Pediatric Type 1 Diabetes Mellitus Treatment & Management

  • Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Stephen Kemp, MD, PhD   more...
 
Updated: Oct 4, 2011
 

Approach Considerations

All children with type 1 diabetes mellitus require insulin therapy. The following are also required in treatment:

  • Blood glucose testing strips
  • Urine ketone testing tablets or strips
  • Blood ketone testing strips

A well-organized diabetes care team can provide all necessary instruction and support in an outpatient setting. The only immediate requirement is to train the child or family to check blood glucose levels, to administer insulin injections, and to recognize and treat hypoglycemia. The patient and/or family should have 24-hour access to advice and know how to contact the team. Children should wear some form of medical identification, such as a medic alert bracelet or necklace.[37, 38]

Awareness of hypoglycemia becomes impaired over time, and severe hypoglycemia can occur without warning. Hypoglycemia is more likely to affect people who maintain low blood sugar levels and who already suffer frequent hypoglycemic attacks. Overzealous or inadequate treatment of hypoglycemia can lead to serious consequences.

Failure to regularly examine for diabetic complications in patients with type 1 diabetes mellitus, especially renal and ophthalmic ones, can be detrimental.

Inpatient care

Where a diabetes care team is available, admission is usually required only for children with DKA. In addition, children with significant dehydration, persistent vomiting, metabolic derangement, or serious intercurrent illness require inpatient management and intravenous rehydration.

Diabetes in pregnancy

Pregnancies should be planned and carefully managed to achieve healthy outcomes for mother and infant. Preconceptual normalization of blood sugars and folic acid supplements (at least 5 mg/d) reduce the otherwise increased risk of congenital heart disease and neural tube defects. Blood sugar control during pregnancy must be strict to avoid hypoglycemia, which may damage the fetus, and persistent hyperglycemia, which leads to fetal gigantism, premature delivery, and increased infant morbidity and mortality. DKA during pregnancy may result in fetal death.

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Diet

Dietary management is an essential component of diabetes care. Diabetes is an energy metabolism disorder, and consequently, before insulin was discovered, children with diabetes were kept alive by a diet severely restricted in carbohydrate and energy intake. These measures led to a long tradition of strict carbohydrate control and unbalanced diets. Current dietary management of diabetes emphasizes a healthy, balanced diet that is high in carbohydrates and fiber and low in fat.

The following are among the most recent dietary consensus recommendations (although they should be viewed in the context of the patient’s culture)[39] :

  • Carbohydrates - Should provide 50-55% of daily energy intake; no more than 10% of carbohydrates should be from sucrose or other refined carbohydrates
  • Fat - Should provide 30-35% of daily energy intake
  • Protein - Should provide 10-15% of daily energy intake

The aim of dietary management is to balance the child's food intake with insulin dose and activity and to keep blood glucose concentrations as close as possible to reference ranges, avoiding extremes of hyperglycemia and hypoglycemia.

The ability to estimate the carbohydrate content of food (carbohydrate counting) is particularly useful for children who receive fast-acting insulin at mealtimes either by injection or insulin pump, as it allows for a more precise matching of food and insulin. Adequate intake of complex carbohydrates (eg, cereals) is important before bedtime to avoid nocturnal hypoglycemia, especially for children getting twice-daily injections of mixed insulin.

The dietitian should develop a diet plan for each child to suit individual needs and circumstances. Regularly review and adjust the plan to accommodate the patient's growth and lifestyle changes.

Low-carbohydrate diets as a management option for diabetes control have regained popularity. Logic dictates that the lower the carbohydrate intake, the less insulin is required. No trials of low-carbohydrate diets in children with type 1 diabetes mellitus have been reported, and such diets cannot be recommended at the present.

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Activity

Type 1 diabetes mellitus requires no restrictions on activity; exercise has real benefits for a child with diabetes. Current guidelines are increasingly sophisticated and allow children to compete at the highest levels in sports.[40] Moreover, most children can adjust their insulin dosage and diet to cope with all forms of exercise.

Children and their caretakers must be able to recognize and treat symptoms of hypoglycemia. Hypoglycemia following exercise is most likely after prolonged exercise involving the legs, such as walking, running or cycling. It may occur many hours after exercise has finished and even affect insulin requirements the following day. A large, presleep snack is advisable following intensive exercise.

