Diabetes Care

S180 Diabetes Care Volume 44, Supplement 1, January 2021
13. Children and Adolescents: American Diabetes Association
Standards of Medical Care in

Diabetesd2021
Diabetes Care 2021;44(Suppl. 1):S180–S199 | https://doi.org/10.2337/dc21-S013
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The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
13. CHILDREN AND ADOLESCENTS
includes the ADA’s current clinical practice recommendations and is intended to

provide the components of diabetes care, general treatment goals and guidelines,
and tools to evaluate quality of care. Members of the ADA Professional Practice
Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-
SPPC), are responsible for updating the Standards of Care annually, or more
frequently as warranted. For a detailed description of ADA standards, statements,
and reports, as well as the evidence-grading system for ADA’s clinical practice
recommendations, please refer to the Standards of Care Introduction (https://doi
.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care
are invited to do so at professional.diabetes.org/SOC.
The management of diabetes in children and adolescents cannot simply be derived

from care routinely provided to adults with diabetes. The epidemiology, patho-
physiology, developmental considerations, and response to therapy in pediatric-onset
diabetes are different from adult diabetes. There are also differences in recom-
mended care for children and adolescents with type 1 diabetes, type 2 diabetes, and
other forms of pediatric diabetes. This section first addresses care for children and
adolescents with type 1 diabetes and next addresses care for children and adolescents
with type 2 diabetes. Monogenic diabetes (neonatal diabetes and maturity-onset
diabetes in the young [MODY]) and cystic fibrosis–related diabetes, which often
present in youth, are discussed in Section 2 “Classification and Diagnosis of Diabetes”
(https://doi.org/10.2337/dc21-S002). Lastly, guidance is provided in this section on
transition of care from pediatric to adult providers to ensure that the continuum of
care is appropriate as an adolescent with diabetes becomes an adult. Due to the nature of
clinical pediatric research, the recommendations for children and adolescents with diabetes
are less likely to be based on clinical trial evidence. However, expert opinion and a review of
available and relevant experimental data are summarized in the American Diabetes
Association (ADA) position statements “Type 1 Diabetes in Children and Adolescents” (1)
and “Evaluation and Management of Youth-Onset Type 2 Diabetes” (2). The ADA
Suggested citation: American Diabetes Associa-
consensus report “Youth-Onset Type 2 Diabetes Consensus Report: Current Status,
tion. 13. Children and adolescents: Standards of
Challenges, and Priorities” (3) characterizes type 2 diabetes in children and evaluates Medical Care in Diabetesd2021. Diabetes Care
treatment options but also discusses knowledge gaps and recruitment challenges in 2021;44(Suppl. 1):S180–S199
clinical and translational research in youth-onset type 2 diabetes. © 2020 by the American Diabetes Association.
Readers may use this article as long as the work is
TYPE 1 DIABETES properly cited, the use is educational and not for
profit, and the work is not altered. More infor-
Type 1 diabetes is the most common form of diabetes in youth (4), although data mation is available at https://www.diabetesjournals
suggest that it may account for a large proportion of cases diagnosed in adult life (5). .org/content/license.
care.diabetesjournals.org Children and Adolescents S181
The provider must consider the unique psychosocial factors that impact imple-
type 1 diabetes with the goal of
aspects of care and management of children mentation of a treatment plan and must
60 min of moderate- to vigorous-
andadolescentswithtype1diabetes,suchas work with the individual and family to
intensity aerobic activity daily,
changes in insulin sensitivity related to phys- overcome barriers or redefine goals as
with vigorous muscle-strength-
ical growth and sexual maturation, ability to appropriate. Diabetes self-management
ening and bone-strengthening
provide self-care, supervision in the childcare education and support requires periodic
activities at least 3 days per week.
and school environment, neurological vul- reassessment, especially as the youth
C
nerability to hypoglycemia and hyperglyce- grows, develops, and acquires the need
13.6 Education about frequent pat-
mia in young children, and possible adverse for greater independent self-care skills.
terns of glycemia during and
neurocognitive effects of diabetic ketoaci- In addition, it is necessary to assess the
after exercise, which may include
dosis (DKA) (6,7). Attention to family dynam- educational needs and skills of, and pro-
initial transient hyperglycemia
ics, developmental stages, and physiologic vide training to, day care workers, school
followed by hypoglycemia, is

differences related to sexual maturity is nurses, and school personnel who are
essential. Families should also
essential in developing and implementing responsible for the care and supervision
receive education on prevention
an optimal diabetes treatment plan (8). of the child with diabetes (9–11).
and management of hypoglyce-
A multidisciplinary team of specialists
Nutrition Therapy
mia during and after exercise,
trained in pediatric diabetes manage-
including ensuring patients have
ment and sensitive to the challenges of Recommendations a pre-exercise glucose level of
children and adolescents with type 1 di- 13.2 Individualized medical nutrition 90–250 mg/dL (5.0–13.9 mmol/
abetes and their families should provide therapy is recommended for L) and accessible carbohydrates
care for this population. It is essential children and adolescents with before, during, and after engag-
that diabetes self-management education type 1 diabetes as an essential ing in activity, individualized ac-
and support, medical nutrition therapy, component of the overall treat- cording to the type/intensity of
and psychosocial support be provided ment plan. A the planned physical activity. E
at diagnosis and regularly thereafter in 13.3 Monitoring carbohydrate in- 13.7 Patients should be educated on
a developmentally appropriate format take, whether by carbohydrate strategies to prevent hypogly-
that builds on prior knowledge by in- counting or experience-based cemia during exercise, after ex-
dividuals experienced with the biolog- estimation, is key to achieving ercise, and overnight following
ical, educational, nutritional, behavioral, optimal glycemic control. B exercise, which may include re-
and emotional needs of the growing child 13.4 Comprehensive nutrition edu- ducing prandial insulin dosing
and family. The appropriate balance be- cation at diagnosis, with annual for the meal/snack preceding
tween adult supervision and indepen- updates, by an experienced reg- (and, if needed, following) ex-
dent self-care should be defined at the istered dietitian nutritionist is ercise, reducing basal insulin
first interaction and reevaluated at sub- recommended to assess caloric doses, increasing carbohydrate
sequent visits, with the expectation that and nutrition intake in relation intake, eating bedtime snacks,
it will evolve as the adolescent gradually to weight status and cardiovas- and/or using continuous glu-
becomes an emerging adult. cular disease risk factors and to cose monitoring. C
Diabetes Self-Management Education inform macronutrient choices. E 13.8 Frequent glucose monitoring
and Support before, during, and after exer-
Dietary management should be individ- cise, with or without use of
Recommendation ualized: family habits, food preferences, continuous glucose monitoring,
13.1 Youth with type 1 diabetes and religious or cultural needs, finances, is important to prevent, detect,
their parents/caregivers (for pa- schedules, physical activity, and the pa- and treat hypoglycemia and hy-
tients aged ,18 years) should tient’s and family’s abilities in numeracy, perglycemia with exercise. C
receive culturally sensitive and de- literacy, and self-management should be
velopmentally appropriate individ- considered. Visits with a registered di- Exercise positively impacts metabolic and
ualized diabetes self-management etitian nutritionist should include assess- psychological health in children with type
education and support according ment for changes in food preferences 1 diabetes (13). While it affects insulin
to national standards at diagnosis over time, access to food, growth and sensitivity, physical fitness, strength
and routinely thereafter. B development, weight status, cardiovas- building, weight management, social in-
cular risk, and potential for eating dis- teraction, mood, self-esteem building,
No matter how sound the medical reg- orders. Dietary adherence is associated
imen, it can only be effective if the family and creation of healthful habits for adult-
with better glycemic control in youth
and/or affected individuals are able to hood, it also has the potential to cause
with type 1 diabetes (12).
implement it. Family involvement is a both hypoglycemia and hyperglycemia.
vital component of optimal diabetes Physical Activity and Exercise See below for strategies to mitigate
management throughout childhood and hypoglycemia risk and minimize hyper-
Recommendations
adolescence. The pediatric diabetes care glycemia with exercise. For an in-depth
13.5 Exercise is recommended for all
team must be capable of evaluating the discussion, see recently published re-
children and adolescents with
educational, behavioral, emotional, and views and guidelines (14–16).
S182 Children and Adolescents Diabetes Care Volume 44, Supplement 1, January 2021
Overall, it is recommended that youth disproportionately affects racial/ethnic

