Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association.

During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. Recommendations regarding children and adolescents have generally been included as only a minor portion of these documents. For example, the most recent ADA position statement on “Standards of Medical Care for Patients With Diabetes Mellitus” (last revised October 2003) included “special considerations” for children and adolescents (1). Other position statements included age-specific recommendations for screening for nephropathy (2) and retinopathy (3) in children with diabetes. In addition, the ADA has published guidelines pertaining to certain aspects of diabetes that apply exclusively to children and adolescents, including care of children with diabetes at school (4) and camp (5) and a consensus statement on type 2 diabetes in children and adolescents (6). The purpose of this document is to provide a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus (7). Several excellent detailed guidelines and chapters on type 1 diabetes in pediatric endocrinology texts exist, including those by the International Society of Pediatric and Adolescent Diabetes (ISPAD) (8), by the Australian Pediatric Endocrine Group (www.chw.edu/au/prof/services/ endocrinology/apeg), in Lifshitz’s Pediatric Endocrinology (9–11), and by Plotnick and colleagues (12,13). Children have characteristics and needs that dictate different standards of care. The management of diabetes in children must take the major differences between children of various ages and adults into account. For example, insulin doses based only on body size are likely to be incorrect; the consequences of hypoglycemic events are distinctly different between adults and children; risks for diabetic complications are likely influenced by puberty; and the targets of education need to be adjusted to the age and developmental stage of the patient with diabetes and must include the parent or caregiver. In caring for children with diabetes, professionals need to understand the importance of involving adults in the child’s diabetes management. Young children, including school-aged children, are unable to provide their own diabetes care, and middle school and high school students should not be expected to independently provide all of their own diabetes management care. Thus, the education about how to care for a child and adolescent with diabetes must be provided to the entire family unit, emphasizing ageand developmentally appropriate selfcare and integrating this into the child’s diabetes management (14). The goal should be a gradual transition toward independence in management through middle school and high school. Adult supervision remains important throughout the transition.