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Long-Term Monitoring

Regular outpatient review with a specialized diabetes team improves short- and long-term outcomes.[45] Most teams have a nurse specialist or educator, a dietitian, and a pediatrician with training in diabetes care. Other members can include a psychologist, a social worker, and an exercise specialist. Involvement with the team is intense over the first few weeks after diagnosis while family members learn about diabetes management.[46, 47]

Conduct a structured examination and review at least once annually to examine the patient for possible complications. Examination and review should include the following:

  • Growth assessment
  • Injection site examination
  • Examination of the hands, feet, and peripheral pulses for signs of limited joint mobility, peripheral neuropathy, and vascular disease
  • Evaluation for signs of associated autoimmune disease
  • Blood pressure

In individuals aged 11 years or older, further examination should include the following:

  • Retinoscopy or other retinal screening, such as photography
  • Urine examination for microalbuminuria
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Contributor Information and Disclosures
Author

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH  Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH is a member of the following medical societies: British Medical Association, British Society of Paediatric Endocrinology and Diabetes, International Society of Pediatric and Adolescent Diabetes, Royal College of Paediatrics and Child Health, and Royal College of Physicians

Disclosure: Roche Diabetes Care Honoraria Speaking and teaching

Specialty Editor Board

Arlan L Rosenbloom, MD  Adjunct Distinguished Service Professor Emeritus of Pediatrics, University of Florida College of Medicine; Fellow of the American Academy of Pediatrics; Fellow of the American College of Epidemiology

Arlan L Rosenbloom, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Epidemiology, American Pediatric Society, Endocrine Society, Florida Pediatric Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London)  Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

The author would like to thank Dr. Tim Cheetham and Dr. Debbie Matthews, Colleagues at the Royal Victoria Infirmary, Newcastle upon Tyne, for reading through the manuscript and for years of support.

References

  1. Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith GJ. Type 2 diabetes in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:17-32. [Medline].

  2. Porter JR, Barrett TG. Acquired non-type 1 diabetes in childhood: subtypes, diagnosis, and management. Arch Dis Child. Dec 2004;89(12):1138-44. [Medline]. [Full Text].

  3. Barrett TG. Differential diagnosis of type 1 diabetes: which genetic syndromes need to be considered?. Pediatr Diabetes. Oct 2007;8 Suppl 6:15-23. [Medline].

  4. Hattersley A, Bruining J, Shield J, Njolstad P, Donaghue KC. The diagnosis and management of monogenic diabetes in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:33-42. [Medline].

  5. Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:134-45. [Medline].

  6. Hershey T, Perantie DC, Warren SL, et al. Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes. Diabetes Care. Oct 2005;28(10):2372-7. [Medline]. [Full Text].

  7. Patiño-Fernández AM, Delamater AM, Applegate EB, et al. Neurocognitive functioning in preschool-age children with type 1 diabetes mellitus. Pediatr Diabetes. Sep 2010;11(6):424-30. [Medline]. [Full Text].

  8. d'Annunzio G, Malvezzi F, Vitali L, Barone C, Giacchero R, Klersy C, et al. A 3-19-year follow-up study on diabetic retinopathy in patients diagnosed in childhood and treated with conventional therapy. Diabet Med. Nov 1997;14(11):951-8. [Medline].

  9. Jones CA, Leese GP, Kerr S, et al. Development and progression of microalbuminuria in a clinic sample of patients with insulin dependent diabetes mellitus. Arch Dis Child. Jun 1998;78(6):518-23. [Medline]. [Full Text].

  10. Barkai L, Madacsy L. Cardiovascular autonomic dysfunction in diabetes mellitus. Arch Dis Child. Dec 1995;73(6):515-8. [Medline].

  11. Mohn A, Di Michele S, Di Luzio R, et al. The effect of subclinical hypothyroidism on metabolic control in children andadolescents with Type 1 diabetes mellitus. Diabet Med. Jan 2002;19(1):70-3. [Medline].

  12. Barera G, Bonfanti R, Viscardi M, et al. Occurrence of celiac disease after onset of type 1 diabetes: a 6-year prospectivelongitudinal study. Pediatrics. May 2002;109(5):833-8. [Medline]. [Full Text].