that information to treatment
participate in 60 min of moderate- (e.g., minorities in the U.S. (24–28). Therefore,
decisions. E
brisk walking, dancing) to vigorous- (e.g., diabetes care providers should monitor
13.13 Providers should consider ask-
running, jumping rope) intensity aerobic weight status and encourage a healthy
ing youth and their parents
activity daily, including resistance and diet, exercise, and healthy weight as key
about social adjustment (peer
flexibility training (17). Although uncom- components of pediatric type 1 diabetes
relationships) and school per-
mon in the pediatric population, patients care.
formance to determine whether
should be medically evaluated for co-
School and Child Care further intervention is needed. B
morbid conditions or diabetes complica-
As a large portion of a child’s day is spent 13.14 Assess youth with diabetes
tions that may restrict participation in an
in school and/or day care, training of for psychosocial and diabetes-
exercise program. As hyperglycemia can
school or day care personnel to provide related distress, generally start-
occur before, during, and after physical
care in accordance with the child’s in- ing at 7–8 years of age. B

activity, it is important to ensure that the
dividualized diabetes medical management 13.15 Offer adolescents time by them-
elevated glucose level is not related to
plan is essential for optimal diabetes man- selves with their care provider(s)
insulin deficiency that would lead to
agement and safe access to all school or day starting at age 12 years, or when
worsening hyperglycemia with exercise
care sponsored opportunities (10,11,29). In developmentally appropriate. E
and ketosis risk. Intense activity should
addition, federal and state laws require 13.16 Starting at puberty, precon-
be postponed with marked hyperglyce-
schools, day care facilities, and other ception counseling should be
mia (glucose $350 mg/dL [19.4 mmol/
entities to provide needed diabetes care incorporated into routine di-
L]), moderate to large urine ketones, and/
to enable the child to safely access the abetes care for all girls of child-
or b-hydroxybutyrate (B-OHB) .1.5
school or day care environment. Refer to bearing potential. A
mmol/L. Caution may be needed when
B-OHB levels are $0.6 mmol/L (12,14). the ADA position statements “Diabetes 13.17 Begin screening youth with type
The prevention and treatment of hy- Care in the School Setting” (10) and “Care 1 diabetes for eating disorders
of Young Children With Diabetes in the between 10 and 12 years of age.
poglycemia associated with physical ac-
Child Care Setting” (11) and ADA’s Safe at The Diabetes Eating Problems
tivity include decreasing the prandial
School website (https://www.diabetes Survey-Revised (DEPS-R) is a re-
insulin for the meal/snack before exer-
.org/resources/know-your-rights/safe-at- liable, valid, and brief screening
cise and/or increasing food intake. Pa-
school-state-laws) for additional details. tool for identifying disturbed
tients on insulin pumps can lower basal
eating behavior. B
rates by ;10–50% or more or suspend
for 1–2 h during exercise (18). Decreasing Psychosocial Issues
Rapid and dynamic cognitive, develop-
basal rates or long-acting insulin doses by
Recommendations mental, and emotional changes occur
;20% after exercise may reduce delayed
13.9 At diagnosis and during rou- during childhood, adolescence, and emerg-
exercise-induced hypoglycemia (19). Ac-
tine follow-up care, assess psy- ing adulthood. Diabetes management dur-
cessible rapid-acting carbohydrates and
chosocial issues and family ing childhood and adolescence places
frequent blood glucose monitoring be-
stresses that could impact di- substantial burdens on the youth and
fore, during, and after exercise, with or
abetes management and pro- family, necessitating ongoing assessment
without continuous glucose monitoring,
vide appropriate referrals to of psychosocial status, social determinants
maximize safety with exercise.
trained mental health profes- of health, and diabetes distress in the
Blood glucose targets prior to exercise
sionals, preferably experienced patient and the caregiver during routine
should be 90–250 mg/dL (5.0–13.9 mmol/
in childhood diabetes. E diabetes visits (30–38). It is important to
L). Consider additional carbohydrate in-
13.10 Mental health professionals consider the impact of diabetes on qual-
take during and/or after exercise, depend-
should be considered integral ity of life as well as the development of
ing on the duration and intensity of
members of the pediatric dia- mental health problems related to di-
physical activity, to prevent hypoglyce-
betes multidisciplinary team. E abetes distress, fear of hypoglycemia
mia. For low-to-moderate intensity aer-
13.11 Encourage developmentally ap- (and hyperglycemia), symptoms of anx-
obic activities (30–60 min), and if the
propriate family involvement in iety, disordered eating behaviors and
patient is fasting, 10–15 g of carbohy-
diabetes management tasks for eating disorders, and symptoms of de-
drate may prevent hypoglycemia (20).
children and adolescents, recog- pression (39). Consider assessing youth
After insulin boluses (relative hyperinsu-
nizing that premature transfer for diabetes distress, generally starting at
linemia), consider 0.5–1.0 g of carbohy-
of diabetes care to the child can 7 or 8 years of age (40). Consider screen-
drates/kg per hour of exercise (;30–60
result in diabetes burnout, non-
g), which is similar to carbohydrate re- ing for depression and disordered eating
adherence, and deterioration in
quirements to optimize performance in behaviors using available screening tools
glycemic control. A
athletes without type 1 diabetes (21–23). (30,41). Early detection of depression,
13.12 Providers should assess food
In addition, obesity is as common in anxiety, eating disorders, and learning
security, housing stability/
children and adolescents with type 1 disabilities can facilitate effective treat-
homelessness, health literacy,
diabetes as in those without diabetes. ment options and help minimize adverse
financial barriers, and social/
It is associated with higher frequency effects on diabetes management and
community support and apply
of cardiovascular risk factors, and it disease outcomes (35,40). There are
validated tools, such as the Problem negative effects on diabetes outcomes

is appropriate for many chil-
Areas in Diabetes-Teen (PAID-T) and and health in general. It is important to
dren. B
Parent (P-PAID-T) (36), that can be used recognize the unique and dangerous
13.24 Less stringent A1C goals (such
in assessing diabetes-specific distress in disordered eating behavior of insulin
as ,7.5% [58 mmol/mol]) may
youth starting at age 12 years and in their omission for weight control in type 1
be appropriate for patients who
parent caregivers. Furthermore, the com- diabetes (51) using tools such as the
cannot articulate symptoms of
plexities of diabetes management require Diabetes Eating Problems Survey-Revised
hypoglycemia; have hypoglyce-
ongoing parental involvement in care (DEPS-R) to allow for early diagnosis and
mia unawareness; lack access
throughout childhood with developmen- intervention (41,52–54).
to analog insulins, advanced
tally appropriate family teamwork be- The presence of a mental health pro-
insulin delivery technology, and/
tween the growing child/teen and fessional on pediatric multidisciplinary
or continuous glucose monitor-
parent in order to maintain adherence teams highlights the importance of at-
ing; cannot check blood glucose

