies soon afterdiagnosis. B

13.27 Measure thyroid-stimulatinghormone concentrations at di-agnosis when clinically stableor soon after glycemic controlhas been established. If nor-mal, suggest rechecking every1–2 years or sooner if thepatient has positive thyroidantibodies or develops symp-toms or signs suggestive ofthyroid dysfunction, thyrome-galy, an abnormal growth rate,or unexplained glycemic vari-ability. B

Autoimmune thyroid disease is themost common autoimmune disorderassociated with diabetes, occurring in17–30% of patients with type 1 diabetes(99,103,104). At the time of diagnosis,;25% of children with type 1 diabe-tes have thyroid autoantibodies (105);their presence is predictive of thyroiddysfunctiondmost commonly hypo-thyroidism, although hyperthyroid-ism occurs in ;0.5% of patients withtype 1 diabetes (106,107). For thyroidautoantibodies, a study from Swedenindicated that antithyroid peroxidaseantibodies were more predictive thanantithyroglobulin antibodies in multi-variate analysis (108). Thyroid functiontests may be misleading (euthyroid sicksyndrome) if performed at the time ofdiagnosis owing to the effect of previoushyperglycemia, ketosis or ketoacidosis,

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weight loss, etc. Therefore, if performedat diagnosis and slightly abnormal, thy-roid function tests should be repeatedsoon after a period ofmetabolic stabilityand achievement of glycemic targets.Subclinical hypothyroidism may beassociated with increased risk of symp-tomatic hypoglycemia (109) and reducedlinear growth rate. Hyperthyroidismalters glucose metabolism and usu-ally causes deterioration of glycemiccontrol.

Celiac Disease

Recommendations

13.28 Screen children with type 1diabetes for celiac disease bymeasuring IgA tissue transglu-taminase (tTG) antibodies,with documentation of normaltotal serum IgA levels, soonafter the diagnosis of diabetes,or IgG to tTG and deamida-ted gliadin antibodies if IgAdeficient. B

13.29 Repeat screening within2 years of diabetes diagno-sis and then again after5 years and consider morefrequent screening in chil-dren who have symptomsor a first-degree relative withceliac disease. B

13.30 Individuals with biopsy-confirmed celiac disease shouldbe placed on a gluten-freediet for treatment and to avoidcomplications; they should alsohave a consultation with a die-titian experienced in manag-ing both diabetes and celiacdisease. B

Celiac disease is an immune-mediateddisorder that occurs with increased fre-quency in patients with type 1 diabe-tes (1.6–16.4% of individuals comparedwith 0.3–1% in the general population)(98,101,102,110–114). Screening pa-tients with type 1 diabetes for celiacdisease is further justified by its associ-ation with osteoporosis, iron deficiency,growth failure, and potential increasedrisk of retinopathy and albuminuria(115–118).Screening for celiac disease includes

measuring serum levels of IgA and tissuetransglutaminase antibodies, or, with

IgA deficiency, screening can includemeasuring IgG tissue transglutaminaseantibodies or IgG deamidated gliadinpeptide antibodies. Because most casesof celiac disease are diagnosed withinthe first 5 years after the diagnosis oftype 1 diabetes, screening should beconsidered at the time of diagnosis andrepeated at 2 and then 5 years (112) orif clinical symptoms indicate, such aspoor growth or increased hypoglycemia(113,115).

Although celiac disease can be di-agnosed more than 10 years after di-abetes diagnosis, there are insufficientdata after 5 years to determine theoptimal screening frequency. Measure-ment of tissue transglutaminase anti-body should be considered at othertimes in patients with symptoms sug-gestive of celiac disease (112). Moni-toring for symptoms should includeassessment of linear growth and weightgain (113,115). A small bowel biopsyin antibody-positive children is recom-mended to confirm the diagnosis (119).European guidelines on screening forceliac disease in children (not specific tochildren with type 1 diabetes) suggestthat biopsy may not be necessary insymptomatic children with high anti-body titers (i.e., greater than 10 timesthe upper limit of normal) provided thatfurther testing is performed (verifica-tion of endomysial antibody positivityon a separate blood sample). Whetherthis approach may be appropriatefor asymptomatic children in high-risk groups remains an open question,though evidence is emerging (120).It is also advisable to check for celiacdisease–associated HLA types in pa-tients who are diagnosed without asmall intestinal biopsy. In symptomaticchildren with type 1 diabetes and con-firmed celiac disease, gluten-free dietsreduce symptoms and rates of hypogly-cemia (121).The challenging dietary re-strictions associated with having bothtype 1 diabetes and celiac diseaseplace a significant burden on individuals.Therefore, a biopsy to confirm the di-agnosis of celiac disease is recommen-ded, especially in asymptomatic children,before establishing a diagnosis of celiacdisease (122) and endorsing significantdietary changes. A gluten-free diet wasbeneficial in asymptomatic adults withpositive antibodies confirmed by biopsy(123).

Management of Cardiovascular RiskFactors

Hypertension Screening

Recommendations

13.31 Blood pressure should bemea-sured at each routine visit. Chil-dren found to have elevatedblood pressure (systolic bloodpressure or diastolic bloodpressure $90th percentile forage, sex, and height or, inadolescents$13 years, systolicbloodpressure 120–129mmHgwith diastolic blood pressure,80 mmHg) or hypertension(systolic blood pressure or di-astolic blood pressure $95thpercentile for age, sex, andheight or, in adolescents $13years, systolic blood pressure$130 mmHg or diastolic bloodpressure $80 mmHg) shouldhave elevated blood pressureconfirmed on three separatedays. B

Hypertension Treatment

Recommendations

13.32 Initial treatment of elevatedblood pressure (systolic bloodpressure or diastolic bloodpressure consistently $90thpercentile for age, sex, andheight or $120/80 mmHg inadolescents $13 years) in-cludes dietary modificationand increased exercise, if ap-propriate, aimed at weightcontrol. If target blood pres-sure is not reached within 3–6months of initiating lifestyleintervention, pharmacologictreatment should be consid-ered. E

