• Maintain a balance between tight glucose control & avoiding hypoglycemia
• To eliminate polyuria & nocturia
• To prevent ketoacidosis
• To permit normal growth & development w/ minimal effect on lifestyle

Insulin Preparations

• Goal of therapy is to duplicate normal physiologic secretion of insulin
• May be used in both Type 1 & Type 2 diabetes mellitus (DM)
  • Patient w/ severe hyperglycemia (random plasma/venous blood glucose ≥250 mg/dL), HbA_IC >9%, &/or ketosis should be treated initially w/ Insulin to achieve metabolic control
•  Insulin requirements are based on body weight, age & pubertal status
• Newly diagnosed Type 1 DM usually require approx 0.5-1 U/kg/day
• Both multiple-dose Insulin injections (MDI) & continuous subcutaneous Insulin infusion (CSII) should be offered at the time of diagnosis or if control of blood glucose is not achieved
• Younger children require lower doses
• Patients at puberty require 1.5 U/kg/day due to hormonal changes
• Prandial Insulin should be matched according to carbohydrate intake, premeal glucose, & physical activity
• Presence of diabetic ketoacidosis (DKA) & use of steroids also require higher doses
• Type 2 DM
  • Initiate treatment in type 2 DM patients w/ severe hyperglycemia (>11.1 mmol/L), glycosylated hemoglobin (HbA_1c) >8.5%, or signs/ symptoms of severe insulin deficiency (eg DKA, ketoacidosis) despite lifestyle modifications (balanced diet & regular exercise)
  • Use during times of illness or stress to maintain glycemic control
  •  Use when patients are unable to maintain adequate control w/ diet, exercise & oral antidiabetic agents
• Patients, parents/caregivers need to be instructed on monitoring of blood glucose & educated to adjust Insulin dose based on blood glucose levels
  • Especially during times of illness, changes in food intake & physical activity
• Signs & management of hypoglycemia must be explained
• Exact time course of each Insulin will depend on each particular preparation & site of injection

Short- & Rapid-Acting Insulins

• Acts as mealtime insulin
• Administer before meals, 30-60 minutes before meals, to mimic normal physiologic increases of insulin
• Regular insulin
  • As a mealtime insulin, its use may be limited because the onset is not rapid enough to meet the quick, unpredictable increase in postprandial blood glucose
  • Also considered a basal insulin as its duration of action may extend beyond the time required for food absorption
• Newer rapid-acting insulin analogues (eg Insulin aspart & Insulin lispro) seem to have better postprandial blood glucose control
  • They have more rapid onset of action & shorter duration of action than Regular Insulin
  • Premeal control before the next meal may be difficult due to the short duration of action if used alone w/o a long- or intermediate-acting Insulin

Intermediate- & Long-Acting Insulins

• Mimics normal physiologic basal insulin secretion
• Neutral protamine Hagedorn (NPH) & Lente Insulins produce significant hypoglycemic effect during the midrange of their duration 
• Long-acting Insulins create more controlled postprandial glucose elevation & hypoglycemia between meals & are reduced at nighttime
• Usually given 1-2x/day

Insulin Combinations

• Patients often require MDI using combinations of short-, rapid-, intermediate- or long-acting insulin before meals & at bedtime for optimal control of blood glucose
• Clinical studies show that combination of 2-3 doses of short- or rapid-acting insulin w/ intermediate-acting insulin do not sufficiently achieve optimal glycemic control
• Combination of rapid-acting insulin & long-acting insulin may result in stable glycemic control & less hypoglycemia especially at night
  • It allows coverage for snacks, however, requires intensive blood glucose monitoring, improved medical nutrition therapy (MNT) & careful insulin adjustment w/ exercise

Insulin Pump Therapy

• CSII consists of regular- & rapid-acting insulins administered subcutaneous (SC) in an external infusion pump
• Can be programmed to deliver constant amount of basal insulin & boluses of insulin for meals
  • Increased physical activity can be managed by reducing amount of basal insulin
• May be used instead of multiple daily injections to provide intensive diabetes management
  • Provides closer approximation of normal plasma Insulin profiles & increased flexibility regarding timing of meals & snacks compared
  • Associated w/ improved metabolic control & reduced risk of severe hypoglycemia w/o affecting psychosocial outcomes in adolescents w/ Type 1 DM
  • May improve metabolic control in children 7-10 years
• Consider a sensor-augmented low glucose threshold suspend pump in patients w/ frequent nocturnal hypoglycemia &/or hypoglycemia unawareness

