are symptomatic and meet standard criteria for diagnosis, as defined by the ADA. Hemoglobin A1c levels may not be reliable in patients with certain conditions that affect hemoglobin levels, including sickle cell disease, glucose-6-phosphate dehydrogenase deficiency, and recent blood loss. These patients should be diagnosed based on plasma glucose levels instead of HbA1c. In the absence of clinical symptoms, two abnormal screening results are required for diagnosis. Complications and related conditions All pediatric patients with T1DM are at risk for conditions related to the disease pathophysiology or complications of inadequate management. Associated autoimmune conditions that commonly coexist with T1DM include thyroid dysfunction and celiac disease (ADA et al., 2022e). Periodic screening is recommended, even in the absence of classic symptoms. Thyroid function tests may be abnormal at the time of diabetes diagnosis and should be repeated after metabolic stability for confirmation. Patients with subclinical hypothyroidism may be at increased risk of reduced linear growth and symptomatic hypoglycemia, and hyperthyroidism can alter glucose metabolism, which worsens glycemic control. Celiac disease is linked to osteoporosis, iron deficiency, and growth failure. Most new-onset cases of celiac
Healthcare Consideration: If a patient meets criteria for diagnosis based on hemoglobin A1c but not based on plasma glucose levels, the hemoglobin A1c level should be repeated. Hemoglobin A1c is an indirect measure of average plasma glucose levels and can be confounded by hemoglobinopathies or assay interference. First, confirm that the patient does not have a condition that affects hemoglobin, such as sickle cell disease, pregnancy, or recent hemodialysis. These patients should receive a diagnosis based only on plasma blood glucose. For all other patients, a confirmatory second level is required for diagnosis (ADA et al., 2022a). disease in patients with T1DM occur within the first 5 years of diabetes diagnosis, so patients and caregivers should be counseled to monitor for symptoms in addition to recommended screening. Patients may be predisposed to other autoimmune conditions, such as dermatomyositis and Addison disease, although these conditions are much less common. Other related conditions are complications of poor glycemic control, including retinopathy and neuropathy. Optimizing diabetes management is essential for prevention of these and other complications, and screening is recommended for all patients with a T1DM diagnosis (ADA et al., 2022e). These recommendations are summarized in Table 1.
Table 1. Screening Recommendations for Patients with Type 1 Diabetes Mellitus
Related Condition/Complication Screening Frequency*
Immediate screening (soon after diagnosis)
Thyroid disease
Screen every 1–2 years or sooner if symptoms develop
Celiac disease
Screen within 2 years and at 5 years postdiagnosis or sooner if symptoms develop Screen at each office visit with target of <90th percentile for age/sex/height OR <120/80 mmHg for patients 13 years of age and older Screen once patient is normoglycemic (hyperglycemia may confound results), at 9–11 years of age, and every 3 years thereafter if LDL <100 mg/dL Screen at 5 years postdiagnosis if patient >10 years old or postpubertal then annually Screen at 3–5 years postdiagnosis if patient >10 years old or postpubertal then every 2 years Screen at 5 years postdiagnosis if patient ≥10 years old or postpubertal then annually accelerated arteriosclerosis. Dyslipidemia is best measured through a non-HDL level, which can conveniently be measured in a nonfasting state. Smoking can adversely affect cardiovascular and diabetes-related outcomes (ADA et al., 2022e). Cigarette smoking, including electronic cigarettes, should be strongly discouraged. Electronic cigarettes are the most frequently used tobacco product in adolescents, and use is on the rise (Chin et al., 2021). Providers should screen for and discourage tobacco use in the pediatric population to prevent cardiovascular disease later in life. Microvascular complications, including nephropathy, retinopathy, and neuropathy, may develop as a result of diabetes (ADA et al., 2022e). The risk of all three increases with time postdiagnosis, and all are linked to poor glycemic control. Early detection is essential for early intervention; however, screening does not start until a few years postdiagnosis.
Hypertension
Dyslipidemia
Chronic screening
Nephropathy
Retinopathy
Neuropathy
Source: American Diabetes Association Professional Practice Committee, Draznin, B., Aroda, V. R., Bakris, G., Benson, G., Brown, F. M., Freeman, R., Green, J., Huang, E., Isaacs, D., Kahan, S., Leon, J., Lyons, S. K., Peters, A. L., Prahalad, P., Reusch, J., & Young-Hyman, D. (2022). 14. Children and adolescents: Standards of medical are in diabetes, 2022. Diabetes Care, 45 (Suppl 1), S208-S231. https://doi.org/10.2337/dc22-S014 *Frequency of screening assumes “normal” findings; abnormal findings may warrant more frequent screenings and/or interventions beyond the scope of this course
Early detection and management of these conditions is essential to minimize long-term complications. One area of concern is cardiovascular health. According to a recent study, children with T1DM onset before 10 years of age are at a 30-fold increased relative risk of coronary heart disease and acute myocardial infarction in their early adult years (Rawshani et al., 2018). Although this study did not factor in glycemic control prior to enrollment, the results highlight the importance of addressing cardiovascular risk soon after diabetes diagnosis. Hypertension should be confirmed via measurement of blood pressure on three separate visits, as values may elevate in response to anxiety and other stressors (ADA et al., 2022e). Children and adolescents with T1DM also have a high prevalence of lipid abnormalities, as diabetes may lead to the development of
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