Diabetes Care Volume 48, Supplement 1, January 2025 S283

14. Children and Adolescents: American Diabetes Association

Professional Practice Committee*
Standards of Care in
Diabetes—2025
Diabetes Care 2025;48(Suppl. 1):S283–S305 | [Link]

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14. CHILDREN AND ADOLESCENTS
The American Diabetes Association (ADA) “Standards of Care in Diabetes” 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, an
interprofessional expert committee, 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 and a full list of Professional Practice Com-
mittee members, please refer to Introduction and Methodology. Readers who wish
to comment on the Standards of Care are invited to do so at [Link]
.org/SOC.

The management of diabetes in children and adolescents (individuals <18 years of

age) cannot simply be derived from care routinely provided to adults with diabetes.
The epidemiology, pathophysiology, developmental considerations, and response to
therapy in pediatric diabetes are often different from those of adult diabetes. There
are also differences in recommended care for children and adolescents with type 1
diabetes, type 2 diabetes, and other forms of diabetes. This section is divided into
two major parts: the first part addresses care for children and adolescents with type 1
diabetes, and the second part addresses care for children and adolescents with type 2
diabetes. Monogenic diabetes (neonatal diabetes and maturity-onset diabetes of the
young) and cystic fibrosis-related diabetes, which are often present in youth, are dis-
cussed in Section 2, “Diagnosis and Classification of Diabetes.” Table 14.1A and Table
14.1B provide an overview of the recommendations for screening and treatment of
complications and related conditions in pediatric type 1 diabetes and type 2 diabetes,
respectively. In addition to comprehensive diabetes care, youth with diabetes should
*A complete list of members of the American
receive age-appropriate and developmentally appropriate pediatric care, including im- Diabetes Association Professional Practice Committee
munizations as recommended by the Centers for Disease Control and Prevention (CDC) can be found at [Link]
(1). To ensure continuity of care as a person with diabetes becomes an adult, guidance Duality of interest information for each author is
is provided at the end of this section on the transition from pediatric to adult diabetes available at [Link]
care. Suggested citation: American Diabetes Association
Due to the nature of pediatric clinical research, the recommendations for children Professional Practice Committee. 14. Children and
and adolescents with diabetes are less likely to be based on clinical trial evidence. adolescents: Standards of Care in Diabetes—2025.
However, expert opinion and a review of available and relevant experimental data Diabetes Care 2025;48(Suppl. 1):S283–S305
are summarized in the American Diabetes Association (ADA) position statements © 2024 by the American Diabetes Association.
“Type 1 Diabetes in Children and Adolescents” (2) and “Evaluation and Management Readers may use this article as long as the
work is properly cited, the use is educational
of Youth-Onset Type 2 Diabetes” (3). Finally, other sections in the Standards of Care and not for profit, and the work is not altered.
may have recommendations that apply to youth with diabetes and are referenced in More information is available at [Link]
the narrative of this section. .[Link]/journals/pages/license.
 S284

Table 14.1A—Recommendations for screening and treatment of complications and related conditions in pediatric type 1 diabetes
Thyroid disease Celiac disease Hypertension Nephropathy Retinopathy Neuropathy Dyslipidemia
Corresponding 14.29 and 14.30 14.31–14.33 14.34–14.37 14.43 and 14.44 14.45–14.47 14.48 14.38–14.42
recommendations
Children and Adolescents

Method Thyroid-stimulating IgA tTG if total IgA normal; Blood pressure Albumin-to-creatinine Dilated fundoscopy or Foot exam with foot pulses, Lipid profile, nonfasting
hormone; consider IgG tTG and deamidated monitoring ratio; random sample retinal photography pinprick, 10-g acceptable initially
antithyroglobulin gliadin antibodies if IgA acceptable initially monofilament sensation
and antithyroid deficient tests, vibration, and ankle
peroxidase antibodies reflexes

When to start Soon after diagnosis Soon after diagnosis At diagnosis Puberty or $10 years old, Puberty or $11 years old, Puberty or $10 years old, Soon after diagnosis;
whichever is earlier, and whichever is earlier, and whichever is earlier, and preferably after
diabetes duration of 5 diabetes duration of diabetes duration of glycemia has improved
years 3–5 years 5 years and $2 years old

Follow-up frequency Every 1–2 years if thyroid Within 2 years and then Every visit If normal, annually; if If normal, every 2 years; If normal, annually If LDL <100 mg/dL, repeat
antibodies negative; at 5 years after abnormal, repeat with consider less frequently at 9–11 years old; then,
more often if symptoms diagnosis; sooner if confirmation in two of (every 4 years) if A1C if <100 mg/dL,
develop or presence of symptoms develop three samples over <8% and eye every 3 years
thyroid antibodies 6 months (first morning professional agrees
void is recommended)

Goal NA NA <90th percentile for age, Albumin-to-creatinine ratio No retinopathy No neuropathy LDL <100 mg/dL
sex, and height; if <30 mg/g
$13 years old,
<120/80 mmHg

Treatment Appropriate treatment of After confirmation, start Lifestyle modification for Optimize glycemia and blood Optimize glycemia; Optimize glycemia; If abnormal, optimize
underlying thyroid gluten-free diet elevated blood pressure pressure; ACE inhibitor* treatment per referral to neurology glycemia and medical
disorder (90th to <95th percentile if albumin-to-creatinine ophthalmology nutrition therapy; if
for age, sex, and height ratio is elevated in two of after 6 months LDL
or, if $13 years old, three samples over >160 mg/dL or
120–129/<80 mmHg); 6 months >130 mg/dL with
lifestyle modification and cardiovascular risk
ACE inhibitor or ARB* for factor(s), initiate statin
hypertension ($95th therapy (for those aged
percentile for age, sex, >10 years)*
and height or, if $13
years old, $130/80
mmHg)

ARB, angiotensin receptor blocker; NA, not applicable; tTG, tissue transglutaminase. *Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and medication should be
avoided in individuals of childbearing age who are not using reliable contraception.
Diabetes Care Volume 48, Supplement 1, January 2025

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Table 14.1B—Recommendations for screening and treatment of complications and related conditions in pediatric type 2 diabetes
Polycystic ovary
Metabolic dysfunction– syndrome (for
associated steatotic Obstructive adolescent female
Hypertension Nephropathy Neuropathy Retinopathy Dyslipidemia liver disease sleep apnea individuals)
Corresponding 14.72–14.75 14.76–14.80 14.81 and 14.82 14.83–14.86 14.93–14.97 14.87 and 14.88 14.89 14.90 and 14.91
[Link]/care

recommendations
Method Blood pressure Albumin-to-creatinine Foot exam with foot Dilated Lipid profile AST and ALT Screening for Screening for
monitoring ratio; random pulses, pinprick, 10-g fundoscopy measurement symptoms symptoms;
sample acceptable monofilament laboratory
initially sensation tests, evaluation if positive
vibration, and ankle symptoms
reflexes

When to start At diagnosis At diagnosis At diagnosis At or soon Soon after diagnosis, At diagnosis At diagnosis At diagnosis
after diagnosis preferably after
glycemia has
improved

Follow-up frequency Every visit If normal, annually; If normal, annually If normal, annually Annually Annually Every visit Every visit
if abnormal, repeat or every 2 years
with confirmation in if glycemic goals
two of three are achieved
samples over 6
months

Goal <90th percentile for age, <30 mg/g No neuropathy No retinopathy LDL <100 mg/dL, HDL NA NA NA
sex, and height; if >35 mg/dL,
$13 years old, triglycerides
<130/80 mmHg <150 mg/dL

Treatment Lifestyle modification for Optimize glycemia Optimize glycemia; Optimize glycemia; If abnormal, optimize Refer to gastroenterology If positive symptoms, If no contraindications,
elevated blood pressure and blood pressure; referral to neurology treatment per glycemia and medical for persistently refer to sleep oral contraceptive
(90th to <95th percentile ACE inhibitor* if ophthalmology nutrition therapy; if elevated or worsening specialist and pills; medical
for age, sex, and height albumin-to- LDL >130 mg/dL after transaminases polysomnogram nutrition therapy;
or, if $13 years old, creatinine ratio is 6 months, initiate metformin
120–129/<80 mmHg); elevated in two of statin therapy (for
lifestyle modification and three samples over 6 those aged >10
ACE inhibitor or ARB* for months years);* if triglycerides
hypertension ($95th >400 mg/dL fasting
percentile for age, sex, or >1,000 mg/dL
and height or, if $13 nonfasting, begin
years, $130/80 mmHg) fibrate

ARB, angiotensin receptor blocker; NA, not applicable; tTG, tissue transglutaminase. *Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counseling, and medication should be
avoided in individuals of childbearing age who are not using reliable contraception.
Children and Adolescents
S285

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S286 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

TYPE 1 DIABETES support (DSMES) according to national nuts and seeds, and low-fat dairy
Type 1 diabetes is the most common standards at diagnosis and routinely products, and minimize consump-
form of diabetes in youth (4), although thereafter. B tion of red meat, sugar-sweetened
there are more adults living with and di- beverages, sweets, refined grains, and
agnosed with type 1 diabetes (5). The processed foods). B
health care professional must consider Self-management in pediatric diabetes in-
14.5 Meal composition impacts post-
the unique aspects of care and manage- volves both the youth and their parents
prandial glucose excursions. Educa-
ment of children and adolescents with or adult caregivers. No matter how sound
tion on the impact of high-fat and
type 1 diabetes, such as changes in insu- the medical plan is, it will only be effec-
high-protein meals and the adjust-
lin sensitivity related to physical growth tive if the family and/or affected individu-
ment of insulin dosing is necessary. A
and sexual maturation, ability to provide als can implement it. Family involvement
14.6 Strongly advise comprehensive
self-care, supervision in the childcare and is a vital component of optimal diabetes
nutrition education at diagnosis, and

