What are the ISPAD 2024 guideline recommendations for managing type 1 diabetes in children and adolescents?

ISPAD 2024 Guidelines for Type 1 Diabetes Management in Children and Adolescents

The ISPAD 2024 guidelines recommend automated insulin delivery (AID) systems as the preferred technology for youth with type 1 diabetes, with a new glycemic target of HbA1c ≤6.5% (48 mmol/mol) when advanced diabetes technologies are available, or ≤7.0% (53 mmol/mol) in other settings. 1

Core Technology Recommendations

Glucose Monitoring

• Real-time CGM or intermittently scanned CGM should be offered at diagnosis or as soon as possible for all youth with type 1 diabetes on multiple daily injections or insulin pump therapy 2
• Youth should monitor glucose levels multiple times daily (up to 6-10 times/day) including before meals, at bedtime, and during high-risk situations like physical activity or driving 2
• The choice of CGM device should be based on individual and family circumstances, desires, and needs 2

Insulin Delivery Technology Hierarchy

The 2024 guidelines establish a clear technology preference order 2, 3:

1. First-line: Automated Insulin Delivery (AID) systems - Should be offered to all youth with type 1 diabetes capable of using the device safely (either independently or with caregiver support)
2. Second-line: Insulin pump therapy alone - Offer to those on multiple daily injections who cannot use AID systems
3. Students must be supported at school in using all prescribed diabetes technology including CGM, insulin pumps, connected insulin pens, and AID systems 2

This represents a significant shift toward prioritizing integrated, automated systems that reduce the burden of diabetes management while optimizing glycemic outcomes.

Glycemic Targets

The 2024 ISPAD guidelines introduce tiered HbA1c targets based on technology access 1:

• ≤6.5% (48 mmol/mol) for those with access to CGM and AID systems - this should be encouraged when safely achievable
• ≤7.0% (53 mmol/mol) in other settings or when the lower target cannot be achieved without significant hypoglycemia

HbA1c goals must be individualized and reassessed over time, with <7% appropriate for many children and adolescents 2. More stringent goals like <6.5% may be appropriate for selected individuals if achievable without significant hypoglycemia or adverse treatment effects.

Psychosocial and Family Support

Developmental Considerations

• Ongoing parental involvement is essential throughout childhood and adolescence - developmentally appropriate family teamwork helps maintain engagement and prevent glycemic deterioration 2
• Offer adolescents private time with healthcare professionals starting at age 12 or when developmentally appropriate 2
• Starting at puberty, incorporate preconception counseling into routine care for all individuals of childbearing potential 2

Mental Health Screening

The guidelines emphasize proactive mental health surveillance 2:

• Screen for diabetes distress starting at age 7-8 years using validated tools for both youth and parents
• Screen for depression and disordered eating behaviors using available screening tools
• Early detection facilitates effective treatment and minimizes adverse effects on diabetes management
• Refer to behavioral health professionals (ideally with pediatric diabetes experience) when psychological symptoms are identified
• Evidence-based interventions include cognitive-behavioral therapy, mindfulness-based approaches, and other modalities

Common pitfall: Failing to assess psychosocial status and diabetes distress during routine visits. The rapid cognitive, developmental, and emotional changes during childhood and adolescence place substantial burdens on youth and families, necessitating ongoing assessment of quality of life and behavioral health problems.

Screening and Prevention

A major addition to the 2024 guidelines addresses screening for risk of type 1 diabetes and monitoring early-stage disease 4:

• The guidelines now include recommendations for screening high-risk individuals (such as family members)
• Monitoring protocols for those with early-stage T1D (stages 1 and 2) are provided
• Teplizumab is discussed as the first FDA-approved immunotherapy to delay progression from stage 2 to stage 3 T1D
• Screening advantages include prevention of life-threatening DKA and reduction in associated morbidity and mortality 5

Practical Implementation

Glycemic Assessment

• Assess glycemic status at least every 3 months 2
• Blood glucose monitoring should be individualized based on pharmacologic treatment 2

Team-Based Care

The guidelines emphasize that successful T1D management requires:

• Not only optimal glycemic outcomes but a holistic approach encompassing all life aspects 6
• Goals include optimal glycemic values, quality of life and life expectancy similar to peers, prevention of long-term complications, and prevention of severe hypoglycemia 6
• Diabetes teams need to follow current recommendations, adapt them to clinical practice, and provide guidance to families 6

Key caveat: The evidence strongly supports that technology access creates a two-tiered system of care. While AID systems and CGM are recommended as first-line, not all families have equal access to these technologies. Providers must work within available resources while advocating for broader technology access to optimize outcomes for all children with type 1 diabetes.

The 2024 ISPAD guidelines represent a significant evolution toward technology-driven, personalized diabetes care with more ambitious glycemic targets when advanced technologies are available, while maintaining realistic goals for those without such access.