FAQ: How should pediatricians hand off teens with diabetes?

The International Society for Pediatric and Adolescent Diabetes (ISPAD), the European Association for the Study of Diabetes (EASD), and the American Diabetes Association (ADA) have released a joint consensus report on the transition of adolescents and young adults with diabetes from pediatric to adult diabetes care. The report is being published simultaneously in Diabetologia, Hormone Research in Paediatrics, and Diabetes Care, and it was approved by the boards of all 3 organizations.

The working group arrived at 31 consensus statements that address the full transition continuum as well as 3 distinct phases: pre-transfer, transfer, and post-transfer. The statements are organized around a framework called PROACT, and the authors stress that the recommendations should serve as a guide to be adapted to local health systems, clinic resources, and team composition rather than a fixed protocol.

Why is the move from pediatric to adult care considered a high-risk period?

Young adulthood brings substantial physiological, psychological, sexual, and social change, and the prefrontal cortex, which governs decision-making, planning, and impulse control, is still developing. These factors can undermine diabetes self-management. The report notes that missed appointments, emergency service use, and inpatient admissions rise during the transition period, with corresponding increases in the risk of premature morbidity and mortality. Health services for this age group are also inconsistent worldwide.

The authors define transition of care as a purposeful, planned process that typically begins in early adolescence and ends during emerging adulthood. It is described as far more than sending a medical file or transfer letter; it should be planned, individualized, and built on ongoing collaboration among the young person, caregivers, and both the pediatric and adult teams.

How was the consensus developed?

The working group followed the ACCORD recommendations for consensus reports and the AGREE II recommendations for clinical guidelines. The process had 5 steps: a review of existing diabetes-specific guidelines, a prior position statement, general recommendations, and online toolkits; a systematic review of the literature; a global survey of health care professionals; a global survey of young people with diabetes and their caregivers; and a Delphi survey.

The systematic review covered peer-reviewed studies published from January 2018 through December 2023 and categorized them as intervention studies (n = 26), non-intervention/non-qualitative studies (n = 33), or qualitative studies (n = 24). Evidence was graded using the ADA system. Recommendations supported by A- or B-level evidence were included automatically, while those graded C or E went to the Delphi panel for validation.

How strong is the evidence behind the 31 statements?

Most of the statements rest on expert consensus. Statements 1 through 5, which cover individualized care, the vulnerability of emerging adults, psychosocial screening, vascular risk factor screening, and annual mental health monitoring, draw on the existing evidence base and carry a B grade (statement 4 is graded A/B). The remaining 26 statements are grade E and were endorsed by the Delphi panel.

The authors acknowledge several limitations. Of the 26 intervention studies, only 1 was an RCT; most were pre-post evaluations, and most interventions showed no benefit on metabolic outcomes, with variable improvements in care satisfaction and transition readiness. None provided long-term follow-up. The protocols for the 2 published systematic reviews were not preregistered, and no studies were excluded based on quality, which the authors note may affect the credibility of statements that rely on them.

What did the surveys of clinicians and young people reveal?

The health care professional survey drew 372 respondents, mostly physicians (74.5%), and 37.1% practiced in low- and middle-income countries. Few centers used a transition readiness tool (32.8%), had dedicated transition personnel (23.0%), or sent written information to the receiving team (29.6%). Access to psychological support (25.8%), combined clinics (35.2%), dedicated transition clinics (34.9%), and structured transition education (22.5%) was limited, and 91.9% reported barriers to providing a good transition. Respondents from low- and middle-income countries were more likely than those from high-income countries to cite a need for funding (P = .01), a structured protocol (P < .001), and education (P < .001).

The survey of young people aged 14 to 25 years and their caregivers included 90 people with diabetes (mean age, 18.5 ± 3.6 years) and 56 caregivers across 29 countries. Care satisfaction was higher among those still attending pediatric clinics than among those in adult clinics. Overall, 45.2% reported transfer-related concerns, fewer than half felt their psychosocial needs were adequately met, and almost 25% felt unprepared in some areas of self-management. The most frequently requested services were combined pediatric and adult clinics (56.2%) and psychological support (50.7%).

What is the PROACT framework?

PROACT summarizes the strategies the report recommends at every stage of transition:

• Plan ahead with timely planning
• Educate and Review on an ongoing basis
• Involve Others, including caregivers, peers, and professional teams in pediatric, adult, and general practice
• Assess transition readiness and outcomes
• Provide age-appropriate Care
• Track outcomes over time

The report pairs PROACT with a 3-step template for developing a clinic transition guide: identify the team, prepare content that applies PROACT across the pre-transfer, transfer, and post-transfer stages, and plan for long-term follow-up.