  13. Infante JR, Rosenbloom AL, Silverstein JH, et al. Changes in frequency and severity of limited joint mobility in children withtype 1 diabetes mellitus between 1976-78 and 1998. J Pediatr. Jan 2001;138(1):33-7. [Medline].

  14. Gloyn AL, Pearson ER, Antcliff JF, Proks P, Bruining GJ, Slingerland AS. Activating mutations in the gene encoding the ATP-sensitive potassium-channel subunit Kir6.2 and permanent neonatal diabetes. N Engl J Med. Apr 29 2004;350(18):1838-49. [Medline].

  15. Patterson CC, Carson DJ, Hadden DR. Epidemiology of childhood IDDM in Northern Ireland 1989-1994: low incidence in areas with highest population density and most household crowding. Northern Ireland Diabetes Study Group. Diabetologia. Sep 1996;39(9):1063-9. [Medline].

  16. Hyoty H, Hiltunen M, Knip M, et al. A prospective study of the role of coxsackie B and other enterovirus infections in the pathogenesis of IDDM. Childhood Diabetes in Finland (DiMe) Study Group. Diabetes. Jun 1995;44(6):652-7. [Medline].

  17. Mohr SB, Garland CF, Gorham ED, Garland FC. The association between ultraviolet B irradiance, vitamin D status and incidence rates of type 1 diabetes in 51 regions worldwide. Diabetologia. Aug 2008;51(8):1391-8. [Medline].

  18. Dabelea D, Bell RA, D'Agostino RB Jr, Imperatore G, Johansen JM. Incidence of diabetes in youth in the United States. JAMA. Jun 27 2007;297(24):2716-24. [Medline].

  19. Silink M. Childhood diabetes: a global perspective. Horm Res. 2002;57 Suppl 1:1-5. [Medline].

  20. Harjutsalo V, Forsblom C, Groop PH. Time trends in mortality in patients with type 1 diabetes: nationwide population based cohort study. BMJ. Sep 8 2011;343:d5364. [Medline]. [Full Text].

  21. Soltesz G, Patterson CC, Dahlquist G. Worldwide childhood type 1 diabetes incidence--what can we learn from epidemiology?. Pediatr Diabetes. Oct 2007;8 Suppl 6:6-14. [Medline].

  22. Craig ME, Hattersley A, Donaghue KC. Definition, epidemiology and classification of diabetes in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:3-12. [Medline].

  23. Felner EI, Klitz W, Ham M, Lazaro AM, Stastny P, Dupont B. Genetic interaction among three genomic regions creates distinct contributions to early- and late-onset type 1 diabetes mellitus. Pediatr Diabetes. Dec 2005;6(4):213-20. [Medline].

  24. DiLiberti JH, Lorenz RA. Long-term trends in childhood diabetes mortality: 1968-1998. Diabetes Care. Aug 2001;24(8):1348-52. [Medline].

  25. [Best Evidence] Dahlquist G, Kallen B. Mortality in childhood-onset type 1 diabetes: a population-based study. Diabetes Care. Oct 2005;28(10):2384-7. [Medline].

  26. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. Oct 1999;81(4):318-23. [Medline]. [Full Text].

  27. Koltin D, Daneman D. Dead-in-bed syndrome - a diabetes nightmare. Pediatr Diabetes. Oct 2008;9(5):504-7. [Medline].

  28. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. Sep 30 1993;329(14):977-86. [Medline].

  29. Gallego PH, Wiltshire E, Donaghue KC. Identifying children at particular risk of long-term diabetes complications. Pediatr Diabetes. Oct 2007;8 Suppl 6:40-8. [Medline].

  30. Donaghue KC, Chiarelli F, Trotta D, Allgrove J, Dahl-Jorgensen K. Microvascular and macrovascular complications associated with diabetes in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:195-203. [Medline].

  31. Kordonouri O, Maguire AM, Knip M, et al. Other complications and associated conditions with diabetes in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:204-10. [Medline].

  32. Swift PG. Diabetes education in children and adolescents. Pediatr Diabetes. Sep 2009;10 Suppl 12:51-7. [Medline].

  33. Brink S, Laffel L, Likitmaskul S, et al. Sick day management in children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:146-53. [Medline].