13.33 In addition to lifestyle modifi-cation, pharmacologic treat-ment of hypertension (systolicbloodpressureordiastolicbloodpressureconsistently$95thper-centile for age, sex, andheight or$140/90 mmHg in adolescents$13years) shouldbeconsideredas soon as hypertension is con-firmed. E

13.34 ACE inhibitors or angioten-sin receptor blockers shouldbe considered for the initialpharmacologic treatment of

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hypertension E in childrenand adolescents, followingreproductive counseling dueto the potential teratogeniceffects of both drug classes. E

13.35 The goal of treatment is bloodpressure consistently ,90thpercentile for age, sex, andheight or ,120/,80 mmHgin children $13 years. E

Blood pressure measurements shouldbe performed using the appropriate sizecuff with the child seated and relaxed.Hypertension should be confirmed on atleast three separate days. Evaluationshould proceed as clinically indicated(124). Treatment is generally initiatedwith an ACE inhibitor, but an angiotensinreceptor blocker can be used if the ACEinhibitor is not tolerated (e.g., due tocough) (125).

Dyslipidemia Testing

Recommendations

13.36 Initial lipid testing should beperformed when initial glyce-mic control has been achievedand age is $2 years. If initialLDL cholesterol is#100mg/dL(2.6mmol/L), subsequent test-ing should be performed at9-11 years of age. B Initialtesting may be done witha nonfasting non-HDL choles-terol level with confirmatorytesting with a fasting lipidpanel.

13.37 If LDL cholesterol values arewithin the accepted risk level(,100 mg/dL [2.6 mmol/L]), alipid profile repeated every3 years is reasonable. E

Dyslipidemia Treatment

Recommendations

13.38 If lipids are abnormal, initialtherapy should consist of op-timizing glucose control andmedical nutrition therapy tolimit the amount of caloriesfrom fat to 25–30%, saturatedfat to,7%, cholesterol,200mg/day, avoidance of transfats, and aim for ;10% calo-ries from monounsaturatedfats. A

13.39 After the age of 10 years, addi-tion of a statin may be consid-ered in patients who, despitemedical nutrition therapy andlifestyle changes, continue tohave LDL cholesterol .160mg/dL (4.1 mmol/L) or LDLcholesterol .130 mg/dL (3.4mmol/L) and one or more car-diovascular disease risk factors,following reproductive counsel-ing because of the potentialteratogenic effects of statins. E

13.40 The goal of therapy is an LDLcholesterol value,100 mg/dL(2.6 mmol/L). E

Population-based studies estimate that14–45% of children with type 1 diabe-tes have two or more atheroscleroticcardiovascular disease (ASCVD) riskfactors (126–128), and the prevalenceof cardiovascular disease (CVD) risk factorsincreases with age (128) and among racial/ethnic minorities (21), with girls having ahigher risk burden than boys (127).Pathophysiology.The atherosclerotic pro-cess begins in childhood, and althoughASCVD events are not expected to occurduring childhood, observations using avariety of methodologies show thatyouth with type 1 diabetes may havesubclinical CVD within the first decade ofdiagnosis (129–131). Studies of carotidintima-media thickness have yielded in-consistent results (124,125).Screening. Diabetes predisposes to de-velopment of accelerated arteriosclero-sis. Lipid evaluation for these patientscontributes to risk assessment and iden-tifies an important proportion of thosewith dyslipidemia. Therefore, initialscreening should be done soon afterdiagnosis. If the initial screen is normal,subsequent screening may be done at9–11 years of age, which is a stable timefor lipid assessment in children (132).Non-HDL cholesterol level has beenidentified as a significant predictor ofthe presence of atherosclerosisdas pow-erful as any other lipoprotein cholesterolmeasure in children and adolescents. Forboth children and adults, non-HDL cho-lesterol level seems to bemore predictiveof persistent dyslipidemia and, therefore,atherosclerosis and future events thantotal cholesterol, LDL cholesterol, or HDLcholesterol levels alone. A major advan-tage of non-HDL cholesterol is that it can

be accurately calculated in a nonfastingstate and is therefore practical to obtainin clinical practice as a screening test(133). Youth with type 1 diabetes have ahigh prevalence of lipid abnormalities(126,134).

Even if normal, screening should berepeated within 3 years, as glycemiccontrol and other cardiovascular riskfactors can change dramatically duringadolescence (135).Treatment. Pediatric lipid guidelines pro-vide some guidance relevant to childrenwith type 1 diabetes (124,132,136,137);however, there are few studies onmodifying lipid levels in children withtype 1 diabetes. A 6-month trial of di-etary counseling produced a signifi-cant improvement in lipid levels (138);likewise, a lifestyle intervention trialwith 6 months of exercise in adoles-cents demonstrated improvement inlipid levels (139). Data from the SEARCHfor Diabetes in Youth (SEARCH) studyshow that improved glucose over a 2-yearperiod is associated with a more favor-able lipid profile; however, improved gly-cemia alone will not normalize lipids inyouth with type 1 diabetes and dys-lipidemia (135).

Although intervention data are sparse,the American Heart Association catego-rizes children with type 1 diabetes in thehighest tier for cardiovascular risk andrecommends both lifestyle and pharma-cologic treatment for thosewithelevatedLDL cholesterol levels (137,140). Initialtherapy should be with a nutrition planthat restricts saturated fat to 7% of to-tal calories and dietary cholesterol to200 mg/day. Data from randomized clin-ical trials in children as youngas 7monthsof age indicate that this diet is safe anddoes not interfere with normal growthand development (141).

Neither long-term safety nor cardio-vascular outcome efficacy of statin ther-apy has been established for children;however, studies have shown short-termsafety equivalent to that seen in adultsand efficacy in lowering LDL cholesterollevels in familial hypercholesterolemia orsevere hyperlipidemia, improving endo-thelial function and causing regressionof carotid intimal thickening (142,143).Statins are not approved for patientsaged ,10 years, and statin treatmentshould generally not be used in chil-dren with type 1 diabetes before thisage. Statins are contraindicated in

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pregnancy; therefore, prevention of un-planned pregnancies is of paramount im-portance for postpubertal girls (seeSection 14 “Management of Diabetes inPregnancy,” https://doi.org/10.2337/dc20-S014, for more information). The multi-center, randomized, placebo-controlledAdolescent Type 1 Diabetes Cardio-RenalIntervention Trial (AdDIT) provides safetydata on pharmacologic treatment withan ACE inhibitor and statin in adolescentswith type 1 diabetes.