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school environment, neurological vulnera- management throughout childhood and
at least annually as needed, by an
bility to hypoglycemia and hyperglycemia adolescence. As parents or caregivers are
experienced registered dietitian nutri-
in young children, and possible adverse critical to diabetes self-management in
tionist to assess the eating pattern in
neurocognitive effects of diabetic keto- youth, diabetes care requires an approach
relation to weight status, age-appro-
acidosis (DKA) (6,7). Attention to family that places the youth and their parents or
priate growth, and cardiovascular dis-
dynamics, developmental stages, and caregivers at the center of the care model.
ease risk factors. E
physiologic differences related to sexual The pediatric diabetes care team must be
maturity is essential in developing and capable of evaluating the educational,
implementing an optimal diabetes treat- behavioral, emotional, and psychosocial Nutrition management should be indi-
ment plan (8). Additionally, more people factors that impact treatment plan im- vidualized: family habits, food preferen-
(adults and youth) with type 1 diabetes plementation and must work with the ces, religious or cultural needs, finances,
are experiencing obesity than in the past, youth and family to overcome barriers schedules, physical activity, and the youth’s
which adds to the complexity of living or redefine goals as appropriate. As the and family’s abilities in numeracy, literacy,
with and managing type 1 diabetes (9). youth grows, develops, and acquires the and self-management should be consid-
An interprofessional team trained in need and desire for greater independent ered. Visits with a registered dietitian nutri-
pediatric diabetes management and sen- self-care skills, DSMES requires periodic tionist, preferably experienced in working
sitive to the challenges of children and and routine (e.g., at each follow-up visit) with pediatric populations with diabetes,
adolescents with type 1 diabetes and reassessment. The pediatric diabetes team should include assessment for changes in
their families should provide diabetes- should work with the youth and their pa- food preferences over time, access to food,
specific care for this population. It is rents or caregivers to ensure there is not a growth and development, weight status,
essential that diabetes self-management premature transfer of self-management cardiovascular risk, and potential for dis-
education and support (DSMES), medical tasks to the youth during this time. In addi- ordered eating. Following recommended
nutrition therapy (MNT), and psychoso- tion, it is important to assess the educa- eating patterns is associated with better
cial and behavioral support be provided tional needs and skills of, and provide glycemic outcomes in youth with type 1
at diagnosis and routinely (e.g., at each training to, daycare workers, school nurses, diabetes (12).
follow-up visit) thereafter in a develop- and school personnel who are responsible Although carbohydrate content is the
mentally appropriate format that builds for the care and supervision of the child primary variable for calculation of meal-
on prior knowledge by a team of health with diabetes (2,10,11). time insulin doses, meals with higher fat
care professionals experienced with the and protein content can cause early
biological, educational, nutritional, behav- Nutrition Therapy hypoglycemia and delayed postprandial
ioral, and emotional needs of the growing glucose excursions. Some adjustments in
Recommendations
child and family. The diabetes team, con- insulin dosing, including an increase in
14.2 Individualized medical nutrition
sidering the youth’s developmental and the calculated dose and a split dose, will
therapy (MNT) is recommended for
psychosocial needs, should ask about and improve postprandial glucose manage-
youth with type 1 diabetes as an es-
discuss diabetes management responsi- ment (13–17).
sential component of the overall treat-
bilities with youth and parents or care- ment plan. A
givers on an ongoing basis. Physical Activity and Exercise
14.3 Monitoring carbohydrate intake,
whether by carbohydrate counting or Recommendations
Diabetes Self-Management Education experience-based estimation, is a key 14.7 Physical activity is recommended
and Support for all youth with type 1 diabetes with
component to optimizing glycemic
Recommendation management. B the goal of 60 min of moderate- to
14.1 Youth with type 1 diabetes and 14.4 Advise youth with type 1 diabe- vigorous-intensity aerobic activity daily,
their parents or caregivers (for individ- tes and their caregivers to strive for with vigorous muscle-strengthening and
uals aged <18 years) should receive an eating pattern emphasizing key nu- bone-strengthening activities at least
culturally sensitive and developmen- trition principles (including nonstarchy 3 days per week. C
tally appropriate individualized diabe- vegetables, whole fruits, legumes, fish 14.8 Advise frequent glucose monitor-
tes self-management education and and other lean protein, whole grains, ing before, during, and after exercise,
[Link]/care Children and Adolescents S287

via blood glucose meter and/or con- when B-OHB levels are $0.6 mmol/L School and Child Care
(12,19). As a large portion of a youth’s day is
tinuous glucose monitoring (CGM), to
Prevention and treatment of hypogly- spent in school and/or daycare, training
prevent, detect, and treat hypoglyce-
cemia associated with physical activity of school or daycare personnel to provide
mia and hyperglycemia associated
includes decreasing prandial insulin for care in accordance with the child’s indi-
with exercise. C
the meal or snack before exercise and/or vidualized diabetes medical management
14.9 Youth and their parents or
increasing food intake. Youth on insulin plan is essential for optimal diabetes
caregivers should receive education
pumps without automated insulin delivery management and safe access to all
on goals and management of glyce-
mia before, during, and after physi- (AID) can lower basal rates by 10–50% school- or daycare–sponsored opportuni-
or more or suspend for 1–2 h during ex- ties (11,37,38). In addition, federal and
cal activity, individualized according
ercise (25). Decreasing basal rates or state laws require schools, daycare facili-
to the type and intensity of the
planned physical activity. C long-acting insulin doses by 20% after ties, and other entities to provide needed

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exercise may reduce delayed exercise- diabetes care to enable the child to
14.10 Youth and their parents or care-
induced hypoglycemia (26). Accessible safely access the school or daycare envi-
givers should be educated on strate-
rapid-acting carbohydrates and frequent ronment. Refer to the ADA position
gies to prevent hypoglycemia during,
blood glucose monitoring before, during, statements “Diabetes Care in the School
after, and overnight following physical
and after exercise, with or without contin- Setting” (11) and “Care of Young Chil-
activity and exercise. Treatment for
uous glucose monitoring (CGM), maxi- dren With Diabetes in the Childcare and
hypoglycemia should be accessible
mize safety with exercise. Using AID Community Setting” (38) and the ADA’s
before, during, and after engaging in
systems may improve time in range (TIR) Safe at School website ([Link]/
activity. C
(70–180 mg/dL) during exercise, and resources/know-your-rights/safe-at-school-
youth can use brand-specific settings that state-laws) for additional details.
Physical activity and structured exercise are more conservative or increase the gly-
positively impact metabolic and psycho- cemic goal to prevent hypoglycemia (27). Psychosocial Care
logical health in children with type 1 dia- Blood glucose goals prior to physical Recommendations
betes (18). While it can have positive activity and exercise are 126–180 mg/dL 14.11 At diagnosis and during rou-
effects on insulin sensitivity, physical fit- (7.0–10.0 mmol/L) but should be individu- tine follow-up care, screen youth
ness, strength building, cardiorespiratory alized based on the type, intensity, and with type 1 diabetes for psychosocial
fitness, weight management, social inter- duration of activity (19,21). The accuracy concerns (e.g., diabetes distress, depres-
action, mood, self-esteem building, and of CGM systems varies depending on the sive symptoms, and disordered eating),
the creation of healthful habits for adult- type of exercise (28–30). Consider addi- family factors, and behavioral health
hood, it also has the potential to cause tional carbohydrate intake during and/or concerns that could impact diabetes
both hypoglycemia and hyperglycemia. after exercise, depending on duration and management with age-appropriate
See below for strategies to mitigate intensity of physical activity, to prevent standardized and validated tools. Refer
hypoglycemia risk and minimize hypergly- hypoglycemia. For low- to moderate- to a qualified behavioral health profes-
cemia associated with exercise. For an intensity aerobic activities (30–60 min), sional, preferably experienced in child-
in-depth discussion, see previously pub- and if the youth is fasting, 10–15 g of car- hood diabetes, when indicated. B
lished reviews and guidelines (19–23). bohydrate may prevent hypoglycemia (21). 14.12 Behavioral health professio-
Overall, it is recommended that all After insulin boluses (relative hyperinsuli- nals should be considered integral
youth participate in 60 min of moderate- nemia), consider 0.5–1.0 g of carbohy- members of the pediatric diabetes
intensity (e.g., brisk walking and dancing) drates/kg per hour of exercise (30–60 g), interprofessional team. E
to vigorous-intensity (e.g., running and similar to carbohydrate requirements for 14.13 Encourage developmentally ap-
jumping rope) aerobic activity daily, in- optimizing performance in athletes with- propriate family involvement in dia-
cluding resistance and flexibility training out type 1 diabetes (31,32). betes management tasks for children
(24). Although uncommon in the pediat- For children and adolescents with and adolescents, recognizing that pre-
ric population, youth should be medically type 1 diabetes and obesity, physical ac- mature or unsupportive transfer of di-
evaluated for comorbid conditions or tivity and exercise are key components abetes care responsibility to the youth
diabetes complications that may restrict of diabetes care. Obesity is equally com-
can contribute to diabetes distress,
participation in an exercise program. As mon in youth with or without type 1 dia-
lower engagement in diabetes self-
hyperglycemia can occur before, during, betes. Having obesity is associated with
management behaviors, and deterio-
and after physical activity, it is important a higher frequency of cardiovascular risk
ration in glycemia. A
to ensure the elevated glucose level is factors, and it disproportionately affects
14.14 Health care professionals should
not related to insulin deficiency, as that youth from racial and ethnic minoritized
screen for food security, housing stabil-
can lead to worsening hyperglycemia groups (e.g., Black and Latino youth)
ity, health literacy, financial barriers,
with exercise and ketosis risk. Intense ac- (9,33–36). Therefore, diabetes health
and social or community support and
tivity should be postponed with marked care professionals should monitor weight
apply that information to treatment de-
hyperglycemia (glucose $350 mg/dL status and encourage a healthy eating
cisions. E
[$19.4 mmol/L]), moderate to large urine pattern, physical activity, and healthy
14.15 Health care professionals should
ketones, and/or b-hydroxybutyrate (B-OHB) weight as key components of pediatric
consider asking youth and their parents
>1.5 mmol/L. Caution may be needed type 1 diabetes care.
S288 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

or caregivers about social adjustment secrecy around eating and excessive con- be related to academic progress and stu-
(peer relationships) and school perfor- cern about weight) are present using avail- dents’ functioning in the school setting,
mance to determine whether further able screening tools (47). Youth with type 1 which highlights the need for appropriate
intervention is needed. B diabetes have an increased risk of disor- accommodations and access to diabetes-
14.16 Offer adolescents time by them- dered eating behavior as well as clinical eat- related support in school (58).
selves with their health care professio- ing disorders, with serious short-term and Shared decision-making with youth re-
nal(s) at a developmentally appropriate long-term negative effects on diabetes out- garding the adoption of management plan
age. E comes and health in general. It is important components and self-management behav-
14.17 Starting at puberty, precon- to recognize the unique and dangerous dis- iors can improve diabetes self-efficacy,
ception counseling should be incor- ordered eating behavior of insulin omission participation in diabetes care, and glyce-
porated into routine diabetes care for weight management in type 1 diabetes mic outcomes (9,59). For example, well-
for all individuals of childbearing po- (48). designed decision aids can engage youth

