12. Children and Adolescents

TYPE 1 DIABETES Three-quarters of all cases of type 1 diabetes are diagnosed in individuals ,18 years of age (although recent data using genetic risk scoring would suggest that over 40% of patients with autoimmune diabetes are diagnosed over the age of 30 years) (1). The provider must consider the unique aspects of care and management of children and adolescents with type 1 diabetes, such as changes in insulin sensitivity related to physical growth and sexual maturation, ability to provide self-care, supervision in the child care and school environment, and neurological vulnerability to hypoglycemia and hyperglycemia in young children, as well as possible adverse neurocognitive effects of diabetic ketoacidosis (DKA) (2,3). Attention to family dynamics, developmental stages, and physiological differences related to sexual maturity are all essential in developing and implementing an optimal diabetes treatment plan (4). Due to the paucity of clinical research in children, the recommendations for children and adolescents are less likely to be based on clinical trial evidence. However, expert opinion and a review of available and relevant experimental data are summarized in the American Diabetes Association (ADA) position statement “Care of Children and Adolescents With Type 1 Diabetes” (5) and have been updated in the ADA position statement “Type 1 Diabetes Through the Life Span” (6). A multidisciplinary team of specialists trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families should provide care for this population. It is essential that diabetes self-management education (DSME) and support (DSMS), medical nutrition therapy, and psychosocial support be provided at diagnosis and regularly thereafter in a developmentally appropriate format that builds on prior knowledge by individuals experienced with the educational, nutritional, behavioral, and emotional needs of the growing child and family. The appropriate balance between adult supervision and independent self-care should be defined at the first interaction and reevaluated at subsequent visits. The balance between adult supervision and independent self-care will evolve as the adolescent gradually becomes an emerging young adult.