What are alternative regimens to the basal-bolus approach for managing Type 1 Diabetes Mellitus (T1DM) in children?

Alternative Regimens for Type 1 Diabetes Mellitus in Children

Continuous subcutaneous insulin infusion (CSII) or insulin pump therapy should be offered as the primary alternative to basal-bolus multiple daily injection regimens for children with Type 1 Diabetes Mellitus. 1

Insulin Pump Therapy (CSII)

Insulin pump therapy offers several advantages over traditional basal-bolus regimens:

• Delivers rapid-acting insulin continuously for basal needs with patient-activated boluses at mealtimes
• Particularly beneficial for very young children with unpredictable eating patterns 1
• Associated with more stable glycemic control and less hypoglycemia compared with regimens using intermediate and short insulin 2
• Allows for more precise insulin dosing and flexibility with meal timing
• Enables temporary basal rate adjustments for exercise or illness

Automated Insulin Delivery Systems

• Hybrid closed-loop systems that combine insulin pumps with continuous glucose monitors
• Automatically adjust basal insulin delivery based on glucose readings
• Should be offered to youth with T1DM who are capable of using the device safely 2
• Particularly beneficial for adolescents who may have variable schedules and dietary habits 1

Alternative Multiple Daily Injection Approaches

1. Twice-daily Mixed Insulin Regimens

   • Combination of rapid-acting or short-acting insulin with intermediate-acting insulin
   • May be suitable for younger children with more predictable schedules and eating patterns
   • However, cannot maintain A1C levels within target range for 50-70% of pediatric patients 2

2. Post-meal Insulin Dosing

   • Administering rapid-acting insulin (like lispro) after meals rather than before
   • Particularly useful for very young children with erratic eating habits
   • Allows caregivers to more accurately titrate insulin doses based on actual food intake 2
   • Helps minimize risk of hypoglycemia in unpredictable eaters

3. Basal-plus Approach

   • Single dose of basal insulin with corrective doses of rapid-acting insulin
   • May be preferred for patients with mild hyperglycemia or decreased oral intake 2
   • Consists of a single dose of basal insulin (about 0.1-0.25 U/kg per day) with corrective doses of insulin before meals 2

Considerations for Different Age Groups

Very Young Children (<6 years)

• Higher risk of hypoglycemia
• May benefit from insulin pump therapy and post-meal insulin dosing 1
• Initial dosing may require only minimal amounts of intermediate- or long-acting insulin 2

School-Age Children

• May use two or three doses of rapid-acting or short-acting insulin combined with intermediate-acting insulin 2
• Consider insulin pump therapy for improved flexibility with school schedules

Adolescents

• May need additional insulin for afternoon snacks 1
• Insulin requirements increase significantly during puberty (up to 1.5 units/kg/day) due to growth hormone and sex hormone secretion 2
• Benefit from automated insulin delivery systems to accommodate variable schedules 1

Common Pitfalls to Avoid

• Focusing only on number of injections: Quality of regimen is more important than quantity of injections 1
• Overlooking the honeymoon period: Insulin requirements may be temporarily lower shortly after diagnosis 1
• Using sliding scale insulin alone: Should not be used in patients with type 1 diabetes 2
• Premixed insulin therapy: Associated with high rates of hypoglycemia and not generally recommended 2
• Neglecting psychosocial factors: Can significantly impact adherence and glycemic control 1

Monitoring Requirements

Regardless of regimen chosen:

• Multiple daily blood glucose checks (4-10 times/day) are necessary 2
• Continuous glucose monitoring should be offered to all children on multiple daily injections or insulin pump therapy 2
• Regular assessment of A1C levels with target <7.5% across pediatric age groups 1

The choice between these alternative regimens should be based on the child's age, lifestyle, family support, and ability to manage the technology, with the primary goal of optimizing glycemic control while minimizing hypoglycemia risk and improving quality of life.