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tential. A Given the complexity of psychosocial in comprehensive, unbiased conversations
concerns in the management of type 1 di- with their diabetes care team about treat-
abetes in youth, collaboration between ment options (60). Other examples in-
Rapid and dynamic cognitive, develop- the diabetes health care team and a be- clude creating self-care contracts (61)
mental, and emotional changes occur dur- havioral health professional, ideally with and technology-integrated care that uses
ing childhood, adolescence, and emerging expertise in diabetes, is recommended. blood glucose records shared with the
adulthood. Diabetes management during Early detection of diabetes distress, de- care team to facilitate shared decision-
childhood and adolescence places sub- pression, anxiety, fear of hypoglycemia, making (62). Importantly, health care pro-
stantial burdens on the youth and family, and disordered eating can facilitate effec- fessionals working with youth who are
necessitating ongoing assessment of psy- tive treatment options and help minimize not yet able to provide legal consent must
chosocial status, social determinants of adverse effects on diabetes management balance clinical oversight with promoting
health, and diabetes distress in the youth and disease outcomes (39,42). When developmentally appropriate independence.
and the parents or caregivers during rou- psychological symptoms are identified, Recommendations include providing educa-
tine diabetes visits (39–41). It is important referral to a behavioral health profes- tion tailored to the developmental stage,
to consider the impact of diabetes on sional, ideally with experience in pediat- encouraging gradual responsibility with self-
quality of life as well as the development ric diabetes, may be warranted. Such care, guiding parental involvement as
of behavioral health problems related to professionals can provide individualized, responsibilities change, teaching self-
diabetes distress, symptoms of depres- evidence-based behavioral health care advocacy to prepare for transitions in
sion, symptoms of anxiety, fear of hypo- services, including cognitive-behavioral, care, and incorporating psychosocial sup-
glycemia (and hyperglycemia), disordered mindfulness-based, and other interven- port at all stages (57,63). Although cogni-
eating behaviors, and eating disorders tions (49), to improve psychosocial func- tive abilities vary, the ethical position
(39,42). tioning in youth with type 1 diabetes often adopted is the “mature minor rule,”
Consider screening youth for diabetes (50–52). whereby children after age 12 or 13 years
distress, generally starting at 7 or 8 years of The complexities of diabetes manage- who appear to be mature have the right
age (42), using validated tools for youth ment require ongoing parental involve- to consent or withhold consent to general
and their parents or caregivers (43). The ment in care throughout childhood and medical treatment, except in cases in
U.S. Preventive Services Task Force recom- adolescence. Developmentally appropriate, which refusal would significantly endan-
mends screening for depression in youth supportive family teamwork between the ger health (64).
aged 12–18 years (44). Additional times to growing youth and parent(s) can help Beginning at the onset of puberty or
consider screening for depression include maintain engagement in self-management at diagnosis of diabetes, all individuals
when youth are not meeting treatment behaviors and reduce deterioration in with childbearing potential should re-
goals or when there are significant changes glycemia (53,54). It is appropriate to in- ceive education about the effective use
in medical status or life circumstances. The quire about diabetes-specific family rela- of contraception to prevent unplanned
U.S. Preventive Services Task Force also rec- tionships, including family teamwork and pregnancy, as risks of fetal malforma-
ommends screening for anxiety in youth conflict, during visits; health care profes- tions are associated with elevated A1C.
aged 8–18 years (45). Parents or caregivers sionals can both help families negotiate a Preconception counseling using devel-
and youth at risk for hypoglycemia or fear plan and refer to an appropriate behavioral opmentally appropriate educational and
of hypoglycemia, especially if they have ex- health professional for more in-depth sup- behavioral strategies enables individuals
perienced severe and/or frequent hypogly- port (55). Such professionals can conduct of childbearing potential to make well-
cemic events, should be screened for fear further assessment and deliver evidence- informed decisions (65). Preconception
of hypoglycemia; youth as young as 6 years based behavioral interventions to support counseling resources tailored for adoles-
old can provide reliable self-reports for fear developmentally appropriate, collabora- cents are available at no cost through
of hypoglycemia (46). Lastly, health care tive family involvement in diabetes self- the ADA (66). Refer to the ADA position
professionals should consider screening for management (50,52). Monitoring of social statement “Psychosocial Care for People
disordered eating behaviors when signs adjustment (peer relationships) and school With Diabetes” for further details (42).
and symptoms (e.g., unexplained weight performance can facilitate both well-being The presence of a behavioral health
loss, hyperglycemia, and DKA) and/or be- and academic achievement (56,57). Diabe- professional on pediatric interprofes-
havioral and emotional indicators (e.g., tes management and glycemic levels may sional teams highlights the importance
[Link]/care Children and Adolescents S289

of attending to the psychosocial issues of appropriate for many children and glucose goals recommended by the
diabetes. These psychosocial factors are adolescents. B ADA (67,68), particularly in families in
significantly related to self-management 14.24 Less stringent A1C goals (such which the parents or caregivers as well
difficulties, elevated A1C, reduced quality as <7.5% [<58 mmol/mol]) may be as the child with diabetes participate
of life, and higher rates of acute and chronic appropriate for youth who cannot ar- jointly to perform the required diabe-
diabetes complications. ticulate symptoms of hypoglycemia; tes-related tasks.
have hypoglycemia unawareness; lack Lower A1C in adolescence and young
Glycemic Monitoring, Insulin advanced insulin delivery technology adulthood is associated with a lower risk
Delivery, and Goals and/or CGM; cannot check blood glu- and rate of microvascular and macrovas-
Recommendations cose regularly; or have nonglycemic cular complications (69–71) and demon-
14.18 All youth with type 1 diabetes factors that increase A1C (e.g., high strates the effects of metabolic memory
should monitor glucose levels multi- glycators). B (72–75).

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ple times daily (up to 10 times/day 14.25 Even less stringent A1C goals In addition, type 1 diabetes can be as-
by blood glucose meter or CGM), in- (such as <8% [<64 mmol/mol]) may sociated with adverse effects on cognition
cluding prior to meals and snacks, at be appropriate for individuals with a during childhood and adolescence (6,76),
bedtime, and as needed for safety in history of severe hypoglycemia or lim- and neurocognitive imaging differences
specific situations such as physical ited life expectancy or where the related to hyperglycemia in children pro-
activity, driving, or the presence of harms of treatment are greater than vide another motivation for achieving
symptoms of hypoglycemia. B the benefits. B glycemic goals (6). Several factors, in-
14.19 Real-time CGM A or intermit- 14.26 Health care professionals may cluding young age, severe hypoglycemia
tently scanned CGM C should be offered reasonably suggest more stringent A1C at <6 years of age, DKA, and chronic hy-
for diabetes management at diagnosis goals (such as <6.5% [<48 mmol/ perglycemia (76,77), contribute to ad-
or as soon as possible in youth with dia- mol]) for selected individuals if they verse effects on brain development and
betes on multiple daily injections or in- can be achieved without significant hy- function. However, meticulous use of
sulin pump therapy who are capable of poglycemia, excessive weight gain, neg- therapeutic modalities such as rapid- and
using the device safely (either by them- ative impacts on well-being, or undue long-acting insulin analogs, technological
selves or with caregivers). The choice of burden of care or in those who have advances (e.g., CGM, sensor-augmented
device should be made based on the in- nonglycemic factors that decrease pump therapy, and AID systems), and in-
dividual’s and family’s circumstances, A1C (e.g., lower erythrocyte life span). tensive self-management education now
desires, and needs. Lower goals may also be appropriate make it more feasible to achieve glycemic
14.20 Automated insulin delivery during the honeymoon phase. B goals while reducing the incidence of se-
(AID) systems should be offered for di- 14.27 CGM metrics derived from CGM vere hypoglycemia (78–99). Please refer to
abetes management to youth with use over the most recent 14 days (or Section 7, “Diabetes Technology,” for more
type 1 diabetes who are capable of us- longer for youth with more glycemic var- information on technology to support peo-
ing the device safely (either by them- iability), including time in range (70–180 ple with diabetes.
selves or with caregivers). The choice mg/dL [3.9–10.0 mmol/L]), time below Recent data with newer devices and
of device should be made based on range (<70 mg/dL [<3.9 mmol/L] and insulins indicate that the risk of hypogly-
<54 mg/dL [<3.0 mmol/L]), and time cemia with lower A1C is less than it was
the individual’s and family’s circum-
above range (>180 mg/dL [>10.0 before (100–108). In addition, achieving
stances, desires, and needs. A
mmol/L] and >250 mg/dL [>13.9 lower A1C levels is likely facilitated by
14.21 Insulin pump therapy alone
mmol/L]), are recommended to be used setting lower A1C goals (109). Lower
should be offered for diabetes man-
in conjunction with A1C whenever possi- goals may be possible during the honey-
agement to youth on multiple daily
ble. E moon phase of type 1 diabetes. Special
injections with type 1 diabetes who
consideration should be given to the
are capable of using the device
risk of hypoglycemia in young children
safely (either by themselves or with
Current standards for diabetes manage- (aged <6 years) who are often unable
caregivers) if unable to use AID sys-
ment reflect the need to minimize hy- to recognize, articulate, and/or manage
tems. The choice of device should
perglycemia as safely as possible. The hypoglycemia. However, registry data
be made based on the individual’s
Diabetes Control and Complications Trial indicate that lower A1C goals can be
and family’s circumstances, desires,
(DCCT), which did not enroll children achieved in children, including those
and needs. A
<13 years of age, demonstrated that aged <6 years, without increased risk
14.22 Students must be supported at
near normalization of blood glucose lev- of severe hypoglycemia (101). Recent
school in the use of diabetes technol-
els was more difficult to achieve in ado- data have demonstrated that the use of
ogy, including CGM, insulin pumps,
lescents than in adults. Nevertheless, real-time CGM lowered A1C and in-
connected insulin pens, and AID sys-
the increased use of basal-bolus plans, creased TIR in adolescents and young
tems, as prescribed by their diabetes
insulin pumps, frequent blood glucose adults and was associated with a lower
care team. E
monitoring, CGM, AID systems, goal risk of hypoglycemia (110). Please refer
14.23 A1C goals must be individual-
setting, and improved education has to Section 6, “Glycemic Goals and Hypo-
ized and reassessed over time. An
been associated with more children glycemia,” for more information on glyce-
A1C of <7% (<53 mmol/mol) is
and adolescents reaching the blood mic assessment.
S290 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

A strong relationship exists between diabetes, screening for thyroid dysfunc- ketosis or ketoacidosis, weight loss, etc.
the frequency of blood glucose monitor- tion and celiac disease should be consid- Therefore, if performed at diagnosis and
ing and glycemic management (97–99, ered (118–122). Periodic screening in slightly abnormal, thyroid function tests
111,112). Glucose levels for all children asymptomatic individuals has been rec- should be repeated soon after a period of
and adolescents with type 1 diabetes ommended, but the optimal frequency metabolic stability and achievement of
should be monitored multiple times daily of screening is unclear. glycemic goals. Subclinical hypothyroidism
by blood glucose monitoring and/or CGM. Although much less common than thy- may be associated with an increased risk
Recent data on children and adults sug- roid dysfunction and celiac disease, other of symptomatic hypoglycemia and dyslipi-
gest that use of CGM soon after type 1 autoimmune conditions, such as Addison demia (129,130) and a reduced linear
diabetes diagnosis is associated with disease (primary adrenal insufficiency), growth rate. Hyperthyroidism alters glu-
improved A1C (84,85,113). In the U.S., autoimmune hepatitis, autoimmune gas- cose metabolism and usually causes dete-
real-time CGM is approved for nonad- tritis, dermatomyositis, and myasthenia rioration of glycemia.