and to prevent deterioration in glycemic tending to the psychosocial issues of
regularly; or have nonglycemic
control (42,43). As diabetes-specific fam- diabetes. These psychosocial factors are
factors that increase A1C (e.g.,
ily conflict is related to poorer adherence significantly related to self-management
high glycators). B
and glycemic control, it is appropriate to difficulties, suboptimal glycemic control,
13.25 Even less stringent A1C goals
inquire about such conflict during visits reduced quality of life, and higher rates of
(such as ,8% [64 mmol/mol])
and to either help to negotiate a plan for acute and chronic diabetes complications.
may be appropriate for patients
resolution or refer to an appropriate
with a history of severe hypo-
mental health specialist (44). Monitoring Glycemic Control
glycemia,limitedlifeexpectancy,
of social adjustment (peer relationships)
Recommendations or where the harms of treatment
and school performance can facilitate
13.18 Whenever possible, children are greater than the benefits. B
both well-being and academic achieve-
and adolescents with type 1 13.26 Providers may reasonably sug-
ment (45). Suboptimal glycemic control
diabetes should be treated with gest more stringent A1C goals
is a risk factor for underperformance at
intensive insulin regimens, ei- (such as ,6.5% [48 mmol/mol])
school and increased absenteeism (46).
ther via multiple daily injections for selected individual patients if
Shared decision-making with youth
or continuous subcutaneous they can be achieved without
regarding the adoption of regimen
insulin infusion. A significant hypoglycemia, nega-
components and self-management be-
13.19 All children and adolescents tive impacts on well-being, or
haviors can improve diabetes self-efficacy,
with type 1 diabetes should undueburdenofcare,or in those
adherence, and metabolic outcomes
self-monitor glucose levels who have nonglycemic factors
(25,47). Although cognitive abilities vary,
multiple times daily (up to that decrease A1C (e.g., lower
the ethical position often adopted is the
6–10 times/day by glucose erythrocyte life span). Lower tar-
“mature minor rule,” whereby children
meter or continuous glucose gets may also be appropriate
after age 12 or 13 years who appear to be
monitoring), including prior during the honeymoon phase. B
“mature” have the right to consent or
to meals and snacks, at bed- 13.27 Continuous glucose monitoring
withhold consent to general medical treat-
time, and as needed for safety (CGM) metrics derived from
ment, except in cases in which refusal
in specific situations such as CGM use over the most recent
would significantly endanger health (48).
exercise, driving, or the pres- 14 days (or longer for patients
Beginning at the onset of puberty or at
ence of symptoms of hypogly- with more glycemic variability),
diagnosis of diabetes, all adolescent girls
cemia. B including time in ranges (within
and women with childbearing potential
13.20 When used properly, real-time target, below target, and above
should receive education about the risks
continuous glucose monitoring target), are recommended to
of malformations associated with poor
in conjunction with insulin ther- be used in conjunction with A1C
metabolic control and the use of effective
apy is a useful tool to lower whenever possible. E
contraception to prevent unplanned
and/or maintain A1C levels
pregnancy. Preconception counseling us-
and/or reduce hypoglycemia. A Current standards for diabetes manage-
ing developmentally appropriate educa-
13.21 When used properly, intermit- ment reflect the need to minimize hy-
tional tools enables adolescent girls to
tently scanned continuous glu- perglycemia as safely as possible. The
make well-informed decisions (49). Pre-
cose monitoring in conjunction Diabetes Control and Complications Trial
conception counseling resources tailored
for adolescents are available at no cost
with insulin therapy can be (DCCT), which did not enroll children ,13
useful to replace self-monitoring years of age, demonstrated that near
through the ADA (50). Refer to the ADA
of blood glucose. B normalization of blood glucose levels was
position statement “Psychosocial Care
13.22 Automated insulin delivery more difficult to achieve in adolescents
for People With Diabetes” for further
systems may be considered to than in adults. Nevertheless, the in-
details (40).
improve glycemic control. A creased use of basal-bolus regimens,
Youth with type 1 diabetes have an
13.23 A1C goals must be individual-
increased risk of disordered eating be- insulin pumps, frequent blood glucose
ized and reassessed over time.
havior as well as clinical eating disorders monitoring, goal setting, and improved
An A1C of ,7% (53 mmol/mol)
with serious short-term and long-term patient education has been associated
with more children and adolescents recognize, articulate, and/or manage hypo-
the diagnosis of type 1 diabe-
reaching the blood glucose targets rec- glycemia. However, registry data indicate
tes and if symptoms develop.
ommended by the ADA (55–58), partic- that A1C targets can be achieved in children,
B
ularly in patients of families in which both including those aged ,6 years, without
the parents and the child with diabetes increased risk of severe hypoglycemia
Because of the increased frequency of
participate jointly to perform the re- (87,98). Recent data have demonstrated
other autoimmune diseases in type 1
quired diabetes-related tasks. that the use of real-time CGM lowered
diabetes, screening for thyroid dysfunc-
Lower A1C in adolescence and young A1C and increased time in range in ado-
tion and celiac disease should be considered
adulthood is associated with lower risk lescents and young adults and, in children
(107–111). Periodic screening in asymp-
and rate of microvascular and macro- aged ,8 years old, was associated with
tomatic individuals has been recommen-
vascular complications (59–63) and lower risk of hypoglycemia (100,101).
ded, but the optimal frequency of screening
demonstrates the effects of metabolic A strong relationship exists between
is unclear.

memory (64–67). frequency of blood glucose monitoring
Although much less common than thy-
In addition, type 1 diabetes can be and glycemic control (78–85,102,103).
roid dysfunction and celiac disease, other
associated with adverse effects on cog- All children and adolescents with type 1
autoimmune conditions, such as Addison
nition during childhood and adolescence diabetes should self-monitor glucose lev-
disease (primary adrenal insufficiency),
(6,68,69), and neurocognitive imaging els multiple times daily by glucose meter
autoimmune hepatitis, autoimmune gas-
differences related to hyperglycemia in or CGM. In the U.S., real-time CGM is
tritis, dermatomyositis, and myasthenia
children provide another motivation for approved for nonadjunctive use in chil-
gravis, occur more commonly in the pop-
lowering glycemic targets (6). DKA has dren aged 2 years and older, and in-
ulation with type 1 diabetes than in the
been shown to cause adverse effects on termittently scanned CGM is approved
general pediatric population and should
brain development and function. Addi- for nonadjunctive use in children aged
be assessed and monitored as clinically
tional factors (70–73) that contribute to 4 years and older. Metrics derived from
indicated. In addition, relatives of pa-
adverse effects on brain development CGM include percent time in target
tients should be offered testing for islet
and function include young age, severe range, below target range, and above
autoantibodies through research stud-
hypoglycemia at ,6 years of age, and target range (104). While studies in-
ies (e.g., TrialNet) for early diagnosis
chronic hyperglycemia (74,75). However, dicate a relation between time in range
of preclinical type 1 diabetes (stages 1
meticulous use of new therapeutic mo- and A1C (105,106), it is still uncertain
and 2).
dalities such as rapid- and long-acting what the ideal target time in range should
insulin analogs, technological advances be for children, and further studies are Thyroid Disease
(e.g., continuous glucose monitoring needed. Please refer to Section 7 “Dia-
[CGM], sensor-augmented pump therapy betes Technology” (https://doi.org/10 Recommendations
with automatic low glucose suspend, and .2337/dc21-S007) for more information 13.29 Consider testing children with
automated insulin delivery systems), and on the use of blood glucose meters, type 1 diabetes for antithyroid
intensive self-management education now CGM, and insulin pumps. More informa- peroxidase and antithyroglobulin
make it more feasible to achieve excellent tion on insulin injection technique can antibodies soon after diagnosis. B
glycemic control while reducing the inci- be found in Section 9 “Pharmacologic 13.30 Measure thyroid-stimulating hor-
dence of severe hypoglycemia (76–86). Approaches to Glycemic Treatment” moneconcentrationsatdiagnosis
In selecting individualized glycemic tar- (https://doi.org/10.2337/dc21-S009). whenclinicallystableorsoonafter
gets, the long-term health benefits of glycemic control has been estab-
achieving a lower A1C should be bal- lished. If normal, suggest recheck-
Key Concepts in Setting Glycemic ingevery1–2yearsorsoonerifthe
anced against the risks of hypoglycemia
Targets patient has positive thyroid anti-
and the developmental burdens of in-
c Targets should be individualized, and
tensive regimens in children and youth. bodies or develops symptoms or
lower targets may be reasonable based signs suggestive of thyroid dys-
Recent data with newer devices and
on a benefit-risk assessment. function, thyromegaly, an abnor-
insulins indicate that the risk of hypo-
c Blood glucose targets should be mod-
glycemia with lower A1C is less than it mal growth rate, or unexplained
ified in children with frequent hypogly- glycemic variability. B
was before (77,87–95). Some data sug-
cemia or hypoglycemia unawareness.
gest that there could be a threshold
c Postprandial blood glucose values Autoimmune thyroid disease is the most
where lower A1C is associated with more
should be measured when there is a common autoimmune disorder associated
hypoglycemia (96,97); however, the con-
discrepancy between preprandial blood with diabetes, occurring in 17–30% of pa-
fidence intervals were large, suggesting
glucose values and A1C levels and to tients with type 1 diabetes (108,112,113). At
great variability. In addition, achieving
assess preprandial insulin doses in those the time of diagnosis, ;25% of children
lower A1C levels is likely facilitated by
on basal-bolus or pump regimens. with type 1 diabetes have thyroid auto-
setting lower A1C targets (98,99). Lower
goals may be possible during the “hon- Autoimmune Conditions antibodies (114), the presence of which
eymoon” phase of type 1 diabetes. Spe- is predictive of thyroid dysfunctiondmost
Recommendation commonly hypothyroidism, although hy-
cial consideration should be given to the
risk of hypoglycemia in young children 13.28 Assess for additional autoim- perthyroidism occurs in ;0.5% of pa-
(aged ,6 years) who are often unable to mune conditions soon after tients with type 1 diabetes (115,116). For
thyroid autoantibodies, a study from failure, and potential increased risk of asymptomatic adults with positive anti-
Sweden indicated that antithyroid per- retinopathy and albuminuria (124–127). bodies confirmed by biopsy (132).
oxidase antibodies were more predictive Screening for celiac disease includes
than antithyroglobulin antibodies in mul- measuring serum levels of IgA and tissue
transglutaminase antibodies, or, with IgA Management of Cardiovascular Risk
tivariate analysis (117). Thyroid function
Factors
tests may be misleading (euthyroid sick deficiency, screening can include mea-
Hypertension Screening
syndrome) if performed at the time of suring IgG tissue transglutaminase anti-
diagnosis owing to the effect of previous bodies or IgG deamidated gliadin peptide Recommendation
hyperglycemia, ketosis or ketoacidosis, antibodies. Because most cases of celiac 13.34 Blood pressure should be mea-
weight loss, etc. Therefore, if performed disease are diagnosed within the first sured at each routine visit.
at diagnosis and slightly abnormal, thy- 5 years after the diagnosis of type 1 Children found to have elevated
roid function tests should be repeated diabetes, screening should be considered blood pressure (systolic blood

