What is the recommended treatment for type 1 diabetes mellitus in pediatrics?

Treatment of Type 1 Diabetes Mellitus in Pediatrics

Most children with type 1 diabetes should be treated with intensive insulin regimens via either multiple daily injections (MDI) of prandial and basal insulin or continuous subcutaneous insulin infusion (CSII), using rapid-acting insulin analogs before meals combined with long-acting basal insulin analogs. 1

Core Insulin Regimen

Basal-Bolus Therapy Structure

• Insulin therapy is essential for survival in all children with type 1 diabetes, with the goal of mimicking normal physiological insulin secretion patterns 1
• Approximately 50% of total daily insulin dose should be basal insulin and 50% as prandial insulin, with initial total daily doses typically 0.4-1.0 units/kg/day (commonly starting at 0.5 units/kg/day for metabolically stable patients) 2
• Insulin requirements increase during puberty to as much as 1.5 units/kg/day due to hormonal influences of growth hormone and sex hormone secretion 1

Basal Insulin Selection and Dosing

• Long-acting insulin analogs (glargine, detemir, or degludec) are preferred over NPH insulin due to lower risk of hypoglycemia, especially nocturnal hypoglycemia, and a more constant action profile 2, 3
• Administer once daily (usually at bedtime) or twice daily depending on the specific insulin analog and individual patient response 2
• Glargine has an onset of 2-4 hours, no peak, and duration up to 24 hours; detemir has similar onset and no peak with 12-24 hour duration; degludec provides >24 hour coverage 1
• Adjust basal insulin dose based on fasting and pre-meal glucose levels 2

Prandial Insulin Selection and Dosing

• Rapid-acting insulin analogs (aspart, lispro, or glulisine) should be used before meals rather than regular human insulin, as they provide faster onset (0.25-0.5 hours), peak at 1-3 hours, and shorter duration (3-5 hours) 1, 2
• Administer immediately before meals (0-15 minutes) for optimal postprandial glucose control 4
• Adjust prandial doses based on carbohydrate content of the meal, pre-meal glucose level, and anticipated physical activity using insulin-to-carbohydrate ratios 2
• For very young children (ages 2-6) with erratic eating patterns, rapid-acting insulin analogs can be administered after meals to more accurately match actual food intake and minimize hypoglycemia risk 1

Glycemic Targets and Monitoring

HbA1c Goals

• Target HbA1c <7.5% for most children and adolescents with type 1 diabetes, though this should be adjusted based on individual patient and family circumstances 1, 2
• Measure HbA1c every 3 months to assess overall glycemic control 1
• The Diabetes Control and Complications Trial (DCCT) demonstrated that severity and duration of hyperglycemia directly correlate with risk of microvascular complications in adolescents 1

Glucose Monitoring

• Frequent glucose monitoring is essential, preferably with continuous glucose monitoring (CGM) systems 2
• With increasing CGM use, assess time in target range (3.9-10 mmol/L or 70-180 mg/dL) and frequency of hypoglycemia in addition to HbA1c 1
• Blood ketone meters measuring β-hydroxybutyrate are preferred over urine ketone testing for easier sampling in young children and more accurate correlation with clinical status 1

Continuous Subcutaneous Insulin Infusion (CSII/Pump Therapy)

• CSII may be considered for patients who do not achieve glucose targets with MDI or experience frequent/severe hypoglycemia 2
• Studies demonstrate that CSII users have lower A1C levels, lower hypoglycemia rates, improved quality of life, and higher treatment satisfaction compared to conventional regimens 1
• CSII provides greater flexibility in meal timing and content with adjustable basal rates and patient-activated bolus doses 2, 5

Critical Diagnostic Considerations Before Treatment

Distinguishing Diabetes Type

• In overweight/obese adolescents, distinguish between type 1 and type 2 diabetes by measuring islet autoantibodies and plasma/urinary C-peptide concentrations, as 10% of patients aged 10-17 with type 2 phenotype have islet autoimmunity 1
• Be alert for monogenic diabetes (MODY) in antibody-negative youth, and neonatal diabetes in children diagnosed within the first 6 months of life, as these may be inappropriately treated with insulin when other therapies are more appropriate 1

Exercise Management

• Recommend 60 minutes of moderate-to-vigorous aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week 1
• Pre-exercise glucose levels should be 90-250 mg/dL (5-13 mmol/L) before starting physical activity 1
• Prevent exercise-induced hypoglycemia by reducing prandial insulin for the meal/snack before exercise by 10-50%, increasing carbohydrate intake, and/or reducing basal insulin doses by 20% after exercise 1
• Postpone intense activity if glucose ≥350 mg/dL (19.4 mmol/L) with moderate-to-large urine ketones or β-hydroxybutyrate >1.5 mmol/L 1

Common Pitfalls to Avoid

• Avoid over-basalization: Regular evaluation of insulin dose adequacy is critical; do not simply increase basal insulin without addressing prandial coverage 2
• Do not use regular human insulin 30 minutes before meals when rapid-acting analogs are available, as analogs provide superior postprandial control and lower hypoglycemia risk 1, 2
• Do not overlook the "honeymoon period": After this phase ends, most patients require intensification from 2-3 daily injections to basal-bolus regimens to maintain target A1C 1
• Fasting morning ketosis may occur in younger children without illness or metabolic deterioration and should not automatically trigger aggressive intervention 1