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junctive use in children aged 2 years gravis, occur more commonly in the popu-
and older, and intermittently scanned lation with type 1 diabetes than in the Celiac Disease
CGM is approved for nonadjunctive use general pediatric population and should
Recommendations
in children aged 4 years and older. Pa- be assessed and monitored as clinically in-
14.31 Screen youth with type 1 diabe-
rents, caregivers, and youth should be dicated. In addition, relatives of youth
tes for celiac disease by measuring IgA
offered initial and ongoing education with type 1 diabetes should be offered
tissue transglutaminase (tTG) antibod-
and support for CGM use. Behavioral testing for islet autoantibodies through re-
ies, with documentation of normal to-
support may further improve ongoing search studies (e.g., TrialNet) and national
tal serum IgA levels, soon after the
CGM use (114). Metrics derived from programs for early diagnosis of preclinical
diagnosis of diabetes, or IgG tTG and
CGM include percent TIR, time below tar- type 1 diabetes (stages 1 and 2).
deamidated gliadin antibodies if IgA is
get range, and time above target range
deficient. B
(115). While studies indicate a relationship Thyroid Disease 14.32 Repeat screening for celiac dis-
between TIR and A1C (116,117), it is still ease within 2 years of diabetes diagno-
Recommendations
uncertain what the ideal goal TIR sis and then again after 5 years and
14.29 Consider testing children with
should be for children, and further consider more frequent screening in
type 1 diabetes for antithyroid per-
studies are needed. Please refer to Sec- youth who have symptoms or a first-
oxidase and antithyroglobulin anti-
tion 7, “Diabetes Technology,” for more degree relative with celiac disease. B
bodies soon after diagnosis. B
information on the use of blood glu- 14.33 Individuals with confirmed ce-
14.30 Measure thyroid-stimulating
cose meters, CGM, and insulin pumps. liac disease should be placed on a
hormone concentrations at diagnosis
More information on insulin injection when clinically stable or soon after op- gluten-free diet for treatment and to
technique can be found in Section 9, timizing glycemia. If normal, suggest avoid complications. Youth and their
“Pharmacologic Approaches to Glycemic rechecking every 1–2 years or sooner caregivers should also have a consul-
Treatment.” if the youth has positive thyroid anti- tation with a registered dietitian nu-
bodies or develops symptoms or signs tritionist experienced in managing
Key Concepts in Setting Glycemic Goals
suggestive of thyroid dysfunction, thy- both diabetes and celiac disease. B
• Glycemic goals should be individualized, romegaly, an abnormal growth rate, or
and lower goals may be reasonable unexplained glycemic variability. B
based on a benefit-risk assessment. Celiac disease is an immune-mediated dis-
• Blood glucose goals should be modified order that occurs with increased frequency
in children with frequent hypoglycemia Autoimmune thyroid disease is the most in people with type 1 diabetes (1.6–16.4%
or hypoglycemia unawareness. common autoimmune disorder associated of individuals compared with 0.3–1% in
• Postprandial blood glucose values with diabetes, occurring in 17–30% of indi- the general population) (118,121,122,
should be measured when there is a viduals with type 1 diabetes (119,123,124). 131–134). Screening people with type 1
discrepancy between preprandial blood At the time of diagnosis, 25% of children diabetes for celiac disease is further justi-
glucose values and A1C levels and to as- with type 1 diabetes have thyroid autoan- fied by its association with osteoporosis,
sess preprandial insulin doses in those tibodies (125), the presence of which is iron deficiency, growth failure, and po-
on basal-bolus or pump plans. predictive of thyroid dysfunction—most tential increased risk of retinopathy and
commonly hypothyroidism, although hy- albuminuria (135–137).
Autoimmune Conditions perthyroidism occurs in 0.5% of people Screening for celiac disease includes
with type 1 diabetes (126,127). For thy- measuring serum levels of IgA and tissue
Recommendation
roid autoantibodies, a study from Sweden transglutaminase (tTG) IgA antibodies,
14.28 Assess for additional autoim-
indicated that antithyroid peroxidase anti- or, with IgA deficiency, screening can in-
mune conditions soon after the di-
bodies were more predictive than antith- clude measuring tTG IgG antibodies or
agnosis of type 1 diabetes and if
yroglobulin antibodies in multivariate deamidated gliadin peptide IgG antibod-
clinically relevant. B
analysis (128). Thyroid function tests may ies. Because most cases of celiac disease
be misleading (euthyroid sick syndrome) if are diagnosed within the first 5 years af-
Because of the increased frequency of performed at the time of diagnosis owing ter the diagnosis of type 1 diabetes,
other autoimmune diseases in type 1 to the effect of previous hyperglycemia, screening should be considered at the
[Link]/care Children and Adolescents S291

time of diagnosis and repeated at 2 and Hypertension Treatment

[<2.6 mmol/L]), a lipid profile repeated
then 5 years (132) or if clinical symptoms Recommendations every 3 years is reasonable. E
indicate, such as poor growth or in- 14.35 Treatment of elevated blood
creased hypoglycemia (135). pressure (defined as 90th to <95th
Although celiac disease can be diag- percentile for age, sex, and height or, in Dyslipidemia Treatment
nosed more than 10 years after diabe- adolescents aged $13 years, 120–129/ Recommendations
tes diagnosis, there are insufficient data <80 mmHg) is lifestyle modification fo- 14.40 If lipids are abnormal, initial
after 5 years to determine the optimal cused on healthy nutrition, physical ac- therapy should consist of optimizing
screening frequency. Measurement of tivity, sleep, and, if appropriate, weight glycemia and MNT to limit the amount
tTG antibody should be considered at management. C of calories from fat to 25–30% and sat-
other times in individuals with symptoms 14.36 After excluding other causes, in urated fat to <7%, limit cholesterol to
suggestive of celiac disease (132). Moni- addition to lifestyle modification, ACE <200 mg/day, avoid trans fats, and

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toring for symptoms should include an as- inhibitors or angiotensin receptor block- aim for 10% calories from monoun-
sessment of linear growth and weight gain ers should be started for treatment saturated fats. A
(135). A small-bowel biopsy in antibody- of confirmed hypertension (defined as 14.41 Consider age-approved statins,
positive children is recommended to con- blood pressure consistently $95th per- in addition to MNT and lifestyle
firm the diagnosis (138). European guide- centile for age, sex, and height or, in changes, for youth with type 1 diabetes
lines on screening for celiac disease in adolescents aged $13 years, $130/80 who have LDL cholesterol $130 mg/dL
children (not specific to children with mmHg). Due to the potential terato- ($3.4 mmol/L). E Individuals of child-
type 1 diabetes) suggest that biopsy may genic effects, individuals of childbear- bearing age should receive reproductive
not be necessary in symptomatic children ing age should receive reproductive counseling, and lipid-lowering medica-
with high antibody titers (i.e., >10 times counseling, and ACE inhibitors and an- tions should be avoided in most individ-
the upper limit of normal) provided that giotensin receptor blockers should be uals of childbearing age who are not
further testing is performed (verification avoided in individuals of childbearing using reliable contraception. B
of endomysial antibody positivity on a age who are not using reliable contra- 14.42 The goal of therapy is an
separate blood sample). Whether this ception. B LDL cholesterol value <100 mg/dL
approach may be appropriate for asymp- 14.37 The goal of treatment is blood (<2.6 mmol/L). E
tomatic children in high-risk groups re- pressure <90th percentile for age, sex,
mains an open question, though evidence and height or, in adolescents aged
is emerging (139). It is also advisable to $13 years, <130/80 mmHg. C Population-based studies estimate that
check for celiac disease–associated HLA 14–45% of children with type 1 diabetes
types in individuals who are diagnosed have two or more atherosclerotic cardio-
without a small intestinal biopsy. In symp- Blood pressure measurements should be vascular disease risk factors (144–146),
tomatic children with type 1 diabetes and performed using the appropriate size cuff and the prevalence of cardiovascular dis-
confirmed celiac disease, gluten-free diets with the youth seated and relaxed. Ele- ease (CVD) risk factors increase with age
reduce symptoms and rates of hypoglyce- vated blood pressure should be confirmed (146) and among racial and ethnic mi-
mia (140). The challenging eating plan on at least three separate days, and ambu- noritized groups (33), with girls having a
restrictions associated with having both latory blood pressure monitoring should higher risk burden than boys (145).
type 1 diabetes and celiac disease place a be considered. Evaluation should proceed
significant burden on individuals. There- as clinically indicated (141,142). Treatment Pathophysiology. The atherosclerotic pro-
fore, a biopsy to confirm the diagnosis of is generally initiated with an ACE inhibitor, cess begins in childhood, and although ath-
celiac disease is recommended, especially but an angiotensin receptor blocker can be erosclerotic cardiovascular disease events
in asymptomatic children, before estab- used if the ACE inhibitor is not tolerated are not expected to occur during child-
lishing a diagnosis of celiac disease and (e.g., due to cough) (143). hood, observations using a variety of meth-
endorsing significant eating plan changes. odologies show that youth with type 1
Dyslipidemia Screening diabetes may have subclinical CVD within
Management of Cardiovascular Risk Recommendations the first decade of diagnosis (147–149).
Factors 14.38 Initial lipid profile should be Studies of carotid intima media thickness
Hypertension Screening performed soon after diagnosis, prefer- have yielded inconsistent results (142,143).
Recommendation ably after glycemia has improved and
14.34 Blood pressure should be mea- age is $2 years. If initial LDL choles- Screening. Diabetes predisposes the indi-
sured at every routine visit. In youth terol is #100 mg/dL (#2.6 mmol/L), vidual to the development of accelerated
with high blood pressure (blood pres- subsequent testing should be per- arteriosclerosis. Lipid evaluation for these
sure $90th percentile for age, sex, formed at 9–11 years of age. B Initial individuals contributes to risk assessment
and height or, in adolescents aged testing may be done with a nonfasting and identifies an important proportion of
$13 years, blood pressure $120/80 lipid level with confirmatory testing those with dyslipidemia. Therefore, initial
mmHg) on three separate measure- with a fasting lipid panel. screening should be done soon after di-
ments, ambulatory blood pressure mon- 14.39 If LDL cholesterol values are within agnosis. If the initial screen is normal,
itoring should be strongly considered. B the accepted risk level (<100 mg/dL subsequent screening may be done at
9–11 years of age, which is a stable time
S292 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

for lipid assessment in children (150). Long-term safety and cardiovascular importance of routine screening to ensure
Children with a primary lipid disorder outcome efficacy of statin therapy have early diagnosis and timely treatment of al-
(e.g., familial hyperlipidemia) should be been established for children with famil- buminuria (163). An estimation of glomer-
referred to a lipid specialist. Non-HDL ial hypercholesterolemia (161). At the ular filtration rate (GFR), calculated with
cholesterol level has been identified as time of this writing, rosuvastatin is indi- GFR-estimating equations using serum cre-
a significant predictor of the presence cated for children as young as 6 years atinine, height, age, and sex (164), should
of atherosclerosis—as powerful as any old (162). Statins should be avoided in be considered at baseline and repeated as
other lipoprotein cholesterol measure in individuals of childbearing age who are indicated based on clinical status, age, dia-
children and adolescents. For both chil- not using reliable contraception (see betes duration, and therapies. Improved
dren and adults, non-HDL cholesterol Section 15, “Management of Diabetes methods are needed to screen for early
level seems to be more predictive of per- in Pregnancy,” for more information). GFR loss, since estimated GFR is inaccurate
sistent dyslipidemia and, therefore, ath- The multicenter, randomized, placebo- at GFR >60 mL/min/1.73 m2 (164,165).

