1. Overview & Diagnosis
Type 1 diabetes (T1D) is the most common endocrine disease in children.
Presentation: Classic symptoms (polyuria, polydipsia, weight loss) are common. However, DKA is the initial presentation in 15-67% of cases.
Urgency: Suspicion of diabetes in a child is a medical emergency. Immediate referral and confirmation are required to prevent DKA.
Differentiation: While T1D is autoimmune (positive antibodies: GAD, IA-2, ZnT8), Type 2 diabetes is rising in youth.
Type 1: Leaner, younger, autoimmune markers, insulin deficient.
Type 2: Obesity, acanthosis nigricans, family history of T2D, insulin resistant.
Monogenic (MODY): Strong multi-generational family history, negative antibodies.
2. Management Targets
Glycemic targets in pediatrics balance the need to prevent long-term complications with the risk of severe hypoglycemia and the developmental burden of care.
A1C Target: 7.5% for all children and adolescents (age < 18).
Note: This differs from the adult target of 7.0%.
Rationale: To minimize neurocognitive impairment from severe hypoglycemia in young brains while protecting against vascular complications.
Intensive Therapy: Basal-bolus regimens (MDI) or Insulin Pumps (CSII) are the standard of care to achieve these targets.
3. Acute Complications: Pediatric DKA
Management of DKA in children differs significantly from adults due to the risk of Cerebral Edema.
Cerebral Edema: The leading cause of diabetes-related death in children.
Risk Factors: Younger age, new onset, severe acidosis, rapid fluid administration, rapid drop in osmolality.
Fluid Management:
Do NOT bolus fluids aggressively unless in shock.
Rehydrate gradually over 48 hours.
Use isotonic fluids (0.9% NaCl) initially.
Insulin: Start IV insulin infusion (0.05–0.1 units/kg/h) only 1–2 hours AFTER starting fluid replacement. Do not give an IV insulin bolus.
4. Routine Screening & Autoimmune Comorbidities
Children with T1D are at higher risk for other autoimmune conditions.
Thyroid Disease: Screen at diagnosis and then every 2 years. (Hypothyroidism affects growth).
Celiac Disease: Screen at diagnosis and then every 1–2 years. (Symptoms: poor growth, anemia, unpredictable hypoglycemia).
Complication Screening (Retinopathy, Nephropathy, Neuropathy):
Neuropathy and Retinopathy Start Screening: At 15 years of age, provided diabetes duration is 5 years.
- Nephropathy Start Screening: At 12 years of age in those with duration of type 1 diabetes >5 years
5. Psychosocial & Developmental Stages
Diabetes management must be adapted to the child’s developmental stage.
Infants/Toddlers: Parents manage all care. Risk of severe hypoglycemia affecting brain development is high.
Preschoolers: Can help pick injection sites but cannot manage tasks. Picky eating makes dosing difficult.
School Age: Can perform tasks (testing, bolusing) but require supervision. They cannot be solely responsible.
Adolescents: Transition to autonomy but high risk of rebellion, burnout, and eating disorders (insulin omission for weight loss).
Transition Care: Structured transition to adult care should begin in early adolescence and occur gradually.
6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations
Key takeaways from the “Recommendations” section (Page S244).
DKA Protocol: Management of DKA should follow pediatric-specific protocols (gradual rehydration, no insulin bolus) to avoid cerebral edema [Grade D, Consensus].
Targets: Target A1C is 7.5% for all children/adolescents [Grade D, Consensus].
Regimens: Children should be treated with intensive insulin therapy (MDI or Pump) matched to food and activity [Grade A, Level 1].
Autoimmune Screening: Screen for Thyroid and Celiac disease at diagnosis and regularly thereafter [Grade D, Consensus].
Complication Screening: Screen for retinopathy, and neuropathy starting at 15 years of age with a duration of diabetes of 5 years. Screen for nephropathy starting at 12 years of age with diabetes duration of 5 years. [Grade D, Consensus].
Psychosocial: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].
- Dyslipidemia: Screen at 12 and 17 years of age.
- Hypertension: Screen all children with type 1 diabetes at least twice a year