ISPAD Clinical Practice Consensus Guidelines 2018
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Chapter 8: Glycemic control targets and glucose monitoring 1 D. Maahs The authors have thoroughly revised and updated this chapter taking into account the impact of diabetes technology on current management and safely attainable glycemic control. While acknowledging the NICE guidelines and proposed Swedish guidelines, they have chosen <7% to be the new ISPAD HbA1c target. Both in the summary and at the conclusion of the chapter, they have stated that targets should be individually determined with the goal of achieving a value as close to normal as possible while avoiding severe hypoglycemia as well as frequent mild and moderate hypoglycemia and optimizing quality of life. I personally endorse this recommendation. HbA1c is a "barometer" of psychosocial functioning, and for many children and adolescents, the crucially important family support and socioeconomic resources necessary to ensure good outcomes are not available. For such patients, every encounter in the Diabetes Clinic can feel like a failure because the HbA1c is ALWAYS above the specified target value. We must never forget that we are taking care of children with an incurable disease and, despite its great importance in long-term health outcomes, we must continue take care of the "whole child". I have several additional minor comments that warrant attention.   P.2 In the Executive Summary and Recommendations: the precise meaning is unclear of the statement:  “These assessments also enable evaluating:  ·     Each individual’s glycemic determinants ·     Health care center care ·     Compliance with stated standards …” The authors should be more explicit.   Page 3 articulate symptoms of hypoglycemia or hyperglycemia    Reference #30 specifically refers to higher A1c in African Americans. Add references to show variation in HbA1c values despite similar BG values in other populations?   Page 6 operating hazardous machinery   P. 8 “… although some CGM values must still be confirmed by fingerstick glucose measurement (57). Explain when this is necessary.   P.10 It is my understanding that the flash CGM device is placed on the back of the upper arm (not forearm)?   P.11 references 82,83 are out of place   P.13 #94 is not the correct citation for this statement; ditto #96   P. 14 insulin delivery devices (not decides)
by J. Wolfsdorf
Monday, April 16, 2018
Stages of type 1 diabetes in children and adolescents 3 D. Maahs Thank you all so much for putting these important guidelines together. I’d like to offer a thought re: [Differentiating between type 1 and type 2 diabetes at diagnosis (pgs. 2 & 10)Features suggesting the diagnosis of type 2 diabetes rather than type 1 diabetes at diagnosis include: •Overweight or obesity •Age greater than 10 years •Strong family history of type 2 diabetes •Acanthosis nigricans •High-risk racial or ethnic group •Undetectable islet autoantibodies] The inclusion of high-risk racial or ethnic group here stands out to me as potentially problematic. I understand the impetus, as rates of T2D are higher in African American and Latino populations than NHW, but at the same time, since rates of DKA at diagnosis for youth with T1D are higher in African American and Latino populations as well(1) and rates of obesity/overweight are high in AA youth with T1D and also rising across all ethnic/racial groups,(2,3) I would be concerned that the inclusion of this statement here might inadvertently cause bias, resulting in T1D being overlooked in racial/ethnic minority youth. This is unlikely to happen, but even if it happens once, it could be life-threatening for the individual. Perhaps a caveat something along the following lines:High-risk racial or ethnic group**Youth of high-risk racial or ethnic groups are also at increased risk for DKA at diagnosis of T1D,(1) so it is particularly important that they be screened for antibodies when T1D is suspected. Thank you so much for the hard work.Katie Bibliography1. Dabelea D, Rewers A, Stafford JM, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics 2014;133(4):e938-45. doi:10.1542/peds.2013-2795.2. Liu LL, Lawrence JM, Davis C, et al. Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth study. Pediatr Diabetes 2010;11(1):4-11. doi:10.1111/j.1399-5448.2009.00519.x.3. Mayer-Davis EJ, Beyer J, Bell RA, et al. Diabetes in African American youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study. Diabetes Care 2009;32 Suppl 2:S112-22. doi:10.2337/dc09-S203.
by K. Souris
Sunday, April 8, 2018
Chapter 18: Microvascular and macrovascular complications 2 D. Maahs Thank youTeam ISPAD for work well done. I have gone through the complications, I do not know if I missed, where do we place cataract? We have seen some patients who are poorly controlled with cataract as early as after 2 years of diagnosis.Dr Lucy N. W. Mungai
by L. Mungai-Wainaina
Thursday, April 5, 2018
Chapter 7: Delivery of ambulatory diabetes care to children and adolescents 1 D. Maahs Thank you for a very comprehensive overview of diabetes care. The section on analysis of health care costs and utilisation is expecially useful. Could the authors discuss optimal ratios patients to health care professionals ?Exec summary last point of “processes of diabetes care” is unclear: “assistance to access care”. Reference to Telehealth in Diabetes Technology chapter should be made.Page 5: last paragraph of Exec Summary would be better starting stronger: “Governments and policy makers must be involved .....Figure 1 should include SI units for blood glucose valuesPage 53. Section on Sensor-augmented pump needs more detail (ref) on cost-effectiveness which is referred to from Denmark and Sweden.
