Treatment of both type 1 and type 2 diabetes should take a holistic approach to the child in the context of family and greater environment. There are many common themes to management of diabetes in the pediatric patient, regardless of pathogenesis. Effective diabetes management requires access to a multidisciplinary diabetes team including a physician, diabetes nurse educator, registered dietician, and psychologist or social worker.
A. General Priniciples for Diabetes Management
The HbA1c level reflects the average blood glucose levels over the previous 3 months. The overarching goals of therapy in diabetes include prevention of acute and long-term complications by reducing chronic hyperglycemia while maximizing the quality of life. In T1D, these goals must be tempered by preventing frequent or prolonged hypoglycemia and associated morbidities. Each child should have targets individually determined to aim for the lowest HbA1c that can be sustained without severe hypoglycemia or frequent moderate hypoglycemia. In T2D, addressing obesity and associated comorbidities, when present, is also a major focus in maximizing health outcomes (see Chapters 4 and 11).
2. Patient and family education
All caregivers need to learn about diabetes, how to give insulin injections, perform home blood glucose monitoring, and handle acute complications. While teenagers can be taught to perform many of the tasks of diabetes management, they do better when supportive, not overbearing, parents continue to be involved in management of their disease. The use of educational books (see Understanding Diabetes and Understanding Insulin Pumps, Continuous Glucose Monitors, and the Artificial Pancreas) can be very helpful to the family.
The diagnosis of diabetes changes lives of the affected families and brings on relentless challenges. It is impossible to take a “vacation” from diabetes without some unpleasant consequences. The stress imposed on the family around the time of initial diagnosis may lead to feelings of shock, denial, sadness, anger, fear, and guilt. Meeting with a counselor to express these feelings at the time of diagnosis helps with long-term adaptation. Persisting adjustment problems may indicate underlying dysfunction of the family or psychopathology of the child or caregiver. Young people with T1D are more frequently diagnosed with and treated for psychiatric disorders, disordered eating, neurocognitive learning problems, and poor coping skills than the general population. In T2D, socioeconomic status and obesity, are both risk factors for the disease as well as for psychological stress, depression, and other mental illness.
Routine assessment should be made of developmental adjustment to and understanding of diabetes management, including diabetes-related knowledge, insulin adjustment skills, goal setting, problem-solving abilities, regimen adherence, and self-care autonomy and competence. This is especially important during late childhood and prior to adolescence. General and diabetes-related family functioning such as communication, parental involvement and support, and roles and responsibilities for self-care behaviors need to be assessed. Teaching parents effective behavior management skills, especially at diagnosis and prior to adolescence, emphasizes involvement and support, effective problem-solving, self-management skills, and realistic expectations. Adolescents should be encouraged to assume increased responsibility for diabetes management, but with continued, mutually-agreed parental involvement and support. The transition to adult diabetes care should be negotiated and planned between adolescents, their parents, and the diabetes team well in advance of the actual transfer.
A thorough dietary history should be obtained including the family’s dietary habits and traditions, the child’s typical meal times, and patterns of food intake. Regular aerobic exercise is important for children with diabetes. Exercise fosters a sense of well-being; helps increase insulin sensitivity (a drop in glycemia in response to insulin); and helps maintain proper weight, blood pressure, and HDL-cholesterol levels.
B. Treatment of Type 1 Diabetes
1. Home blood glucose monitoring
All families must be able to monitor blood glucose levels at least four times daily—and more frequently in patients who have glucose-control problems or intercurrent illnesses. Blood glucose levels can be monitored using any downloadable meter. Target levels when no food has been eaten for 2 or more hours vary according to age (Table 35–2).
Table 35–2.Target glucose levels. ||Download (.pdf) Table 35–2. Target glucose levels.
|Age (y) ||Glucose Level |
|Before Meals (≥ 2 h fast) ||Bedtime/Overnight |
|< 6 ||80–180 mg/dL (4.4–10 mmol/L) ||120–200 mg/dL (6.7–11 mmol/L) |
|6–17 ||70–150 mg/dL (3.9–8.3 mmol/L) ||90–150 mg/dL (5–8.3 mmol/L)* |
|≥ 18 ||70–130 mg/dL (3.9–7.2 mmol/L) ||90–150 mg/dL (5–8.3 mmol/L)* |
The frequency of self-monitoring of blood glucose correlates with improved HbA1c. Blood glucose results, insulin dosage, and events, for example, illness, parties, exercise, menses, and episodes of hypoglycemia or ketonuria/ketosis should be recorded in a logbook or downloaded. Regular evaluation by the family helps to see patterns, adjust insulin dosage and, if needed, communicate with health care providers. If more than 50% of the values are above the desired range for age or more than 15% below the desired range, the insulin dosage needs to be adjusted.