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erosclerosis and future events than total controlled Adolescent Type 1 Diabetes The AdDIT study in adolescents with type 1
cholesterol, LDL cholesterol, or HDL cho- Cardio-Renal Intervention Trial (AdDIT) diabetes demonstrated the safety of ACE
lesterol level alone. A major advantage provides safety data on pharmacologic inhibitor treatment, but the treatment did
(151) of non-HDL cholesterol is that it treatment with an ACE inhibitor and not change the albumin-to-creatinine ratio
can be accurately calculated in a nonfast- statin in adolescents with type 1 diabe- over the course of the study (142).
ing state and therefore is practical to ob- tes (142).
tain in clinical practice as a screening test Retinopathy
(152). Youth with type 1 diabetes have Microvascular Complications Recommendations
a high prevalence of lipid abnormalities Nephropathy Screening 14.45 An initial dilated and compre-
(144,151). Even if normal, screening
Recommendation hensive eye examination is recom-
should be repeated within 3 years, as A1C
14.43 Annual screening for albumin- mended once youth have had type 1
and other cardiovascular risk factors can
uria with a random (morning sample diabetes for 3–5 years, provided they
change dramatically during adolescence
preferred to avoid effects of exer- are aged $11 years or puberty has
(153).
cise) spot urine sample for albumin- started, whichever is earlier. B
to-creatinine ratio should be consid- 14.46 After the initial examination, re-
Treatment. Pediatric lipid guidelines pro- peat dilated and comprehensive eye
vide some guidance relevant to children ered at puberty or at age >10 years,
whichever is earlier, once the youth examination every 2 years. Less fre-
with type 1 diabetes and secondary dysli- quent examinations, every 4 years,
pidemia (142,154,155); however, there has had diabetes for 5 years. B
may be acceptable on the advice of an
are few studies on modifying lipid levels eye care professional and based on
in children with type 1 diabetes. A 6-month risk factor assessment, including a his-
trial of nutritional counseling produced a Nephropathy Treatment
tory of A1C <8% (<64 mmol/mol). B
significant improvement in lipid levels Recommendation 14.47 Programs that use retinal pho-
(156); likewise, a lifestyle intervention trial 14.44 An ACE inhibitor or an angioten- tography (with remote reading or use
with 6 months of exercise in adolescents sin receptor blocker, titrated to nor- of a validated assessment tool) to im-
demonstrated improvement in lipid levels malization of albumin excretion, may prove access to diabetic retinopathy
(157). Data from the SEARCH for Diabetes be considered when elevated urinary screening can be appropriate screening
in Youth (SEARCH) study show that im- albumin-to-creatinine ratio (>30 mg/g) strategies for diabetic retinopathy. Such
proved glucose over a 2-year period is asso- is documented (two of three urine programs need to provide pathways for
ciated with a more favorable lipid profile; samples obtained over a 6-month inter- timely referral for a comprehensive eye
however, improved glycemia alone will not val following efforts to improve glyce- examination when indicated. B
normalize lipids in youth with type 1 diabe- mia and normalize blood pressure). E
tes and dyslipidemia (158). Due to the potential teratogenic ef-
Although intervention data are sparse, fects, individuals of childbearing age Retinopathy (like albuminuria) most com-
the American Heart Association catego- should receive reproductive counseling, monly occurs after the onset of puberty
rizes children with type 1 diabetes in the and ACE inhibitors and angiotensin re- and after 5–10 years of diabetes duration
highest tier for cardiovascular risk and rec- ceptor blockers should be avoided in in- (166). It is currently recognized that there
ommends both lifestyle and pharmaco- dividuals of childbearing age who are is a low risk of development of vision-
logic treatment for those with elevated not using reliable contraception. B threatening retinal lesions prior to 12 years
LDL cholesterol levels (159,160). Initial of age (167,168). A 2019 publication based
therapy should include a nutrition plan on the follow-up of the DCCT adolescent
that restricts saturated fat to 7% of total Data from 7,549 participants <20 years cohort supports a lower frequency of
calories and dietary cholesterol to 200 mg/ of age in the T1D Exchange clinic regis- eye examinations than previously recom-
day (150). Data from randomized clinical try emphasize the importance of meet- mended, particularly in adolescents with
trials in children as young as 7 months of ing glycemic and blood pressure goals, A1C closer to the goal range (169,170).
age indicate that this nutrition plan is safe particularly as diabetes duration increases, Autonomous artificial intelligence screen-
and does not interfere with normal growth to reduce the risk of diabetic kidney dis- ing for diabetic retinopathy has been
and development. ease. The data also underscore the shown to increase access to this routine
[Link]/care Children and Adolescents S293

health maintenance (171). Referrals should diabetes but also from type 2 diabetes in pancreatic autoantibodies tested to ex-
be made to eye care professionals with ex- adults and has unique features, such as a clude the possibility of autoimmune
pertise in diabetic retinopathy and experi- more rapidly progressive decline in b-cell type 1 diabetes. B
ence in counseling pediatric individuals function and accelerated development of
and families on the importance of preven- diabetes complications (3,176). Long-term
tion, early detection, and intervention. follow-up data from the Treatment Op- In recent years, incidence and prevalence
tions for Type 2 Diabetes in Adolescents of type 2 diabetes in adolescents have in-
Neuropathy and Youth (TODAY) study reported most creased dramatically, especially in histori-
individuals with type 2 diabetes diagnosed cally marginalized communities (185). A
Recommendation
as youth had microvascular complications few studies suggest oral glucose tolerance
14.48 Consider an annual comprehen- tests or fasting plasma glucose values as
by young adulthood (177). Type 2 diabetes
sive foot exam at the start of puberty or more suitable diagnostic tests than A1C in
disproportionately impacts youth from
at age $10 years, whichever is earlier,

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historically marginalized communities and the pediatric population, especially among
once the youth has had type 1 diabetes certain ethnicities (186), while fasting glu-
can occur in complex psychosocial and
for 5 years. The examination should cose alone may overdiagnose diabetes in
cultural environments, which may make it
include inspection, assessment of foot children (187,188). In addition, many of
difficult to implement and sustain healthy
pulses, pinprick, and 10-g monofilament these studies do not recognize that diabe-
lifestyle changes and self-management
sensation tests, testing of vibration sen- tes diagnostic criteria are based on long-
behaviors (9,178–181). Additional risk
sation using a 128-Hz tuning fork, and term health outcomes, and validations
factors associated with type 2 diabetes
ankle reflex tests. B are not currently available in the pediatric
in youth include obesity and excess adi-
posity (182), family history of diabetes population (189). An analysis of National
Diabetic neuropathy rarely occurs in pre- possibly mediated by shared genetics, Health and Nutrition Examination Survey
pubertal children or after only 1–2 years of lifestyle, and environmental factors (183), (NHANES) data suggests using A1C for
diabetes (166), although data suggest a female sex, maternal gestational diabetes screening of high-risk youth (190). The
prevalence of distal peripheral neuropathy mellitus (184), and adverse social determi- ADA acknowledges the limited data sup-
of 7% in 1,734 youth with type 1 diabetes nants of health (176). porting A1C for diagnosing type 2 diabetes
and association with the presence of CVD As with type 1 diabetes, youth with in children and adolescents. Although A1C
risk factors (172,173). A comprehensive type 2 diabetes spend much of the day is not recommended for diagnosis of dia-
foot exam, including inspection, palpation in school. Therefore, close communica- betes in children with cystic fibrosis or
of dorsalis pedis and posterior tibial pulses, tion with and the cooperation of school symptoms suggestive of acute onset of
and determination of proprioception, vi- personnel are essential for optimal dia- type 1 diabetes, and only A1C assays with-
bration, and monofilament sensation, betes management and safety and max- out interference are appropriate for chil-
should be performed annually along with imal academic opportunities. dren with hemoglobinopathies, the ADA
an assessment of symptoms of neuro- continues to recommend A1C for diagno-
pathic pain (173). Foot inspection can be Screening and Diagnosis sis of type 2 diabetes in this population
performed at each visit to educate youth Recommendations
(186).
regarding the importance of foot care (see 14.49 Risk-based screening for predia-
Diagnostic Challenges
Section 12, “Retinopathy, Neuropathy, and betes and/or type 2 diabetes should
be considered after the onset of pu- Given the current obesity epidemic, dis-
Foot Care”).
berty or $10 years of age, whichever tinguishing between type 1 and type 2
occurs earlier, in youth with over- diabetes in children can be difficult.
TYPE 2 DIABETES
weight (BMI $85th percentile) or obe- Overweight and obesity are common in
For information on risk-based screening for children with type 1 diabetes (34), and
type 2 diabetes and prediabetes in youth, sity (BMI $95th percentile) and who
diabetes-associated autoantibodies and
please refer to Section 2, “Diagnosis and have one or more additional risk fac-
ketosis may be present in pediatric indi-
Classification of Diabetes.” For additional tors for diabetes (see Table 2.5 for evi-
viduals with clinical features of type 2 dia-
support for these recommendations, see dence grading of other risk factors).
betes (including obesity and acanthosis
the ADA position statement “Evaluation 14.50 If screening is normal, repeat
nigricans) (187). The presence of islet
screening at a minimum of 2-year in-
and Management of Youth-Onset Type 2 autoantibodies has been associated with
tervals E or more frequently if BMI is
Diabetes” (3). faster progression to insulin deficiency
increasing. C
The prevalence of type 2 diabetes in (187). At the onset of diabetes, DKA oc-
14.51 Fasting plasma glucose, 2-h
youth has continued to increase over the curs in 11% of youth aged 10–19 years
plasma glucose during a 75-g oral glu-
past 20 years (4). The CDC published pro- with type 2 diabetes (191). Although un-
cose tolerance test, and A1C can be
jections for type 2 diabetes prevalence common, type 2 diabetes has been ob-
used to test for prediabetes or diabe-
using the SEARCH database. Assuming a served in prepubertal children under the
tes in children and adolescents. B
2.3% annual increase, the prevalence in age of 10 years, thus it should be part of
14.52 Children and adolescents with
those under 20 years of age will quadru- the differential in children with suggestive
overweight or obesity in whom the
ple in 40 years (174,175). symptoms (192). Finally, obesity contrib-
diagnosis of type 2 diabetes is being
Evidence suggests that type 2 diabetes utes to the development of type 1 diabetes
considered should have a panel of
in youth is different not only from type 1 in some individuals (193), which further
S294 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

blurs the lines between diabetes types. We Glycemic Goals 14.66 If glycemic goals are no lon-
must acknowledge that people with type 1 ger met with metformin (with or
Recommendations
diabetes can also experience weight gain without long-acting insulin), gluca-
14.58 Real-time CGM or intermittently
and insulin resistance. However, accurate gon-like peptide 1 (GLP-1) receptor
scanned CGM should be offered for
diagnosis is critical, as treatment plans, ed- agonist therapy and/or empagliflo-
diabetes management in youth with
ucational approaches, nutrition advice, zin should be considered in children
type 2 diabetes on multiple daily injec-
and outcomes differ markedly between 10 years of age or older. A
tions or insulin pumps who are capable
individuals with predominantly insulin 14.67 When choosing glucose-lower-
of using the device safely (either by
resistance and absolute insulinopenia ing or other medications for youth
themselves or with a caregiver). The
phenotypes. The significant diagnostic dif- with overweight or obesity and type 2
choice of device should be made based
ficulties posed by maturity-onset diabetes diabetes, consider medication-taking
on an individual’s and family’s circum-
of the young are discussed in Section 2, behavior and the medications’ effect
stances, desires, and needs. E
“Diagnosis and Classification of Diabetes.”