by K. Donaghue
Thursday, March 29, 2018
Diabetes Technologies Chapter 5 D. Maahs Thanks for the opportunity to comment on this important new chapter to the ISPAD guidelines ‘stable’I note the previous comments / suggestions already posted on this chapter.I’d like to highlight the following for consideration / clarification:1. Conflict of interest statement This is always a rather tricky / sensitive issue - but one that is nevertheless very relevant to this this chapter given its subject matter. I believe that all of the authors listed are significantly involved in either supporting or leading diabetes technology research programmes. The authors may therefore be perceived as having a ‘vested interest’ and therefore potentially ‘conflicted’.I suggest that for the sake of transparency and openness that a conflict of interest statement for each contributing author should be included at the beginning of this chapter. This should clarify the grant funding / support received for their research in this area - from both charitable and industry sources. Also the usual relationships with industry partners should be clarified (honoraria; lectures etc…), including whether they hold shares in any of these companies; hold intellectual property (IP) rights or patents in the area of diabetes technologies.2. Executive summary.a. “CSII reduces chronic complications of T1D in youth, despite similar hemoglobin A1C (HbA1c) achieved in those on multiple daily injection (MDI) therapy (B)” As far I can ascertain, this statement is based on observations made by one study. I am therefore not convinced that this merits inclusion in the executive summary, certainly not as currently written. Whilst the evidence rating assigned to this statement - B - may be correct, it is only based on the results from a single study. The statement should be either removed or, at least, rephrased. If the latter I suggest - “CSII has been shown in one study to be associated with a reduction in chronic complications of T1D in youth, despite similar hemoglobin A1C (HbA1c) achieved in those on multiple daily injection (MDI) therapy (B)”b.“Sensor augmented pump (SAP) therapy is superior in children and adolescents over MDI with self-monitoring of blood glucose (SMBG) in reduction of HbA1c without an increase in hypoglycemia or severe hypoglycemia (A)” - This statement seems a bit overstated given the body of evidence presented (mainly extrapolated from the STAR3 trial), the fact that SAP ‘success’ is heavily dependent on the amount of sensor usage, and that it is not supported so far by ‘real world’ observations. Suggest rephrase / moderate - appropriately 
3. Section 3 - Page 4 & 5a. “Furthermore, data from meta-analyses conducted by various groups have depicted similar findings with pump therapy”.I am not sure this is entirely true /correct. The authors appears to have overlooked other - perhaps more robust / rigorous - meta-analyses undertaken to those cited that have different conclusions. For example Yeh , et al. Ann Intern Med. 2012;157(5):336-47 b. The discussion regarding the pooled analyses from the DPV / T1DX and NPDA paper (Sherr et al, Diabetologia 2016) - should address / acknowledge the limitations of this study - i.e. its cross-sectional nature, etc… HbA1c values in the NPDA cohort were significantly higher than those observed in the DPV / T1Dx cohorts. Differences between CSII and MDI in the better controlled DPV and T1DX cohorts were small and perhaps of debatable ‘clinical’ significance?d. Discussion / mention regarding the DPV “database analysis of almost 10,000 participants” (Karges et al , JAMA 2017) merits further explanation and clarification. Why are the key data from this study not shown / highlighted here - particularly regarding HbA1c? Whilst the differences in HbA1c between CSII vs MDI in this analysis may have been statistically significant (p= <0.001) their clinical significance (8.04% vs 8.22%; difference = -0.18%) is debatable, and are unlikely to be of any significant benefit over the long-term in terms of chronic complications reductions or from a health economic perspective.Thus the statement “Thus, the benefits of pump use have now been echoed in various registry assessments.” therefore seems, again, rather overstated and presumptive.General commentsI wonder if the following topics / themes need specific inclusion, or in some areas, more in depth consideration and clarification: a. Statistically significant vs clinical significant observations. Some statistically significant results may not necessarily be of clinical significance and should accordingly be interpreted with this in mind.b. Health-economic considerations / implications. This topic is not really mentioned. What are the future challenges we face regarding the costs of diabetes technology. Does the current evidence base justify the drive to make the use of diabetes technologies the new ‘standard of care’ from a health economic perspective?c. Access to technology - I wonder if more explicit, practical, recommendations should be made regarding who should be strongly considered / prioritised for access to diabetes technologies? This is particularly relevant given that in many health care systems access to technologies may be significantly restricted or rationed through limited funding. For example:1. What specific clinical situations / scenarios should diabetes technologies be strongly considered / recommended or prioritised ?Table 1 - partially addresses this issue - but only for CSII and not for CGM / SAP. Also the indications highlighted on Table 1 are very broad / vague to say the least, and are based on recommendations made in 2007. Given the evidence base has moved on since then - could these recommendations be better defined or refined and made more specific?2. Identifying the ‘type’ of patients / families - who are likely to represent a “good fit for the device”. Are there any specific factors / characteristics - psychological; behavioural, social etc… - that would support or preclude consideration for using a specific diabetes technology? What factors are likely to determine success / failure? Can these be listed?Are there any ‘tools’ / resources that could help ‘screen’ to identify patients / families who may (or may not) do well with technology. 3. There is an appropriate focus on “barriers to [technology] uptake” and recommendations to “conduct a brief assessment of barriers” and to “problem-solve”, yet no practical advice is provided as to how this should be done, other than perhaps to refer to a psychologist. However - not all (many) health care systems will have ready access to a clinical psychologist or to psychological services.