Some families are able to make these changes independently, whereas others need help from the health care provider by telephone, fax, email or via data shared in the cloud to optimize insulin dose between visits. Children with diabetes should be evaluated by a diabetes provider every 3 months to check compliance, adjust insulin dose according to growth, measure HbA1c, and review blood glucose patterns, as well as for routine review of systems, physical examination, and laboratory tests (see Table 35–1).
CGM is now routinely available and can tremendously improve diabetes management if used most of the time. Subcutaneous glucose levels are obtained every 1–5 minutes from a sensor placed under the skin. The sensor must be replaced every 6–7 days. A transmitter sends glucose levels via radio waves or Bluetooth from the sensor to a receiver that can be inside an insulin pump, smartphone, or separate receiver device. As with insulin pump therapy, intensive education and follow-up is required, usually at a specialty diabetes center. The user is trained on how to keep the real-time displayed blood glucose “between the lines,” that is, in the personalized range. Low and high blood glucose alarms can be set and in some systems CGM data may be used to automatically change insulin pump delivery rate. At the time of consultation, data from CGM devices and pumps are routinely downloaded for analysis of patterns.
The FDA has now approved insulin dosing based on the Dexcom CGM glucose values, which reduces the need for fingersticks, particularly in the school setting. As subcutaneous glucose levels can lag behind blood glucose levels in times of rapid change, finger stick blood glucose is still recommended for treatment and monitoring of recovery from hypoglycemic or significant hyperglycemic events.
2. Nutritional management
Nutritional management in children with T1D does not require a restrictive diet, just a healthy dietary regimen from which both children and their families can benefit. Insulin pump and MDI therapy utilize carbohydrate counting in which the grams of carbohydrate to be eaten are counted and a matching dose of insulin is administered. This plan allows for the most freedom and flexibility in food choices, but it requires expert education and commitment and may not be suitable for many families or situations, such as for school lunches and teenagers. Alternatively to a precise carb counting, “exchanges” are taught to estimate 10- or 15-g servings of carbohydrate.
Insulin has three key functions: (1) it allows glucose to pass into the cell for oxidative utilization; (2) it decreases the physiologic production of glucose, particularly in the liver; and (3) it turns off lipolysis and ketone production.
a. Insulin treatment of new-onset type 1 diabetes—In children who present without DKA and have adequate oral intake, the initial insulin dose can be administered subcutaneously as 0.2 U/kg of short-acting insulin (regular) or, preferentially, rapid-acting analog: lispro (Humalog), aspart (NovoLog), or glulisine (Apidra). At the same time, 0.2–0.3 U/kg of long-acting insulin analog—glargine (Lantus or Basaglar), detemir (Levemir), or degludec (Tresiba)—can be administered subcutaneously to provide the “basal” level of insulin. This usually suffices for the initial 12–24 hours preceding systematic diabetes education.
The dose is adjusted with each injection during the first week. The rule of thumb is to start insulin at the low end of the estimated daily requirement and titrate it up based on frequent (q2–4h) blood-glucose monitoring or CGM glucose levels. The initial daily dose of insulin is higher in the presence of ketosis, infection, obesity, or steroid treatment. It also varies with age, pubertal status and severity of onset. A total subcutaneous daily dose of 0.3–0.7 U/kg/day may suffice in prepubertal children, while pubertal or overweight children and those with initial HbA1c > 12% commonly require 1.0–1.5 U/kg/day of insulin during the initial week of treatment. Children younger than age 12 years cannot reliably administer insulin without adult supervision because they may lack fine motor control and/or may not understand the importance of accurate dosage.
The insulin dose peaks about 1 week after diagnosis and decreases slightly with the waning of glucotoxicity and voracious appetite. Approximately 3–6 weeks after diagnosis, most school children and adolescents experience a partial remission or “honeymoon period.” Temporary decrease in the insulin dose during this period is necessary to avoid severe hypoglycemia. The remission tends to last longer in older children, but is rarely complete and never permanent. Other types of diabetes should be considered in patients with unusually low insulin requirements.
b. Long-term insulin dosage—Children usually receive a rapid-acting insulin to cover food intake or correct high blood glucose and a long-acting insulin to suppress endogenous hepatic glucose production. This is achieved by combining insulins with the desired properties. Understanding the onset, peak, and duration of insulin activity is essential (Table 35–3).
