Treatment of Diabetes in Children
For children with type 1 diabetes, intensive insulin therapy via multiple daily injections or insulin pump is the essential treatment, while children with type 2 diabetes should be treated with metformin as first-line pharmacologic therapy along with lifestyle modifications. 1, 2
Type 1 Diabetes Management
Insulin Therapy
- Essential for survival in all children with type 1 diabetes 1
- Recommended regimens:
- Intensive insulin therapy via either:
- Initial dosing: 0.5-1.0 units/kg/day, adjusted based on:
- Age (infants/prepubertal children require lower doses)
- Pubertal status (requirements increase during puberty, up to 1.5 units/kg/day)
- Presence of ketoacidosis 1
Insulin Types and Administration
- Rapid-acting analogs (aspart, lispro, glulisine):
- Long-acting analogs (detemir, glargine, degludec):
- Shortest needles (4-mm pen, 6-mm syringe) are recommended to minimize pain and avoid intramuscular injection 3
Glycemic Targets
- A1C target: <7.5% for most children with type 1 diabetes 1, 2
- Monitor A1C every 3 months 1
- Target blood glucose ranges:
- Before meals: 90-130 mg/dL
- Bedtime/overnight: 90-150 mg/dL 2
- Consider time in target range and frequency of hypoglycemia with continuous glucose monitoring 1
Monitoring and Education
- Self-monitoring of blood glucose or continuous glucose monitoring is essential 1, 4
- Comprehensive diabetes education including:
- Insulin administration techniques
- Blood glucose monitoring
- Recognition and treatment of hypoglycemia
- Carbohydrate counting
- Sick day management 2
Type 2 Diabetes Management
Initial Treatment Approach
- Metformin is first-line pharmacologic therapy for children ≥10 years with type 2 diabetes if renal function is normal 1, 2
- Start low and titrate up to 2,000 mg daily as tolerated 2
Treatment Algorithm Based on Presentation
- For A1C <8.5% without acidosis: Start with metformin 1
- For A1C ≥8.5% with symptoms: Start long-acting insulin (0.5 units/kg/day) while initiating metformin 1
- For ketoacidosis: Start IV insulin until acidosis resolves, then transition to subcutaneous insulin while initiating metformin 1
Additional Pharmacologic Options
- If glycemic targets not met with metformin:
Comprehensive Care for All Children with Diabetes
Screening and Monitoring
- Screen for additional autoimmune conditions (thyroid dysfunction, celiac disease) 1, 2
- Monitor for hypertension and dyslipidemia 1
- Regular screening for complications after 2-5 years of diagnosis 2
Lifestyle Management
- Medical nutrition therapy with age-appropriate protein intake 2
- Carbohydrate counting for meal planning 1, 2
- Regular physical activity 2
- For type 2 diabetes: focus on nutrient-dense foods and decreased consumption of calorie-dense, nutrient-poor foods 1
Hypoglycemia Management
- Provide glucagon emergency kit and proper training 2
- Glucose (15g) is preferred treatment for conscious individuals with hypoglycemia 1
Common Pitfalls and Caveats
- Distinguishing between type 1 and type 2 diabetes can be challenging in overweight/obese adolescents; measurement of islet autoantibodies and C-peptide is recommended 1, 2
- Monogenic diabetes (1.2-4% of pediatric diabetes) is frequently misdiagnosed as type 1 diabetes 1, 2
- Insulin requirements change during "honeymoon phase" shortly after diagnosis of type 1 diabetes, requiring dose adjustments 1
- Lipohypertrophy from repeated insulin injections in the same site can distort insulin absorption; proper site rotation is essential 3
By implementing these evidence-based treatment strategies, clinicians can effectively manage diabetes in children while minimizing complications and optimizing quality of life.