by C. Acerini
Saturday, March 24, 2018
Chapter 19: Other complications and associated conditions 0 D. Maahs Dear ISPAD member/friend, Thank you for your continued interest in the 2018 ISPAD Clinical Practice Consensus Guidelines and in the previous drafts chapters we shared with you. We are happy to announce that the Chapter 19: Other complications and associated conditions in children and adolescents with type 1 diabetes is now ready for you to read and comment on. We are looking forward to hearing your thoughts and input on this chapter.  Kind regards, David Maahs ISPAD Secretary-General
by D. Maahs
Wednesday, March 21, 2018
Chapter 5: Management of cystic fibrosis-related diabetes Locked Topic 4 D. Maahs Dr. Goldsmith makes a good point. “Usual” diabetes criteria based on risk of micro vascular disease may not be appropriate in C F. However, the selection of different numbers upon which to base a diagnosis would at this point be totally arbitrary. Until we have more outcomes data for specific glucose cut-off levels we are stuck with current OGGT criteria.
by A. Moran
Monday, March 12, 2018
Chapter 17: Adolescence Locked Topic 3 D. Maahs Thank you for your comments. We have amended the article according to the suggestions. Dr. Ethel Codner
by E. Codner
Monday, March 5, 2018
Chapter 10: Nutritional management Locked Topic 10 D. Maahs Dear Beth,Thanks again for your comments! To further address the issues you have raised we have strengthened the statement (and made it more positive!) that if a child or family choose to routinely consume a diet <40% carbohydrate it is recommended that they are reviewed by a dietitian to ensure the diet is nutritionally sound and meeting the child's energy needs. Often though it is the parent, not the child that chooses to follow a low carbohydrate diet.We have also stated more clearly that if the adolescent is post pubertal and growth is complete lower carbohydrate lifestyle choices may be safely incorporated. A statement has also been added on the use of very low carbohydrate diets (ketogenic) in the short term treatment of obesity in adolescents with type 1.We do have more to learn from families that successfully manage this style of eating, however evidence to date indicates it can be potentially unsafe and restrictive and not necessary for optimal glycaemic outcomes. Other non- dietary behaviours may also be contributing to the successful implementation of these diets.Thanks again Beth! Great topic and we feel the chapter is much better because of your valuable input in raising this. Kind regards, Carmel
by C. Smart
Friday, February 23, 2018
Chapter 6: Diabetes Education Locked Topic 3 D. Maahs The forum discussion on Chapter 6: Diabetes Education is now closed. While ISPAD does very much appreciate your feedback, kindly note that any comments posted here after 02/12/2018 will only be taken into account for the 2022 Guidelines! Thank you very much for your understanding.
