If the pediatric patient with type 1 diabetes is only mildly ill, he or she may be managed in the hospital with something along the lines of the following protocol from the Royal Children’s Hospital Melbourne.
Many pediatricians and family physicians will choose to immediately refer the child to a tertiary care center for inpatient management by a pediatric endocrinologist and their diabetes education team.
New presentation diabetes, mildly ill
< 3% dehydration, no acidosis and not vomiting
Investigations for all children newly diagnosed with diabetes
- Check blood ketones (bedside test) on all patients presenting with BGL ≥11.1mmol/l [link to Conversion Table].
- If ketones positive (>0.6), assess for acidosis with a venous blood gas; if pH <7.30, proceed as per the DKA guideline.
- Ketones may be present without acidosis; if this is the case, continue to monitor ketones with each BGL to ensure they are clearing with insulin therapy (monitor until 2 consecutive levels are <0.6 and again if any BGL is > 15.0mmol/l [link to Coversion Table]).
- GAD antibodies, insulin antibodies, coeliac screen, thyroid function tests
Additional tests to consider
- For children / adolescents who are overweight or have clinical evidence of acanthosis nigricans:
- C-peptide and insulin levels (may help to distinguish Type 2 diabetes, although T1DM still more likely in this scenario)
- lipid profile
The decision about the individual insulin regimen will be made by the paediatric diabetes team in discussion with the family and child. The regimens outlined below are a guide only and individual clinicians may recommend an alternative approach.
- 0.25 units/kg of quick-acting insulin s.c. stat.
- If within 2 hr prior to a meal defer and give meal-time dose only.
- Halve dose if ≤4 yr old. Dose may be lower if not ketotic.
Standard insulin regimens in newly diagnosed patients may comprise either of the two regimens below:
1. Twice daily injections of a mixture of short and intermediate-acting insulins:
Usually commence with total daily dose (TDD) of 1 unit/kg/day but this may need modification (e.g. less in younger child aged <5years).
This is given as 2/3 of TDD in morning, 1/3 of TDD at night. 2/3 of each dose as intermediate-acting insulin, 1/3 as short-acting insulin.
Note: In children who will be starting twice daily injections but who present after 2200 hrs, it may be too late to start with a mixture of intermediate and short acting insulins. In this instance, give 0.25 U/kg short-acting insulin, which may need to be repeated after 4-6 hours, with a snack (depending on BGL,,ketones and interval to breakfast).
2. Multiple daily injections (MDI) of insulin using a long-acting insulin analogue at night and pre-meal injections of rapid-acting insulin analogue
Also start with TDD of ~1.0 U/kg/day.
- Give 0.4U/kg as basal insulin (long-acting insulin analogue eg insulin glargine) at ~20,00- 21,00 hrs.
- Give the remainder as rapid-acting insulin in 3 equal doses before meals (i.e. ~0.2 U/kg before each main meal).
- If children who will start MDI regimens present during the day, slightly higher pre-meal doses may be necessary (e.g. 0.25 U/kg) until basal insulin is given that evening.
In general, multiple daily injection regimens offer greater lifestyle flexibility (around mealtimes, sport etc); however the child must be old enough to learn how to administer insulin using a pen device without parental supervision (e.g. at school). This is usually possible with children aged >10 years. Twice daily mixed injections are usually commenced in children <10years.
When to admit/consult local paediatric team:
- All new presentations of diabetes. In many places these children need to be admitted for commencement of insulin and diabetic education.
When to consider transfer to tertiary centre:
- Children requiring care above the level of comfort of the local hospital.