Adequate Glucose Control for Pediatric Type 1 Diabetes
Most children with type 1 diabetes should be treated with intensive insulin regimens using either multiple daily injections (MDI) of prandial and basal insulin or continuous subcutaneous insulin infusion (CSII), targeting an A1C <7.5% with quarterly monitoring. 1, 2
Glycemic Targets
Target A1C <7.5% for all pediatric age groups, though <7.0% is reasonable if achievable without excessive hypoglycemia. 1 This recommendation reflects the balance between preventing microvascular complications (demonstrated by the DCCT trial showing direct correlation between hyperglycemia severity/duration and complication risk) and avoiding severe hypoglycemia that can impair neurocognitive development. 1
- Measure A1C every 3 months to assess overall glycemic control. 1
- Blood glucose targets: 90-130 mg/dL before meals and 90-150 mg/dL at bedtime/overnight. 1
- With continuous glucose monitoring (CGM), also assess time in range (70-180 mg/dL), time below target, and time above target in addition to A1C. 1
Important caveat: The traditional concern about targeting lower A1C in young children due to hypoglycemia risk has been revised because chronic hyperglycemia causes adverse neurocognitive effects and brain development abnormalities on imaging. 1
Insulin Regimen
Core Approach
Use intensive insulin therapy with combinations of rapid-acting and long-acting insulin analogs rather than older intermediate-acting insulins. 1, 2
Basal-bolus regimen structure: 2
- 50% of total daily dose as basal insulin (long-acting analog: glargine, detemir, or degludec)
- 50% as prandial insulin (rapid-acting analog: aspart, lispro, or glulisine given before meals)
- Initial total daily dose: 0.4-1.0 units/kg/day 2
Insulin requirements increase during puberty to as much as 1.5 units/kg/day due to growth hormone and sex hormone effects. 1, 2
Multiple Daily Injections (MDI)
- Long-acting basal insulin once or twice daily (glargine has up to 24-hour duration, detemir 12-24 hours, degludec >24 hours). 1
- Rapid-acting insulin before each meal (onset 0.25-0.5 hours, peak 1-3 hours, duration 3-5 hours). 1
- Rapid-acting analogs demonstrate superior glycemic control and reduced hypoglycemia compared to regular human insulin in pediatric patients with suboptimal baseline control. 1
Continuous Subcutaneous Insulin Infusion (CSII)
Offer CSII to youth capable of using the device safely (with or without caregiver assistance). 1 CSII users demonstrate:
- Lower A1C levels 1, 2
- Lower hypoglycemia rates 1, 2
- Improved diabetes-related quality of life and treatment satisfaction 1, 2
- Less fear of hypoglycemia 1
However, randomized trials in children show no significant A1C difference between CSII and MDI when both are used intensively, though CSII offers greater flexibility. 3, 4
Automated Insulin Delivery Systems
Automated insulin delivery systems should be offered to youth with type 1 diabetes capable of safe device use, as they improve glycemic control and reduce hypoglycemia in adolescents. 1
Monitoring Strategy
Blood Glucose Monitoring
Self-monitor blood glucose multiple times daily: 1
- Before each meal
- At bedtime
- As needed for safety during exercise, driving, or hypoglycemia symptoms
Continuous Glucose Monitoring
Real-time CGM or intermittently scanned CGM should be offered to youth on MDI or CSII who can use the device safely. 1 Benefits correlate directly with adherence to ongoing device use. 1
Ketone Monitoring
Blood ketone meters measuring β-hydroxybutyrate are preferred over urine ketone testing, particularly in young children where urine collection is difficult. 1 Note that fasting morning ketosis may occur in younger children without metabolic deterioration. 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 weekly. 2
Pre-exercise glucose should be 90-250 mg/dL (5-13 mmol/L) before starting physical activity. 2
Prevent exercise-induced hypoglycemia by: 2
- Reducing prandial insulin for the pre-exercise meal/snack by 10-50%
- Increasing carbohydrate intake
- Reducing basal insulin doses by 20% after exercise
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. 2
Common Pitfalls
Avoid using only two or three daily injections of mixed insulins after the honeymoon period, as cross-sectional studies show 50-70% of pediatric patients cannot maintain target A1C with such regimens. 1 The number of injections alone does not ensure optimal control without proper dose adjustment and carbohydrate counting. 1
Do not delay intensive insulin therapy due to age concerns—the evidence now supports aggressive glycemic control across all pediatric age groups given the neurocognitive risks of chronic hyperglycemia. 1
Ensure school personnel are involved in the treatment plan and support use of diabetes technology including CGM and insulin pumps. 1