Type 1 Diabetes Screening in Pediatrics: Putting Guidelines Into Practice

In its 2025 Standards of Care in Diabetes, the American Diabetes Association (ADA) included a formal recommendation for autoantibody-based screening for early-stage type 1 diabetes (T1D) in at-risk individuals.1 The 2026 update2 expands guidance on screening and monitoring, emphasizing the importance of early detection and intervention for those with a family history of T1D or known elevated genetic risk.If widely adopted, these T1D screening recommendations could have important health implications. Diagnosing T1D in its presymptomatic stages (ie, stages 1 and 2) may prevent life-threatening occurrences of diabetic ketoacidosis (DKA) and allow for early intervention to preserve beta cell function and delay progression to symptomatic (stage 3) T1D. Notably, teplizumab, the first Food and Drug Administration–approved immunotherapy for stage 2 T1D, delayed clinical progression by a median of approximately 2 years in a pivotal trial.3Often, people with presymptomatic (stage 1 and 2) T1D are not diagnosed until symptoms are clinically overt, resulting in substantial health impacts, emotional distress, and financial burdens (eg, the cost of emergency care visits). By contrast, early detection gives people with T1D and families/caregivers time to process the diagnosis while gaining skills and knowledge needed for lifelong diabetes management.Unfortunately, T1D screening is still done primarily in research-based settings, while real-world testing practices remain inconsistent. Implementation lags due to hurdles in clinical workflow, competing clinical priorities, insurance/billing issues, and resource limitations.4 As a result, many clinicians are underprepared to provide screening and support. Moreover, without consistent coverage by public and commercial insurers, the benefits of screening may accrue only to those who can afford out-of-pocket costs, widening existing disparities in T1D outcomes.According to ADA guidance, screening should be offered to anyone with a family history of T1D or known markers of genetic risk.1 However, up to 90% of T1D cases have no familial connection,5 indicating that, regardless of familial risk, clinicians should maintain a high index of suspicion for T1D. Population-based screening could yield a 60% increase in the number of children diagnosed with early-stage T1D, one analysis suggests.6 Population-based pediatric screening programs have been initiated internationally, including the Fr1da study in Germany, the ELSA study in the United Kingdom, and the D1Ce Screen pilot project in Italy. However, multiple uncertainties about mass screening still need to be adequately addressed, including cost-effectiveness, access to care, and adequacy of health care infrastructure.With these concerns in mind, the Diabetes Leadership Council convened representatives of major medical societies, professional associations, patient advocacy groups, and academic and community medical practices to discuss current challenges and opportunities to optimize T1D screening uptake and follow-up care. The roundtable focused on the role of frontline clinicians and their position to meaningfully increase screening uptake and identification of early-stage T1D. Pediatricians, family physicians, and other primary care clinicians will encounter at-risk individuals more frequently than specialists, providing more opportunities for T1D detection.To support a primary care–focused approach, initiatives are needed to educate and engage. In practice, many have insufficient knowledge of T1D and its complications; consequently, T1D is often overlooked or misdiagnosed. In one study, 16% of individuals diagnosed with T1D before the age of 18 were initially diagnosed with a different condition. Compared with a correct initial diagnosis, misdiagnosis was associated with an 18% increased risk of DKA.7Education is needed on the importance of early T1D detection and recommendations for screening, management, and monitoring of autoantibody-positive patients. Insufficient knowledge can negatively impact screening uptake. For example, many primary care clinicians associate a T1D diagnosis with a DKA crisis; as such, they may simply accept this life-threatening complication as unavoidable, rather than preventable based on detection of presymptomatic T1D.Lack of formal training is a significant barrier to screening uptake. Education on T1D screening has not been widely integrated into medical education and training programs. There is an urgent need for hands-on training alongside informational guides, interactive case-based activities, infographic-based posters, and other materials designed to increase T1D screening competence.Lack of familiarity with testing options is a significant source of T1D testing inertia. Primary care clinicians should be aware of available autoantibody screening options, including: Commercial