Smoking

Recommendations

13.41 Elicit a smoking history at initialand follow-up diabetes visits;discourage smoking in youthwhodo not smoke and encour-age smoking cessation in thosewho do smoke. A

13.42 E-cigarette use should be dis-couraged. A

The adverse health effects of smokingare well recognized with respect to fu-ture cancer and CVD risk. Despite this,smoking rates are significantly higheramong youth with diabetes than amongyouth without diabetes (144,145). Inyouth with diabetes, it is important toavoid additional CVD risk factors. Smok-ing increases the risk of onset of albu-minuria; therefore, smoking avoidance isimportant to prevent both microvascu-lar and macrovascular complications(132,146). Discouraging cigarette smok-ing, including e-cigarettes (147,148), isan important part of routine diabetescare. In light of recent Centers for Dis-ease Control and Prevention evidenceof deaths related to e-cigarette use(149,150), no persons should be advisedtousee-cigarettes, eitherasaway to stopsmoking tobacco or as a recreationaldrug. In younger children, it is importantto assess exposure to cigarette smoke inthe home because of the adverse effectsof secondhand smoke and to discourageyouth from ever smoking if exposed tosmokers in childhood.

Microvascular Complications

Nephropathy Screening

Recommendations

13.43 Annual screening for albumin-uria with a random (morningsample preferred to avoid

effects of exercise) spot urinesampleforalbumin-to-creatinineratio should be considered atpuberty or at age .10 years,whichever is earlier, once thechild has had diabetes for 5years. B

Nephropathy Treatment

Recommendations

13.44 An ACE inhibitor or an angio-tensin receptor blocker, titratedto normalization of albumin ex-cretion,maybeconsideredwhenelevated urinary albumin-to-creatinine ratio (.30 mg/g) isdocumented (twoof threeurinesamples obtained over a 6-month interval following ef-forts to improve glycemiccontrol and normalize bloodpressure). E

Data from 7,549 participants ,20 yearsof age in the T1D Exchange clinic reg-istry emphasize the importance ofgood glycemic and blood pressure con-trol, particularly as diabetes durationincreases, in order to reduce the riskof diabetic kidney disease. The data alsounderscore the importance of routinescreening to ensure early diagnosis andtimely treatment of albuminuria (151).An estimation of glomerular filtrationrate (GFR), calculated using GFR estimat-ing equations from the serum creatinine,height, age, and sex (152), should beconsidered at baseline and repeated asindicated based on clinical status, age,diabetes duration, and therapies. Im-proved methods are needed to screenfor early GFR loss, since estimated GFR isinaccurate at GFR .60 mL/min/1.73 m2

(152,153). The AdDIT study in adoles-centswith type 1 diabetes demonstratedsafety of ACE inhibitor treatment, but thetreatment did not change the albumin-to-creatinine ratio over the course of thestudy (124).

Retinopathy

Recommendations

13.45 An initial dilated and compre-hensive eye examination is rec-ommended once youth havehad type 1 diabetes for 3–5years, provided they are aged

$11 years or puberty hasstarted, whichever is earlier.B

13.46 After the initial examination,repeat dilated and compre-hensive eye examination every2 years. Less frequent exami-nations, every 4 years, maybe acceptable on the adviceof an eye care professionaland based on risk factor as-sessment, including a historyof glycemic control with A1C,8%. B

Retinopathy (like albuminuria) mostcommonly occurs after the onset ofpuberty and after 5–10 years of diabetesduration (154). It is currently recognizedthat there is low risk of development ofvision-threatening retinal lesions prior to12 years of age (155,156). A 2019 publi-cation based on the follow-up of theDCCT adolescent cohort supports lowerfrequency of eye examinations than pre-viously recommended, in particular inadolescents with A1C closer to the tar-get range (157,158). Referrals shouldbe made to eye care professionalswith expertise in diabetic retinopathyand experience in counseling pediatricpatients and families on the importanceof prevention, early detection, and in-tervention.

Neuropathy

Recommendation

13.47 Consider an annual compre-hensive foot exam at the startof puberty or at age$10 years,whichever is earlier, once theyouth has had type 1 diabetesfor 5 years. B

Diabetic neuropathy rarely occurs inprepubertal children or after only 1–2years of diabetes (154), although datasuggest a prevalence of distal peripheralneuropathy of 7% in 1,734 youth withtype 1 diabetes and associated with thepresence of CVD risk factors (159,160). Acomprehensive foot exam, including in-spection, palpation of dorsalis pedis andposterior tibial pulses, and determina-tion of proprioception, vibration, andmonofilament sensation, should be per-formed annually along with an assess-ment of symptoms of neuropathic pain(160). Foot inspection can be performedat each visit to educate youth regarding

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the importance of foot care (see Sec-tion 11 “Microvascular Complicationsand Foot Care,” https://doi.org/10.2337/dc20-S011).

TYPE 2 DIABETES

For information on testing for type 2diabetes and prediabetes in childrenand adolescents, please refer to Sec-tion 2 “Classification and Diagnosisof Diabetes” (https://doi.org/10.2337/dc20-S002). For additional support forthese recommendations, see the ADAposition statement “Evaluation andMan-agement of Youth-Onset Type 2 Di-abetes” (2).Type 2 diabetes in youth has increased

over the past 20 years, and recent esti-mates suggest an incidence of ;5,000new cases per year in the U.S. (161). TheCenters for Disease Control and Preven-tion published projections for type 2diabetes prevalence using the SEARCHdatabase; assuming a 2.3% annual in-crease, the prevalence in those under20 years of agewill quadruple in 40 years(162,163).Evidence suggests that type 2 diabetes

in youth is different not only from type 1diabetes but also from type 2 diabe-tes in adults and has unique features,such as amore rapidly progressive declinein b-cell function and accelerated de-velopment of diabetes complications(2,164).Type 2 diabetes disproportion-ately impacts youth of ethnic and ra-cial minorities and can occur in complexpsychosocial and cultural environments,which may make it difficult to sustainhealthy lifestyle changes and self-management behaviors (22,165–168).Additional risk factors associated withtype2diabetes in youth include adiposity,family history of diabetes, female sex, andlow socioeconomic status (164).As with type 1 diabetes, youth with

type 2 diabetes spendmuch of the day inschool. Therefore, close communicationwith and the cooperation of school per-sonnel are essential for optimal diabetesmanagement, safety, and maximal aca-demic opportunities.

