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Insulin Initiation in Children and Adolescents with T1D

Proper diabetes education at a young age can reduce amount of common errors…

The primary clinical objective to be achieved with insulin therapy initiation is the elimination of ketosis and hyperglycemic events with prevention of chronic problems. Insulin therapy is the primary management of type 1 diabetes, which should be intended at achieving good glycemic control, with the accomplishment of hemoglobin A1c <7.5%, pre-meal self-monitored blood glucose of 90–130 mg/dL, bedtime self-monitored blood glucose of 100–140 mg/dL, average blood glucose level of 120–160 mg/dL and no ketonuria.

Education plays a major role in controlling diabetes epidemic. Education should be implemented starting from diagnosis to insulin therapy. It is a difficult process, but it is best done by a multidisciplinary team qualified in pediatric diabetes. Two classes of insulin are available for use in type 1 diabetics utilizing bolus/prandial insulins and basal insulins. Insulin glargine and glulisine can be utilized in children older than 6 years, lispro in children older than 3 years and detemir and aspart in children older than 2 years. Degludec insulin is currently not approved for pediatric usage. The start of insulin therapy should consist of ≥2 daily bolus and ≥1 basal insulin injections.

Mutual errors in insulin therapy include inappropriate administration (technique, site and rotation), extreme self-titration, improper mixing, insulin syringe (insulin vial mismatch), and sliding scale. Reaching adult targets for glycemic control is not always specified and may be dangerous for some children, and reaching targets may need much effort from the family and care team to get the correct insulin system. The American Diabetes Association guidelines recommend HbA1c targets of <8.0% for children

In summary, type 1 diabetes needs insulin for management and it requires a multidisciplinary team work with education forming the foundation of management.

Practical Pearls:

  • To achieve the proper glycemic goal in pediatrics, a multidisciplinary team work is required.
  • Adolescents should target pediatric glucose levels and not adults levels to increase better glycemic control.
  • Children less the age of 6 should target an A1c of less than 8.0%.

Wangnoo SK. “Initiating insulin therapy in children and adolescents with type 1 diabetes mellitus.” Indian J Endocrinol Metab. 2015;19(Suppl 1):S68-70.