Management of Early Onset Type 1 Diabetes
For children and adolescents with newly diagnosed type 1 diabetes, multiple daily insulin injections or continuous subcutaneous insulin infusion should be initiated immediately upon diagnosis, along with comprehensive diabetes education for both the patient and family. 1
Understanding Type 1 Diabetes Staging
Type 1 diabetes develops in three distinct stages before becoming clinically apparent:
- Stage 1: Presence of β-cell autoimmunity (≥2 islet autoantibodies) with normoglycemia; presymptomatic 1, 2
- Stage 2: Presence of β-cell autoimmunity with dysglycemia (IFG and/or IGT); presymptomatic 1, 2
- Stage 3: Symptomatic disease with insulin deficiency requiring insulin therapy 1, 3
Diagnosis
Diagnosis of type 1 diabetes in children is confirmed by:
- Classic symptoms (polyuria, polydipsia, weight loss, fatigue) plus random plasma glucose ≥200 mg/dL 1
- Fasting plasma glucose ≥126 mg/dL 1
- 2-hour plasma glucose ≥200 mg/dL during OGTT 1
- HbA1c ≥6.5% (48 mmol/mol) 1
Initial Management
Insulin Therapy
Initiate insulin therapy immediately upon diagnosis to prevent metabolic decompensation 1
Recommended regimens:
Early initiation of insulin pump therapy is associated with:
- Lower HbA1c values
- Reduced rates of hypoglycemic coma
- Fewer hospitalizations
- Better cardiovascular risk profile 4
Insulin Types and Administration
- Rapid-acting analogs (aspart, lispro, glulisine): Onset 0.25-0.5h, peak 1-3h, duration 3-5h 1
- Long-acting analogs (glargine, detemir, degludec): Onset 2-4h, no peak, duration 12-24+ hours 1, 5
- Insulin dosing: Initially based on weight, but requires individualization and frequent adjustment 1, 5
Education and Self-Management
- Educate patients and families on:
Ongoing Management
Glycemic Targets
- Target HbA1c <7.5% for children and adolescents with type 1 diabetes 1
- Monitor A1C every 3 months to assess overall glycemic control 1
- Consider other metrics with CGM use, such as time in target range and frequency of hypoglycemia 1
Monitoring
- Self-monitoring of blood glucose (SMBG) multiple times daily 1
- Continuous glucose monitoring (CGM) should be considered, especially for those requiring frequent blood glucose monitoring 1
- Sensor-augmented insulin pump therapy with threshold suspend feature can reduce nocturnal hypoglycemia 6
Screening for Comorbidities
- Screen for thyroid autoantibodies at diagnosis and monitor TSH every 1-2 years 6
- Screen for other autoimmune conditions such as celiac disease 6
Special Considerations
Diabetic Ketoacidosis (DKA)
- Immediate treatment required with insulin and fluid replacement in an inpatient setting under experienced supervision 1
- Initial insulin therapy is essential when presenting with ketoacidosis or marked ketosis 1
Distinguishing Type 1 from Type 2 Diabetes
- In overweight/obese adolescents, distinguishing between type 1 and type 2 diabetes may be challenging 1
- Measure islet autoantibodies and consider plasma or urinary C-peptide to aid diagnosis 1
- Consider monogenic diabetes (MODY) in antibody-negative youth with diabetes 1
Common Pitfalls and Caveats
- Delay in diagnosis and treatment can lead to rapid metabolic deterioration and should be avoided 1
- Insulin doses based only on body size are likely to be incorrect and require frequent adjustment 1
- Expecting complete independence in diabetes management from children and adolescents is unrealistic; adult supervision remains important throughout transition to independence 1
- Misdiagnosis of type 1 vs. type 2 diabetes can lead to inappropriate treatment; careful evaluation is necessary in overweight adolescents 1
Future Directions
- Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and GLP-1 receptor agonists may find use in management in the future 7
- Disease-modifying therapies like teplizumab may delay disease progression in presymptomatic stages 2
- Automated insulin delivery systems are changing the landscape of type 1 diabetes management with improved glycemic control and decreased hypoglycemia 7