This document discusses the challenges of managing type 1 diabetes in young children. It notes the increasing incidence of type 1 diabetes, especially in younger age groups. Managing diabetes in young children is difficult due to their unpredictable eating and activity patterns, periods of rapid growth, and susceptibility to illness. It discusses strategies for insulin management during these unpredictable periods as well as the evolving understanding children have of their diabetes over time and the importance of providing age-appropriate experiences for development.

1. Diabetes Management In Early
Childhood
Chasing a Moving Target
Deborah Holtorf, MPH, MSN, NP
March 9, 2013
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2. Type 1 Diabetes in Young Children
Epidemiological Trends
 Type 1 diabetes has increased in incidence and
prevalence during the late 20th and early 21st centuries.
 During this time period there has been a shift towards a
younger age of onset.
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3. Type 1 Diabetes in Young Children
Epidemiological Trends
SEARCH for Diabetes in Youth Study
JAMA 2007;297:2716-2724
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4. Type 1 Diabetes in Young Children
Epidemiological Trends
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5. EURODIAB ACE study group
Lancet 2000;355:873-876
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Age (yrs)
Increased
Incidence %
0-4 6.3
5-9 3.1
10-14 2.4

6. Type 1 Diabetes
Goals of Therapy (ADA)
Plasma blood glucose range (mg/dl)
Values by age before meals bedtime A1c
Toddler/preschooler 100-180 110-200 <8.5 but >
7.5%
(<6 yrs)
School age (6-12 yrs) 90-180 100-180 <8%
Adolescents 90-130 90-150 <7.5%*
Key concepts in setting glycemic goals:
 Goals should be individualized and lower goals may be
reasonable based on benefit-risk assessment.
 Goals should be higher than those listed above in children with
frequent hypoglycemia or hypoglycemic unawareness.
 Postprandial blood glucose should be measured when there is a
disparity between pre-prandial values and A1c levels.
*A lower goal (<7%) is reasonable if it can be achieved without
excessive hypoglycemia.

7. Type 1 Diabetes
Guidelines of Therapy (ISPAD)
 ISPAD (International Society for Pediatric and Adolescent
Diabetes) recommends A1C less than 7.5%, with
higher goals based on risk factors rather than age of
child.
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8. Challenges of Caring for Young Children
With Diabetes
 Unpredictable eating patterns
 Unpredictable activity patterns
 Hypoglycemic unawareness
 Periods of rapid growth
 Susceptibility to communicable illness
 Evolving understanding of what diabetes is and how it
impacts identity
 Need for age-appropriate developmental experiences
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9. Unpredictable Eating Patterns
Insulin
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10. Insulin Therapy – Human Insulin/Analogs
Insulin Preparation Onset Peak Duration
Very rapid-acting insulin analogs
Insulin lispro (Humalog) 5-15 min 30-90 min 3-5 h
Insulin aspart (Novolog) 5-15 min 30-90 min 3-5 h
Insulin glulisine (Apidra) 5-15 min 30-90 min` 3-5 h
Rapid-acting insulin
Regular 30-60 min 2-3 h 5-8 h
Intermediate-acting insulin
NPH 2-4 h 4-10 h 10-16 h
Long-acting insulin
Insulin glargine (Lantus) 2-4 h “peakless” 23-25 h
Insulin detimir (Levemir) 2-4 h “peakless” 16-20 h

11. Unpredictable Eating Pattern
Insulin Plans
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 Basal/bolus by multiple injections
 Insulin pump therapy
 Insulin plans that include NPH

12. Unpredictable Eating Pattern
Insulin Plans – Insulin Pumps
 An insulin pump has the potential to provide:
 Insulin delivery that more closely resembles physiologic
insulin production.
 Flexibility in timing and amount of food eaten, exercise, and
sleep patterns.
 Short term dosing modifications to address unexpected
activity, illness, and travel.
 Fewer “shots”.

13. Unpredictable Eating Pattern
Insulin Plans
Insulin Pumps
 A pump is not “smart”. It requires accurate and regular
information from the user, including blood glucose
data, grams of carbohydrate to be eaten, need for
modified bolus patterns, and temporary basal rate
adjustments.
 A pump uses only rapid-acting insulin to meet all insulin
needs. If insulin is not being delivered due to a pump or
infusion set failure, ketones will be produced. If this
situation is not addressed appropriately, the rise in
ketones will lead to ketoacidosis.
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14. Unpredictable Activity Patterns
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15. Unpredictable Activity Patterns
Hypoglycemia
 Hypoglycemia is the main risk factor when children
are active
 Insulin cannot be turned off or limited once it is
delivered
 Young children are unaware of symptoms of
hypoglycemia, and older children miss symptoms
when focused on activity
 Young children are less likely to experience a blood
glucose raising adrenaline response during
vigorous activity

