Approach Considerations
All children with type 1 diabetes mellitus require insulin therapy. The following are also required in treatment:
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Blood glucose testing strips
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Urine ketone testing tablets or strips
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Blood ketone testing strips
Strategies to help patients and their parents achieve the best possible glycemic management are crucial. A 2-year randomized clinical trial found that a practical, low-intensity behavioral intervention delivered during routine care improved glycemic outcomes. [54]
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. [5, 55]
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.
Early probiotic use and islet autoimmunity in infants predisposed to DM1
Data from the multinational Environmental Determinants of Diabetes in the Young (TEDDY) study suggest that probiotic supplementation before the age of 3 months in infants with type 1 diabetes (DM1)–associated HLA-DR-DQ alleles is linked to a reduction in the risk of developing pancreatic beta-cell islet autoimmunity as compared with infants older than 3 months who received probiotics or those not given any probiotics (hazard ratio [HR], 0.62; 95% confidence interval, 0.45-0.84; P =0.0018). [56, 57] The association was particularly strong in infants younger than 1 month who received probiotic supplementation relative to those given probiotics when older than 12 months or not at all (HR, 0.63; P =0.022). [57]
Results from 7468 infants in the ongoing prospective birth-cohort study varied across countries: Of 575 infants (7.7%) with islet-cell autoimmunity, 9.1% were from Germany, 8.7% from Finland, 8.6% from Sweden, and 6.3% from the United States. [57] Testing included detection of the islet autoantibodies GADA, IAA, or IA-2A at two consecutive visits. [56, 57] The HR ratios for the link between early probiotic use and islet-cell autoimmunity were 0.65 (P =0.37) for Germany, 0.72 (P =0.10) for Finland, 0.42 (P =0.0165) for Sweden, and 0.62 (P =0.50) for the United States. [56]
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) [58] :
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Carbohydrates - Should provide 50-55% of daily energy intake; no more than 10% of carbohydrates should be from sucrose or other refined carbohydrates
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Fat - Should provide 30-35% of daily energy intake
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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.
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. [59] 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.
Long-Term Monitoring
Regular outpatient review with a specialized diabetes team improves short- and long-term outcomes. [60] 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. [61, 62]
Conduct a structured examination and review at least once annually to examine the patient for possible complications. Examination and review should include the following:
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Growth assessment
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Injection site examination
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Examination of the hands, feet, and peripheral pulses for signs of limited joint mobility, peripheral neuropathy, and vascular disease
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Evaluation for signs of associated autoimmune disease
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Blood pressure
In individuals aged 11 years or older, further examination should include the following:
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Retinoscopy or other retinal screening, such as photography
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Urine examination for microalbuminuria
Continuous Glucose Monitoring
The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 recommend consideration of continuous glucose monitoring for children and adolescents with type 1 diabetes, whether they are using injections or continuous subcutaneous insulin infusion, to aid in glycemic control. [63]
Continuous glucose monitors (CGMs) contain subcutaneous sensors that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pagerlike device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia.
CGMs have several drawbacks. First, there is a lag between glucose levels in the interstitial space and levels in capillary blood, so that the levels recorded by the CGM may differ from a fingerstick (capillary) glucose reading. For that reason, the trends (ie, whether the glucose levels are rising or falling) tend to be more helpful.
Second, patients may overtreat hyperglycemia (repeatedly giving insulin because the glucose levels do not fall rapidly enough—a phenomenon known as stacking), as well as overtreat low glucose levels (because the glucose levels rise slowly with ingestion of carbohydrate).
Use of CGMs may help to prevent significant glucose variability in patients receiving either multiple daily injection therapy or continuous insulin infusion therapy. [64, 65] Additionally, continuous glucose monitoring is associated with reduced time spent in hypoglycemia. [66] Whether glucose variability is detrimental in the absence of hypoglycemia remains an unresolved question; in any event, variability leads to the expense of frequent testing.
Artificial Pancreas
Closed-loop systems, also known as artificial pancreases, are in development for use in improving glycemic control in type 1 diabetes. These systems include a CGM that is in constant communication with an infusion pump, with a blood glucose device (eg, a glucose meter) utilized for CGM calibration. An external processor, such as a cell phone, runs control algorithm software, receiving data from the CGM. The data is used to perform a series of calculations, producing dosing instructions that are sent to the infusion pump. [67]
In September 2016, the US Food and Drug Administration (FDA) approved the first artificial pancreas, Medtronic's MiniMed 670G, for persons aged 14 years or older with type 1 diabetes. A hybrid closed-loop system, it still requires patients to determine the number of carbohydrates in their food and input that data into the system, manually requesting the insulin dose needed for meals. [68] In June 2018, the FDA extended the MiniMed 670G’s approval to children aged 7-13 years with type 1 diabetes. [69]
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Possible mechanism for development of type 1 diabetes.
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The effects of insulin deficiency.
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Representation of activity profile of some available insulins.
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Some of the available insulin injection devices.
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A selection of available insulin pumps.
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Some of the available blood glucose monitors.
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Diabetes Sick Day Rules.
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Taking Diabetes Back to School.
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Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