laboratories such as LabCorp and Quest DiagnosticsEnable Biosciences, which offers at-home testing kits, including partnerships with organizations such as Breakthrough T1D (formerly Juvenile Diabetes Research Foundation)TrialNet (trialnet.org), which offers screening of relatives and clinical studiesAutoimmunity Screening for Kids (ASK), a pediatric research study that offers screening for US residents aged 1 year and older, with or without T1D family historyScreening Central, which offers various screening options and free clinician follow-upEvidence suggests primary care clinicians who learn about T1D screening are receptive and enthusiastic about the opportunity to improve patient health. In a pilot conducted by the Georgia Academy of Family Physicians, most participants were unfamiliar with the latest T1D screening recommendations (unpublished data, presented at the Diabetes Leadership Council T1D Screening Roundtable). However, once recommendations were introduced, participants readily agreed to: Discuss family screening with patients with diagnosed T1D; andRe-screen patients with uncontrolled T2D, as the initial diagnosis may have been incorrect or incomplete.Participants endorsed the value of clear guidance on which tests to order, coding for reimbursement, and patient support resources. However, physicians were unclear on how to proceed following a positive T1D screening result, suggesting that identifying autoantibodies is only 1 step in a complex process.Implementing a broad-based clinical workflow can help clinicians navigate the complexities of T1D care, spanning early detection, timely management, and ongoing follow-up. Workflow processes can be customized per institution and evolve over time to optimize screening uptake and ongoing care.Figure 1 illustrates a landmark Early T1D Clinic model. Primary care is vital to steps throughout the workflow, particularly diagnosis and staging, education, long-term monitoring, and connecting individuals to psychosocial support and mental health services. Psychosocial support, integrated into the local endocrinology program, is essential given the psychological impact of presymptomatic diagnosis on patients and families.Collaborations between primary care and endocrinology can foster uptake of T1D screening strategies. Several promising models include: Mini-fellowships: Intensive, time-limited programs to equip frontline clinicians with skills and confidence to implement screening and ongoing management of early-stage T1D, potentially reducing burden on subspecialists.Project ECHO: This adult learning model incorporates telementoring of primary care clinicians in a collaborative group setting alongside an endocrinologist.Ask the Experts (asktheexperts.org): Facilitates consultations directly with pediatric endocrinologists for guidance on screening, diagnosis, and management.Lunch-and-learn sessions: Informal presentations by local endocrinology specialists, allowing primary care providers to learn about screening and discuss region-specific resources.Grand rounds presentations: Pediatric and family medicine grand rounds can reach a broad clinician audience, including those in rural areas when virtual attendance is supported.To encourage and foster T1D screening implementation in pediatrics and other primary care settings, roundtable participants recommended multiple strategies: Standardize early detection: T1D screening should be viewed as an essential part of preventive care that can “piggyback” on routine screenings and blood draws whenever possible.Acknowledge and address blind spots: To improve primary care knowledge and confidence, relationships with endocrinologists can be strengthened through mentorship, consultation, or grand rounds.Build support tools: Practical, easy-to-use resources can help fuel interest and build confidence in ability to screen and manage early-stage T1D.Commit to early intervention: Clinicians should be empowered to regularly follow up with patients with positive autoantibodies, engage in shared decision-making, and access referral networks to ensure smooth transitions of care.Leverage electronic medical records: Platforms can be configured to support prompts, screening order sets, and guideline-based reminders.We aim to encourage the development of strategies to emphasize the importance of T1D early detection, integrate screening into routine health care encounters, and support implementation of T1D screening. With concerted efforts, substantial progress can be made toward increasing preparedness, preventing life-threatening complications, and delaying progression to symptomatic T1D. There is a critical need for pediatricians and other primary care clinicians to support screening practices. Pediatricians and other primary care clinicians are well positioned for greater collaboration with the multidisciplinary team, ensuring early detection, timely intervention, and improved outcomes.