16. Unpredictable Activity Patterns
Hypoglycemia
 Too little carbohydrate to sustain prolonged activity
 Too much insulin available or “on board”
 Unplanned activity
 Swimming and sledding

17. Unpredictable Activity Patterns
Hyperglycemia
 Too little insulin before during, and/or after exercise
 Too much carbohydrate consumed before or during
exercise
 Unplanned naps
 Rainy days

18. Unpredictable Activity Patterns
Tools
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19. Unpredictable Insulin Patterns
Insulin Management
 Program a temporary basal rate 10-30% less than usual
rate, 30-90 minutes before, during, and /or 30-90 minutes
after activity
 Correct elevated blood glucose to a higher target (180-200
mg/dL) prior to exercise
 Modify insulin-to-carbohydrate ratio for meal or snack
before exercise
 Disconnect insulin pump for a maximum of 1-2
hours, giving 50% of anticipated missed insulin as bolus
before disconnection
 Consider untethered approach to pump management if
activity requires pump to be disconnected for more than 1-
2 hours during a 24-hour period
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20. Unpredictable Exercise Patterns
Carbohydrate Adjustment
 Estimate 5-15 grams of extra carbohydrate for
every 30 minutes of vigorous activity depending on
body weight and intensity of activity
 Add fat and protein to help carbohydrate last longer
during activity
 Decrease carbohydrate and fat content of meals and
snacks on low activity days if child is not underweight

21. Hypoglycemic Unawareness

22. Hypoglycemic Unawareness
 Increase blood glucose monitoring during and after
activity
 Increase blood glucose monitoring during episodes of
illness
 Consider use of continuous glucose monitoring device in
consultation with diabetes care providers

23. Periods of Rapid Growth

24. Periods of Rapid Growth
 Adequate insulin is needed to utilize carbohydrate for
growth. Children with diabetes who do not get enough
insulin will grow and gain more slowly than would be
predicted by their genetics.
 Children who have frequent episodes of low blood sugar
and/or whose caretakers are unusually frightened by
hypoglycemia may gain excess weight
 Hormones that accompany rapid growth cause increased
insulin resistance
 Growth hormone is usually active during periods of deep
sleep causing a young child to have different daily
patterns of insulin need than an older child has

25. Susceptibility to Communicable Illness
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26. Susceptibility to Communicable Illness
 Children’s day to day activities bring them into contact
with a variety of viral and bacterial illnesses
 Even mild viruses such as colds can increase insulin
requirements
 Gastrointestinal illnesses with vomiting and diarrhea can
result in poor absorption of carbohydrate and
dehydration causing blood glucose to fall and ketones to
rise.
 Management of “sick days” requires frequent blood
glucose and ketone monitoring, assessment of fluid and
carbohydrate intake, and regular contact the child’s
diabetes team as needed.
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27. Susceptibility to Communicable Illness
 Be sure you have a copy of and understand your
diabetes team’s sick day protocol.
 Check your supply and the expiration date of ketone
strips regularly.
 Use blood ketone strips for assessing ketones on sick
days if possible.
 Discuss when use of “mini-glucagon” injections might be
use with your diabetes team.
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28. Evolving understanding of what diabetes is
and how it impacts identity
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29. Evolving understanding of what diabetes is
and how it impacts identity
 Infant/toddler: 0-36 months
 Developing understanding of words and routines
 Reflects caretakers’ emotions and expressions
 Begins to recognized difference between self and others,
but does not make any meaning of distinction.
 Usually incorporates diabetes management tasks into daily
routine after initial objections.
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30. Evolving understanding of what diabetes is
and how it impacts identity
 Preschool: (3-5 years)
 Magical thinking
 Explores ways of gaining attention including physical
complaint
 Begins to experience feelings of guilt – diabetes as
punishment or somehow caused by thoughts
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31. Evolving understanding of what diabetes is
and how it impacts identity
 School age: (6-8 years)
 Continued magical thinking
 Beginning awareness of own appearance and abilities vs.
peers
 Understanding of contagion may generalize to non-
contagious conditions
 View of self based on approval/disapproval of important
others
 May begin to avoid peer who is perceived as different
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32.  School age (8-10 years)
 Diminished magical thinking
 Identity defined in comparison to others
 Increased awareness of peers’ academic and athletic
abilities
 Adheres to rigid group norms – abled child may abandon
friend perceived as disabled
 Increased responsibility for health habits
 May use health issue to avoid new challenges.
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Evolving understanding of what diabetes is
and how it impacts identity

33. Need for Age-Appropriate Developmental
Experiences
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34. Need for Age Appropriate Developmental
Experiences
 Play groups
 Preschool
 Kindergarten and elementary school
 Physical activity
 Diabetes camps
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