by D. Maahs
Monday, February 12, 2018
Ch.15:Management of children & adolescents with diabetes requiring surgery 1 D. Maahs Dear authors, I have several comments and suggestions for your consideration.   P.3 Increasing use of glucose monitoring   P.4 … scheduled as the first case of the day on the surgical list … insulin regimen   P.8 Type 2 diabetes “Patients undergoing a major surgical procedure expected to last at least 2 hours should be monitored and started on an IV insulin infusion” Provide more specific instructions about what should be monitored and how frequently.   P. 9 insertion of grommets   P.10 “… all surgery or investigations under anesthesia that are more than minor …” Require BG monitoring before, hourly during, and after the procedure to detect hypo- and hyperglycemia”   P.12 “… despite use of a tight blood glucose control protocol”   Use of “diabetic” is not recommended; diabetic is repeatedly used throughout the manuscript. At least in the USA where I live and work, there is an ongoing campaign to raise awareness that people with diabetes do not want to be referred to as diabetics.  “… poorly controlled individuals with diabetes”   “Since the adult literature shows that outcomes are affected by the state of patients with diabetes before undergoing surgery, these studies allow us to make the following recommendations: …”   There are currently sufficient data (plural) …   P.13 In the discussion about pediatric reports in the critical care setting, the authors should be explicit that these studies were performed in children who did not have diabetes.   P.15 does “electrical equipment” refer to electrcautery?   P.17 “Must be admitted to hospital if receiving general anesthesia” Does this recommendation refer to BEFORE the procedure? In the US, many patients with well controlled diabetes who are scheduled for major procedures arrive in the pre-operative suite early in the AM on the day of the procedure. Health insurance does not pay for admission on the day before surgery in such cases. If the patient has other reasons to be hospital or diabetes is not well controlled, then admission before surgery would be approved.   Insulin regimen   Make a recommendation about how frequently BG should be measured intra-operatively   Why reduce long-acting basal insulin by 50% or basal infusion rate by 20% if the dose has been properly calibrated?   Continue usual basal rate   P.19 Why 80% of the usual correction factor if BG >250 mg/dL? Indicate a target BG to calculate the correction dose. At my institution, we use 150 mg/dL as the correction target in the setting of surgery and anesthesia.   P19 What BOHB concentration defines “significant ketone production”?  see also P.20   “glucose status” – I suspect this means current BG concentration?   P.23 insulin regimen   P.25 Potassium Here, the authors point out that it is potentially dangerous to add potassium to the IV fluids in case there is an urgent need for rapid fluid resuscitation. For clarity, I suggest re-writing the sentence: “Monitor electrolytes pre- and post-operatively.  Only after completion of surgery and when the patient’s vital signs are stable, consider adding potassium chloride 20 mmol/L of intravenous fluid”
by J. Wolfsdorf
Saturday, February 10, 2018
Chapter 12: Hypoglycemia Locked Topic 11 D. Maahs We want to thank all members who provided feedback on the Hypoglycemia chapter.  These comments were used to update the chapter.  Specific responses are provided in the attached PDF.
by D. Maahs
Monday, January 29, 2018
Chapter 3: Type 2 Diabetes Locked Topic 2 D. Maahs Excellent, comprehensive coverage of this topic!  Some comments and suggestions for the authors' consideration Page 4 bullet 3 Highlight that this should be a FASTING lipid profile? 3aii (1) states fasting   Page 7 2nd line from bottom of page: typo ethnic/racial   Page 8 so as not to offend our Canadian colleagues, include Canadian First Nation youth in the list of high risk populations   Page 9 3rd line from bottom of page typo: autoimmune-mediated T1D   Page 9 The most recent report from SEARCH for Diabetes in Youth study indicated that in youth with T2D, DKA at presentation decreased from 11.7% 2002-2003 to 5.7% in 2008-2010. Dabelea, D et al Pediatrics 2014;133(4):e938-45     Page 10 Because measurement of diabetes autoantibodies may not be available or cost may be prohibitive, one us has to rely on clinical criteria. The article by Julia von Oettingen in Pediatric Diabetes 2016;17(6):416-425 provides a simple clinical scoring system (weight Z-score, age and race) that may be useful in these circumstances (low resource settings).   Page 11 … as the insulin resistance of puberty wanes   Page 24 Indicate whether the goals levels refer to fasting or non-fasting samples… or does it matter? Fasting samples more difficult to obtain in clinical practice. May require patent returning to clinic on another day and this adds to the patient’s burden (inconvenient, cost of travel, time off work, missed school, etc.).
by J. Wolfsdorf
Sunday, January 28, 2018
Chapter 9: Insulin Locked Topic 6 D. Maahs Dear all, Than you for the nice Guideline. In comment to fergus I would like to add, that the aim of the JAMA paper comparing CSII and MDI was to Show that we see fewer adverse Events like DKA and sever hypoglycemia in the real world Setting outside a RCT. I agree that the difference in HbA1c is not very high however taking into account that most patients/families on CSII additionally have a better quality of live (Müller-Godeffroy E, Treichel S, Wagner VM; German Working Group for Paediatric Pump Therapy.Diabet Med. 2009 May;26(5):493-501. doi: 10.1111/j.1464-5491.2009.02707.x.) I would suggest there is still some evidence favoring CSII.Howevere the treatement decission is allways an indiviual decission taking into accoutn all familiar and Patient related arguments. I know I am to late but I wanted to comment on the discussionBW Thomas Kapellen
by T. Kapellen
Friday, January 26, 2018
Chapter 11: Diabetic ketoacidosis and hyperglycemic hypersmolar state Locked Topic 4 D. Maahs The forum discussion on Chapter 11: Diabetic ketoacidosis and hyperglycemic hypersmolar state is now closed. While ISPAD does very much appreciate your feedback, kindly note that any comments posted here after 25/01/2018 will only be taken into account for the 2022 Guidelines! Thank you very much for your understanding.
by D. Maahs
Thursday, January 25, 2018

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