ISPAD Clinical Practice Consensus Guidelines 2018
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Chapter 6: Diabetes Education Locked Topic 4 D. Maahs We want to thank all members who provided feedback on the Diabetes Education chapter.   These comments were used to update the chapter.   Specific responses are provided in the attached PDF.
by D. Maahs
Tuesday, June 12, 2018
Chapter 13: Sick day management in children and adolescents with diabetes Locked Topic 0 D. Maahs Dear Members, You will find here attached the final draft of the Chapter on Sick day management in children & adolescents with diabetes. Kind regards, David Maahs
by D. Maahs
Tuesday, June 12, 2018
Ch.15:Management of children & adolescents with diabetes requiring surgery Locked Topic 2 D. Maahs We want to thank all members who provided feedback on the Management of children & adolescents with diabetes requiring surgery These comments were used to update the chapter.  Specific responses are provided in the attached PDF.
by D. Maahs
Monday, June 11, 2018
Chapter 16: Psychological Issues 2 D. Maahs Dear authors, Thank you for this great chapter.In the section on Disordered Eating I wondered if cross reference should be made to the Nutrition chapter where screening tools are discussed? Early detection and intervention remains a challenge in many paediatric centres.Very Best Wishes,Carmel Smart
by C. Smart
Friday, June 8, 2018
Chapter 19: Other complications and associated conditions Locked Topic 2 D. Maahs Dear Thomas, Many thanks for your thoughtful comments, we agree and will include mention of MS in the overview of autoimmune conditions with references to provide readers with the opportunity to explore this topic in greater detail if they wish. Farid Mahmud and Maria Craig.
by F. Mahmud
Tuesday, May 29, 2018
Chapter 7: Delivery of ambulatory diabetes care to children and adolescents Locked Topic 4 D. Maahs We want to thank all members who provided feedback on the Delivery of ambulatory diabetes care to children and adolescents chapter.  These comments were used to update the chapter.  Specific responses are provided in the attached PDF.
by D. Maahs
Monday, May 28, 2018
Chapter 21: Management of type 1 diabetes in school 1 D. Maahs Dear David and All, it is a pleasure to see the chapter on Diabetes in School finally announced. Hope that we can get interest in what has been written and many good comments, best gun
by G. Forsander
Monday, May 14, 2018
Chapter 3: Type 2 Diabetes Locked Topic 3 D. Maahs We want to thank all members who provided feedback on the Type 2 Diabetes chapter.  These comments were used to update the chapter.  Specific responses are provided in the attached PDF.
by D. Maahs
Friday, May 11, 2018
Chapter 10: Nutritional management Locked Topic 11 D. Maahs Dear members,Thank you very much for your helpful comments on the Nutrition chapter. The feedback we received has been addressed and incorporated into the revised version of the chapter. Best Wishes,Carmel on behalf of all authors
by C. Smart
Wednesday, May 9, 2018
Chapter 1: Definition, epidemiology, diagnosis and classification Locked Topic 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 chapter 1 on Definition, epidemiology and classification of diabetes in children and adolescents 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
Monday, April 30, 2018
Chapter 8: Glycemic control targets and glucose monitoring Locked Topic 4 D. Maahs Thank you for this new and thoroughly revised document, which reads very well. I agree with differentiated targets for HbA1c, but would suggest the following, referring to the World Bank as we do in other situations, for example membership fees: ≤ 6.5% (48 mmol/mol): All high-income countries with access to pumps and sensors ≤ 7.0% (52 mmol/mol): Middle-high income countries where MDI with analogs is available ≤ 7.5% (58 mmol/mol): Low or middle-low countries with access only to limited BG monitoring and human insulin Patients with hypoglycemia unawareness need higher glucose levels just for a short time (14 days) to restore a higher awareness threshold level, not higher HbA1c targets (Fanelli CG, Diabetes 1993;42:1683-89.). We must respect that all children have the right to the same effectiveness of treatment to ensure lowest possible risk of both long-term complications and early cognitive development. The barrier in treatment and target setting should be the economy in the place where the child lives, not the performance and willingness of caregivers in optimizing the therapy below a certain HbA1c threshold, provided this can be done without an increase in moderate or severe hypoglycemia. Many studies have shown that this is possible. The huge difference in mean HbA1c over all age groups in 8 high-income countries [varying between 7.6% (59 mmol/mol) in Sweden and 8.8% (72 mmol/mol) in Wales in 2013 (Charalampopoulos D. Diabetes Care 2018;online)] shows clearly that well funded health care systems can perform and provide quite differently. The percentage below the current ISPAD target 7.5% was 49% in Sweden and 17% in Wales. This is concerning, but the study should also be viewed from the optimistic side, ie showing what is achievable. Important processes for improvement in pediatric diabetes care are ongoing in many countries, and where not, health politics unfortunately has not steered this way. I am missing a recommendation to keep track of mean glucose levels over 7, 14 and 30 days as this will give the family a good picture of the level of glycemic control at home, and prompt for adjustments when increasing levels are found. Although there is a wide variation in the individual relationship between glucose levels and HbA1c, the individual family can easily keep track of changes. Downloading data from meters and CGM devices should be recommended at home and office visits. Mean glucose level and SD over 14 days should be recorded at visits as well as % below 4.0 mmol/l (70 mg/dl) and time in target. Defining the target for families is important. Many studies use 3.9-10 mmol/l (70-200 mg/dl), while we in Sweden use 4-8 mmol/l (70-145 mg/dl). The discussion on low and high glycators is interesting, but only mentioned in the recommendations. I am missing the scientific background. So far there seems not to be sufficient evidence to conclude that high glycators can be given higher HbA1c targets. You refer only to a very brief summary of the 2015 NICE guidelines where a target HbA1c of 48 mmol/l (6.5%) is recommended. The most important sentence in the NICE 2015 guidelines is in my opinion (page 20): “Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimize the risk of long-term complications.” This is a