Oral Antidiabetic Agent

Metformin

• A biguanide approved for nonketotic pediatric patients w/ Type 2 DM
• May be used as monotherapy or in combination w/ Insulin
• 1st line therapy for newly diagnosed type 2 DM-pediatric patients
• May also be used to prevent type 2 DM in patients w/ impaired glucose tolerance, increased fasting glucose, or HbA_1c 5.7-6.4%
• Actions: Improve insulin action at the liver which decreases hepatic glucose production
  • Increase peripheral glucose uptake & utilization
• Effects: Significantly reduces HbA_1c & improves fasting plasma glucose (FPG) & postprandial blood glucose
  • Maintains or decreases weight, decreases low-density lipoprotein cholesterol (LDL-C) & triglycerides (TG)
  • May also normalize ovulatory abnormalities in patients w/ polycystic ovarian syndrome (PCOS)
• Contraindicated in patients w/ moderate to severe renal insufficiency
• Should not be given to patient w/ ketosis because it may precipitate lactic acidosis
  • May be started once the child recovers from ketosis after treatment by rehydration & w/ Insulin
• Insulin should be added whenever glucose control cannot be achieved after 3-6 months of Metformin therapy

Diabetes Management Education

• Healthcare providers expert in childhood diabetes mellitus (DM) should educate the patient & family about DM
  • An individualized Diabetes Medical Management Plan (DMMP) should be developed by the healthcare provider for the parent/guardian’s, child’s, & school staff’s use during school days
• Education should be personalized to the needs of the patient & the family, culturally sensitive & paced to accommodate individual needs
  • For infants & toddlers, parents must assume the responsibility of daily management
    • Severe hypoglycemia w/ seizures or coma are highest in infants
    • Measurement of blood glucose must be done first before ignoring a temper tantrum
  • For preschooler patients, education should be directed towards the parents & caregivers
  • For school-aged patients, education should still be directed towards parents & may include patient
    • School-aged patients can begin to assume some of the daily management tasks & those listed in the DMMP
  • For adolescent patients, education should be directed to the patient w/ the parents
• The family must learn the “basics”
  • Monitor the child’s blood glucose & urine ketones
  • Prepare & inject the correct Insulin dose subcutaneous (SC) at the proper time
  • Recognize & treat low blood glucose reactions
  • Have basic meal plan
• The behavior of the family towards diet is an important factor to help w/ child obesity
  • The following should be avoided:
    • Eating-out
    • Skipping breakfast
    • Preparing sumptuous meals
    • Serving large meal portions
• Written materials covering these basic topics help the family during the first few days
• They should receive ongoing education regarding the prevention of complications of diabetes
• Inform the patient & their family about the general health problems & complications of smoking
  • Encourage children & adolescents to stay away from cigarette smoking
  • Offer smoking cessation counselling & treatment to patients who already learned to smoke
• Diabetes management education is associated w/ improved patient knowledge on DM, improved self-care behavior, improved clinical outcomes like lower glycosylated hemoglobin (HbA_1c) & improved quality of life

Monitoring of Blood Glucose

• Recommended in most patients w/ DM & is associated w/ improved HbA_1c, ease of medication adjustment, avoidance of hypoglycemia & increased lifestyle flexibility
• Benefits will be increased when patients adjust dietary choices, medication & activity in response to blood glucose levels
• Calibration & control solution need to be used on a regular basis based on manufacturer’s recommendations
• Patients should be aware if value given by glucometer is based on whole blood glucose or calibrated to plasma glucose
  • Plasma glucose is the level measured by most labs
• Patients need to be instructed on how to use the data to modify nutrition, exercise & pharmacotherapy, & maintain glycemic control
  • Healthcare provider should monitor patient’s technique
• Monitoring of blood glucose should be done more often when modifying therapy
• Testing may be needed 6-8x/day; should be individualized based on patient’s glycemic status
• Daily fasting blood glucose measure is recommended for patients on long-acting Insulin therapy
• Blood glucose monitoring may be done using 2 techniques: self-monitoring blood glucose (SMBG) or HbA_1C

Self-monitoring blood glucose (SMBG)

• Recommended timing for SMBG in patients on multiple dose Insulin (MDI) or Insulin pump therapy
  • Prior to meals/snacks
  • Pre-exercise or physical activity
  • Before bedtime
  • When hypoglycemia is suspected
  • After administration of anti-hypoglycemic agents
  • Prior to participating in critical activities
• For non-Insulin-treated patients, studies show that SMBG is helpful in HbA_1C lowering w/in 6 months duration

Continuous glucose monitoring (CGM)

• May be helpful in pediatric patients treated w/ intensive Insulin regimen together w/ SMBG
• The real-time sensor alarms in CGM devices are helpful tools in monitoring hypo/hyperglycemia
  • Studies have shown a decrease in HbA_1c for patients frequently using the device
  • Should be offered to patients w/ type 1 DM w/ frequent severe hypoglycemia, impaired hypoglycemia awareness w/ complications (seizures, anxiety), those unable to recognize or communicate about hypoglycemia symptoms, neonates/infants/pre-schoolers, & children participating in high-level physical activities