Screening and Diagnosis

Recommendations

13.48 Risk-based screening for pre-diabetes and/or type 2 diabe-tes should be considered in

children and adolescents afterthe onset of puberty or $10years of age, whichever oc-curs earlier, with overweight(BMI$85thpercentile)orobe-sity (BMI$95thpercentile)andwho have one or more addi-tional risk factors for diabetes(see Table 2.4 for evidencegrading of other risk factors).

13.49 If tests are normal, repeat test-ing at a minimum of 3-yearintervals E, or more frequentlyif BMI is increasing. C

13.50 Fasting plasma glucose, 2-hplasma glucose during a 75-goral glucose tolerance test, andA1C can be used to test forprediabetes or diabetes in chil-dren and adolescents. B

13.51 Children and adolescents withoverweight orobesity inwhomthe diagnosis of type 2 diabe-tes is being considered shouldhave a panel of pancreaticautoantibodies tested to ex-clude the possibility of auto-immune type 1 diabetes. B

In the last decade, the incidenceand prevalence of type 2 diabetes inadolescents has increased dramatically,especially in racial and ethnic minoritypopulations (132,169). A few recentstudies suggest oral glucose tolerancetests or fasting plasma glucose values asmore suitable diagnostic tests than A1Cin the pediatric population, especiallyamong certain ethnicities (170), al-though fasting glucose alone may over-diagnose diabetes in children (171,172).In addition,manyof these studies donotrecognize that diabetes diagnostic cri-teria are based on long-term healthoutcomes, and validations are not cur-rently available in the pediatric popu-lation (173). ADA acknowledges thelimited data supporting A1C for diag-nosing type 2 diabetes in children andadolescents. Although A1C is not rec-ommended for diagnosis of diabetes inchildrenwith cysticfibrosis or symptomssuggestive of acute onset of type 1 di-abetes, and only A1C assays withoutinterference are appropriate for chil-dren with hemoglobinopathies, ADAcontinues to recommend A1C fordiagnosis of type 2 diabetes in thispopulation (174,175).

Diagnostic Challenges

Given the current obesity epidemic, dis-tinguishing between type 1 and type 2diabetes in children can be difficult.Overweight and obesity are commonin children with type 1 diabetes (23),and diabetes-associated autoantibodiesand ketosis may be present in pediatricpatients with features of type 2 diabetes(including obesity and acanthosis nigri-cans) (171). The presence of islet auto-antibodies has been associated withfaster progression to insulin deficiency(171). At onset, DKA occurs in ;6% ofyouth aged 10–19 years with type 2 di-abetes (176). Althoughuncommon, type2diabetes has been observed in prepuber-tal childrenunder theageof10, andthus itshould be part of the differential in chil-dren with suggestive symptoms (177).Finally, obesity (178) contributes to thedevelopment of type 1 diabetes in someindividuals, which further blurs the linesbetween diabetes types. However, accu-rate diagnosis is critical, as treatment regi-mens, educational approaches, dietaryadvice, and outcomes differ markedly be-tween patients with the two diagnoses.The significant diagnostic difficultiesposed by MODY are discussed in sec-tion 2 “Classification and Diagnosis ofDiabetes” (https://doi.org/10.2337/dc20-S002). In addition, there are rare andatypical diabetes cases that representa challenge for clinicians and researchers.

Management

Lifestyle Management

Recommendations

13.52 All youth with type 2 diabetesand their families should re-ceive comprehensive diabe-tes self-management educationand support that is specificto youth with type 2 diabe-tes and is culturally compe-tent. B

13.53 Youth with overweight/obesityand type 2 diabetes and theirfamilies should be providedwith developmentally andculturally appropriate compre-hensive lifestyle programs thatare integrated with diabetesmanagement to achieve 7–10%decrease in excess weight. C

13.54 Given the necessity of long-term weight management forchildren and adolescents with

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type 2 diabetes, lifestyle inter-vention should be based ona chronic care model and of-fered in the context of diabe-tes care. E

13.55 Youth with diabetes, like allchildren, should beencouragedto participate in at least 30–60min of moderate-to-vigorousphysical activity at least 5 daysper week (and strength train-ing on at least 3 days/week) Band to decrease sedentary be-havior. C

13.56 Nutrition for youth with type2 diabetes, like for all chil-dren, should focus on healthyeating patterns that empha-size consumption of nutrient-dense, high-quality foods anddecreased consumption of cal-orie-dense,nutrient-poor foods,particularly sugar-addedbever-ages. B

Glycemic Targets

Recommendations

13.57 Home self-monitoring of bloodglucose regimens should be in-dividualized, taking into consid-eration the pharmacologictreatment of the patient. E

13.58 A1C should bemeasured every3 months. E

13.59 A reasonable A1C target formost children and adolescentswith type 2 diabetes treatedwith oral agents alone is,7% (53 mmol/mol). Morestringent A1C targets (suchas ,6.5% [48 mmol/mol])may be appropriate for se-lected individual patients ifthey can be achieved withoutsignificant hypoglycemia orother adverse effects of treat-ment.Appropriatepatientsmightinclude those with short dura-tion of diabetes and lesserdegrees of b-cell dysfunctionand patients treated with life-style or metformin only whoachieve significant weight im-provement. E

13.60 Less-stringent A1C goals (suchas 7.5% [58 mmol/mol]) maybe appropriate if there is in-creased risk of hypoglycemia. E

