Management of Type 1 Diabetes Mellitus in Children
A basal-bolus insulin regimen using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) is the recommended management approach for children with Type 1 Diabetes Mellitus. 1
Insulin Therapy Options
Basal-Bolus Regimen
Multiple Daily Injections (MDI):
- Long-acting insulin analog (glargine) for basal coverage
- Rapid-acting insulin analog (aspart, lispro, glulisine) before meals for bolus coverage
- Provides better glycemic control and less hypoglycemia compared to conventional regimens 1
Continuous Subcutaneous Insulin Infusion (CSII/Insulin Pump):
- Delivers rapid-acting insulin continuously for basal needs
- Patient-activated boluses at mealtimes
- Particularly beneficial for very young children with unpredictable eating patterns 1
Insulin Dosing
- Initial dosing: 0.5-1.0 units/kg/day, adjusted based on:
- Age
- Pubertal status
- Presence of ketoacidosis 2
- Insulin requirements increase with growth and during puberty (up to 1.5 units/kg/day) 1
- Basal insulin: 40-50% of total daily dose
- Bolus insulin: 50-60% of total daily dose, divided before meals
Blood Glucose Monitoring
Self-monitoring of blood glucose (SMBG) multiple times daily:
- Before meals
- Before bedtime
- As needed for safety (exercise, driving, symptoms of hypoglycemia) 1
Continuous Glucose Monitoring (CGM):
- Should be considered for all children with T1DM
- Associated with lower mean A1C levels
- Particularly beneficial for detecting nocturnal hypoglycemia 1
Glycemic Targets
- A1C goal: <7.5% across all pediatric age groups 1
- Blood glucose targets:
- Before meals: 90-130 mg/dL (5.0-7.2 mmol/L)
- Bedtime/overnight: 90-150 mg/dL (5.0-8.3 mmol/L) 1
Nutritional Management
- Individualized medical nutrition therapy is essential 1
- Carbohydrate counting is key for optimal glycemic control:
- Match insulin doses to carbohydrate intake using insulin-to-carbohydrate ratios
- For young children with erratic eating patterns, consider post-meal insulin dosing 1
- Annual updates with a registered dietitian to assess:
- Caloric intake
- Weight status
- Cardiovascular risk factors 1
Physical Activity Management
- 60 minutes of moderate to vigorous physical activity daily 1
- Pre-exercise glucose targets: 90-250 mg/dL (5.0-13.9 mmol/L)
- Strategies to prevent exercise-induced hypoglycemia:
- Reduce prandial insulin for meals before exercise
- Increase carbohydrate intake
- Reduce basal insulin rates (for pump users)
- Consider bedtime snacks to prevent delayed hypoglycemia 1
Psychosocial Support
- Regular assessment for:
- Diabetes distress (starting at 7-8 years of age)
- Depression
- Disordered eating behaviors
- Family stresses 1
- Provide referrals to mental health professionals experienced in pediatric diabetes 1
Monitoring for Complications and Comorbidities
- Autoimmune conditions:
- Screen for thyroid dysfunction and celiac disease soon after diagnosis and if symptoms develop 1
Special Considerations
Very young children (<6 years):
- Higher risk of hypoglycemia due to inability to recognize/articulate symptoms
- Consider insulin pump therapy from diagnosis
- Post-meal insulin dosing may be appropriate for erratic eaters 1
Adolescents:
Important Pitfalls to Avoid
Delaying intensive insulin therapy: Early initiation of MDI/CSII results in better long-term glycemic control compared to conventional therapy 3
Focusing only on number of injections: The quality of the regimen (basal-bolus approach) is more important than simply increasing injection frequency 1
Overlooking the honeymoon period: Insulin requirements may be lower initially after diagnosis but will increase after this period ends 1
Neglecting psychosocial factors: These significantly impact adherence, glycemic control, and quality of life 1
By implementing this comprehensive management approach, children with Type 1 Diabetes can achieve optimal glycemic control while minimizing the risk of acute complications and preventing long-term microvascular and macrovascular complications.