Version July 2025
| Complication/comorbidity of diabetes | Approach to screening | When to start | How often to repeat | Abnormal result | Management | Consistent with ISPAD and/or ADA guidance |
| History and review of glycemic trends | ||||||
| Hyperglycemia |
| First visit after diagnosis of diabetes | Every 3 months | Frequent blood glucose above target range | Adjustment of insulin regimen based on glucose targets | ISPAD and ADA |
| Hypoglycemia |
| First visit after diagnosis of diabetes | Every 3 months | Frequent episodes of hypoglycemia (blood glucose level <70 mg/dL), especially with hypoglycemia unawareness* |
| ISPAD and ADA |
| Physical examination | ||||||
| Elevated BP |
| At diagnosis with diabetes | Every 3 months | Elevated BP (prehypertension) confirmed on multiple measurements using appropriate technique¶:
|
| ISPAD |
| Hypertension | Hypertension confirmed on multiple measurements using appropriate technique¶:
|
| ISPAD and ADA | |||
| Impaired growth velocity |
| At diagnosis with diabetes, for patients who are still growing | Measure height every 3 to 6 months until adult height attained (no growth for 2 consecutive visits) | Growth velocity below expected for age and pubertal stage |
| Generally consistent with both |
| Delayed puberty |
| At diagnosis with diabetes, for patients ≥8 years | Yearly until pubertal stage IV-V | Delayed puberty/cessation of pubertal progression |
| |
| Weight gain or weight loss |
| At diagnosis with diabetes | Every 3 to 6 months | Unintentional weight loss | If A1C is at or near target, detailed clinical evaluation with attention to restrictive/disordered eating and symptoms of other comorbid diseases (eg, celiac disease, autoimmune adrenal insufficiency, autoimmune hyperthyroidism) | |
| Rapid or excessive weight gain (BMI ≥95th percentile) | Evaluate for excessive insulin administration and fear of hypoglycemia | |||||
| Neuropathy |
| At age ≥10 years or start of puberty (whichever is earlier) beginning 5 years after diabetes diagnosis◊ | Yearly | Reduced sensation (vibratory, proprioceptive, pressure) | Optimize glycemic management | ADA |
| Psychosocial assessment | ||||||
| Diabetes distress |
| Beginning at approximately 8 years of age | Annually, or more frequently if evidence of distress | Concern for significant diabetes distress | Refer to mental health clinician | General screening recommended by ADA and ISPAD§ |
| Depression |
| Beginning at approximately 10 to 11 years of age | Annually, or more frequently if evidence of depression | Concern for clinical depression | Refer to mental health clinician | |
| Eating disorders |
| Beginning at 10 to 11 years of age | Annually, or more frequently if concern for disordered eating | Concern for disordered eating behaviors | Refer to mental health clinician and, if needed, to eating disorder treatment program | |
| Smoking/vaping |
| Beginning at 10 to 11 years of age | Every 3 months to 1 year | Report of engaging in smoking or vaping |
| ADA and ISPAD |
| Laboratory assessment | ||||||
| Suboptimal glycemic management (long-term) |
| At diagnosis of diabetes | At each visit | A1C >7% (target for most children and adolescents)¥[3] | Optimize glycemic management | ADA and ISPAD |
| Diabetic kidney disease |
| Age ≥10 years (or onset of puberty, if earlier), beginning 5 years after diabetes diagnosis◊ |
| Urine albumin-to-creatinine ratio ≥30 mg albumin/g creatinine (3.4 mg/mmol) in at least 2 of 3 first-morning urine samples within 3 to 6 months, after ruling out other causes of proteinuria‡ |
| ADA |
| Hyperlipidemia |
| Age ≥2 years, shortly after diagnosis with diabetes, once blood glucose is largely within range†,** |
| Fasting LDL 100 to 129 mg/dL** | Nonpharmacologic intervention:
| ADA and ISPAD |
| Fasting LDL ≥130 mg/dL** | Pharmacologic intervention (statins¶¶):
| ISPAD | ||||
| Hypothyroidism caused by autoimmune thyroiditis |
| At or soon after diabetes diagnosis† | Repeat TSH every 1 to 2 years, or sooner if:
| Elevated TSH, low or low to normal T4 | Treatment with levothyroxine as needed | ADA and ISPAD |
| Celiac disease |
| At diagnosis of diabetes | Repeat within 2 years of diagnosis, then after 2 to 5 years or sooner if:
| Positive tTG antibodies with normal total IgA levels |
| ADA and ISPAD |
| Additional in-office screening | ||||||
| Retinopathy |
| Age ≥11 years (or onset of puberty, if earlier), beginning 3 to 5 years after diabetes diagnosis◊ | Repeat every 2 years; frequency of monitoring may change in the following circumstances:
| Background, preproliferative, or proliferative retinopathy |
| ADA |
| Screening for basic social needs |
| At diagnosis | At every visit¥¥ |
| Referral to social work/social services, but largely determined by local resources | General screening recommended by ADA and ISPAD§ |
A1C: hemoglobin A1C (glycated hemoglobin); ACEi: angiotensin-converting enzyme inhibitor; ADA: American Diabetes Association; ARB: angiotensin receptor blocker; BMI: body mass index; BP: blood pressure; CGM: continuous glucose monitoring; DBP: diastolic blood pressure; DEPS-R: Diabetes Eating Problems Survey-Revised; DKA: diabetic ketoacidosis; eGFR: estimated glomerular filtration rate; HDL: high-density lipoprotein; IgA: immunoglobulin A; ISPAD: International Society for Pediatric and Adolescent Diabetes; LDL: low-density lipoprotein; PAID-Peds: Problem Areas in Diabetes Survey-Pediatric Version; PAID-PR: Problem Areas in Diabetes Survey-Parent Revised Version; PHQ-2: Patient Health Questionnaire-2; PHQ-9: Patient Health Questionnaire-9; SBP: systolic blood pressure; SMR: Sexual Maturity Rating (a staging system for pubertal development); T1DM: type 1 diabetes mellitus; T4: thyroxine; TSH: thyroid-stimulating hormone; tTG: tissue transglutaminase.
* Hypoglycemia unawareness soon after T1DM diagnosis is primarily a concern in young children and children with developmental delays or disabilities impacting the ability to communicate symptoms.
¶ If BP is elevated on initial measurement, we proceed with multiple measurements spaced at least 2 minutes apart during that clinic visit. The optimal technique involves use of an appropriately sized cuff in patients who have rested for 3 to 5 minutes prior to measurement. If BP is elevated on multiple measurements, confirmation in another setting (eg, at the primary care pediatrician's and/or school nurse's office) may be useful to rule out situational elevations in BP. In some centers, ambulatory BP monitors may be available for patients to take home, though this is not required.
Δ ACEi and ARBs have teratogenic potential, so appropriate counseling on pregnancy prevention should be provided for patients who can become pregnant. Aim for BP consistently <90th percentile for age, sex, and height.
◊ Screening may be started sooner (eg, <5 years after diabetes onset) and performed more frequently in patients with any of the following: blood glucose persistently above target range (eg, A1C >7.5%), evidence of inadequate adherence to insulin regimen (eg, recurrent episodes of DKA), or other vascular complications (eg, retinopathy, neuropathy).
§ General screening for psychological and social concerns is recommended by the ADA and ISPAD, but preference for specific instruments is not indicated.
¥ More or less stringent goals may be appropriate for individual patients, depending on their personal history of severe hyperglycemia, severe hypoglycemia, and hypoglycemia unawareness.
‡ Abnormal results should be confirmed on at least 2 occasions, ideally on a first-morning sample to rule out orthostatic albuminuria or with a 24-hour urine collection. Other causes of albuminuria (eg, transient albuminuria, exercise-induced albuminuria, nephrotic syndrome, fever) should be ruled out.
† Lipid profile measurement and thyroid screening should be performed once blood glucose is within the target range on the current insulin regimen.
** If the initial sample was nonfasting (random) and the results abnormal, confirm with a fasting lipid panel prior to treatment.
¶¶ Statins have teratogenic potential, so appropriate counseling on pregnancy prevention should be provided for patients who can become pregnant.
ΔΔ Antithyroid antibodies (thyroid autoantibodies [eg, antithyroid peroxidase and antithyroglobulin]) should only be obtained once at first screening. Only repeat if thyroid disease develops.
◊◊ More frequent screening for celiac disease may be appropriate for children who have a first-degree relative with celiac disease. Measurement of tTg is sufficient if IgA is normal. Antibody testing is only valid if performed on a gluten-containing diet.
§§ Causes of vision impairment in children include history of direct eye injury, amblyopia, and cataracts. For more information, refer to UpToDate content on these diagnoses.
¥¥ Guidance is consistent with general care for pediatric patients. Refer to UpToDate content on screening for poverty for more information.
With additional information from:
