DIABETES MANAGEMENT IN CHILDREN AND ADOLESCENTS

The overarching goal for treating and managing diabetes in children is centered around maintaining normal physical growth and positive psychosocial development by establishing good glycemic control and preventing acute and chronic complications as far as possible (ADA, 2017a).

Pharmacotherapy

Insulin therapy is the primary treatment for type 1 diabetes and also often implemented for type 2 diabetes. The discovery of insulin in 1921 was a turning point in the treatment of type 1 diabetes. Prior to the introduction of insulin therapy, the life expectancy of children with type 1 diabetes was around one year from the time of diagnosis (Tamborlane, 2021).

Insulin needs for children will fluctuate significantly as the child grows. When children are first diagnosed with type 1 diabetes, the most common treatment requirement is 0.5–0.8 units of insulin per kilogram of body weight per day. However, when the child with T1D enters puberty, the need for insulin therapy sharply increases to 1.0–1.5 units/kg/body weight daily. During growth spurts children may need two to three insulin dose adjustments on a weekly basis (ADA, 2017a).

Insulin pumps with continuous glucose monitoring are becoming more popular and work well for children. In toddlers and preschool-age children it has been shown that using an insulin pump delivers a more dependable dose of basal insulin (ADA, 2017a; ADA, 2020a). (See also “Monitoring Blood Glucose” below.)

For children with type 2 diabetes, treatment is frequently started with the oral anti-hyperglycemic medication Metformin. Presently Metformin is approved for children 10 years of age and older (ADA, 2017a). However, Metformin does not achieve therapeutic outcomes in many children with T2D, and these children need to start on insulin therapy soon after diagnosis (Curry, 2016).

Monitoring Blood Glucose

The recommendation for children with T1D is for blood glucose checks before meals and at bedtime. This necessitates that some blood glucose checks be done while the child is at school or for preschool-age children while at daycare (ADA, 2017b). Children with T2D will also require several blood glucose checks on a daily basis, especially if they start on insulin therapy (FDA, 2018).

Blood glucose monitoring for young children requires the use of fine-gauge lancets and adjustable ends on the lancing machine. Clinicians must teach parents and guardians of young children how to choose the superficial-depth setting on the lancet device, to use the side of the child’s fingers for testing, and to observe the sites for soreness and bruising (ADA, 2017a).

The ADA recommends continuous glucose monitoring (CGM) for children and youth with T1D, whether they are being managed by insulin injections or by continuous subcutaneous insulin infusion. CGM can be used for children as young as 2 years. Research has also shown that CGM improves the quality of life for adolescents with T1D and decreases levels of diabetes distress (ADA, 2020a; NIDDK, 2017; Spero, 2018).

While strong evidence exists for the use of CGM in those with T1D, less evidence exists for its use in T2D. However, the evidence available does demonstrate that CGM offers similar benefits to patients with T2D as to those with T1D (Lin et al., 2021).

A continuous glucose monitor will automatically screen blood glucose levels. The monitor may be a stand-alone device or part of an insulin pump. A small sensor is placed under the patient’s skin; typical sites are the belly or arm. The sensor measures the glucose in the interstitial fluid under the skin. A transmitter wirelessly relays that information to a monitor, and the monitor converts the reading to a blood glucose number. An alarm rings when the blood glucose levels are out of range.

Some monitors transmit information directly to a smartphone or tablet and to a second individual’s smartphone, such as a parent’s, if a child’s blood glucose levels move out-of-range. The sensor performs glucose testing every few minutes, making it possible for the patient or caretaker to see the blood glucose level at a glance, at any given time, including overnight. Apart from reducing the number of finger sticks, continuous glucose monitoring allows for more accurate decision-making regarding balancing food, exercise, and medications (Spero, 2018; NIDDK, 2017).

CGM requires a physician’s prescription. Most insurance plans cover the cost, but there may still be considerable copayments. Clinicians must oftentimes guide the patient to seek help through partnerships with patient advocates who speak to the insurance carrier on behalf of families.

Parents and caregivers must be made aware of the learning curve involved in switching to CGM from fingersticks, and the patient’s diabetes management team must assess the family’s willingness and motivation to invest the time and effort needed to successfully use CGM. Also, it is important for the clinician to inform parents and caregivers that fingersticks are still required to calibrate the device and to confirm an out-of-range glucose reading before instigating treatment.

To successfully use CGM, the clinician must ensure that the child and parents are trained on the following points:

• The low alerts on the CGM must be turned on.
• The alert onset must be set above the point where hypoglycemia develops.
• Every low alert signal must be addressed immediately and consistently.
  (Scheiner, 2020)

Preventing Hypoglycemia

Hypoglycemia is a common occurrence in type 1 diabetes; it can also occur in those with type 2 diabetes but usually to a lesser degree (Worldwide Diabetes, 2021). Hypoglycemia is a major concern for children with diabetes, especially hypoglycemia occurring during the night.

Accurately pinpointing the exact rate of occurrence of hypoglycemia is difficult since asymptomatic hypoglycemia frequently occurs in children with type 1 diabetes and is often not recognized. Studies have shown that severe hypoglycemia is much more likely to occur in younger children between the ages of 2–6 years as compared to those in the 18–26 age range (Tamborlane, 2021).

Symptoms of hypoglycemia include:

• Shakiness, which may manifest as slight shaking or trembling
• Sweating on the face and over the body, comparable to the sweating that occurs with exercising
• Feeling of hunger, often developing suddenly and felt more intensely the lower the blood glucose levels
• Fast heartbeat
• Inability to concentrate
• Dizziness or lightheadedness
• Irritability or moodiness
• Anxiety or nervousness
• Headache
• Paleness, clammy feeling
  (Mayo Clinic, 2019; Diabetes Care Community, 2021)

Preventing episodes of hypoglycemia is best achieved by monitoring blood glucose levels before meals and at bedtime.

Doing blood glucose checks before, during, and after exercise or sports indicates how these activities affect a child’s blood glucose levels and may indicate the need for a snack before or after exercise or playing sports. Changes in insulin dosing may also be required on days when the child is more active (Kelly & Gilliland, 2018).

The ADA cautions that when establishing individualized blood glucose ranges, attention must be given to the danger of hypoglycemia based on the age of the child. Children under the age of 6 are usually not able to identify hypoglycemia, express what they are feeling to others, or manage the condition themselves (ADA, 2020a).

The ADA points out that individualized A1C targets are attainable in children, even those under the age of 6, without amplifying the risk of severe hypoglycemia. The ADA advises lowering and maintaining blood sugar levels in children in a series of distinct stages (ADA, 2020a).

NOCTURNAL HYPOGLYCEMIA

Nocturnal hypoglycemia is frequent in children with diabetes, usually occurring in the earlier part of the night. It correlates with bedtime blood glucose values of <150 mg/dL (ADA, 2017a). For children with nocturnal hypoglycemia, middle-of-the-night blood glucose monitoring is advisable.

Testing at midnight and again at around 3 a.m. on a weekly basis can help parents recognize a pattern in their child’s nocturnal blood glucose levels and assess whether changes to a child’s diabetes management are successful or not. For instance, middle-of-the-night testing may indicate the need for a bedtime snack and whether such a snack was adequate or not (Kelly & Gilliland, 2018).

Parents are also encouraged to perform a middle-of-the-night blood glucose test after a child has participated in strenuous exercise or sporting activities because a child with diabetes can develop hypoglycemia several hours after the activity or exercise is over.

Young children are not always able to express in words what they are feeling, and a child refusing to sleep, showing signs of irritability, and/or crying may be experiencing hypoglycemia. Parents are instructed to perform a blood glucose check to determine if hypoglycemia is the cause of such behaviors (ADA, 2017a).

TREATING HYPOGLYCEMIA IN CHILDREN

Consuming Carbohydrates

Hypoglycemia in children is treated by consuming 15 grams of carbohydrates. Good sources for children are 4-ounce juice boxes, regular soda, nonfat milk, and raisins. Parents are instructed to wait for 15 minutes and then recheck the child’s blood sugar. If it is still low (<70 mg/dL), the child is treated with a second 15 grams of carbohydrates.

Foods containing fats, such as chocolate, should not be used to treat hypoglycemia, since the fat content can hinder the action of the carbohydrates and thus extend the acute hypoglycemic episode.

Glucagon Administration

Glucagon is a hormone produced by the alpha cells in the islets of Langerhans in the pancreas; it is also available as a medication to treat episodes of hypoglycemia. When administered, glucagon activates the release of glucose into the blood stream. It normally takes 10–15 minutes after the administration of glucagon for blood glucose to return to a safe level.

Glucagon is indicated when the individual is exhibiting signs and symptoms of hypoglycemia and cannot safely swallow food or fluids, is unconscious, or is having seizure activity (Children with Diabetes, 2021; NCH, 2020). Glucagon can be administered in the presence of nasal congestion or a cold, and it can be used in children ages 4 years and older.

Parents and caregivers of children ages with diabetes are instructed on when and how to administer glucagon for severe hypoglycemia. Traditional glucagon comes in a kit that includes a powder and a liquid that must be mixed together prior to injection. Glucagon shots can be administered in the upper arms, thighs, or buttocks. Glucagon is injected in the same way as insulin. Other forms of glucagon therapy have received FDA approval, including a premixed autoinjector and a nasal powder (Baqsimi), which can be administered even to a patient who is unconscious since it does not need to be actively inhaled but is absorbed through the nasal tissue (ADA, 2020a, 2017b; Pietrangelo, 2021; Werner, 2019; Children with Diabetes, 2021).

Precautions include:

• After administering Glucagon, do not leave the child alone. Call 911 for further assistance.
• Keep the child on their side since vomiting is a side-effect of glucagon administration. (Other side effects can include headache, flushing, and a rapid heartbeat.)
• Once the child is alert and can safely swallow, provide oral carbohydrates to treat hypoglycemia; this can be in the form of fruit juice or non-diet soda.

Medical Nutritional Therapy

Individualized medical nutritional therapy is an indispensable part of a treatment plan to manage diabetes in children and youth. At the time of diagnosis with diabetes, the child is referred to a registered dietitian with experience in managing children with diabetes. Yearly follow-up visits are included in the child’s comprehensive plan of care (ADA, 2020a).

Medical nutritional therapy is geared toward the child’s age and stage of development. Meal planning must take into consideration the number of calories a child needs for growth. The goal is to help the child reach and maintain a healthy weight. Strategies may include:

• Teaching parents and children about portion control
• Aiming for three meals and three snacks daily
• Planning each meal to contain the same amount of carbohydrates
• Including healthy fats in the diet
• Not regarding a particular food as “off-limits,” while teaching how different foods affect blood glucose and how and when certain foods, especially treats, should be included into the meal plan
• Working with parents to set a goal for the whole family to gradually replace soda and other sugary drinks (e.g., juices, sports drinks) with plain water or low-fat milk
• Teaching parents and children about the importance of reading food labels and how to understand what they mean
  (NIH, 2021)

Meal planning for toddlers and preschoolers can take skill and patience. Toddlers in particular are prone to reject foods that add variety to their diet. Parents are advised that young children require morning, afternoon, and bedtime snacks to ensure a ready source of glycogen (ADA, 2017a). However, very young children may not complete a meal or snack, which makes it extremely difficult for parents of children with T1D to safely dose insulin prior to meal times. In these instances, rapid-acting insulin analogs given after a meal are recommended. Parents are instructed to determine the insulin dose based on what the child actually ate (ADA, 2017a).