fact, not a target. After changing the target from 7.0% to 6.5% in Sweden, I have communicated this to every family in my practice. Not one family has objected; on the contrary they have appreciated an honest and straight forward message. From there on we have discussed individual targets and personal limitations. If you add risk of chronic complications to the emerging evidence of the detrimental effect of chronic hyperglycemia on the developing brain (Mauras N. Diabetes 2015;64:1770-9.), there can be no question on the crucial effect of the level of metabolic control in young children. Chronic hyperglycemia and glucose fluctuations during the years of brain development have been shown to affect growth of hippocampus negatively, questioning the current practice of tolerating some hyperglycemia to minimize the risk of hypoglycemia in young children with T1D (Foland-Ross LC. Pediatr Diabetes 2018;online). Chronic hyperglycemia early in life will affect the brain’s structure and development negatively (white matter dysfunction due to demyelination). (Aye T, Diabetes Care 2012;35:2167-73). This can result in the brain being more vulnerable to any subsequent insult (hypoglycaemia, head injury, alcoholism, other central nervous system conditions) that occurs later in the child’s life (Ryan, C. Pediatr Diabetes 2006;7:289-97). We had a well-attended pro- and con discussion at the ISPAD meeting in Innsbruck, and arguments for a lower HbA1c target than the current 7.5% are now included in the chapter. The lower targets of 6.5% in UK and Sweden are mentioned. However, I am surprised at finding the sentence “these guidelines admit that there is “no evidence” for this decrease”. The mentioned reference is to NICE, but just a mini-summary where evidence levels are not within the scope of the contents. The full NICE 2015 Guidelines provide both interesting reading and reference to evidence: Page 173 in the pediatric guidelines (Children full-guideline-435396349.pdf): “An HbA1c threshold of 6.5% (DCCT units) was developed jointly with the developers of the guidance for type 1 diabetes in adults because although older studies indicated an association between lower HbA1c values and an increased risk of severe hypoglycaemia, this relationship is less clear with modern management strategies.” Page 193 in the adult guidelines (Adults-full-guideline-435400241.pdf) Overall, low quality evidence from 43 studies (mostly observational and mostly case-series but including 3 randomised controlled trials), showed that with lower HbA1c values the risk and incidence of clinical outcomes was significantly reduced. The main outcomes assessed by the evidence included mortality, CVD, CHD, stroke, retinopathy, low-level (micro) albuminuria, severe hypoglycaemia. Of these outcomes, all but hypoglycaemia rates were improved with lower HbA1c and/or intensive insulin therapy. Page 199: In selecting an HbA1c target for the management of individuals with type 1 diabetes, the GDG (Guideline Development Group) recognised that individuals should achieve a target that minimised the risk of developing complications from glycaemia. Retinopathy is often the first microvascular complication to develop from inadequate glycaemic control, and particular attention was paid to the risk of retinopathy at varying levels of glycaemia reported by the Diabetes Control and Complications Trial. The GDG selected an HbA1c target of 6.5 % on the grounds that a minimal risk of retinopathy was achieved at this level, with further improvements in HbA1c not achieving any further significant reduction in retinopathy risk. …the (DCCT) target for the intensive therapy group was an HbA1c of 6.05%. This was achieved at least once during the study by 44% of participants using intensive therapy; but sustained there by only 5%. The mean HbA1c achieved over the trial by the intensive therapy group was just under 7%. The GDG therefore selected a target HbA1c value that is lower than the achieved HbA1c of the DCCT, as the evidence supports as associated with meaningful reduction in risk of complications, recognising that achieving the value of 7%, as done in the DCCT, was more likely if the target was set lower than this. Pediatric guidelines again: page 174: “The study demonstrated that those healthcare professionals who aim for tighter glycaemic control achieve tighter glycaemic control in the children and young people they care for “(Swift, P. Pediatr Diabetes 2010;11:271-8.) (also consistent with Hanberger L.Diabetes Res Clin Pract. 2012 Jun;96:331-8.). Page 175 “Although the guideline development group agreed that the HbA1c target for children and young people with type 1 diabetes should be set at 48 mmol/mol (6.5%) they recognised that this might not be achieved in every case. In accordance with recommendations in the guideline on type 1 diabetes in adults, the group made an additional recommendation that diabetes services should document the proportion of children and young people with type 1 diabetes who achieve an HbA1c level of 53 mmol/mol (7%) or lower.” “The recommended target HbA1c level of 48 mmol/mol (6.5%) represents a tightening of glycaemic control compared with the 2004 guideline (which recommended that children and young people with type 1 diabetes and their families should be informed that the target for long-term glycaemic control was an HbA1c level of less than 7.5% without frequent disabling hypoglycaemia and that their care package should be designed to attempt to achieve this). The guideline development group emphasised that the result of the change would be to reduce the risk of long-term complications of type 1 diabetes in a population that will have a long duration of diabetes because the condition starts before adulthood.” I look forward to a continued discussion on this important topic, perhaps the most important message in the Guidelines, and would therefore ask that the time for comments is extended.
by R. Hanas
Sunday, April 29, 2018
Chapter 14: Exercise Locked Topic 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 chapter 14 on Exercise in children and adolescents with 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, April 25, 2018
Stages of type 1 diabetes in children and adolescents Locked Topic 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 Locked Topic 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
Diabetes Technologies Chapter Locked Topic 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 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 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 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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