soon after a period of metabolic stability at the time of diagnosis and repeated at pressure or diastolic blood
and achievement of glycemic targets. 2 and then 5 years (121) or if clinical pressure $90th percentile for
Subclinical hypothyroidism may be asso- symptoms indicate, such as poor growth age, sex, and height or, in
ciated with increased risk of symptomatic or increased hypoglycemia (122,124). adolescents $13 years, systolic
hypoglycemia (118) and reduced linear Although celiac disease can be di- blood pressure 120–129 mmHg
growth rate. Hyperthyroidism alters glu- agnosed more than 10 years after di- with diastolic blood pressure
abetes diagnosis, there are insufficient ,80 mmHg) or hypertension
cose metabolism and usually causes de-
data after 5 years to determine the op- (systolic blood pressure or di-
terioration of glycemic control.
timal screening frequency. Measurement astolic blood pressure $95th
Celiac Disease of tissue transglutaminase antibody percentile for age, sex, and height
should be considered at other times in or, in adolescents $13 years,
Recommendations patients with symptoms suggestive of ce- systolic blood pressure $130
13.31 Screen children with type 1 di- liac disease (121). Monitoring for symp- mmHg or diastolic blood pres-
abetes for celiac disease by toms should include assessment of linear sure $80 mmHg) should have
measuring IgA tissue transglu- growth and weight gain (122,124). A small elevated blood pressure con-
taminase (tTG) antibodies, with bowel biopsy in antibody-positive children firmed on three separate days.
documentation of normal total is recommended to confirm the diagnosis B
serum IgA levels, soon after the (128). European guidelines on screening for
diagnosis of diabetes, or IgG to celiac disease in children (not specific to
tTG and deamidated gliadin children with type 1 diabetes) suggest that Hypertension Treatment
antibodies if IgA deficient. B biopsy may not be necessary in symptom-
13.32 Repeat screening within 2 years Recommendations
atic children with high antibody titers (i.e.,
of diabetes diagnosis and then 13.35 Initial treatment of elevated
greater than 10 times the upper limit of
again after 5 years and consider blood pressure (systolic blood
normal) provided that further testing is
more frequent screening in chil- pressure or diastolic blood pres-
performed (verification of endomysial
dren who have symptoms or a sure consistently $90th percen-
antibody positivity on a separate blood
first-degree relative with celiac tile for age, sex, and height or
sample). Whether this approach may be
disease. B $120/80 mmHg in adolescents
appropriate for asymptomatic children in
13.33 Individuals with confirmed ce- $13 years) includes dietary
high-risk groups remains an open ques-
liac disease should be placed modification and increased ex-
tion, though evidence is emerging (129).
on a gluten-free diet for treat- ercise, if appropriate, aimed at
It is also advisable to check for celiac
ment and to avoid complica- weight control. If target blood
disease–associated HLA types in patients
tions; they should also have a pressure is not reached within
who are diagnosed without a small in-
consultation with a dietitian 3–6 months of initiating life-
testinal biopsy. In symptomatic children
experienced in managing both style intervention, pharmacologic
with type 1 diabetes and confirmed celiac
diabetes and celiac disease. treatment should be considered.
disease, gluten-free diets reduce symp-
B E
toms and rates of hypoglycemia (130).
13.36 In addition to lifestyle modifica-
The challenging dietary restrictions as-
Celiac disease is an immune-mediated tion, pharmacologic treatment
sociated with having both type 1 diabetes
disorder that occurs with increased fre- of hypertension (systolic blood
and celiac disease place a significant
quency in patients with type 1 diabetes pressure or diastolic blood pres-
burden on individuals. Therefore, a bi-
(1.6–16.4% of individuals compared with sure consistently $95th percen-
opsy to confirm the diagnosis of celiac
0.3–1% in the general population) tile for age, sex, and height or
disease is recommended, especially in
$140/90 mmHg in adolescents
(107,110,111,119–123). Screening patients asymptomatic children, before establish-
$13 years) should be consid-
with type 1 diabetes for celiac disease is ing a diagnosis of celiac disease (131)
ered as soon as hypertension is
further justified by its association with and endorsing significant dietary changes.
confirmed. E
osteoporosis, iron deficiency, growth A gluten-free diet was beneficial in
total cholesterol, LDL cholesterol, or HDL

13.37 ACE inhibitors or angiotensin 13.42 After the age of 10 years, ad-
cholesterol levels alone. A major advantage
receptor blockers should be dition of a statin may be con-
of non-HDL cholesterol is that it can be
considered for the initial phar- sidered in patients who, despite
accurately calculated in a nonfasting state
macologic treatment of hy- medical nutrition therapy and
and is therefore practical to obtain in clinical
pertension E in children and lifestyle changes, continue to
practice as a screening test (142). Youth with
adolescents, following repro- have LDL cholesterol .160 mg/
type 1 diabetes have a high prevalence of
ductive counseling due to the dL (4.1 mmol/L) or LDL choles-
lipid abnormalities (135,143).
potential teratogenic effects terol .130 mg/dL (3.4 mmol/L)
Even if normal, screening should be
of both drug classes. E and one or more cardiovascular
repeated within 3 years, as glycemic con-
13.38 The goal of treatment is blood disease risk factors, following
pressure consistently ,90th reproductive counseling for fe- trol and other cardiovascular risk factors
percentile for age, sex, and males because of the potential can change dramatically during adoles-