13.61 A1C targets for patients oninsulin should be individual-ized, taking into account therelatively low rates of hypogly-cemia in youth-onset type 2diabetes. E

Pharmacologic Management

Recommendations

13.62 Initiate pharmacologic therapy,in addition to lifestyle therapy,at diagnosis of type 2 diabetes.A

13.63 In incidentally diagnosed ormetabolically stable patients(A1C ,8.5% [69 mmol/mol] andasymptomatic),metforministheinitial pharmacologic treatmentof choice if renal function isnormal. A

13.64 Youth with marked hypergly-cemia (blood glucose $250mg/dL [13.9 mmol/L], A1C$8.5% [69 mmol/mol]) with-out acidosis at diagnosis whoare symptomatic with polyuria,polydipsia, nocturia, and/orweight loss should be treatedinitiallywith basal insulinwhilemetformin is initiated and ti-trated. B

13.65 In patients with ketosis/ketoacidosis, treatment withsubcutaneous or intravenousinsulin should be initiated torapidly correct the hypergly-cemia and the metabolic de-rangement. Once acidosis isresolved, metformin should beinitiated while subcutane-ous insulin therapy is contin-ued. A

13.66 In individuals presenting withsevere hyperglycemia (bloodglucose $600 mg/dL [33.3mmol/L]), consider assessmentfor hyperglycemic hyperosmo-lar nonketotic syndrome. A

13.67 If glycemic targets are nolonger met with metformin(with or without basal insu-lin), liraglutide (a glucagon-likepeptide 1 receptor agonist)therapy should be consideredin children 10 years of age orolder if they have no pastmedical history or family his-tory of medullary thyroid

carcinoma or multiple endo-crine neoplasia type 2. A

13.68 Patients treated with basal in-sulin up to 1.5 units/kg/daywho do not meet A1C targetshould be moved to multipledaily injections with basal andpremeal bolus insulins. E

13.69 In patients initially treated withinsulin and metformin who aremeeting glucose targets basedon home blood glucose moni-toring, insulin can be taperedover 2–6 weeks by decreasingthe insulin dose 10–30% everyfew days. B

13.70 Use of medications not ap-proved by the U.S. Food andDrug Administration for youthwith type 2 diabetes is notrecommended outside of re-search trials. B

Treatment of youth-onset type 2 diabe-tes should include lifestyle management,diabetes self-management education,and pharmacologic treatment. Initialtreatment of youth with obesity anddiabetes must take into account thatdiabetes type is often uncertain in thefirst few weeks of treatment, due tooverlap in presentation, and that a sub-stantial percentage of youth with type 2diabetes will present with clinically sig-nificant ketoacidosis (180). Therefore,initial therapy should address the hyper-glycemia and associated metabolic de-rangements irrespective of ultimatediabetes type, with adjustment of ther-apy once metabolic compensation hasbeen established and subsequent infor-mation, such as islet autoantibody results,becomes available. Figure 13.1 providesan approach to initial treatment of new-onset diabetes in youth with overweightor obesity.

Glycemic targets should be individu-alized, taking into consideration long-term health benefits of more stringenttargets and risk for adverse effects,such as hypoglycemia. A lower targetA1C in youth with type 2 diabetes whencompared with those recommendedin type 1 diabetes is justified by lowerrisk of hypoglycemia and higher risk ofcomplications (181–184).

Patients and their families must pri-oritize lifestyle modifications suchas eating a balanced diet, achieving

S172 Children and Adolescents Diabetes Care Volume 43, Supplement 1, January 2020

and maintaining a healthy weight, andexercising regularly. A family-centeredapproach to nutrition and lifestylemodification is essential in childrenwith type 2 diabetes, and nutrition rec-ommendations should be culturally ap-propriate and sensitive to familyresources (see Section 5 “FacilitatingBehavior Change and Well-being to Im-prove Health Outcomes,” https://doi.org/10.2337/dc20-S005). Given the com-plex social and environmental contextsurrounding youth with type 2 diabetes,individual-level lifestyle interventionsmaynot be sufficient to target the complexinterplay of family dynamics,mental health,community readiness, and the broaderenvironmental system (2).A multidisciplinary diabetes team,

including a physician, diabetes nurseeducator, registered dietitian, and psy-chologist or social worker, is essential.In addition to achieving glycemic tar-gets and self-management education

(185–187), initial treatment must includemanagement of comorbidities such asobesity, dyslipidemia, hypertension, andmicrovascular complications.

Current pharmacologic treatment op-tions for youth-onset type 2 diabetesare limited to three approved drugsdinsulin, metformin, and liraglutide (2).Presentation with ketoacidosis or markedketosis requires a period of insulin ther-apy until fasting and postprandial glyce-mia have been restored to normal ornear-normal levels. Metformin therapymay be used as an adjunct after resolu-tion of ketosis/ketoacidosis. Initial treat-ment should also be with insulin whenthe distinction between type 1 diabetesand type 2 diabetes is unclear and inpatients who have random blood glu-cose concentrations $250 mg/dL (13.9mmol/L)and/orA1C$8.5%(69mmol/mol)(188).

When insulin treatment is notrequired, initiation of metformin is

recommended. The Treatment Optionsfor Type 2 Diabetes in Adolescents andYouth (TODAY) study found that metfor-min alone provided durable glycemiccontrol (A1C #8% [64 mmol/mol] for6 months) in approximately half of thesubjects (189). The RISE Consortiumstudy did not demonstrate differencesinmeasures of glucose orb-cell functionpreservation between metformin andinsulin, but there was more weight gainwith insulin (190).

To date, the TODAY study is the onlytrial combining lifestyle and metformintherapy in youth with type 2 diabetes;the combination did not perform betterthan metformin alone in achieving du-rable glycemic control (189).