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14.59 Glycemic status should be as- on weight. E
In addition, there are rare and atypical dia- 14.68 For youth not meeting glycemic
sessed at least every 3 months. E
betes cases that represent a challenge for goals, consider maximizing noninsulin
14.60 Consider setting an A1C goal
clinicians and researchers.
of <6.5% (<48 mmol/mol) for most therapies (metformin, a GLP-1 receptor
children and adolescents with type 2 agonist, and empagliflozin) before initi-
Management ating and/or the intensifying insulin
diabetes who have a low risk of hy-
Lifestyle Management therapy plan. E
poglycemia. For those at higher risk
Recommendations of hypoglycemia, A1C goals should 14.69 In individuals initially treated
14.53 All youth with type 2 diabe- be individualized as clinically appro- with insulin and metformin and/or
tes and their families should receive priate. C other glucose-lowering medications who
comprehensive DSMES that is spe- are meeting glucose goals based on
cific to youth with type 2 diabetes blood glucose monitoring or CGM, insu-
and is culturally appropriate. B Pharmacologic Management lin can be tapered over 2–6 weeks by
14.54 Youth with overweight or obesity Recommendations decreasing the insulin dose 10–30%
and type 2 diabetes and their families 14.61 Initiate pharmacologic therapy, every few days. B
should be provided with developmen- in addition to behavioral counseling
tally and culturally appropriate com- for healthful nutrition and physical ac-
Treatment of youth-onset type 2 diabetes
prehensive lifestyle programs that are tivity changes, at diagnosis of type 2
should include lifestyle management,
integrated with diabetes management diabetes. A
DSMES, and pharmacologic treatment. Ini-
to achieve at least a 7–10% decrease 14.62 In individuals with incidentally
tial treatment of youth with obesity and
in excess weight. B diagnosed or metabolically stable dia-
diabetes must consider that diabetes type
14.55 Given the necessity of long- betes (A1C <8.5% [<69 mmol/mol]
is often uncertain in the first few weeks of
term weight management for youth and asymptomatic), metformin is the
treatment due to overlap in presentation
with type 2 diabetes, lifestyle interven- initial pharmacologic treatment of
and that a substantial percentage of youth
tion should be based on a chronic care choice if kidney function is normal. A
with type 2 diabetes will present with clini-
model and offered in the context of di- 14.63 Youth with marked hyperglyce-
cally significant ketoacidosis (194). There-
abetes care. E mia (blood glucose $250 mg/dL [$13.9
fore, initial therapy should address the
14.56 Youth with prediabetes and mmol/L], A1C $8.5% [$69 mmol/mol])
hyperglycemia and associated metabolic
type 2 diabetes, like all children and without acidosis at diagnosis who are
derangements irrespective of ultimate dia-
adolescents, should be encouraged symptomatic with polyuria, polydipsia,
betes type, with adjustment of therapy
to participate in at least 60 min of nocturia, and/or weight loss should be
once metabolic compensation has been
moderate to vigorous physical activity treated initially with long-acting insulin
established and subsequent information,
daily (with muscle and bone strength while metformin is initiated and ti-
such as islet autoantibody results, be-
training at least 3 days/week) B and to trated. B
comes available. Figure 14.1 provides an
decrease sedentary recreational screen 14.64 Initiate subcutaneous or in-
approach to the initial treatment of new-
time. C travenous insulin treatment in indi-
onset diabetes in youth with overweight
14.57 Nutrition for youth with predi- viduals with ketoacidosis to rapidly
or obesity with clinical suspicion of type 2
abetes and type 2 diabetes, like for correct the hyperglycemia and the
all children and adolescents, should diabetes.
metabolic derangement. Once aci-
focus on key nutrition principles (i.e., Glycemic goals should be individual-
dosis is resolved, metformin should
eat more nonstarchy vegetables, ized, taking into consideration the long-
be initiated while subcutaneous in-
whole fruits, legumes, whole grains, term health benefits of more stringent
sulin therapy is continued. A
nuts and seeds, and low-fat dairy goals and risk for adverse effects, such
14.65 In individuals presenting with
products and eat less meat, sugar- as hypoglycemia. A lower A1C goal of
severe hyperglycemia (blood glucose
<6.5% in youth with type 2 diabetes
sweetened beverages, sweets, refined $600 mg/dL [$33.3 mmol/L]), consider
grains, and processed or ultraprocessed compared with <7% recommended in
assessment for hyperglycemic hyperos-
foods). B type 1 diabetes is justified by a lower
molar state. A
risk of hypoglycemia and higher risk of
[Link]/care Children and Adolescents S295

For new-onset diabetes in youth with overweight or obesity with clinical suspicion of
type 2 diabetes, initiate lifestyle management and diabetes education

A1C 8.5% A1C 8.5%

Acidosis and/or DKA and/or HHS
No acidosis or ketosis No acidosis with or without ketosis

• Metformin
• Manage DKA or HHS
• Metformin • Titrate up to 2,000 mg
• Intravenous insulin until acidosis resolves,
• Titrate up to 2,000 mg per day as per day as tolerated
then subcutaneous, as for type 1 diabetes
tolerated • Long-acting insulin: start at 0.5 units/kg/day
until results of antibody testing are known
and titrate every 23 days based on BGM

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Pancreatic autoantibodies

NEGATIVE POSITIVE

• Continue or start metformin • Continue or initiate MDI insulin or pump

• If on insulin, titrate guided by glucose therapy, as for type 1 diabetes
values • Discontinue metformin

A1C goals not met

• Continue metformin
• Consider adding GLP1 receptor agonist or SGLT2 inhibitor
approved for youth with type 2 diabetes
• Consider prioritizing and maximizing noninsulin medications to
minimize weight gain before escalating insulin doses
• Titrate or initiate insulin therapy; if using long-acting insulin only
and glycemic goal are not met with escalating doses, add prandial
insulin; total daily insulin dose may exceed 1 unit/kg/day

Figure 14.1—Management of new-onset diabetes in youth with overweight or obesity with clinical suspicion of type 2 diabetes. A1C 8.5% =
69 mmol/mol. BGM, blood glucose monitoring; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; GLP-1, glucagon-like peptide 1; HHS,
hyperosmolar hyperglycemic state; MDI, multiple daily injections; SGLT2, sodium–glucose cotransporter 2. Adapted from the ADA position statement
“Evaluation and Management of Youth-Onset Type 2 Diabetes” (3).

complications in youth with type 2 dia- youth with type 2 diabetes, individual-level cotransporter 2 inhibitors. Presentation
betes (177,195–199). lifestyle interventions may not be sufficient with ketoacidosis or marked ketosis re-
Self-management in pediatric diabetes to address the complex interplay of family quires a period of insulin therapy until
involves both the youth and their parents dynamics, behavioral health, community fasting and postprandial glycemia have
or adult caregivers. Individuals and their readiness, and the broader environmental been restored to normal or near-normal
families should receive education and sup- system (3). levels. Insulin pump therapy may be con-
port for healthful nutrition and physical An interprofessional diabetes team, sidered as an option for those on long-
activity, such as a balanced meal plan, including a physician, diabetes care and term multiple daily injections who are able
achieving and maintaining a healthy education specialist (CDCES), registered to safely manage the device. Initial treat-
weight, and regular physical activity. dietitian nutritionist, and behavioral health ment should also be with insulin when the
Physical activity should include aerobic, specialist or social worker, is essential. In ad- distinction between type 1 diabetes and
muscle-strengthening, and bone-strength- dition to achieving glycemic goals and type 2 diabetes is unclear and in individuals
ening activities (24). A family-centered self-management education (200–202), who have random blood glucose concen-
approach to nutrition and lifestyle modifi- initial treatment must include manage- trations $250 mg/dL ($13.9 mmol/L)
cation is essential in children and adoles- ment of comorbidities such as obesity, and/or A1C $8.5% ($69 mmol/mol)
cents with type 2 diabetes, and nutrition dyslipidemia, hypertension, and micro- (203). Metformin therapy should be added
recommendations should be culturally ap- vascular complications. after resolution of ketosis or ketoacidosis.
propriate and sensitive to family resources Current pharmacologic treatment options When initial insulin treatment is not re-
(see Section 5, “Facilitating Positive Health for youth-onset type 2 diabetes are lim- quired, initiation of metformin is recom-
Behaviors and Well-being to Improve ited to four approved drug classes: insulin, mended as first-line therapy. The TODAY
Health Outcomes”). Given the complex so- metformin, glucagon-like peptide 1 (GLP-1) study found that metformin alone pro-
cial and environmental context surrounding receptor agonists, and sodium–glucose vided durable glycemic management (A1C
S296 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

#8% [#64 mmol/mol] for 6 months) in with type 2 diabetes who have class 2 the Pediatric Bariatric Study Group and
approximately half of the subjects (204). obesity or higher (BMI >35 kg/m2 or Teen-LABS study, have demonstrated the
The Restoring Insulin Secretion (RISE) >120% of 95th percentile for age and effectiveness of metabolic surgery in ado-
Consortium study did not demonstrate sex, whichever is lower) and who have lescents (221–225). However, long-term
differences in measures of glucose or elevated A1C and/or serious comorbid- data on the rates of complications, reopera-
b-cell function preservation between ities despite lifestyle and pharmacologic tions, nutritional deficiencies, and diabetes
metformin and insulin, but there was intervention. A recurrence are still needed.
more weight gain with insulin (205). 14.71 Metabolic surgery should be
To date, the TODAY study is the only performed only by an experienced sur- Prevention and Management of
trial combining lifestyle and metformin Diabetes Complications
geon working as part of a well-organized
therapy in youth with type 2 diabetes; the and engaged interprofessional team, Hypertension
combination did not perform better than including a surgeon, endocrinologist, Recommendations