height or ,120/,80 mmHg in teratogenic effects of statins. E cence (144).
children $13 years. E 13.43 The goal of therapy is an LDL Treatment. Pediatric lipid guidelines pro-
cholesterol value ,100 mg/dL vide some guidance relevant to children
Blood pressure measurements should be (2.6 mmol/L). E with type 1 diabetes and secondary
performed using the appropriate size cuff dyslipidemia (133,141,145,146); how-
with the child seated and relaxed. Hyper- Population-based studies estimate that ever, there are few studies on modifying
tension should be confirmed on at least 14–45% of children with type 1 diabetes lipid levels in children with type 1 di-
three separate days. Evaluation should have two or more atherosclerotic car- abetes. A 6-month trial of dietary coun-
proceed as clinically indicated (133). Treat- diovascular disease (ASCVD) risk factors seling produced a significant improvement
ment is generally initiated with an ACE (135–137), and the prevalence of cardio- in lipid levels (147); likewise, a lifestyle
inhibitor, but an angiotensin receptor vascular disease (CVD) risk factors in- intervention trial with 6 months of exercise
blocker can be used if the ACE inhibitor creases with age (137) and among racial/ in adolescents demonstrated improvement
is not tolerated (e.g., due to cough) (134). ethnic minorities (24), with girls having a in lipid levels (148). Data from the SEARCHfor
higher risk burden than boys (136). Diabetes in Youth (SEARCH) study show that
Dyslipidemia Testing Pathophysiology. The atherosclerotic pro- improved glucose over a 2-year period is
cess begins in childhood, and although associated with a more favorable lipid
Recommendations
ASCVD events are not expected to occur profile; however, improved glycemia alone
13.39 Initial lipid testing should be
during childhood, observations using a will not normalize lipids in youth with
performed when initial glyce-
variety of methodologies show that type 1 diabetes and dyslipidemia (144).
mic control has been achieved
youth with type 1 diabetes may have Although intervention data are sparse,
and age is $2 years. If initial
subclinical CVD within the first decade of the American Heart Association catego-
LDL cholesterol is #100 mg/dL
diagnosis (138–140). Studies of carotid rizes children with type 1 diabetes in the
(2.6 mmol/L), subsequent test-
intima-media thickness have yielded in- highest tier for cardiovascular risk and
ing should be performed at 9–
consistent results (133,134). recommends both lifestyle and pharma-
11 years of age. B Initial testing
may be done with a nonfasting Screening. Diabetes predisposes to de- cologic treatment for those with elevated
non-HDL cholesterol level with velopment of accelerated arteriosclero- LDL cholesterol levels (146,149). Initial ther-
confirmatory testing with a sis. Lipid evaluation for these patients apy should be with a nutrition plan that
fasting lipid panel. contributes to risk assessment and iden- restricts saturated fat to 7% of total calories
13.40 If LDL cholesterol values are tifies an important proportion of those and dietary cholesterol to 200 mg/day. Data
within the accepted risk level with dyslipidemia. Therefore, initial from randomized clinical trials in children as
(,100 mg/dL [2.6 mmol/L]), a screening should be done soon after young as 7 months of age indicate that this
lipid profile repeated every diagnosis. If the initial screen is normal, diet is safe and does not interfere with
3 years is reasonable. E subsequent screening may be done at 9– normal growth and development (150).
11 years of age, which is a stable time for Neither long-term safety nor cardio-
Dyslipidemia Treatment lipid assessment in children (141). Chil- vascular outcome efficacy of statin ther-
dren with a primary lipid disorder (e.g., apy has been established for children;
Recommendations
familial hyperlipidemia) should be re- however, studies have shown short-term
13.41 If lipids are abnormal, initial
ferred to a lipid specialist. Non-HDL safety equivalent to that seen in adults
therapy should consist of op-
cholesterol level has been identified as a and efficacy in lowering LDL cholesterol
timizingglucosecontrolandmed-
significant predictor of the presence of levels in familial hypercholesterolemia
ical nutrition therapy to limit the
atherosclerosisdas powerful as any or severe hyperlipidemia, improving
amount of calories from fat
other lipoprotein cholesterol measure in endothelial function and causing regres-
to 25–30%, saturated fat to ,7%,
children and adolescents. For both chil- sion of carotid intimal thickening (151,152).
cholesterol ,200 mg/day, avoid-
dren and adults, non-HDL cholesterol Statins are not approved for patients
ance of trans fats, and aim for
level seems to be more predictive of aged ,10 years, and statin treatment
;10% calories from monoun-
persistent dyslipidemia and, therefore, should generally not be used in children
saturated fats. A
atherosclerosis and future events than with type 1 diabetes before this age.
Statins are contraindicated in pregnancy;

preferred to avoid effects of 13.49 After the initial examination,
therefore, prevention of unplanned preg-
exercise) spot urine sample for repeat dilated and compre-
nancies is of paramount importance. Sta-
albumin-to-creatinine ratio should hensive eye examination every
tins should be avoided in females of
be considered at puberty or at 2 years. Less frequent exami-
childbearing age who are sexually active
age .10 years, whichever is nations, every 4 years, may be
and not using reliable contraception
earlier, once the child has had acceptable on the advice of an
(see Section 14 “Management of Di-
diabetes for 5 years. B eye care professional and based
abetes in Pregnancy,” https://doi.org/10
on risk factor assessment, in-
.2337/dc21-S014, for more information).
cluding a history of glycemic
The multicenter, randomized, placebo- Nephropathy Treatment control with A1C ,8%. B
controlled Adolescent Type 1 Diabetes
Cardio-Renal Intervention Trial (AdDIT) Recommendation
13.47 An ACE inhibitor or an angioten- Retinopathy (like albuminuria) most

provides safety data on pharmacologic
sin receptor blocker, titrated to commonly occurs after the onset of
treatment with an ACE inhibitor and statin
normalization of albumin excre- puberty and after 5–10 years of diabetes
in adolescents with type 1 diabetes.
tion, may be considered when duration (163). It is currently recognized
Smoking elevated urinary albumin-to- that there is low risk of development of
creatinine ratio (.30 mg/g) is vision-threatening retinal lesions prior to
Recommendations 12 years of age (164,165). A 2019 publi-
documented (two of three
13.44 Elicit a smoking history at initial cation based on the follow-up of the
urine samples obtained over
and follow-up diabetes visits; DCCT adolescent cohort supports lower
a 6-month interval following
discourage smoking in youth frequency of eye examinations than pre-
efforts to improve glycemic
who do not smoke and encour- viously recommended, in particular in
control and normalize blood
age smoking cessation in those adolescents with A1C closer to the target
pressure). E
who do smoke. A range (166,167). Referrals should be
13.45 Electronic cigarette use should
Data from 7,549 participants ,20 years made to eye care professionals with
be discouraged. A expertise in diabetic retinopathy and
of age in the T1D Exchange clinic registry
emphasize the importance of good gly- experience in counseling pediatric pa-
The adverse health effects of smoking are tients and families on the importance
cemic and blood pressure control, par-
well recognized with respect to future of prevention, early detection, and
ticularly as diabetes duration increases,
cancer and CVD risk. Despite this, smok- intervention.
in order to reduce the risk of diabetic
ing rates are significantly higher among
kidney disease. The data also underscore
youth with diabetes than among youth Neuropathy
the importance of routine screening to
without diabetes (153,154). In youth
ensure early diagnosis and timely treat- Recommendation
with diabetes, it is important to avoid
ment of albuminuria (160). An estimation 13.50 Consider an annual compre-
additional CVD risk factors. Smoking in-
of glomerular filtration rate (GFR), cal- hensive foot exam at the start
creases the risk of onset of albuminuria;
culated using GFR estimating equations of puberty or at age $10 years,
therefore, smoking avoidance is impor-
from the serum creatinine, height, age, whichever is earlier, once the
tant to prevent both microvascular and
and sex (161), should be considered at youth has had type 1 diabetes
macrovascular complications (141,155).
baseline and repeated as indicated based for 5 years. B
Discouraging cigarette smoking, includ-
on clinical status, age, diabetes duration,
ing electronic cigarettes (156,157), is an
and therapies. Improved methods are Diabetic neuropathy rarely occurs in pre-
important part of routine diabetes care.
needed to screen for early GFR loss, since pubertal children or after only 1–2 years
In light of recent Centers for Disease
estimated GFR is inaccurate at GFR .60 of diabetes (163), although data suggest
Control and Prevention evidence of
mL/min/1.73 m 2 (161,162). The AdDIT a prevalence of distal peripheral neurop-
deaths related to electronic cigarette use
study in adolescents with type 1 diabetes athy of 7% in 1,734 youth with type 1
(158,159), no persons should be ad-
demonstrated the safety of ACE inhibitor diabetes and association with the pres-
vised to use electronic cigarettes, either
treatment, but the treatment did not ence of CVD risk factors (168,169). A
as a way to stop smoking tobacco or as a
change the albumin-to-creatinine ratio comprehensive foot exam, including in-
recreational drug. In younger children, it
over the course of the study (133). spection, palpation of dorsalis pedis and
is important to assess exposure to cig-
arette smoke in the home because of the Retinopathy posterior tibial pulses, and determina-
adverse effects of secondhand smoke and tion of proprioception, vibration, and
Recommendations
to discourage youth from ever smoking. monofilament sensation, should be per-
13.48 An initial dilated and compre-
formed annually along with an assessment
hensive eye examination is rec-
Microvascular Complications of symptoms of neuropathic pain (169).
ommended once youth have
Nephropathy Screening Foot inspection can be performed at each
had type 1 diabetes for 3–5
visit to educate youth regarding the im-
Recommendation years, provided they are aged
portance of foot care (see Section 11 “Mi-
13.46 Annual screening for albuminuria $11 years or puberty has
crovascular Complications and Foot Care,”
with a random (morning sample started, whichever is earlier. B
https://doi.org/10.2337/dc21-S011).
TYPE 2 DIABETES diabetes in children can be difficult.

