1、14. Children and Adolescents:Standards of Medical Care inDiabetes2022Diabetes Care 2022;45(Suppl. 1):S208S231 | https:/doi.org/10.2337/dc22-S014American Diabetes AssociationProfessional Practice Committee*The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes the ADA
2、s current clinical practice recommendations and is intended toprovide the components of diabetes care, general treatment goals and guidelines,and tools to evaluate quality of care. Members of the ADA Professional PracticeCommittee, a multidisciplinary expert committee (https:/doi.org/10.2337/dc22-SP
3、PC),are responsible for updating the Standards of Care annually, or more frequently as war-ranted. For a detailed description of ADA standards, statements, and reports, as well asthe evidence-grading system for ADAs clinical practice recommendations, please refertotheStandardsofCareIntroduction(http
4、s:/doi.org/10.2337/dc22-SINT).Readerswhowish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.The management of diabetes in children and adolescents cannot simply be derivedfrom care routinely provided to adults with diabetes.The epidemiology, pathophys-iolog
5、y, developmental considerations, and response to therapy in pediatric diabetesare often different from adult diabetes.There are also differences in recommendedcare for children and adolescents with type 1 diabetes, type 2 diabetes, and otherforms of pediatric diabetes. This section is divided into t
6、wo major parts: the firstpart addresses care for children and adolescents with type 1 diabetes, and the sec-ond part addresses care for children and adolescents with type 2 diabetes. Mono-genic diabetes (neonatal diabetes and maturity-onset diabetes in the youngMODY) and cystic fibrosisrelated diabe
7、tes, which are often present in youth, arediscussed in Section 2, “Classification and Diagnosis of Diabetes” (https:/doi.org/10.2337/dc22-S002). Table 14.1A and Table 14.1B provide an overview of the rec-ommendations for screening and treatment of complications and related conditionsin pediatric typ
8、e 1 diabetes and type 2 diabetes, respectively. In addition to compre-hensive diabetes care, youth with diabetes should receive age- and developmentallyappropriate pediatric care, including vaccines and immunizations as recommended bythe Centers for Disease Control and Prevention (CDC) (1). To ensur
9、e continuity of careas an adolescent with diabetes becomes an adult, guidance is provided at the end ofthis section on the transition from pediatric to adult diabetes care.Due to the nature of pediatric clinical research, the recommendations for chil-dren and adolescents with diabetes are less likel
10、y to be based on clinical trialevidence. However, expert opinion and a review of available and relevant experi-mental data are summarized in the American Diabetes Association (ADA) positionstatements “Type 1 Diabetes in Children and Adolescents” (2) and “Evaluation andManagement of Youth-Onset Type
11、2 Diabetes” (3). Finally, other sections in theStandards of Care may have recommendations that apply to youth with diabetesand are referenced in the narrative of this section.*A complete list of members of the AmericanDiabetes Association Professional Practice Com-mittee can be found at https:/doi.o
12、rg/10.2337/dc22-SPPC.Suggested citation: American Diabetes Asso-ciation Professional Practice Committee. 14.Children and adolescents: Standards of MedicalCare in Diabetes2022. Diabetes Care 2022;45(Suppl. 1):S208S231 2021 by the American Diabetes Association.Readers may use this article as long as t
13、hework is properly cited, the use is educationaland not for profit, and the work is not altered.Moreinformationisavailableathttps:/diabetesjournals.org/journals/pages/license.14. CHILDREN AND ADOLESCENTSS208Diabetes Care Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org
14、/care/article-pdf/45/Supplement_1/S208/668184/dc22s014.pdf by guest on 10 July 2022Table 14.1ARecommendations for screening and treatment of complications and related conditions in pediatric type 1 diabetesThyroid diseaseCeliac diseaseHypertensionDyslipidemiaNephropathyRetinopathyNeuropathyCorrespon
15、dingrecommendations14.29 and 14.3014.3114.3314.3414.3714.3814.4214.45 and 14.4614.4714.4914.50MethodThyroid-stimulatinghormone; considerantithyroglobulin andantithyroidperoxidase antibodiesIgA tTG if total IgAnormal; IgG tTG anddeamidated gliadinantibodies if IgAdeficientBlood pressuremonitoringLipi
16、d profile, nonfastingacceptable initiallyAlbumin-to-creatinineratio; random sampleacceptable initiallyDilated fundoscopy orretinal photographyFoot exam with footpulses, pinprick, 10-gmonofilamentsensation tests,vibration, and anklereflexesWhen to startSoon after diagnosisSoon after diagnosisAt diagn
17、osisSoon after diagnosis;preferably afterglycemia hasimproved and $2years oldPuberty or 10 yearsold, whichever isearlier, and diabetesduration of 5 yearsPuberty or $11 years old,whichever is earlier, anddiabetes duration of 35yearsPuberty or $10 yearsold, whichever isearlier, and diabetesduration of
