Balancing universal and targeted screening for type 1 diabetes

In this interview with Contemporary Pediatrics, Shara Bialo, MD, senior medical director at Sanofi, discusses the critical evolution of type 1 diabetes (T1D) screening, emphasizing a shift from reacting to symptoms to identifying disease biology in its early, presymptomatic stages.

Bialo characterizes the debate between targeted and universal screening as a “both/and” conversation. While targeted screening for children with first-degree relatives is a logical starting point, it is insufficient as a stand-alone strategy. Approximately 90% of children who develop T1D have no family history of the disease, meaning a purely targeted approach misses the vast majority of future cases. Targeted screening should be considered the “floor, not the ceiling,” with pediatricians moving toward broader screening as access improves.

T1D is a progressive autoimmune disease in which immune-mediated destruction of pancreatic beta cells can occur over months or years before symptoms appear. Stage 1 disease is defined by the presence of 2 or more islet autoantibodies, with blood sugar remaining normal.

Stage 2 is defined as when 2 or more autoantibodies are present, and blood sugars become mildly abnormal but remain clinically asymptomatic. Once a child has 2 or more autoantibodies, the progression to clinical T1D approaches 100%.

Primary care physicians (PCPs) often miss subtle metabolic changes during these stages, such as rising glucose variability, intermittent post-meal hyperglycemia, or a slowly rising hemoglobin A_1c. By the time classic symptoms such as increased thirst or frequent urination are obvious, the child may already be in life-threatening diabetic ketoacidosis (DKA).

Identifying early-stage T1D triggers a referral to pediatric endocrinology, but the PCP remains a vital partner. PCPs operationalize the monitoring plan in daily life, maintaining a lower threshold to check for glucose or ketones during routine sick visits. This proactive approach shifts the clinical focus from crisis management to empowerment, allowing families to avoid emergency presentations and potentially access therapies that delay the onset of insulin dependence.

The most pervasive misconception is that a lack of family history equates to no meaningful risk. Modern clinical practice must evolve to recognize that T1D is “real” long before insulin dependence begins. Early identification reduces DKA rates and improves family preparedness through immunologic screening before the disease ever becomes symptomatic.

No relevant disclosures.