For information on risk-based screening who have one or more addi-
Overweight and obesity are common in
for type 2 diabetes and prediabetes in tional risk factors for diabetes
children with type 1 diabetes (26), and
children and adolescents, please refer to (see Table 2.4 for evidence
diabetes-associated autoantibodies and
Section 2 “Classification and Diagnosis of grading of other risk factors).
ketosis may be present in pediatric pa-
Diabetes” (https://doi.org/10.2337/ 13.52 If tests are normal, repeat test-
tients with features of type 2 diabetes
dc21-S002). For additional support for ing at a minimum of 3-year
(including obesity and acanthosis nigri-
these recommendations, see the ADA intervals E, or more frequently
cans) (180). The presence of islet auto-
position statement “Evaluation and if BMI is increasing. C
antibodies has been associated with
Management of Youth-Onset Type 2 13.53 Fasting plasma glucose, 2-h
faster progression to insulin deficiency
plasma glucose during a 75-g
Diabetes” (2). (180). At onset, DKA occurs in ;6% of
Type 2 diabetes in youth has increased oral glucose tolerance test, and
youth aged 10–19 years with type 2
A1C can be used to test for

over the past 20 years, and recent esti- diabetes (186). Although uncommon,
mates suggest an incidence of ;5,000 prediabetes or diabetes in chil-
type 2 diabetes has been observed in
new cases per year in the U.S. (170). The dren and adolescents. B
prepubertal children under the age of 10
Centers for Disease Control and Preven- 13.54 Children and adolescents with
years, and thus it should be part of the
tion published projections for type 2 overweight or obesity in whom
differential in children with suggestive
diabetes prevalence using the SEARCH the diagnosis of type 2 diabe-
symptoms (187). Finally, obesity contributes
database; assuming a 2.3% annual in- tes is being considered should
to the development of type 1 diabetes in
crease, the prevalence in those under have a panel of pancreatic
some individuals (188), which further blurs
20 years of age will quadruple in 40 years autoantibodies tested to ex-
the lines between diabetes types. However,
(171,172). clude the possibility of auto-
accurate diagnosis is critical, as treatment
Evidence suggests that type 2 diabetes immune type 1 diabetes. B
regimens, educational approaches, dietary
in youth is different not only from type 1 advice, and outcomes differ markedly
In the last decade, the incidence and
diabetes but also from type 2 diabetes in between patients with the two diagno-
prevalence of type 2 diabetes in adoles-
adults and has unique features, such as a ses. The significant diagnostic difficulties
cents has increased dramatically, especially
more rapidly progressive decline in b-cell posed by MODY are discussed in Section
in racial and ethnic minority populations
function and accelerated development of 2 “Classification and Diagnosis of Diabetes”
(141,178). A few studies suggest oral glu-
diabetes complications (2,173).Type 2 di- (https://doi.org/10.2337/dc21-S002). In
cose tolerance tests or fasting plasma
abetes disproportionately impacts youth addition, there are rare and atypical di-
glucose values as more suitable diagnos-
of ethnic and racial minorities and can abetes cases that represent a challenge
tic tests than A1C in the pediatric pop-
occur in complex psychosocial and cul- for clinicians and researchers.
ulation, especially among certain ethnicities
tural environments, which may make it
(179), although fasting glucose alone Management
difficult to sustain healthy lifestyle
may overdiagnose diabetes in children
changes and self-management behaviors Lifestyle Management
(180,181). In addition, many of these
(25,174–177). Additional risk factors as-
studies do not recognize that diabetes Recommendations
sociated with type 2 diabetes in youth
diagnostic criteria are based on long- 13.55 All youth with type 2 diabetes
include adiposity, family history of di-
term health outcomes, and validations andtheir families should receive
abetes, female sex, and low socioeco-
are not currently available in the pediat- comprehensive diabetes self-
nomic status (173).
ric population (182). A recent analysis of management education and
As with type 1 diabetes, youth with
National Health and Nutrition Examina- support that is specific to youth
type 2 diabetes spend much of the day in
tion Survey (NHANES) data suggests using with type 2 diabetes and is
school. Therefore, close communication
A1C for screening of high-risk youth (183). culturally appropriate. B
with and the cooperation of school per-
The ADA acknowledges the limited 13.56 Youth with overweight/obesity
sonnel are essential for optimal diabetes
data supporting A1C for diagnosing type and type 2 diabetes and their
management, safety, and maximal aca-
2 diabetes in children and adolescents. families should be provided
demic opportunities.
Although A1C is not recommended for di- with developmentally and cul-
agnosis of diabetes in children with cystic turally appropriate compre-
Screening and Diagnosis
fibrosis or symptoms suggestive of acute hensive lifestyle programs
Recommendations onset of type 1 diabetes, and only A1C that are integrated with diabetes
13.51 Risk-based screening for pre- assays without interference are appro- management to achieve 7–10%
diabetes and/or type 2 diabe- priate for children with hemoglobinop- decrease in excess weight. C
tes should be considered in athies, the ADA continues to recommend 13.57 Given the necessity of long-
children and adolescents after A1C for diagnosis of type 2 diabetes in term weight management for
the onset of puberty or $10 this population (184,185). children and adolescents with
years of age, whichever occurs type 2 diabetes, lifestyle interven-
earlier, with overweight (BMI tion should be based on a chronic
$85th percentile) or obesity Diagnostic Challenges care model and offered in the
(BMI $95th percentile) and Given the current obesity epidemic, dis- context of diabetes care. E
tinguishing between type 1 and type 2
Pharmacologic Management
13.58 Youth with prediabetes and 13.72 In patients initially treated with
type 2 diabetes, like all children Recommendations insulin and metformin who are
and adolescents, should be en- 13.65 Initiate pharmacologic therapy, meeting glucose targets based
couraged to participate in at in addition to behavioral coun- on home blood glucose moni-
least 60 min of moderate to seling for healthful nutrition toring, insulin can be tapered
vigorous physical activity daily and physical activity changes, over 2–6 weeks by decreasing
(with muscle and bone strength at diagnosis of type 2 diabetes. the insulin dose 10–30% every
training at least 3 days/week) B A few days. B
and to decrease sedentary be- 13.66 In incidentally diagnosed or met- 13.73 Use of medications not approved
havior. C abolically stable patients (A1C by the U.S. Food and Drug Ad-
13.59 Nutrition for youth with pre- ,8.5% [69 mmol/mol] and ministration for youth with type
diabetes and type 2 diabetes, asymptomatic), metforminis the 2 diabetes is not recommended

like for all children, should focus initial pharmacologic treatment outside of research trials. B
on healthy eating patterns that of choice if renal function is
emphasize consumption of nu- normal. A Treatment of youth-onset type 2 diabetes
trient-dense, high-quality foods 13.67 Youth with marked hypergly- should include lifestyle management, di-
and decreased consumption of cemia (blood glucose $250 abetes self-management education, and
calorie-dense, nutrient-poor mg/dL [13.9 mmol/L], A1C pharmacologic treatment. Initial treat-
foods, particularly sugar-added $8.5% [69 mmol/mol]) with- ment of youth with obesity and diabetes
beverages. B out acidosis at diagnosis who must take into account that diabetes type
are symptomatic with polyuria, is often uncertain in the first few weeks of
polydipsia, nocturia, and/or treatment, due to overlap in presentation,
Glycemic Targets
weight loss should be treated and that a substantial percentage of youth
Recommendations initially with basal insulin while with type 2 diabetes will present with
13.60 Home self-monitoring of blood metformin is initiated and ti- clinically significant ketoacidosis (189).
glucose regimens should be in- trated. B Therefore, initial therapy should address
dividualized, taking into con- 13.68 In patients with ketosis/ the hyperglycemia and associated meta-
sideration the pharmacologic ketoacidosis, treatment with bolic derangements irrespective of ulti-
treatment of the patient. E subcutaneous or intravenous mate diabetes type, with adjustment of
13.61 Glycemic status should be as- insulin should be initiated to therapy once metabolic compensation
sessed every 3 months. E rapidly correct the hyperglyce- has been established and subsequent
13.62 A reasonable A1C target for mia and the metabolic derange- information, such as islet autoantibody
most children and adolescents ment. Once acidosis is resolved, results, becomes available. Figure 13.1
with type 2 diabetes treated metformin should be initiated provides an approach to initial treatment
with oral agents alone is ,7% while subcutaneous insulin ther- of new-onset diabetes in youth with over-
(53 mmol/mol). More stringent apy is continued. A weight or obesity with clinical suspicion
A1C targets (such as ,6.5% 13.69 In individuals presenting with of type 2 diabetes.
[48 mmol/mol]) may be appro- severe hyperglycemia (blood Glycemic targets should be individual-
priate for selected individual glucose $600 mg/dL [33.3 ized, taking into consideration long-term
patients if they can be achieved mmol/L]), consider assessment health benefits of more stringent targets
without significant hypoglyce- for hyperglycemic hyperosmo- and risk for adverse effects, such as
mia or other adverse effects of lar nonketotic syndrome. A hypoglycemia. A lower target A1C in youth
treatment. Appropriate patients 13.70 If glycemic targets are no lon- with type 2 diabetes when compared with
might include those with short ger met with metformin (with those recommended in type 1 diabetes is
duration of diabetes and lesser or without basal insulin), lira- justified by lower risk of hypoglycemia and
degrees of b-cell dysfunction glutide (a glucagon-like peptide higher risk of complications (190–193).
and patients treated with life- 1 receptor agonist) therapy Patients and their families should re-
style or metformin only who should be considered in chil- ceive counseling for healthful nutrition
achieve significant weight im- dren 10 years of age or older if and physical activity changes such as
provement. E they have no past medical his- eating a balanced diet, achieving and
13.63 Less stringent A1C goals (such tory or family history of med- maintaining a healthy weight, and exer-
as 7.5% [58 mmol/mol]) may be ullary thyroid carcinoma or cising regularly. Physical activity should
appropriate if there is increased multiple endocrine neopla- include aerobic, muscle-strengthening,
risk of hypoglycemia. E sia type 2. A and bone-strengthening activities (17).
13.64 A1C targets for patients on 13.71 Patients treated with basal in- A family-centered approach to nutrition
insulin should be individualized, sulin who do not meet glycemic
and lifestyle modification is essential in
taking into account the relatively target should be moved to mul-
children and adolescents with type 2 di-
low rates of hypoglycemia in tiple daily injections with basal
abetes, and nutrition recommendations
youth-onset type 2 diabetes. E and premeal bolus insulins. E
should be culturally appropriate and