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metformin alone in achieving durable gly- registered dietitian nutritionist, behav- 14.72 Blood pressure should be mea-
cemic levels (204). ioral health specialist, and nurse. A sured at every clinic visit. In youth with
Randomized controlled trials in youth high blood pressure (blood pressure
have shown that GLP-1 receptor agonists $ 90th percentile for age, sex, and
are safe and effective for decreasing A1C The results of weight loss and lifestyle height or, in adolescents aged $13 years,
(206–210) and promoting weight loss at interventions for obesity in children and $120/80 mmHg) on three separate
higher doses approved for obesity (211). adolescents have been disappointing, and measurements, ambulatory blood pres-
Use of GLP-1 receptor agonists can in- treatment options as adjuncts to lifestyle sure monitoring should be strongly con-
crease the frequency of gastrointestinal therapy are limited. Recent U.S. Food and sidered. B
side effects and should not be used in in- Drug Administration–approved medications 14.73 After excluding secondary hyper-
dividuals with a family history of medul- for youth ages 12 years and older include tension, treatment of elevated blood
lary thyroid cancer. phentermine and topiramate extended- pressure (defined as 90th to <95th per-
In addition to GLP-1 receptor agonists, release capsules and GLP-1 receptor ago- centile for age, sex, and height or, in
sodium–glucose cotransporter-2 inhibitors nists (211,215–217). Over the last decade, adolescents aged $13 years, 120–129/
are well-studied drugs in adults with type 2 weight loss surgery has been increasingly <80 mmHg) is lifestyle modification fo-
diabetes, and empagliflozin is now ap- performed in adolescents with obesity. cused on healthy nutrition, physical ac-
proved for use in youth with type 2 diabe- Small retrospective analyses and a prospec- tivity, sleep, and, if appropriate, weight
tes. In a recent multicenter double-blind, tive multicenter, nonrandomized study sug- management. C
placebo-controlled trial, 158 children with gest that bariatric or metabolic surgery 14.74 In addition to lifestyle modifica-
type 2 diabetes aged between 10 and have benefits in adolescents with obesity tion, ACE inhibitors or angiotensin re-
17 years were randomized to 10 mg empa- and type 2 diabetes like those observed in ceptor blockers should be started for
gliflozin, 5 mg linagliptin, or placebo. Partic- adults. Early follow-up studies indicate that treatment of confirmed hypertension
ipants in the empagliflozin group who did adolescents experience similar degrees of (defined as blood pressure consis-
not have A1C below 7.0% by week 12 weight loss compared with adults and even tently $95th percentile for age, sex,
underwent a second double-blinded ran- higher rates of type 2 diabetes and hyper- and height or, in adolescents aged
domization at week 14 to either remain on tension remission (218). A secondary data $13 years, $130/80 mmHg). Due to
10 mg of empagliflozin or increase their the potential teratogenic effects, indi-
analysis from the Teen-Longitudinal Assess-
dose to 25 mg. In the empagliflozin pooled viduals of childbearing age should
ment of Bariatric Surgery (Teen-LABS) and
group compared with the placebo group, receive reproductive counseling, and
TODAY studies suggests surgical treatment
there was a significant reduction in A1C of ACE inhibitors and angiotensin recep-
of adolescents with severe obesity and
0.84% (P = 0.012). There were no episodes tor blockers should be avoided in indi-
type 2 diabetes is associated with improved
of severe hypoglycemia during the study viduals of childbearing age who are
glycemia compared with the agents used in
(212). not using reliable contraception. B
the TODAY study (219); however, no ran-
Blood glucose monitoring plans should 14.75 The goal of treatment is blood
domized trials have compared the effective-
be individualized, taking into consider- pressure <90th percentile for age, sex,
ness and safety of surgery with those of
ation the pharmacologic treatment of the and height or, in adolescents aged
conventional treatment options in adoles-
person. Although data on CGM in youth $13 years, <130/80 mmHg. C
with type 2 diabetes are sparse (213,214), cents and particularly with the vertical
CGM could be considered in individuals sleeve gastrectomy, which is the most
requiring frequent blood glucose monitor- widely performed metabolic surgery in Nephropathy
ing for diabetes management. adolescents (220). The guidelines used as
Recommendations
an indication for metabolic surgery in ado-
14.76 Urine albumin-to-creatinine ra-
lescents generally include class 2 obesity
tio should be obtained at the time of
Metabolic Surgery or higher (BMI >35 kg/m2 or >120% of
diagnosis and annually thereafter. An
Recommendations 95th percentile for age and sex, whichever
elevated urine albumin-to-creatinine
14.70 Metabolic surgery may be con- is lower, with comorbidities) or BMI
ratio (>30 mg/g creatinine) should be
sidered for the treatment of adolescents >40 kg/m2 with or without comorbidities
confirmed on two of three samples. B
(221–227). A number of groups, including
[Link]/care Children and Adolescents S297

14.77 Estimated glomerular filtration 14.85 Less frequent examination hypertension, and dysglycemia are im-
rate (GFR) should be determined at (every 2 years) may be considered if portant to prevent overt macrovascu-
the time of diagnosis and annually achieving glycemic goals and a normal lar disease in early adulthood. E
thereafter. E eye exam. C
14.78 In youth with diabetes and hy- 14.86 Programs that use retinal pho-
pertension, either an ACE inhibitor or tography (with remote reading or use Dyslipidemia
an angiotensin receptor blocker is rec- of a validated assessment tool) to im- Recommendations
ommended for those with modestly prove access to diabetic retinopathy 14.93 Lipid screening should be per-
elevated urinary albumin-to-creatinine screening can be appropriate screen- formed initially after optimizing gly-
ratio (30–299 mg/g creatinine) and ing strategies for diabetic retinopathy. cemia and annually thereafter. B
should be considered for those with Such programs need to provide path- 14.94 Optimal goals are LDL choles-
urinary albumin-to-creatinine ratio ways for timely referral for a com- terol <100 mg/dL (<2.6 mmol/L),

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>300 mg/g creatinine and/or esti- prehensive eye examination when HDL cholesterol >35 mg/dL (>0.91
mated GFR <60 mL/min/1.73 m2. E indicated. E mmol/L), and triglycerides <150 mg/dL
Due to the potential teratogenic ef- (<1.7 mmol/L). E
fects, individuals of childbearing age 14.95 If lipids are abnormal, initial
should receive reproductive counsel- Metabolic Dysfunction–Associated
therapy should consist of optimizing
Steatotic Liver Disease Recommendations
ing, and ACE inhibitors and angiotensin glycemia and medical nutritional ther-
receptor blockers should be avoided Recommendations apy to limit the amount of calories from
in individuals of childbearing age 14.87 Evaluation of youth with type 2 fat to 25–30% and saturated fat to
who are not using reliable contracep- diabetes for metabolic dysfunction– <7%, limit cholesterol to <200 mg/day,
tion. B associated steatotic liver disease (by avoid trans fats, and aim for 10% cal-
14.79 For youth with nephropathy, measuring AST and ALT) should be done ories from monounsaturated fats for el-
continue monitoring (yearly and/or at diagnosis and annually thereafter. B evated LDL. For elevated triglycerides,
as indicated by urinary albumin-to- 14.88 Referral to gastroenterology MNT should also focus on decreasing
creatinine ratio and estimated GFR) should be considered for persistently carbohydrate intake and increasing die-
to detect disease progression. E elevated or worsening transami- tary n-3 fatty acids in addition to the
14.80 Referral to nephrology is rec- nases. B above changes. A
ommended in case of uncertainty of 14.96 If LDL cholesterol remains
etiology, worsening urinary albumin- >130 mg/dL (>3.4 mmol/L) after
Obstructive Sleep Apnea
to-creatinine ratio, or decrease in esti- 6 months of dietary intervention, ini-
mated GFR. E Recommendation tiate therapy with statin, with a goal
14.89 Screening for symptoms of of LDL <100 mg/dL (<2.6 mmol/L).
sleep apnea should be done at Due to the potential teratogenic ef-
Neuropathy each visit, and referral to a pediat- fects, individuals of childbearing age
Recommendations ric sleep specialist for evaluation should receive reproductive counsel-
14.81 Youth with type 2 diabetes and a polysomnogram, if indicated, ing, and statins should be avoided in
should be screened for the presence is recommended. Obstructive sleep individuals of childbearing age who
of neuropathy by foot examination at apnea should be treated when are not using reliable contraception. B
diagnosis and annually. The examina- documented. B 14.97 If triglycerides are >400 mg/dL
tion should include inspection, assess- (>4.7 mmol/L) fasting or >1,000 mg/dL
ment of foot pulses, pinprick and 10-g (>11.6 mmol/L) nonfasting, optimize
Polycystic Ovary Syndrome
monofilament sensation tests, testing glycemia and begin fibrate, with a goal
of vibration sensation using a 128-Hz Recommendations of <400 mg/dL (<4.7 mmol/L) fasting
tuning fork, and ankle reflex tests. C 14.90 Evaluate for polycystic ovary to reduce risk for pancreatitis. C
14.82 Prevention of neuropathy syndrome in female adolescents with
should focus on achieving glycemic type 2 diabetes, including laboratory
goals. C studies, when indicated. B Cardiac Function Testing
14.91 Metformin, in addition to life- Recommendation
style modification, is likely to improve 14.98 Routine screening for heart dis-
Retinopathy the menstrual cyclicity and hyperan- ease with electrocardiogram, echocar-
Recommendations drogenism in female individuals with diogram, or stress testing is not re-
14.83 Screening for retinopathy should type 2 diabetes. E commended in asymptomatic youth
be performed by dilated fundoscopy at with type 2 diabetes. B
or soon after diagnosis and annually
Cardiovascular Disease
thereafter. C
14.84 Optimizing glycemia is recom- Recommendation Comorbidities may already be present
mended to decrease the risk or slow 14.92 Intensive lifestyle interventions at the time of diagnosis of type 2 diabe-
the progression of retinopathy. B focusing on weight loss, dyslipidemia, tes in youth (176,228). Therefore, blood
pressure measurement, a fasting lipid
S298 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

panel, assessment of random urine attention to symptoms of depression The TODAY study documented high
albumin-to-creatinine ratio, foot exami- and disordered eating, and refer to rates of maternal complications during
nation for neuropathy, and a dilated eye a qualified behavioral health profes- pregnancy and low rates of preconception
examination should be performed at di- sional when indicated. B counseling and contraception use in youth
agnosis. Additional medical conditions 14.101 Starting at puberty, precon- with type 2 diabetes (241). Preconception
that may need to be addressed include ception counseling should be incorpo- counseling tailored for adolescents with
polycystic ovary disease and other co- rated into routine diabetes clinic visits diabetes (including type 2 diabetes) has
morbidities associated with pediatric for all individuals of childbearing po- sustained behavioral benefits (65).
obesity, such as sleep apnea, hepatic tential because of the adverse preg-
steatosis, orthopedic complications, and nancy outcomes in this population. A SUBSTANCE USE IN PEDIATRIC
psychosocial concerns. The ADA position DIABETES
statement “Evaluation and Management
Tobacco, Electronic Cigarettes,