What should care look like across the entire transition continuum?

Statements 1 through 11 apply throughout the process. Care should be individualized and developmentally appropriate, with an emphasis on self-management and consistent use of glucose-lowering medications. Youth should be screened at diagnosis and at routine follow-up for psychosocial concerns such as diabetes distress, depressive symptoms, and disordered eating, using validated, age-appropriate tools, with referral to a qualified behavioral health professional when indicated. Mental health should be monitored at least annually, even in young people who currently appear to be coping well, and micro- and macrovascular risk factor screening should follow ISPAD, EASD, and ADA recommendations.

Clinicians are also asked to encourage continued family involvement while gradually shifting self-management responsibility to the young person, to help patients learn to navigate the health system and reconnect with care if they are lost to follow-up, and to discuss birth control, pregnancy planning, alcohol and drug use, smoking, and driving in the context of diabetes.

When should pediatric teams start talking about transition?

The panel reached consensus that transition conversations should begin at least 12 to 24 months before the planned transfer in most cases. Transition-related topics should be woven into ongoing diabetes education in an age-appropriate and developmentally appropriate way. Pediatric clinicians should assess transition-related knowledge and skills, provide targeted education on any identified gaps, and invite young people to raise their questions and concerns. A transition readiness checklist is endorsed as a helpful way to confirm that education and assessment are complete before transfer, and the report notes that multiple validated tools are freely available, leaving each center to choose its own.

What should a clinic's transition policy include?

Statement 12 calls on pediatric teams to develop a center-specific transition policy or guide describing how the clinic approaches transition preparation and transfer. The document should be shared early and agreed on with patients and caregivers, ideally 12 to 24 months before the anticipated transfer. It should spell out the transition-related roles and responsibilities of each team member, such as the diabetologist, diabetes educator, dietitian, social worker, and psychologist, along with the targeted age range for transfer. The report suggests an age range of 18 to 25 years.

The authors point out that the template is universal but the content must be feasible locally. Some centers have large multidisciplinary teams, while others may rely on a single general pediatrician or nurse.

What does the report recommend at the point of transfer?

Statements 19 through 26 cover the handoff itself. The first appointment with an adult clinician should ideally be scheduled within 3 to 4 months of the final pediatric or joint pediatric-adult visit, or the young person should be helped to arrange it. A written medical summary covering diabetes history, complications, and current management should reach the adult clinician before transfer, with the patient's agreement, and communication between teams should include medications, treatment plans, laboratory results, and complications.

Where possible, the report supports joint pediatric-adult clinics and a dedicated professional, such as a care navigator, transition coordinator, or transition nurse, to handle scheduling and follow-up. A directory of adult clinicians experienced with young adults may also help. Teams should be ready to discuss practical issues including financial costs, insurance, and availability of medicines, and pediatric clinicians should encourage peer connections and peer support activities. If an adult directory is not available, peer support is offered as an alternative that cannot replace adult follow-up but may help keep patients engaged.

What follow-up is recommended after transfer?

During the first year in adult care, visits should be scheduled at least every 3 months to reduce the risk of loss to follow-up. Adult clinicians should assess and address gaps in self-management knowledge, psychosocial health, and practical knowledge of how to access both diabetes-specific and general emergency care. Telehealth and virtual visits can be offered alongside in-person care to add flexibility for young adults with high digital literacy.

What evidence gaps remain?

The authors call for RCTs and longitudinal research with longer follow-up, consistent outcome indicators, outcomes beyond metabolic control and emergency service use, and better descriptions of what drives successful transition, including ethnicity, gender, and health system characteristics. Research on transition in youth with type 2 diabetes is identified as a particular gap. The report also recommends ongoing tracking of transition outcomes, noting that shared electronic health records and quality improvement tools such as the Plan Do Study Act cycle could generate the 3 to 5 years of data needed. The authors anticipate updating the statements as evidence accumulates and suggest they may eventually become chapters in the ISPAD clinical practice guidelines and the ADA Standards of Care.

Reference

de Beaufort C, James S, Weissberg-Benchell J, et al. The transition of youth with diabetes from paediatric to adult diabetes care services: a consensus report of the joint working group of the International Society for Pediatric and Adolescent Diabetes (ISPAD), the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA). Diabetologia. Published online September 14, 2026. doi:10.1007/s00125-026-06803-5