ISPAD Guidelines 2018 Highlighted Chapter

Written on 06/01/2021
Tim Kelly

Chapter 19

Other complications and associated conditions in children and adolescents with type 1 diabetes

Type 1 diabetes may sometimes be associated with some conditions, such as other autoimmune diseases, like celiac disease or thyroiditis. In addition, skin related complications that may occur with the frequent use of insulin pumps and continuous glucose monitoring must also be taken into consideration.

This chapter focuses in how to perform regular screening and management of these conditions.

Regular monitoring of anthropometric measurements and physical development, using growth standards, are essential in the continuous care of children and adolescents with type 1 diabetes.

Screening of thyroid function by measurement of thyroid stimulating hormone (TSH) and antithyroid peroxidase antibodies is recommended at the diagnosis of diabetes and, thereafter, every second year in asymptomatic individuals. More frequent assessment may be indicated in the presence of symptoms, goiter or positive thyroid autoantibodies.


Screening for celiac disease should be performed at the time of diabetes diagnosis, and at 2 and 5 years thereafter, as it is frequently asymptomatic. More frequent assessment is indicated if the clinical situation suggests the possibility of celiac dis- ease or the child has a first-degree relative with celiac disease. 

Screening for IgA deficiency should be performed at diabetes diagnosis. In people with confirmed IgA deficiency, screening for celiac disease should be performed using IgG-specific anti-body tests (tTG or EmA IgG, or both). 

Measurement of human leukocyte antigen (HLA) -DQ2 and HLA- DQ8 is rarely helpful to exclude celiac disease in patients with type 1 diabetes and not recommended as a screening test. Children with type 1 diabetes detected to have positive celiac antibodies on routine screening, should be referred to a pediatric gastroenterologist, as positive serologic testing alone is not diagnostic for celiac disease in this population. 

Upon confirmation of the diagnosis of celiac disease, patients should receive educational support from an experienced pediatric dietitian. Educational materials for patients and families should be made available.

Diabetes care providers should also be alert for the symptoms and signs of drenal insufficiency, although the occurrence is rare.


Routine clinical examination should be undertaken for skin (eg, lipodystrophy) and joint changes (eg, limited joint mobility). Regular screening by laboratory or radiological methods is not recommended. Patient education regarding proper injection techniques, rotating injection sites with each injection and non-reuse of needles remain the best strategies to prevent lipohypertrophy or lipoatrophy. 

Injection sites should be regularly assessed at each clinic visit for lipohypertrophy and lipoatrophy as they are potential causes of glucose variability. Diabetes care providers should be aware of potential skin irritation with use of insulin pumps and continuous glucose monitoring (CGM) by recommending rotation of pump and sensor insertion sites.

Screening for vitamin D deficiency, particularly in high risk groups (celiac disease, darker skin pigmentation) should be considered in young people with type 1 diabetes and treated using appropriate guidelines. 

Check out this presentation by Dr. Farid Mahmud on Screening for and managing celiac disease.

If you want to know more about thyroid disorders in children and adolescents with type 1 diabetes, check out this presentation by Dr. Hemchand Prasad