Diabetes Medical Management Plan (DMMP)

• An individualized management plan for children that can be used during school days & school activities
• Both the student & the school staff should be informed & instructed about a child’s DMMP
• Includes instructions for the following:
  • Blood glucose monitoring
  • Insulin administration
  • Meals & snacks
  • Hypoglycemia & hyperglycemia (symptoms & treatment)
  • Abnormal glucose & ketone levels (checking & appropriate actions)
  • Physical activity
  • Emergency situations & emergency contact list
• Parents should provide the school w/ materials & medications to be used for the DMMP

Medical Nutrition Therapy (MNT)

• Integral component of DM prevention & management
• MNT should be provided at diagnosis & annually thereafter, by an individual experienced w/ the nutritional needs of the growing child & the behavioral issues that have an impact on adolescent diets
• Consult w/ a dietitian experienced in pediatrics & DM to discuss MNT
• Base MNT on recommended dietary intakes appropriate for age, gender, physical activity & growth rate. See Growth Charts in MIMS Pediatrics
  • Conduct a complete medical exam prior to prescribing any low-calorie diet
  • Evaluate height, weight, body mass index (BMI) & MNT plan annually
• Individualize MNT according to food preferences, cultural influences, physical activity patterns, family eating patterns, etc
• Calorie intake of overweight/obese patients should be based on patient’s energy requirements by direct measurement thought indirect calorimetry
• MNT alone or in combination w/ appropriate Insulin therapy averts or relieves symptoms of hyperglycemia in patients w/ diabetes
• Nutritional practices may influence the development of long-term complications of diabetes
• General goals of MNT
  • Attain optimal metabolic outcomes
    • Blood glucose levels in normal range, lipid profile, HbA_1c <7% & blood pressure (BP) which reduces risk of vascular disease
    • Prevent & treat diabetic comorbidities [eg obesity, cardiovascular (CV) disease, hypertension, dyslipidemia, etc]
  • Improve overall health
• MNT goals in Type 1 DM
  • Provide enough energy for growth & development in young DM patients
  • Insulin needs to be integrated into the meal routine & to be based on food choices
  • Patient should be taught flexibility of Insulin dosing & timing
• MNT goals in Type 2 DM
  • Decrease energy intake & increase expenditure of energy as most Type 2 DM patients are overweight/obese
    • A macronutrient diet of ≥900-≤1,200 kcal/day is recommended for children 6-12 years of age
    • ≥1,200 kcal/day for patients ages 13-18 may help improve weight & body composition
  • Reduce Insulin resistance & improve metabolic status especially in young DM patients
  • For overweight/obese youth w/ Type 2 DM, assist w/ appropriate changes of physical activity & eating habits
    • Increased fruits & vegetable in a child’s diet may help decrease risk for obesity; dairy & calcium-rich should is essential & should be included in their diet
    • High-calorie containing beverages & fatty foods should be monitored & restricted in overweight pediatric patients
    • Short-term restriction of high-carbohydrate diet (up to 20-60 grams) may help w/ weight management

Physical Activity

An exercise program that suits individual’s age, fitness, aptitude & interest should be prescribed

• Regular exercise has been shown to improve blood glucose control, reduce CV risk factors, contribute to wt loss & improve well-being
• Pre-exercise evaluation should be done to identify diabetic complications, macrovascular, microvascular & neurological conditions
• A minimum of 60 minutes of moderate-to-vigorous physical activity daily is recommended
• Type 1 DM
  • Hypoglycemic reaction may occur during or w/in hours after exercise
  • Monitor blood glucose before exercise
    • Intake of 15 g of carbohydrate is suggested, less in younger children, for a blood glucose level below target range before exercise
    • Additional 15 g of carbohydrate may be necessary for vigorous physical activity >30 minutes
  • Monitor blood glucose hourly during prolonged vigorous exercise
  • Monitor blood glucose after exercise for carbohydrate intake & prospective insulin dose adjustment
  • Monitor blood glucose before, during & after subscribing to new sports or physical activities

• Type 2 DM
  • Long-term exercise has proven to help prevent & treat type 2 DM
  • Moderate physical activity (eg walking) of at least 150 minutes/week may help prevent or delay type 2 DM
  • At least 60 minutes/day of moderate to strenuous exercise is recommended to reduce BMI & improve glycemic control
  • Exercise has been shown to decrease peripheral insulin resistance
  • Decrease screen time (watching tv, playing video games, computer use) to a maximum of 2 hours/day