A recent randomized clinical trial inchildren aged 10–17 years with type 2diabetes demonstrated the addition ofsubcutaneous liraglutide (up to 1.8 mgdaily) to metformin (with or withoutbasal insulin) as safe and effective to

Figure 13.1—Management of new-onset diabetes in youth with overweight or obesity. A1C 8.5%5 69 mmol/mol. Adapted from the ADA positionstatement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (2). DKA, diabetic ketoacidosis; HHNK, hyperosmolar hyperglycemicnonketotic syndrome; MDI, multiple daily injections.

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decrease A1C (estimated decrease of1.06 percentage points at 26 weeksand 1.30 at 52 weeks), although it didincrease the frequency of gastrointesti-nal side effects (191). In June 2019, theU.S. Food and Drug Administration ap-proved liraglutide injection for treatmentof pediatric patients aged 10 years orolder with type 2 diabetes (192).

Metabolic Surgery

Recommendations

13.71 Metabolic surgerymay be con-sidered for the treatment ofadolescents with type 2 diabe-tes who are markedly obese(BMI.35 kg/m2) andwho haveuncontrolled glycemia and/orserious comorbidities despitelifestyle and pharmacologicintervention. A

13.72 Metabolic surgery should beperformed only by an experi-enced surgeon working as partof a well-organized and en-gaged multidisciplinary teamincluding a surgeon, endocri-nologist, nutritionist, behavioralhealth specialist, and nurse. A

The results of weight-loss and lifestyleinterventions for obesity in children andadolescents have been disappointing,and no effective and safe pharmacologicintervention is available or approved bythe U.S. Food and Drug Administration inyouth. Over the last decade, weight-losssurgery has been increasingly performedin adolescents with obesity. Small retro-spective analyses and a recent prospec-tive multicenter nonrandomized studysuggest that bariatric or metabolic sur-gery may have benefits in obese adoles-cents with type 2 diabetes similar tothose observed in adults. Teenagers ex-perience similar degrees of weight loss,diabetes remission, and improvement ofcardiometabolic risk factors for at least3 years after surgery (193). No random-ized trials, however, have yet comparedthe effectiveness and safety of surgeryto those of conventional treatmentoptions in adolescents (194). The guide-lines used as an indication for metabolicsurgery in adolescents generally includeBMI .35 kg/m2 with comorbidities orBMI .40 kg/m2 with or without comor-bidities (195–206). A number of grou-ps, including the Pediatric BariatricStudy Group and the Teen Longitudinal

Assessment of Bariatric Surgery (Teen-LABS) Study, have demonstrated the ef-fectiveness of metabolic surgery in ado-lescents (199–205).

Prevention and Management ofDiabetes Complications

Nephropathy

Recommendations

13.73 Blood pressure should bemea-sured at every visit. A

13.74 Blood pressure should be op-timized to reduce risk and/orslow the progression of dia-betic kidney disease. A

13.75 If blood pressure is$90th per-centile for age, sex, and heightor, in adolescents $13 years,blood pressure is $120/80mmHg, increased emphasisshould be placed on lifestylemanagementtopromoteweightloss. If blood pressure remainsabove the 90th percentile or,in adolescents $13 years,blood pressure is $120/80after 6 months, antihyperten-sive therapy should be initi-ated. C

13.76 In addition to lifestyle modi-fication, pharmacologic treat-ment of hypertension (systolicbloodpressureordiastolicbloodpressure consistently $95thpercentile for age, sex, andheight or $140/90 mmHg inadolescents$13 years) shouldbe considered as soon as hy-pertension is confirmed. E

13.77 Initial therapeutic options in-clude ACE inhibitors or angio-tensin receptor blockers. Otherbloodpressure–loweringagentsmay be added as needed. C

13.78 Protein intake should be at therecommended daily allowanceof 0.8 g/kg/day. E

13.79 Urine albumin-to-creatinine ra-tio should be obtained at thetime of diagnosis and annuallythereafter. An elevated urinealbumin-to-creatinineratio (.30mg/g creatinine) should beconfirmed on two of threesamples. B

13.80 Estimated glomerular filtrationrate should be determined atthe time of diagnosis and an-nually thereafter. E

13.81 In nonpregnant patients withdiabetes and hypertension,either an ACE inhibitor or anangiotensin receptor blockeris recommended for thosewith modestly elevated uri-nary albumin-to-creatinine ra-tio (30–299 mg/g creatinine)and is strongly recommendedfor those with urinary albumin-to-creatinine ratio .300 mg/gcreatinine and/or estimatedglomerular filtration rate ,60mL/min/1.73 m2. E

13.82 For those with nephropathy,continued monitoring (yearlyurinary albumin-to-creatinineratio, estimated glomerular fil-tration rate, and serum potas-sium) may aid in assessingadherence and detecting pro-gression of disease. E

13.83 Referral to nephrology is rec-ommended in case of uncer-tainty of etiology, worseningurinary albumin-to-creatinineratio, or decrease in estimatedglomerular filtration rate. E

Neuropathy

Recommendations

13.84 Youth with type 2 diabetesshould be screened for thepresence of neuropathy by footexamination at diagnosis andannually.Theexaminationshouldinclude inspection, assess-ment of foot pulses, pinprickand 10-g monofilament sensa-tion tests, testing of vibra-tion sensation using a 128-Hztuning fork, and ankle reflextests. C

13.85 Prevention should focus onachieving glycemic targets. C

Retinopathy

Recommendations

13.86 Screeningforretinopathyshouldbe performed by dilated fundo-scopy or retinal photographyat or soon after diagnosis andannually thereafter. C

13.87 Optimizing glycemia is recom-mended to decrease the risk orslow the progression of reti-nopathy. B

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13.88 Less frequent examination (ev-ery 2 years) may be consid-ered if there is adequateglycemic control and a normaleye exam. C

Nonalcoholic Fatty Liver Disease

Recommendations

13.89 Evaluation fornonalcoholic fattyliver disease (by measuring ASTand ALT) should be done atdiagnosis and annually there-after. B

13.90 Referral to gastroenterologyshould be considered for per-sistently elevated or worsen-ing transaminases. B

Obstructive Sleep Apnea

Recommendation

13.91 Screeningforsymptomsofsleepapnea should be done at eachvisit, and referral to a pediat-ric sleep specialist for evalu-ation and a polysomnogram,if indicated, is recommen-ded. Obstructive sleep apneashould be treated when docu-mented. B

