ISPAD Clinical Practice Consensus Guidelines 2018: Limited Care Guidance Appendix

Whenever possible, follow the guidance described in the full chapter for recommended care (Pediatr Diabetes 2018: 19 (Suppl.27): 7-19).• Diagnostic criteria for all types of diabetes in children and adolescents are based on laboratory measurement of plasma glucose levels (BGL) and the presence or absence of symptoms.If blood glucose testing is unavailable, diabetes can be provisionally diagnosed, in the presence of symptoms, by the finding of high levels of glucose and ketones in the urine.• In geographical areas where the known incidence of type 1 diabetes is low, health care professionals should be aware that there is a higher rate of diabetic ketoacidosis at presentation due to lack of consideration of the diagnosis.• The possibility of other types of diabetes should be considered in the child who has: ○ an autosomal dominant family history of diabetes.○ age less than 12 months and especially in the first 6 months of life.○ associated conditions such as deafness, optic atrophy, or syndromic features.○ mild fasting hyperglycemia (5.5-8.5 mmol [100-150 mg/dL]), especially if young, non-obese, and asymptomatic.○ marked insulin resistance and acanthosis nigricans.○ a history of exposure to drugs known to be toxic to beta cells or cause insulin resistance.○ long interruption of insulin therapy without the occurrence of ketoacidosis.• The differentiation between type 1, type 2, monogenic, and other forms of diabetes has important implications for both treatment and education.Diagnostic tools, which may assist in confirming the diabetes type if the diagnosis is unclear, include:• Diabetes-associated autoantibodies: glutamic acid decarboxylase 65 autoantibodies (GAD); Tyrosine phosphatase-like insulinoma antigen 2 (IA2); insulin autoantibodies (IAA), and β-cell-specific zinc transporter 8 autoantibodies (ZnT8).The presence of one of more of these antibodies confirms the diagnosis of type 1 diabetes.• Molecular genetic testing can help define the diagnosis and treatment of children with suspected monogenic diabetes and should be limited to those who on clinical grounds are likely to be positive. STAGES OF TYPE 1 DIABETES IN CHILDREN AND ADOLESCENTSWhenever possible, follow the guidance described in the full chapter for recommended care (Pediatric Diabetes 2018: 19 (Suppl.27): 20-27).• Individuals with a first-degree relative with type 1 diabetes have an approximately 15-fold increased relative risk of type 1 diabetes.• The majority of children at risk of type 1 diabetes with multiple islet antibodies progress to diabetes within the next 15 years, compared to ~10% who have a single islet antibody.• Individuals with islet autoimmunity who are followed regularly until clinical diagnosis present with lower HbA1c and a lower risk of diabetic ketoacidosis.• Health care professionals should be aware that there are no interventions at present are proven to prevent or delay the onset of type 1 diabetes.• Diagnostic difficulties that may delay diagnosis include:○ The hyperventilation of ketoacidosis may be misdiagnosed as pneumonia or asthma (cough and breathlessness distinguish these conditions from diabetic ketoacidosis).○ Abdominal pain associated with ketoacidosis may simulate an acute abdomen and lead to referral to a surgeon.○ Polyuria and enuresis may be misdiagnosed as a urinary tract infection.