Figure 13.1—Management of new-onset diabetes in youth with overweight or obesity with clinical suspicion of type 2 diabetes. A1C 8.5% 5 69 mmol/
mol. Adapted from the ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (2). DKA, diabetic ketoacidosis; HHNK,
hyperosmolar hyperglycemic nonketotic syndrome; MDI, multiple daily injections; SMBG; self-monitoring of blood glucose.
sensitive to family resources (see Section limited to three approved drugsdinsulin, (A1C #8% [64 mmol/mol] for 6 months)
5 “Facilitating Behavior Change and Well- metformin, and liraglutide (2). Presen- in approximately half of the subjects (198).
being to Improve Health Outcomes,” tation with ketoacidosis or marked ke- The RISE Consortium study did not dem-
https://doi.org/10.2337/dc21-S005). Given tosis requires a period of insulin therapy onstrate differences in measures of
the complex social and environmental until fasting and postprandial glycemia glucose or b-cell function preservation
context surrounding youth with type 2 have been restored to normal or near- between metformin and insulin, but
diabetes, individual-level lifestyle inter- normal levels. Insulin pump therapy may there was more weight gain with insulin
ventions may not be sufficient to target be considered as an option for those on (199).
the complex interplay of family dynam- long-term multiple daily injections who To date, the TODAY study is the only
ics, mental health, community readiness, are able to safely manage the device. trial combining lifestyle and metformin
and the broader environmental system Metformin therapy may be used as an therapy in youth with type 2 diabetes; the
(2). adjunct after resolution of ketosis/ combination did not perform better than
A multidisciplinary diabetes team, ketoacidosis. Initial treatment should metformin alone in achieving durable
including a physician, diabetes care also be with insulin when the distinction glycemic control (198).
and education specialist, registered di- between type 1 diabetes and type 2 A recent randomized clinical trial in
etitian nutritionist, and psychologist or diabetes is unclear and in patients who children aged 10–17 years with type 2
social worker, is essential. In addition to have random blood glucose concentra- diabetes demonstrated the addition of
achieving glycemic targets and self- tions $250 mg/dL (13.9 mmol/L) and/or subcutaneous liraglutide (up to 1.8 mg
management education (194–196), initial A1C $8.5% (69 mmol/mol) (197). daily) to metformin (with or without
treatment must include management When insulin treatment is not re- basal insulin) as safe and effective to
of comorbidities such as obesity, dysli- quired, initiation of metformin is recom- decrease A1C (estimated decrease of
pidemia, hypertension, and microvascu- mended. The Treatment Options for 1.06 percentage points at 26 weeks
lar complications. Type 2 Diabetes in Adolescents and Youth and 1.30 at 52 weeks), although it did
Current pharmacologic treatment op- (TODAY) study found that metformin increase the frequency of gastrointestinal
tions for youth-onset type 2 diabetes are alone provided durable glycemic control side effects (200). Liraglutide is approved
for treatment of type 2 diabetes in youth have yet compared the effectiveness and
mg/g creatinine) should be con-
aged 10 years or older (201). safety of surgery to those of conventional
firmed on two of three samples.
Home self-monitoring of blood glu- treatment options in adolescents (205).
B
cose regimens should be individualized, The guidelines used as an indication for
13.83 Estimated glomerular filtration
taking into consideration the pharmaco- metabolic surgery in adolescents gener-
rate should be determined at
logic treatment of the patient. Although ally include BMI .35 kg/m2 with comor-
the time of diagnosis and an-
data on CGM in youth with type 2 di- bidities or BMI .40 kg/m2 with or without
nually thereafter. E
abetes is sparse (202), CGM could be comorbidities (206–217). A number of
13.84 In nonpregnant patients with
considered in individuals requiring fre- groups, including the Pediatric Bariatric
diabetes and hypertension, ei-
quent blood glucose monitoring for di- Study Group and Teen-LABS study, have
ther an ACE inhibitor or an an-
abetes management. demonstrated the effectiveness of met-
giotensin receptor blocker is
abolic surgery in adolescents (210–216).
recommended for those with

Metabolic Surgery
modestly elevated urinary albu-
Recommendations Prevention and Management of
min-to-creatinine ratio (30–299
13.74 Metabolic surgery may be con- Diabetes Complications
mg/g creatinine) and is strongly
sidered for the treatment of recommended for those with
Nephropathy
adolescents with type 2 diabe- urinary albumin-to-creatinine ra-
tes who have severe obesity Recommendations tio .300 mg/g creatinine and/or
(BMI .35 kg/m 2 ) and who 13.76 Blood pressure should be mea- estimated glomerular filtration
have uncontrolled glycemia sured at every visit. A rate ,60 mL/min/1.73 m2. E
and/or serious comorbidities 13.77 Blood pressure should be op- 13.85 For those with nephropathy,
despite lifestyle and pharma- timized to reduce risk and/or continued monitoring (yearly
cologic intervention. A slow the progression of dia- urinary albumin-to-creatinine
13.75 Metabolic surgery should be betic kidney disease. A ratio, estimated glomerular fil-
performed only by an experi- 13.78 If blood pressure is $90th per- tration rate, and serum potas-
enced surgeon working as part centile for age, sex, and height sium) may aid in assessing
of a well-organized and en- or, in adolescents $13 years, adherence and detecting pro-
gaged multidisciplinary team blood pressure is $120/80 mmHg, gression of disease. E
including a surgeon, endocri- increased emphasis should be 13.86 Referral to nephrology is rec-
nologist, dietitian nutritionist, placed on lifestyle management ommended in case of uncer-
behavioral health specialist, to promote weight loss. If blood tainty of etiology, worsening
and nurse. A pressure remains above the 90th urinary albumin-to-creatinine
percentile or, in adolescents $13 ratio, or decrease in estimated
The results of weight-loss and lifestyle years,bloodpressureis$120/80 glomerular filtration rate. E
interventions for obesity in children and after 6 months, antihypertensive
adolescents have been disappointing, therapy should be initiated. C Neuropathy
and no effective and safe pharmacologic 13.79 In addition to lifestyle modifica-
intervention is available or approved by tion, pharmacologic treatment Recommendations
of hypertension (systolic blood 13.87 Youth with type 2 diabetes
the U.S. Food and Drug Administration in
pressure or diastolic blood should be screened for the
youth. Over the last decade, weight-loss
pressure consistently $95th presence of neuropathy by
surgery has been increasingly performed
percentile for age, sex, and foot examination at diagnosis
in adolescents with obesity. Small retro-
height or $140/90 mmHg in and annually. The examination
spective analyses and a prospective mul-
adolescents $13 years) should should include inspection, as-
ticenter nonrandomized study suggest sessment of foot pulses, pin-
be considered as soon as hy-
that bariatric or metabolic surgery may prick and 10-g monofilament
pertension is confirmed. E
have benefits in adolescents with obesity sensation tests, testing of vibra-
13.80 Initial therapeutic options in-
and type 2 diabetes similar to those tion sensation using a 128-Hz
clude ACE inhibitors or angio-
observed in adults. Teenagers experi- tuning fork, and ankle reflex
tensin receptor blockers. Other
ence similar degrees of weight loss, di- tests. C
blood pressure–lowering agents
abetes remission, and improvement of 13.88 Prevention should focus on
may be added as needed. C
cardiometabolic risk factors for at least achieving glycemic targets. C
13.81 Protein intake should be at the
3 years after surgery (203). A secondary
recommended daily allowance
data analysis from the Teen-Longitudinal
of 0.8 g/kg/day. E
Assessment of Bariatric Surgery (Teen- Retinopathy
13.82 Urine albumin-to-creatinine
LABS) and TODAY studies suggests sur-
ratio should be obtained at the Recommendations
gical treatment of adolescents with 13.89 Screening for retinopathy
time of diagnosis and annually
severe obesity and type 2 diabetes is should be performed by di-
thereafter. An elevated urine
associated with improved glycemic con- lated fundoscopy or retinal
albumin-to-creatinine ratio (.30
trol (204); however, no randomized trials
Comorbidities may already be present at