Polycystic Ovary Syndrome

Recommendations

13.92 Evaluate for polycystic ovarysyndrome in female adoles-cents with type 2 diabetes, in-cluding laboratory studieswhenindicated. B

13.93 Oral contraceptive pills fortreatment of polycystic ovarysyndrome are not contraindi-cated for girls with type 2 di-abetes. C

13.94 Metformin in addition to life-style modification is likely toimprove the menstrual cyclic-ity and hyperandrogenism ingirls with type 2 diabetes. E

Cardiovascular Disease

Recommendation

13.95 Intensive lifestyle interventionsfocusing on weight loss, dyslipi-demia, hypertension, and dys-glycemia are important toprevent overt macrovasculardisease in early adulthood. E

Dyslipidemia

Recommendations

13.96 Lipid testing should be per-formed when initial glycemiccontrol has been achievedand annually thereafter. B

13.97 Optimal goals are LDL choles-terol,100mg/dL (2.6mmol/L),HDL cholesterol .35 mg/dL(0.91 mmol/L), and triglycer-ides,150mg/dL (1.7mmol/L).E

13.98 If lipids are abnormal, initialtherapy should consist of op-timizing glucose control andmedical nutritional therapyto limit the amount of caloriesfrom fat to 25–30%, satu-rated fat to,7%, cholesterol,200 mg/day, avoid transfats, and aim for ;10% cal-ories from monounsaturatedfats for elevated LDL. Forelevated triglycerides, medi-cal nutrition therapy shouldalso focusondecreasingsimplesugar intake and increasing di-etary n-3 fatty acids in additionto the above changes. A

13.99 If LDL cholesterol remains.130 mg/dL after 6 monthsof dietary intervention, initi-ate therapywith statin,with agoal of LDL ,100 mg/dL. B

13.100 If triglycerides are.400 mg/dL (4.7 mmol/L) fasting or.1,000 mg/dL (11.6 mmol/L) nonfasting, optimize glyce-mia and begin fibrate, witha goal of ,400 mg/dL (4.7mmol/L) fasting (to reducerisk for pancreatitis). C

Cardiac Function Testing

Recommendation

13.101 Routine screening for heartdisease with electrocardio-gram, echocardiogram, orstress testing is not recom-mended in asymptomaticyouth with type 2 diabetes. B

Comorbidities may already be presentat the time of diagnosis of type 2 di-abetes in youth (164,207). Therefore,blood pressure measurement, a fast-ing lipid panel, assessment of randomurine albumin-to-creatinine ratio, and

a dilated eye examination should beperformed at diagnosis. Thereafter,screening guidelines and treatment rec-ommendations for hypertension, dys-lipidemia, urine albumin excretion, andretinopathy are similar to those foryouth with type 1 diabetes. Addi-tional problems that may need to beaddressed include polycystic ovary dis-ease and other comorbidities associ-ated with pediatric obesity, such assleep apnea, hepatic steatosis, ortho-pedic complications, and psychosocialconcerns. The ADA position statement“Evaluation and Management of Youth-Onset Type 2 Diabetes” (2) providesguidance on the prevention, screening,and treatment of type 2 diabetes and itscomorbidities in children and adoles-cents.

Youth-onset type 2 diabetes is asso-ciated with significant microvascularand macrovascular risk burden and asubstantial increase in the risk of car-diovascular morbidity and mortality atan earlier age than those diagnosedlater in life (208). The higher complica-tion risk in earlier-onset type 2 diabetesis likely related to prolonged lifetimeexposure to hyperglycemia and otheratherogenic risk factors, including in-sulin resistance, dyslipidemia, hyperten-sion, and chronic inflammation. There islow risk of hypoglycemia in youth withtype 2 diabetes, even if they are beingtreated with insulin (209), and there arehigh rates of complications (181–184).These diabetes comorbidities also appearto be higher than in youth with type 1diabetes despite shorter diabetes dura-tion and lower A1C (207). In addition, theprogression of vascular abnormalitiesappears to be more pronounced inyouth-onset type 2 diabetes comparedwith type 1 diabetes of similar dura-tion, including ischemic heart diseaseand stroke (210).

Psychosocial Factors

Recommendations

13.102 Providers should assess socialcontext, including potentialfood insecurity, housing sta-bility, and financial barriers,and apply that information totreatment decisions. E

13.103 Use patient-appropriate stan-dardized and validated toolsto assess for diabetes distress

care.diabetesjournals.org Children and Adolescents S175

andmental/behavioral healthin youth with type 2 diabetes,with attention to symptoms ofdepression and eating disor-ders, and refer to specialtycare when indicated. B

13.104 When choosing glucose-lowering or other medicationsfor youth with overweight orobesity and type 2 diabetes,consider medication-takingbehavior and their effect onweight. E

13.105 Starting at puberty, precon-ception counseling shouldbe incorporated into routinediabetes clinic visits for allfemales of childbearing po-tential because of the ad-verse pregnancy outcomesin this population. A

13.106 Patients should be screenedfor smoking and alcohol useat diagnosis and regularlythereafter. C

Most youth with type 2 diabetes comefrom racial/ethnic minority groups,have low socioeconomic status, andoften experience multiple psychoso-cial stressors (22,36,165–168). Consid-eration of the sociocultural contextand efforts to personalize diabetes man-agement are of critical importance tominimize barriers to care, enhance ad-herence, and maximize response totreatment.Evidence about psychiatric disorders

and symptoms in youth with type 2 di-abetes is limited (211–215), but given thesociocultural context formany youth andthe medical burden and obesity associ-ated with type 2 diabetes, ongoing sur-veillance of mental health/behavioralhealth is indicated. Symptoms of depres-sion and disordered eating are commonand associated with poorer glycemiccontrol (212,216,217).Many of the drugs prescribed for di-

abetes and psychiatric disorders are as-sociatedwithweight gain and can increasepatients’ concerns about eating, bodyshape, and weight (218,219).The TODAY study documented (220)

that despite disease- and age-specificcounseling, 10.2% of the females inthe cohort became pregnant over an av-erage of 3.8 years of study participation.Of note, 26.4% of pregnancies ended in

a miscarriage, stillbirth, or intrauterinedeath, and 20.5% of the liveborn infantshad a major congenital anomaly.

