Management of DM1 in children requires a comprehensive approach with attention to medical, nutritional, and psychosocial issues. Therapeutic strategies should be flexible with the individual needs of each patient and the family taken into account. Optimal care involves a team of diabetes professionals, including a physician, a diabetes nurse educator, a dietitian, and a social worker or psychologist.
The Diabetes Control and Complications Trial established that intensive insulin therapy, with the goal of maintaining blood glucose concentrations as close to normal as possible, can delay the onset and slow the progression of complications of diabetes (retinopathy, nephropathy, neuropathy). Attaining this goal using intensive insulin therapy can increase the risk of hypoglycemia. The adverse effects of hypoglycemia in young children may be significant because the immature CNS may be more susceptible to glycopenia. Although the risk for diabetic complications increases with duration of diabetes, there is controversy as to whether the increase of risk is slower in the prepubertal years than in adolescence and adulthood.
The goals of therapy differ, depending on the age of thepatient. For children younger than 5 years old, an appropriate goal is maintenance of blood glucose concentrationsbetween 80 and 180 mg/dL. For school-age children, 80 to 150 mg/dL is a reasonable target range. For adolescents, thegoal is 70 to 130 mg/dL. Goals of therapy also should takeinto account other individual characteristics, such as a pasthistory of severe hypoglycemia and the abilities of the patientand family.
Many types of insulin differ in duration of action and time to peak effect (Table 171-2). These insulins can be used in various combinations, depending on the needs and goals of the individual patient. The most commonly used regimen is that of multiple injections of fast-acting insulin given with meals in combination with long-acting basal insulin given at bedtime. This regimen provides flexibility but requires administration of many injections per day and will require assistance for young children. After the total daily dose of insulin is determined, 30% to 50% are given as long-acting insulin, and the remainder is given as fast-acting insulin, divided according to the need for corrections of high glucose levels and for meals. To correct for hyperglycemia, one can determine the insulin sensitivity using the 1800 rule; dividing 1800 by the total daily dose of insulin to determine how many milligrams per deciliter of glucose will decrease with one unit of insulin. The insulin:carbohydrate ratio is used to calculate insulin for the carbohydrate content of food; 450 divided by the total daily dose determines the number of grams of carbohydrate that requires one unit of insulin.
Pumps that provide a continuous SC infusion of short-acting insulin also are available and are being used by children and adolescents who are highly motivated to achieve tight control.
Lispro, aspart, and glulisine insulin are synthetic human insulin analogs in which amino acid alterations result in fast absorption and onset of action (see Table 171-2). Because of the short duration of action, these are used in combination with long-acting insulin. Glargine and detemir are insulin analogs with increased solubility at acidic pH and decreased solubility at physiologic pH. They have a duration of greater than 24 hours and act as a basal insulin.
Newly diagnosed patients in the honeymoon period may require 0.4 to 0.6 U/kg/24 hours. Prepubertal patients with diabetes longer than 1 to 2 years typically require 0.5 to 1 U/kg/24 hours. During middle adolescence when elevated GH concentrations produce relative insulin resistance, insulin requirements increase by 40% to 50%, and doses of 1 to 2 U/kg/24 hours are typical.