photography at or soon after and dysglycemia are impor-
the time of diagnosis of type 2 diabetes in
diagnosis and annually there- tant to prevent overt macro-
youth (173,218). Therefore, blood pres-
after. C vascular disease in early adult-
sure measurement, a fasting lipid panel,
13.90 Optimizing glycemia is recom- hood. E
assessment of random urine albumin-to-
mended to decrease the risk or
Dyslipidemia creatinine ratio, and a dilated eye exam-
slow the progression of reti-
ination should be performed at diagno-
nopathy. B Recommendations sis. Additional medical conditions that
13.91 Less frequent examination (ev- 13.99 Lipid testing should be per- may need to be addressed include poly-
ery 2 years) may be considered if formed when initial glycemic cystic ovary disease and other comor-
there is adequate glycemic con- control has been achieved bidities associated with pediatric obesity,
trol and a normal eye exam. C and annually thereafter. B such as sleep apnea, hepatic steatosis,

13.100 Optimal goals are LDL choles- orthopedic complications, and psycho-
Nonalcoholic Fatty Liver Disease
terol ,100 mg/dL (2.6 mmol/L), social concerns. The ADA position state-
Recommendations HDL cholesterol .35 mg/dL ment “Evaluation and Management of
13.92 Evaluation for nonalcoholic fatty (0.91 mmol/L), and triglycerides Youth-Onset Type 2 Diabetes” (2) provides
liver disease (by measuring AST ,150 mg/dL (1.7 mmol/L). E guidance on the prevention, screening, and
and ALT) should be done at 13.101 If lipids are abnormal, initial treatment of type 2 diabetes and its co-
diagnosis and annually there- therapy should consist of op- morbidities in children and adolescents.
after. B timizing glucose control and Youth-onset type 2 diabetes is asso-
13.93 Referral to gastroenterology medical nutritional therapy ciated with significant microvascular and
should be considered for per- to limit the amount of calories macrovascular risk burden and a sub-
sistently elevated or worsen- from fat to 25–30%, satu- stantial increase in the risk of cardiovas-
ing transaminases. B rated fat to ,7%, cholesterol cular morbidity and mortality at an
,200 mg/day, avoid trans earlier age than in those diagnosed later
Obstructive Sleep Apnea fats, and aim for ;10% cal- in life (219). The higher complication risk
ories from monounsaturated in earlier-onset type 2 diabetes is likely
Recommendation
fats for elevated LDL. For related to prolonged lifetime exposure to
13.94 Screening for symptoms of sleep
elevated triglycerides, medical hyperglycemia and other atherogenic
apnea should be done at each
nutrition therapy should also risk factors, including insulin resistance,
visit, and referral to a pediatric
focus on decreasing simple dyslipidemia, hypertension, and chronic
sleep specialist for evaluation
sugar intake and increasing di- inflammation. There is low risk of hypo-
and a polysomnogram, if indi-
etary n-3 fatty acids in addi- glycemia in youth with type 2 diabetes,
cated,isrecommended.Obstruc-
tion to the above changes. A even if they are being treated with insulin
tive sleep apnea should be
13.102 If LDL cholesterol remains (220), and there are high rates of com-
treated when documented. B
.130 mg/dL after 6 months plications (190–193). These diabetes co-
of dietary intervention, initiate morbidities also appear to be higher than
Polycystic Ovary Syndrome
therapy with statin, with a goal in youth with type 1 diabetes despite
Recommendations of LDL ,100 mg/dL, following shorter diabetes duration and lower A1C
13.95 Evaluate for polycystic ovary reproductive counseling for fe- (218). In addition, the progression of
syndrome in female adolescents males because of the potential vascular abnormalities appears to be
with type 2 diabetes, including teratogenic effects of statins. B more pronounced in youth-onset type
laboratory studies when indi- 13.103 If triglycerides are .400 mg/ 2 diabetes compared with type 1 diabe-
cated. B dL (4.7 mmol/L) fasting or tes of similar duration, including ischemic
13.96 Oral contraceptive pills for treat- .1,000 mg/dL (11.6 mmol/ heart disease and stroke (221).
ment of polycystic ovary syn- L) nonfasting, optimize glyce-
drome are not contraindicated mia and begin fibrate, with Psychosocial Factors
for girls with type 2 diabetes. C a goal of ,400 mg/dL (4.7
Recommendations
13.97 Metformin in addition to life- mmol/L) fasting (to reduce
risk for pancreatitis). C 13.105 Providers should assess food
style modification is likely to
security, housing stability/
improve the menstrual cyclic-
homelessness, health liter-
ity and hyperandrogenism in Cardiac Function Testing
acy, financial barriers, and
girls with type 2 diabetes. E
Recommendation social/community support and
13.104 Routine screening for heart apply that information to treat-
Cardiovascular Disease
disease with electrocardio- ment decisions. E
Recommendation gram,echocardiogram,orstress 13.106 Use patient-appropriate stan-
13.98 Intensive lifestyle interven- testing is not recommended dardized and validated tools
tions focusing on weight loss, in asymptomatic youth with to assess for diabetes distress
dyslipidemia, hypertension, type 2 diabetes. B and mental/behavioral health
liveborn infants had a major congenital outcomes during transition to adult care
in youth with type 2 diabetes,
anomaly. and early adulthood have been docu-
with attention to symptoms of
mented (238,239).
depression and eating disor-
Although scientific evidence is limited,
ders, and refer to specialty TRANSITION FROM PEDIATRIC TO it is clear that comprehensive and co-
care when indicated. B ADULT CARE
ordinated planning that begins in early
13.107 When choosing glucose-low-
Recommendations adolescence is necessary to facilitate a
ering or other medications for
13.110 Pediatric diabetes providers seamless transition from pediatric to
youth with overweight or
should begin to prepare youth adult health care (233,234,240,241).
obesity and type 2 diabetes,
for transition to adult health New technologies and other interven-
consider medication-taking
care in early adolescence and, tions are being tried to support transi-
behavior and their effect on
at the latest, at least 1 year tion to adult care in young adulthood
weight. E

before the transition. E (242–246). A comprehensive discussion
13.108 Starting at puberty, precon-
13.111 Both pediatric and adult di- regarding the challenges faced during
ception counseling should be
abetes care providers should this period, including specific recommen-
incorporated into routine di-
provide support and resour- dations, is found in the ADA position
abetes clinic visits for all fe-
ces for transitioning young statement “Diabetes Care for Emerging
males of childbearing potential
adults. E Adults: Recommendations for Transition
because of the adverse preg-
13.112 Youth with type 2 diabetes From Pediatric to Adult Diabetes Care
nancy outcomes in this popu-
should be transferred to an Systems” (234).
lation. A
adult-oriented diabetes spe- The Endocrine Society in collaboration
13.109 Patients should be screened for
cialist when deemed appro- with the ADA and other organizations has
tobacco, electronic cigarettes,
priate by the patient and developed transition tools for clinicians
and alcohol use at diagnosis
provider. E and youth and families (241).
and regularly thereafter. C
Care and close supervision of diabetes References
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S180 Diabetes Care Volume 44, Supplement 1, January 2021

13. Children and Adolescents: American Diabetes Association

Standards of Medical Care in

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includes the ADA’s current clinical practice recommendations and is intended to

The management of diabetes in children and adolescents cannot simply be derived

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Overall, it is recommended that youth disproportionately affects racial/ethnic

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validated tools, such as the Problem negative effects on diabetes outcomes

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total cholesterol, LDL cholesterol, or HDL

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Statins are contraindicated in pregnancy;

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TYPE 2 DIABETES diabetes in children can be difﬁcult.

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Comorbidities may already be present at

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