For school-age children, medical nutritional therapy must take into account meals at school, afterschool events, sporting activities, parties, eating out, sleepovers at friends’ houses, the child’s changing food tastes, etc. (ADA, 2017a). Clinicians encourage parents and school-age children to work together to develop meal plans, assisting children to acquire the skills they need to become more independent by learning about carbohydrate counting and planning their own food choices and portion sizes.

Adolescents can be more involved in their own care by monitoring their carbohydrate intake and individualizing their meal plan based on greater awareness of their food preferences (ADA, 2020a).

The diabetes management team, along with the child and family, formulate a dietary plan that is adaptive to the needs of the family. The clinician must take into account the child and family’s dietary habits, cultural or religious considerations, financial resources, and mathematical ability to successfully count carbohydrates (ADA, 2020a).

For many children with diabetes, it is important to ensure they are not singled out as needing “special foods” or missing out on the treats enjoyed by siblings or peers. For example, the dietitian may suggest limiting dessert to once a week or adopting certain foods for the entire family. With guidance from the dietitian, the parents and child can discover when it is possible to incorporate more flexibility into the diet plan and when adjustments can be made (Lebow, 2019).

Sick-Day Planning

Illness increases stress, leading to an increase in blood glucose levels. Vomiting and diarrhea can cause dehydration, and an inability to keep food down can result in the body utilizing fat for energy. This may in turn lead to ketoacidosis due to above-normal levels of ketones, which is a serious and possibly fatal condition (see also “Diabetic Ketoacidosis” later in this course).

It is important for children with diabetes and their parents to understand how illness, including minor colds and infections, affects diabetes. Having a practical and workable plan for sick-day management is essential and must be put in place as soon as diabetes is diagnosed. This also reduces fear and anxiety for the child and their parents (ADA, 2017a).

Important elements of a sick-day plan include:

• Never stopping taking insulin or diabetic medications
• Maintaining fluid intake (since dehydration can lead to DKA)
• When vomiting occurs, considering it to be a sign of insulin deficiency until confirmed differently
• Treating the underlying condition
• Implementing more frequent blood glucose checks (every 2 to 4 hours)
• Checking for ketones in urine
  (Beebe et al., 2017; Laffel, 2018)

The intake goal is 15 grams of carbohydrates per hour. Typically, the child is encouraged to drink small amounts of fluids, around 1/2 cup every hour, slowly and without taking large mouthfuls. Recommended foods to avoid hypoglycemia when sick include:

• Jello
• Saltines
• Apple sauce
• Bananas
• Toast
• Graham crackers
• 1/2 cup ice cream
• 1/4 cup sherbet
  (Hess-Fischl, 2020)

Families are instructed on when they should call for medical help and provided with 24-hour contact information for medical assistance, preferably someone on the diabetes management team. They are instructed to call their provider or emergency contact if the child has several episodes of vomiting, diarrhea, refuses to take fluids, has blood glucose levels that remain out of range, becomes lethargic, or develops deep, rapid respirations. Other reasons to seek emergency care include:

• When it is unclear what the causative condition is, if fever persists, or if the child or family feel a need to reach out for help for any reason
• If blood glucose levels are not staying within range (either too high or too low)
• If blood sugar levels continue to rise despite administering extra doses of insulin
• If there is a fruity breath-smell that persists or increases
• If urine ketone levels continue in large amounts despite extra insulin dosing and hydration
• If the child becomes exhausted, starts hyperventilating, shows signs of confusion, or develops acute abdominal pain
• If the child or family do not have adequate supplies to monitor blood glucose levels or insulin to provide treatment
  (Hess-Fischl, 2020; ADA, 2017a; Laffel, 2018)

Sick-day supplies that should always be kept on hand may include:

• Chicken soup, clear broths, and hydration drinks containing water and salt to prevent dehydration
• Glucose tablets, jelly beans, and dried fruits to treat hypoglycemia
• Easily digested sources of carbohydrates (e.g., crackers, noodles, rice, yogurt) to main blood glucose levels
  (Laffel, 2018)