18、 5 yearsFollow-upfrequencyEvery 12 years ifthyroid antibodiesnegative; more oftenif symptoms developor presence ofthyroid antibodiesWithin 2 years andthen at 5 years afterdiagnosis; sooner ifsymptoms developEvery visitIf LDL #100 mg/dL,repeat at 911 yearsold; then, if 100mg/dL, every 3 yearsIf norma
19、l, annually; ifabnormal, repeatwith confirmation intwo of three samplesover 6 monthsIf normal, every 2 years;consider less frequently(every 4 years) if A1C8% and eyeprofessional agreesIf normal, annuallyTargetNANA90th percentile forage, sex, and height;if $13 years old,120/80 mmHgLDL 100 mg/dLAlbumi
20、n-to-creatinineratio 30 mg/gNo retinopathyNo neuropathyTreatmentAppropriate treatmentof underlying thyroiddisorderAfter confirmation,start gluten-freedietLifestyle modification forelevated bloodpressure (90th to95th percentile forage, sex, and height or,if $13 years old,120129/160mg/dL or 130 mg/dL
21、with cardiovascularrisk factor(s), initiatestatin therapy (forthose aged 10years)*Optimize glucose andblood pressurecontrol; ACEinhibitor* if albumin-to-creatinine ratio iselevated in two ofthree samples over 6monthsOptimize glucose control;treatment perophthalmologyOptimize glucosecontrol; referral
22、 toneurologyARB, angiotensin receptor blocker; NA, not applicable; tTG, tissue transglutaminase. *Due to the potential teratogenic effects, females should receive reproductive counseling and medication should beavoided in females of childbearing age who are not using reliable contraception.care.diab
23、etesjournals.orgChildren and AdolescentsS209Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S208/668184/dc22s014.pdf by guest on 10 July 2022Table 14.1BRecommendations for screening and treatment of complications and related conditions in pediatric type 2 diabetesHyperten
24、sionNephropathyNeuropathyRetinopathyNonalcoholicfatty liver diseaseObstructive sleepapneaPolycystic ovariansyndrome (foradolescent females)DyslipidemiaCorrespondingrecom-mendations14.7714.8014.8114.8614.87 and 14.8814.8914.9214.93 and 14.9414.9514.9614.9814.10014.104MethodBlood pressuremonitoringAlb
25、umin-to-creatinineratio; randomsample acceptableinitiallyFoot exam with footpulses, pinprick,10-g monofilamentsensation tests,vibration, andankle reflexesDilated fundoscopyAST and ALTmeasurementScreening forsymptomsScreening forsymptoms;laboratoryevaluation ifpositivesymptomsLipid profileWhen to sta
26、rtAt diagnosisAt diagnosisAt diagnosisAt/soon afterdiagnosisAt diagnosisAt diagnosisAt diagnosisSoon after diagnosis,preferably afterglycemia hasimprovedFollow-upfrequencyEvery visitIf normal, annually; ifabnormal, repeatwith confirmationin two of threesamples over 6monthsIf normal, annuallyIf norma
27、l, annuallyAnnuallyEvery visitEvery visitAnnuallyTarget90th percentile forage, sex, and height;if $13 years old,130/80 mmHg30 mg/gNo neuropathyNo retinopathyNANANALDL 35 mg/dL,triglycerides 150mg/dLTreatmentLifestyle modificationfor elevated bloodpressure (90th to95th percentile forage, sex, and hei
28、ghtor, if $13 years old,120129/130 mg/dL,initiate statintherapy (for thoseaged 10 years)*;if triglycerides400 mg/dLfasting or 1,000mg/dL nonfasting,begin fibrateARB, angiotensin receptor blocker; NA, not applicable. *Due to the potential teratogenic effects, females should receive reproductive couns
29、eling and medication should be avoided in females of childbear-ing age who are not using reliable contraception.S210Children and AdolescentsDiabetes Care Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S208/668184/dc22s014.pdf by guest
30、 on 10 July 2022TYPE 1 DIABETESType 1 diabetes is the most commonform of diabetes in youth (4), althoughdata suggest that it may account for alarge proportion of cases diagnosed inadult life (5). The provider must considerthe unique aspects of care and manage-ment of children and adolescents withtyp
31、e 1 diabetes, such as changes in insu-lin sensitivity related to physical growthand sexual maturation, ability to provideself-care, supervision in the childcare andschool environment, neurological vulner-ability to hypoglycemia and hyperglyce-mia in young children, and possibleadverse neurocognitive
32、 effects of dia-betic ketoacidosis (DKA) (6,7). Attentionto family dynamics, developmental stages,and physiologic differences related to sex-ual maturity is essential in developing andimplementing an optimal diabetes treat-ment plan (8).A multidisciplinary team trained inpediatric diabetes managemen
33、t and sen-sitive to the challenges of children andadolescents with type 1 diabetes andtheir families should provide diabetes-specific care for this population. It isessential that diabetes self-managementeducation and support, medical nutritiontherapy, and psychosocial support beprovided at diagnosi