Table 35–3.Kinetics of insulin action. ||Download (.pdf) Table 35–3. Kinetics of insulin action.
|Type of Insulin ||Begins Working ||Main Effect ||All Gone |
|Regular ||30 min ||95 min ||6–9 h |
|10–15 min ||55 min ||4 h |
|NPH (neutral protamine Hagedorn) ||2–4 h ||6–8 h ||12–15 h |
|3–4 h ||6–18 h ||18–26 h |
|Tresiba (degludec) ||4 h ||no peak ||24–40 h |
|Premixed (available in various combinations) |
|NovoLog 75/25 (75% NPH + 25% lispro) ||15 min ||1–8 h ||12–15 h |
|Humulin 70/30 (70% NPH + 30% regular) ||30 min ||Variable ||12–18 h |
Nearly all children diagnosed with T1D at our center receive insulin from a pump or through basal-bolus multiple daily injections (MDI). This usually consists of 3–4 injections (boluses) of rapid-acting analog before meals and 1–2 injections of long-acting analog insulin. The dose of premeal rapid-acting insulin is calculated based on anticipated carbohydrate content of the meal and additional insulin to correct for high blood glucose, if needed. Sliding scales for dosing of rapid-acting insulin (based only on current blood glucose level) are helpful initially, while families learn carbohydrate counting. This shortcut assumes that the content of carbohydrates, for example in dinner, does not vary from day to day; therefore, this may lead to significant under- and overdosing.
Children younger than 4 years usually need 1 or 2 units of rapid-acting insulin to cover carbohydrate intake. Children aged 4–10 years may require up to 4 units of rapid-acting insulin to cover breakfast and dinner, whereas 4–10 units of rapid-acting insulin are used in older children. These estimates do not include correction for high blood glucose.
Families gradually learn to make small weekly adjustments in insulin dosage based on home blood glucose testing or CGM values. Rapid-acting analog insulin is given 10–20 minutes before eating to account for delay in insulin action. If slower human regular insulin is used, the injections should be given 30–60 minutes before meals—rarely a practical option. In young children who eat unpredictably, it is often necessary to wait until after the meal to decide on the appropriate dose of rapid-acting insulin, which is a compromise between avoiding hypoglycemia and tolerating hyperglycemia after meals.
A long-acting analog insulin glargine (Lantus or Basaglar) or detemir (Levemir) is given once or twice a day to maintain basal insulin levels between meals. Degludec (Tresiba) is administered once daily, whenever convenient. Daily adjustments in long-acting insulin dose usually are not needed. However, decreases should be made for heavy activity (eg, sports, hikes) or overnight events.
In the past, most children would receive two injections per day of rapid-acting insulin and an intermediate-acting insulin (NPH), often mixed just before injection. About two-thirds of the total dosage would be given before breakfast and the remainder before dinner. This regimen has been shown to be inferior in achieving recommended HbA1c levels and avoiding hypoglycemia, compared with the basal-bolus regimen described above. Analog insulin (glargine, detemir) works more efficiently than NPH. When changing a patient from NPH insulin to an analog, initially only 50% of the daily units of long-acting insulin is recommended.
c. Insulin pump treatment—Continuous subcutaneous insulin infusion (insulin pump) therapy is currently the best way to restore the body’s physiologic insulin profile. The standard insulin pump delivers a variable programmed basal rate that corresponds to the diurnal variation in insulin needs. Prepubertal children require higher basal rate in the early part of night, while postpubertal patients who experience the “dawn phenomenon” require higher rates in the morning. Lower rates are set for periods of vigorous activity. The user initiates bolus doses before meals and to correct hyperglycemia. Most pumps can receive wireless transmission of test results from glucose meters, but the patient or caregiver must still manually enter the amount of carbohydrate being consumed. The pump calculates the amount of insulin needed for a meal or correction based on previously entered parameters which include: insulin-to-carbohydrate ratios, insulin sensitivity factor, glycemic target, and duration of insulin action (set at 3–4 hours to protect from accumulating too much insulin). The user may override the suggestion or press a button to initiate the bolus.
Most clinical trials have demonstrated better HbA1c and less severe hypoglycemia with pump therapy, compared to MDI. Pump therapy can improve the quality of life in children who have trouble with or fear of injections or who desire greater flexibility in their lifestyle; for example, with sleeping in, sports, or irregular eating. Insulin pumps can be particularly helpful in young children or infants who have multiple meals and snacks and require multiple small doses of rapid-acting insulin. The newer generation of insulin pumps can deliver as little as 0.025 U/h, but higher rates using diluted insulin may be needed for uninterrupted flow.
Compliance problems include infrequent blood glucose testing, not changing pump infusion sets on a timely basis, not reacting to elevated blood glucose, incorrect carbohydrate counting, or missing the boluses altogether. Side effects of insulin pump treatment include failures of insulin delivery because of a displaced or obstructed infusion set. Insulin pump treatment is significantly more expensive than regimens based on injections. For some patients, pumps may be too difficult to operate; some cannot comply with the multiple testing and carbohydrate counting requirements, or the pump is unacceptable because of body image issues or extreme physical activity (swimming, contact sports).
d. “Artificial pancreas” systems—The newest generation of insulin pumps receive CGM sensor input which leads to automatic changes in insulin infusion. The simplest system available features sensor-initiated automatic suspension of insulin delivery at a predetermined low-glucose level and automatic resumption of the delivery after 2 hours. Other systems react to predicted, rather than current, low or high blood glucose levels. Finally, the MiniMed 670G hybrid closed loop became available in 2017. It replaces a programmed basal rate with variable basal dosing determined automatically in response to CGM input. All current “artificial pancreas” systems still require the wearer to give boluses before meals based on carbohydrate consumption.
4. Exercise and insulin therapy
Hypoglycemia during exercise or in the 2–12 hours after exercise can be prevented by careful monitoring of blood glucose before, during, and after exercise; reducing the dosage of the insulin active at the time of (or after) the exercise; and by providing extra snacks. Fifteen grams of glucose usually covers about 30 minutes of exercise. The use of drinks containing 5%–10% dextrose, such as Gatorade, during the period of exercise is often beneficial. Insulin dose for meals as well as the basal insulin pump rate should be reduced before, during, and sometimes after the exercise; the longer and more vigorous the activity, the greater the reduction in insulin dose.
Families must be educated to check blood or urine ketone levels during any illness, when a fasting blood/CGM glucose level is above 240 mg/dL (13.3 mmol/L), or a randomly measured glucose level is above 300 mg/dL (16.6 mmol/L). The health care provider should be called in the presence of moderate or significant ketonuria or ketonemia (blood β-hydroxybutyrate >1.0 mmol/L, by Precision Xtra meter). Usually 10%–20% of the total daily insulin dosage is given subcutaneously as rapid-acting analog or regular insulin every 3–4 hours until blood glucose normalizes. This prevents progression to ketoacidosis and allows most patients to receive treatment at home. Water is the oral fluid of choice if blood/CGM glucose is more than 250 mg/dL; at lower levels of glycemia, one should switch to Gatorade/Poweraid or other glucose-containing beverages.
Mild ketonuria/ketonemia secondary to fasting or acute gastrointestinal upset and associated with normal or low blood/CGM glucose does not require supplemental insulin treatment. Of note, the brain uses β-hydroxybutyrate as the alternate fuel to glucose in the setting of hypoglycemia. Overtreatment with insulin during a sick day that begins with hyperglycemia and ketosis may lead to severe hypoglycemia resulting in loss of consciousness and/or seizures.
C. Treatment of Type 2 Diabetes
Treatment of T2D in children varies with the severity of the disease.
If the HbA1c is still near normal, family-centered modification of lifestyle is the first line of therapy. Lifestyle intervention is a cornerstone of T2D management in adults; however, results have been more mixed in the pediatric population. This may reflect the complex family and environmental context for T2D in youth, which may be resistant to individual-level interventions. Interventions should emphasize eating a balanced diet, achieving and maintaining a healthy weight and regular exercise. Dietary intervention should be culturally appropriate and recognize limitations in family resources.
Current pharmacologic therapy is limited to two approved medications: metformin and insulin. With HbA1c ≤ 9.0% and no ketosis, metformin is usually started at a dose of 500 mg daily with dose increased weekly to a maximum dose of 1000 mg twice daily. If the presentation is more severe, with ketosis, HbA1c more than 9.0%, random blood glucose levels ≥ 250 mg/dL, or uncertainty regarding the distinction between T1D and T2D, initial treatment should include insulin. Metformin can be initiated after ketosis has resolved. An attempt to wean insulin can be started once fasting and postprandial glucose levels have reached normal or near-normal levels. Clinical trials are underway examining the safety and efficacy of other pharmacologic therapies, but none are currently approved in the pediatric population.
3. Home glucose monitoring
Home blood glucose monitoring is typically less frequent in youth who are treated with metformin or lifestyle alone (eg, first morning and 2-hour postprandial test on 3 days per week); however, those taking insulin may require more frequent testing depending on the dose and type of insulin used.
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