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of Youth-Onset Type 2 Diabetes” (3) Most youth with type 2 diabetes come
Alcohol, and Cannabis
provides guidance on the prevention, from historically marginalized communi-
screening, and treatment of type 2 dia- ties, have low socioeconomic status, and Recommendations
betes and its comorbidities in children often experience multiple psychosocial 14.102 Adolescents and young adults
and adolescents. stressors (9,40,42,231). Consideration of should be screened for tobacco or nic-
Youth-onset type 2 diabetes is associ- the sociocultural context and efforts to otine, electronic cigarettes, substance
ated with significant microvascular and personalize diabetes management are of use, and alcohol use at diagnosis and
macrovascular risk burden and a substan- critical importance to minimize barriers regularly thereafter. C
tial increase in the risk of cardiovascular to care, enhance participation, and maxi- 14.103 Elicit a smoking history at ini-
morbidity and mortality at an earlier age mize response to treatment. Screening tial and follow-up diabetes visits; dis-
than in those diagnosed later in life (177, for food insecurity, housing stability, and courage smoking in youth who do
229). The higher complication risk in earlier- other barriers related to the social deter- not smoke and encourage smoking
onset type 2 diabetes is likely related to minants of health should be part of rou- cessation in those who do smoke. A
prolonged lifetime exposure to hyperglyce- tine pediatric diabetes care (232). Please 14.104 Electronic cigarette use or
mia and other atherogenic risk factors, in- see Section 1, “Improving Care and vaping should be discouraged. A
cluding insulin resistance, dyslipidemia, Promoting Health in Populations,” for fur- 14.105 Advise all youth with diabe-
hypertension, and chronic inflammation. ther information on how to screen and tes not to use cannabis recreation-
There is a low risk of hypoglycemia in youth address social determinants of health–re- ally in any form. E
with type 2 diabetes, even if they are being lated barriers.
treated with insulin (230), and there are Evidence about psychosocial concerns
The adverse health effects of smoking
high rates of complications (196–198,230). in youth with type 2 diabetes is limited
These diabetes comorbidities also appear and use of tobacco products are well rec-
(233–236), but given the sociocultural
to be higher than those in youth with context for many youth, combined with ognized with respect to future cancer and
type 1 diabetes despite shorter diabetes the medical burden and obesity associ- CVD risk. Despite this, smoking rates are
duration and lower A1C (228). In addition, ated with type 2 diabetes, continuous significantly higher among youth with dia-
the progression of vascular abnormalities monitoring of behavioral health is recom- betes than among youth without diabetes
appears to be more pronounced in youth- mended. Symptoms of depression and (242). In youth with diabetes, it is impor-
onset type 2 diabetes than with type 1 di- disordered eating are common and asso- tant to avoid additional CVD risk factors.
abetes of similar duration, including ische- ciated with higher A1C (41,233,237,238). Smoking increases the risk of the onset of
mic heart disease and stroke (229). Early detection of psychological and be- albuminuria; therefore, smoking avoid-
In youth with type 2 diabetes and havioral concerns can facilitate effective ance is important to prevent both micro-
polycystic ovary syndrome, oral contra- treatment options to improve psychoso- vascular and macrovascular complications
ceptives are appropriate agents. cial well-being and support diabetes (42). (150). Discouraging use of tobacco prod-
When psychological symptoms are identi- ucts, including electronic cigarettes (243,
Psychosocial Factors fied, referral to a behavioral health profes- 244), is an important part of routine diabe-
sional, ideally with experience in pediatric tes care. Individuals with diabetes should
Recommendations
diabetes, may be warranted. Although far be advised to avoid vaping and using elec-
14.99 Health care professionals should
less research has been done on psycholog- tronic cigarettes, either as a way to stop
screen for food insecurity, housing sta-
ical and behavioral interventions for youth smoking tobacco or as a recreational drug.
bility, health literacy, financial barriers,
with type 2 diabetes than for youth with In younger children, it is important to as-
and social or community support and
type 1 diabetes, behavioral professionals sess exposure to cigarette smoke in the
apply that information to treatment
can provide behavioral health care services home because of the adverse effects of
decisions. E
to support youth with type 2 diabetes secondhand smoke and to discourage
14.100 Use age-appropriate standard-
(50–52). Many of the medications pre- youth from ever smoking.
ized and validated tools to screen for
scribed for diabetes and psychiatric disor- As alcohol use has implications for gly-
diabetes distress, depressive symp-
ders are associated with weight gain and cemic management and safety in youth
toms, and behavioral health concerns
can increase concerns about eating, body and young adults with diabetes, efforts
in youth with type 2 diabetes, with
shape, and weight (239,240). are warranted to reduce alcohol use and
[Link]/care Children and Adolescents S299

increase education about the risks of alco- Care and close supervision of diabetes nutritionists, and social workers (50,262).
hol use and strategies to minimize risks. A management are increasingly shifted from Resources to enhance social and peer
psychoeducational intervention for adoles- parents and other adults to the youth support during the transition process may
cents with chronic medical conditions, in- with type 1 or type 2 diabetes throughout also be valuable (263). A comprehensive
cluding type 1 diabetes, has demonstrated childhood and adolescence. The shift from discussion regarding the challenges faced
benefits for knowledge, perceived benefits, pediatric to adult health care professio- during this period, including specific recom-
and reduced use (245). See also Section 5, nals, however, often occurs abruptly as mendations, is found in the ADA position
“Facilitating Positive Health Behaviors and the older teen enters the next develop- statement “Diabetes Care for Emerging
Well-being to Improve Health Outcomes.” mental stage, referred to as emerging Adults: Recommendations for Transition
Finally, increased legalization and multi- adulthood (248), which is a critical period From Pediatric to Adult Diabetes Care Sys-
ple formulations of cannabis products have for young people who have diabetes. Dur- tems” (249). Ultimately, there is no age cut-
resulted in increased use of these products ing this period of major life transitions, off for youth with diabetes to transfer to

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among youth and young adults. In 2022, youth may begin to move out of their pa- adult diabetes care. The decision to trans-
30.7% of 12th graders reported using can- rents’ or caregivers’ homes and become fer should be a collaborative process in
nabis in the past year and 6.3% reported increasingly responsible for their diabetes which the youth with diabetes, their care-
using it daily over the past 30 days (246). care. Their new responsibilities include givers, and pediatric diabetes specialists
Cannabis users with type 1 diabetes are at self-management of their diabetes, mak- discuss their readiness, preferences, and
increased risk for hyperglycemic ketosis ing medical appointments, and financing concerns to ensure that the transfer aligns
due to cannabis hyperemesis syndrome health care once they are no longer cov- with their needs and circumstances (256).
(severe nausea, abdominal pain, and vom- ered by their parents’ health insurance The Endocrine Society, in collabora-
iting) (247). For youth with type 1 diabetes plans (ongoing coverage until age 26 years tion with the ADA and other organiza-
presenting with a hyperglycemic emer- is currently available under provisions of tions, has developed transition tools for
gency, health care professionals should the U.S. Affordable Care Act). In addition clinicians and youth and families (254).
consider cannabis hyperemesis syndrome to lapses in health care, this is also a pe-
in individuals with pH $7.4 and bicarbon- riod associated with deterioration in gly- References
ate >15 mmol/L in the presence of ketosis cemic stability; increased occurrence of 1. Centers for Disease Control and Prevention.
(247). Routine diabetes care should dis- acute complications; psychosocial, emo- U.S. COVID-19 Vaccine Product Information. 2024.
courage the use of recreational cannabis tional, and behavioral challenges; and 2024. Accessed 31 August 2024. Available from
in all forms. See Section 5, “Facilitating the emergence of chronic complications
[Link]
Positive Health Behaviors and Well-being 2. Chiang JL, Maahs DM, Garvey KC, et al. Type 1
(249,250). The transfer period from pedi- diabetes in children and adolescents: a position
to Improve Health Outcomes,” for more in-
atric to adult care is prone to fragmenta- statement by the American Diabetes Association.
formation about smoking cessation, to- Diabetes Care 2018;41:2026–2044
tion in health care delivery, which may
bacco, electronic cigarettes, and cannabis 3. Arslanian S, Bacha F, Grey M, Marcus MD,
adversely impact health care quality, cost,
in people with diabetes. White NH, Zeitler P. Evaluation and management of
and outcomes (251). Worsening diabetes youth-onset type 2 diabetes: a position statement
health outcomes during the transition to by the American Diabetes Association. Diabetes
TRANSITION FROM PEDIATRIC TO adult care and early adulthood have been Care 2018;41:2648–2668
ADULT CARE documented (252,253). 4. Lawrence JM, Divers J, Isom S, et al.; SEARCH
for Diabetes in Youth Study Group. Trends in
Comprehensive and coordinated plan- prevalence of type 1 and type 2 diabetes in
Recommendations
ning that begins in early adolescence is children and adolescents in the US, 2001-2017.
14.106 Diabetes care teams should
necessary to facilitate a seamless transition JAMA 2021;326:717–727
implement transition preparation pro- 5. Leslie RD, Evans-Molina C, Freund-Brown J,
from pediatric to adult health care (249,
grams for youth beginning in early ad- et al. Adult-onset type 1 diabetes: current
254). Research on effective interventions
olescence and, at the latest, at least understanding and challenges. Diabetes Care 2021;
to promote successful transition to adult 44:2449–2456
1 year before the anticipated transfer
care is limited, although there are promising 6. Barnea-Goraly N, Raman M, Mazaika P, et al.;
from pediatric to adult health care. E
developments that may improve atten- Diabetes Research in Children Network (DirecNet).
14.107 Interprofessional adult and Alterations in white matter structure in young
dance at follow-up appointments and lower
pediatric health care teams should children with type 1 diabetes. Diabetes Care 2014;
hospitalizations (255,256). Use of transition
provide support and resources for 37:332–340
coordinators, technology to support com- 7. Cameron FJ, Scratch SE, Nadebaum C, et al.;
adolescents, young adults, and their
munication with young adults, and other in- DKA Brain Injury Study Group. Neurological
families prior to and during the trans-
terventions may be useful in addressing the consequences of diabetic ketoacidosis at initial
fer process from pediatric to adult presentation of type 1 diabetes in a prospective
identified needs and preferences of young
health care. C cohort study of children. Diabetes Care 2014;37:
adults for transition (257) and in supporting
14.108 Pediatric diabetes specialists 1554–1562
successful establishment in adult care set- 8. Markowitz JT, Garvey KC, Laffel LMB.
should partner with youth with diabe-
tings (258–261). Given the behavioral, psy- Developmental changes in the roles of patients
tes and their caregivers to engage in
chosocial, and developmental factors that and families in type 1 diabetes management.
shared decision-making for the timing Curr Diabetes Rev 2015;11:231–238
relate to this transition, diabetes care teams
of transfer to an adult diabetes spe- 9. Liu LL, Lawrence JM, Davis C, et al.; SEARCH
addressing transition should include
cialist. There is no age-specific cutoff for Diabetes in Youth Study Group. Prevalence of
physicians, certified diabetes care and overweight and obesity in youth with diabetes in
for youth with diabetes to transfer to
education specialists, nurses, behavioral USA: the SEARCH for Diabetes in Youth study.
an adult diabetes specialist. E
health professionals, registered dietitian Pediatr Diabetes 2010;11:4–11
S300 Children and Adolescents Diabetes Care Volume 48, Supplement 1, January 2025

10. Driscoll KA, Volkening LK, Haro H, et al. Are [Link]/our-work/nutrition-physical-activity/ youth with type 1 diabetes: strategies for
children with type 1 diabetes safe at school? physical-activity-guidelines diabetes care providers. Pediatr Diabetes 2018;
Examining parent perceptions. Pediatr Diabetes 25. Sherr JL, Bergford S, Gal RL, et al. Exploring 19:534–543
2015;16:613–620 factors that influence postexercise glycemia in youth 40. Hill-Briggs F, Adler NE, Berkowitz SA, et al.
11. Cogen F, Rodriguez H, March CA, et al. with type 1 diabetes in the real world: the Type 1 Social determinants of health and diabetes: a
Diabetes care in the school setting: a statement Diabetes Exercise Initiative Pediatric (T1DEXIP) study. scientific review. Diabetes Care 2020;44:258–279
of the American Diabetes Association. Diabetes Diabetes Care 2024;47:849–857 41. Monaghan M, Mara CA, Kichler JC, et al.
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