TRANSITION FROM PEDIATRIC TOADULT CARE

Recommendations

13.107 Pediatric diabetes providersshould begin to prepareyouth for transition to adulthealth care in early adoles-cence and, at the latest, atleast 1 year before the tran-sition. E

13.108 Both pediatric and adult di-abetes care providers shouldprovide support and resour-ces for transitioning youngadults. E

13.109 Youth with type 2 diabetesshould be transferred to anadult-oriented diabetes spe-cialist when deemed appro-priate by the patient andprovider. E

Care and close supervision of diabetesmanagement are increasingly shiftedfrom parents and other adults to theyouth with type 1 or type 2 diabetesthroughout childhood and adolescence.The shift from pediatric to adult healthcare providers, however, often occursabruptly as the older teen enters the nextdevelopmental stage, referred to asemerging adulthood (221), which is acritical period for young people whohave diabetes. During this period ofmajor life transitions, youth begin tomove out of their parents’ homes andmust become fully responsible for theirdiabetes care. Their new responsibilitiesinclude self-management of their diabe-tes, making medical appointments, andfinancing health care, once they are nolonger covered by their parents’ healthinsurance plans (ongoing coverage untilage 26 years is currently available underprovisions of the U.S. Affordable CareAct). In addition to lapses in health care,this is also a period associated withdeterioration in glycemic stability; in-creased occurrence of acute complica-tions; psychosocial, emotional, andbehavioral challenges; and the emer-gence of chronic complications (222–225).The transitionperiod frompediatric to adultcare is prone to fragmentation in healthcaredelivery,whichmayadversely impact

health care quality, cost, and outcomes(226). Worsening diabetes health out-comes during transition to adult careand early adulthood have been docu-mented (227,228).

Although scientific evidence is limited,it is clear that comprehensive and co-ordinated planning that begins in earlyadolescence is necessary to facilitate aseamless transition from pediatric toadult health care (222,223,229,230).New technologies and other interven-tions are being tried to support transi-tion to adult care in young adulthood(231–235) A comprehensive discussionregarding the challenges faced duringthis period, including specific recommen-dations, is found in the ADA positionstatement “Diabetes Care for EmergingAdults: Recommendations for TransitionFrom Pediatric to Adult Diabetes CareSystems” (223).

The Endocrine Society in collaborationwith theADAandother organizations hasdeveloped transition tools for cliniciansand youth and families (230).

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152. Schwartz GJ, Work DF. Measurement andestimation of GFR in children and adolescents.Clin J Am Soc Nephrol 2009;4:1832–1843153. Inker LA, Schmid CH, Tighiouart H, et al.;CKD-EPI Investigators. Estimating glomerular fil-tration rate from serum creatinine and cysta-tin C. N Engl J Med 2012;367:20–29154. Cho YH, Craig ME, Hing S, et al. Microvas-cular complications assessment in adolescentswith 2- to 5-yr duration of type 1 diabetes from1990 to 2006. Pediatr Diabetes 2011;12:682–689155. Scanlon PH, Stratton IM, Bachmann MO,Jones C, Leese GP; Four Nations Diabetic Reti-nopathy Screening Study Group. Risk of diabeticretinopathy at first screen in children at 12 and13 years of age. DiabetMed 2016;33:1655–1658156. Beauchamp G, Boyle CT, Tamborlane WV,et al.; T1D Exchange Clinic Network. Treatablediabetic retinopathy is extremely rare amongpediatric T1D Exchange clinic registry partici-pants. Diabetes Care 2016;39:e218–e219157. Nathan DM, Bebu I, Hainsworth D, et al.;DCCT/EDIC Research Group. Frequency of evi-dence-based screening for retinopathy in type 1diabetes. N Engl J Med 2017;376:1507–1516158. Gubitosi-Klug RA, Bebu I, White NH, et al.;DiabetesControl andComplicationsTrial (DCCT)/Epidemiology of Diabetes Interventions andComplications (EDIC) Research Group*. Screen-ing eye exams in youth with type 1 diabetesunder 18 years of age: once may be enough?Pediatr Diabetes 2019;20:743–749159. Jaiswal M, Divers J, Dabelea D, et al. Prev-alence of and risk factors for diabetic peripheralneuropathy in youth with type 1 and type 2diabetes: SEARCH for Diabetes in Youth Study.Diabetes Care 2017;40:1226–1232160. Pop-Busui R, Boulton AJM, Feldman EL,et al. Diabetic neuropathy: a position statementby the American Diabetes Association. DiabetesCare 2017;40:136–154161. Lawrence JM, ImperatoreG,PettittDJ, etal.Incidence of diabetes in United States youth bydiabetes type, race/ethnicity, and age, 2008–2009 (Abstract). Diabetes 2014;63(Suppl. 1):A407162. ImperatoreG, Boyle JP, ThompsonTJ, et al.;SEARCH for Diabetes in Youth Study Group.Projections of type 1 and type 2 diabetes burdenin the U.S. population aged ,20 years through2050: dynamic modeling of incidence, mortality,and population growth. Diabetes Care 2012;35:2515–2520163. 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. DiabetesCare 2014;37:402–408164. Copeland KC, Zeitler P, Geffner M, et al.;TODAY Study Group. Characteristics of adoles-cents and youth with recent-onset type 2 di-abetes: the TODAY cohort at baseline. J ClinEndocrinol Metab 2011;96:159–167165. Arslanian SA. Metabolic differences be-tween Caucasian and African-American childrenand the relationship to type 2 diabetesmellitus. JPediatr Endocrinol Metab 2002;15(Suppl. 1):509–517166. Naughton MJ, Ruggiero AM, Lawrence JM,et al.; SEARCH for Diabetes in Youth Study Group.Health-related quality of life of children andadolescents with type 1 or type 2 diabetes

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