34、s and regularly there-after in a developmentally appropriateformat that builds on prior knowledge bya team of health care professionals expe-rienced with the biological, educational,nutritional, behavioral, and emotionalneeds of the growing child and family.The diabetes team, taking into consider-at
35、ion the youths developmental andpsychosocial needs, should ask aboutand advise the youth and parents/caregivers about diabetes manage-ment responsibilities on an ongoingbasis.Diabetes Self-Management Educationand SupportRecommendation14.1Youth with type 1 diabetesandtheirparents/caregivers(for patie
36、nts aged 1.5mmol/L. Caution may be needed whenB-OHB levels are $0.6 mmol/L (12,14).The prevention and treatment ofhypoglycemia associated with physicalactivity include decreasing the prandialinsulin for the meal/snack before exer-ciseand/orincreasingfoodintake.Patients on insulin pumps can lowerbasa
37、l rates by ?1050% or more or sus-pend for 12 h during exercise (18).Decreasing basal rates or long-actinginsulin doses by ?20% after exercisemay reduce delayed exercise-inducedhypoglycemia (19). Accessible rapid-act-ing carbohydrates and frequent bloodglucose monitoring before, during, andafter exer
38、cise, with or without continu-ous glucose monitoring (CGM), maxi-mize safety with exercise.Blood glucose targets prior to physicalactivity and exercise should be 126180mg/dL (7.010.0 mmol/L) but should beindividualized based on the type, inten-sity, and duration of activity (14,20). Con-sideradditio
39、nalcarbohydrateintakeduring and/or after exercise, dependingon the duration and intensity of physicalactivity, to prevent hypoglycemia. Forlow- to moderate-intensity aerobic activi-ties (3060 min), and if the youth is fast-ing,1015gofcarbohydratemayprevent hypoglycemia (21). After insulinboluses (re
40、lative hyperinsulinemia), con-sider 0.51.0 g of carbohydrates/kg perhour of exercise (?3060 g), which issimilar to carbohydrate requirements tooptimize performance in athletes with-out type 1 diabetes (2224).In addition, obesity is as common inchildren and adolescents with type 1 dia-betes as in tho
41、se without diabetes. It isassociated with a higher frequency of car-diovascular risk factors, and it dispropor-tionately affects racial/ethnic minorities inthe U.S. (2529). Therefore, diabetes careproviders should monitor weight statusand encourage a healthy diet, exercise,and healthy weight as key
42、components ofpediatric type 1 diabetes care.School and Child CareAs a large portion of a childs day isspent in school and/or day care, trainingof school or day care personnel to pro-vide care in accordance with the childsindividualized diabetes medical manage-ment plan is essential for optimal diabe
43、-tes management and safe access to allschool or day caresponsored opportuni-ties (10,11,30). In addition, federal andstate laws require schools, day carefacilities, and other entities to provideneeded diabetes care to enable the childto safely access the school or day careenvironment. Refer to the A
44、DA positionstatements “Diabetes Care in the SchoolSetting” (10) and “Care of Young Chil-dren With Diabetes in the Child CareSetting” (11) and ADAs Safe at Schoolwebsite (www.diabetes.org/resources/know-your-rights/safe-at-school-state-laws) for additional details.Psychosocial IssuesRecommendations14
45、.9At diagnosis and during rou-tine follow-up care, assess psy-chosocialissuesandfamilystresses that could impact dia-betes management and pro-vide appropriate referrals totrained mental health profes-sionals, preferably experiencedin childhood diabetes. E14.10 Mental health professionalsshould be co
46、nsidered inte-gral members of the pediat-ricdiabetesmultidisciplinaryteam. E14.11 Encouragedevelopmentallyappropriate family involve-ment in diabetes manage-ment tasks for children andadolescents, recognizing thatpremature transfer of diabetescareresponsibilitytotheyouth can result in diabetesburnou
47、t, suboptimal diabetesmanagement, and deteriora-tion in glycemic control. A14.12 Providers should assess foodsecurity,housingstability/homelessness, health literacy,financial barriers, and social/community support and applythat information to treatmentdecisions. E14.13 Providers should consider ask-
48、ing youth and their parents/caregivers about social adjust-ment (peer relationships) andschool performance to deter-mine whether further inter-vention is needed. B14.14 Assess youth with diabetesfor psychosocial and diabe-tes-related distress, gener-ally starting at 78 years ofage. B14.15 Offeradole
49、scentstimebythemselves with their careprovider(s) starting at age 12years, or when developmen-tally appropriate. E14.16 Starting at puberty, precon-ception counseling should beincorporated into routine dia-betes care for all girls ofchildbearing potential. AS212Children and AdolescentsDiabetes Care
50、Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S208/668184/dc22s014.pdf by guest on 10 July 202214.17 Begin screening youth with type1 diabetes for disordered eatingbetween 10 and 12 years ofage. The Diabetes Eating Prob-lems Survey-R
