Variability of insulin requirements depending on age: younger patients with type 1 diabetes may require extra monitoring to avoid adverse glycemic events.
Type 1 diabetes is typically a congenital disease that requires supplementation with exogenous insulins to maintain adequate glycemic homeostasis. It is known that total daily insulin requirements differ between children and adults, but precise insulin variability between adolescents of different ages has not previously been studied. These days, the process of insulin delivery has become almost completely autonomous through the use of pumps, continuous blood glucose monitors, and Bluetooth connectivity. These technological advancements have led researchers to wonder if glycemia should be more closely monitored in younger adolescents to prevent serious hypo- or hyperglycemic events.
A recent multinational randomized retrospective study published in the Diabetes Care journal aimed to determine the variability of insulin requirements in patients with type 1 diabetes of differing ages. A total of 114 patients with type 1 diabetes receiving insulin pump therapy were enrolled into this study; participants were split into a total of 4 categorical age groups (ages 1-6, 7-12, 13-17, and >18). Children aged 7 and older had estimated relatively higher baseline HbA1c levels than those of younger participants (7.3% vs 8.4%, 8.2%, and 8.4%, respectively). Also, young children aged between 1 and 6 years old had higher daily insulin requirements than those of children aged 7 and older.
Daily insulin needs were recorded over the course of three weeks and reported in two separate time groups: nightly between 12:00 and 5:59 a.m. and daily between 6:00 a.m. and 11:59 p.m. The greatest variation of insulin needs were observed in young children aged 1-6 during both night and day times with greater variation occurring in the night. There were significant absolute differences in nightly insulin needs between young children aged 1-6, adolescents aged 13-17, and adults aged 18 or older (difference of 10.2% and 10.7% variation, respectively). Daytime insulin needs showed similar trends to a lesser degree; young children aged 1-6 had a 6.4% higher variation in daytime insulin needs than adolescents aged 13-17 and a 7.0% higher variation in daytime insulin needs than adults aged 18 or older. There were no significant variations in either night time or day time insulin needs between young children aged 1-6 and children aged 7-12. Variability was also significant amongst different sexes; males had 11.5% increased variability in nighttime insulin needs but not daytime needs.
Results from this study demonstrate that young children with type 1 diabetes may require extra consideration when basing insulin therapies on trends in continuous monitoring logs. Insulin pumps are capable of administering constant amounts of insulin throughout the day. This method of administration might not be too practical in young children, considering the results of this study. Larger than normal insulin doses could result in pediatric hypoglycemia, increasing risks of hospitalization. A broad range of study participants were included in this study leading to the presumed generalizability of trial results.
Younger patients with type 1 diabetes may require extra counseling from providers on the importance of titrating insulin doses to specific glycemic targets. Larger frequencies of night time hypoglycemic episodes may occur with larger than normal insulin doses. Younger patients with type 1 diabetes may require extra monitoring and observation from parents and caretakers as they may be unable to verbally express hypoglycemic symptoms. As age increases, smaller variations in insulin requirements manifest and adolescents may be able to self-manage their condition without worry.
- Younger children have increased total daily insulin needs compared to older children and adults.
- Young children aged 1-6 have more variable daily insulin needs than adolescents aged 13-17 and adults aged >18.
- Providers should counsel patients and caregivers of young children with diabetes about the variable insulin requirements.
Dovc K, Boughton C, Tauschmann, et al. Young children have higher variability of insulin requirements: observations during hybrid closed-loop insulin delivery. Diabetes Care 2019; 42(6):[Epub ahead of print]. DOI: 10.2337/dc18-2625
Adam Chalela B.S., PharmD Candidate, USF College of Pharmacy Class of 2020