  34. CDC. National Diabetes Fact Sheet. United States. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf.

  35. [Best Evidence] [Guideline] International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. Diabetes Care. Jun 5 2009;[Medline].

  36. [Guideline] Mosca A, Goodall I, Hoshino T, et al. Global standardization of glycated hemoglobin measurement: the position of the IFCC Working Group. Clin Chem Lab Med. 2007;45(8):1077-80. [Medline].

  37. Clar C, Waugh N, Thomas S. Routine hospital admission versus out-patient or home care in children at diagnosisof type 1 diabetes mellitus. Cochrane Database Syst Rev. 2003;CD004099. [Medline].

  38. Pihoker C, Forsander G, Wolfsdorf J, Klingensmith GJ. The delivery of ambulatory diabetes care to children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:58-70. [Medline].

  39. Smart C, Aslander-van Vliet E, Waldron S. Nutritional management in children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:100-17. [Medline].

  40. Robertson K, Adolfsson P, Scheiner G, Hanas R, Riddell MC. Exercise in children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:154-68. [Medline].

  41. Feutren G, Papoz L, Assan R, et al. Cyclosporin increases the rate and length of remissions in insulin-dependent diabetes of recent onset. Results of a multicentre double-blind trial. Lancet. Jul 19 1986;2(8499):119-24. [Medline].

  42. Rewers M, Gottlieb P. Immunotherapy for the prevention and treatment of type 1 diabetes: human trials and a look into the future. Diabetes Care. Oct 2009;32(10):1769-82. [Medline].

  43. Bach JF. Anti-CD3 antibodies for type 1 diabetes: beyond expectations. Lancet. Aug 6 2011;378(9790):459-60. [Medline].

  44. Delamater AM. Psychological care of children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:175-84. [Medline].

  45. Kaufman FR, Halvorson M, Carpenter S. Association between diabetes control and visits to a multidisciplinary pediatric diabetes clinic. Pediatrics. May 1999;103(5 Pt 1):948-51. [Medline]. [Full Text].

  46. Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: a statement of the AmericanDiabetes Association. Diabetes Care. Jan 2005;28(1):186-212. [Medline]. [Full Text].

  47. Pihoker C, Forsander G, Wolfsdorf J, Klingensmith GJ. The delivery of ambulatory diabetes care: structures, processes, and outcomes of ambulatory diabetes care. Pediatr Diabetes. Dec 2008;9(6):609-20. [Medline].

  48. Bangstad HJ, Danne T, Deeb L, Jarosz-Chobot P, Urakami T, Hanas R. Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes. Sep 2009;10 Suppl 12:82-99. [Medline].

  49. Danne T, Deiss D, Hopfenmuller W, et al. Experience with insulin analogues in children. Horm Res. 2002;57 Suppl 1:46-53. [Medline].

  50. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients withdiabetes mellitus. Cochrane Database Syst Rev. 2004;CD003287. [Medline].

  51. FDA. Early Communication About Safety of Lantus (insulin Glargine). US Food and Drug Administration. Available at http://bit.ly/TtBNv. Accessed July 1, 2009.

  52. Willi SM, Planton J, Egede L, Schwarz S. Benefits of continuous subcutaneous insulin infusion in children with type1 diabetes. J Pediatr. Dec 2003;143(6):796-801. [Medline].

  53. Mortensen HB, Hougaard P. Comparison of metabolic control in a cross-sectional study of 2,873 children and adolescents with IDDM from 18 countries. The Hvidore Study Group on Childhood Diabetes [published erratum appears in Diabetes Care 1997 Jul;20(7):1216]. Diabetes Care. May 1997;20(5):714-20. [Medline].

  54. Danne T, Mortensen HB, Hougaard P, et al. Persistent differences among centers over 3 years in glycemic control and hypoglycemiain a study of 3,805 children and adolescents with type 1 diabetes from the Hvidøre Study Group. Diabetes Care. Aug 2001;24(8):1342-7. [Medline]. [Full Text].

 
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Possible mechanism for development of type 1 diabetes.
The effects of insulin deficiency.
Representation of activity profile of some available insulins.
Some of the available insulin injection devices.
A selection of available insulin pumps.
Some of the available blood glucose monitors.
Diabetes Sick Day Rules.
Taking Diabetes Back to School.
Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
 
 
 
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