2008 Clinical Practice Guidelines - Canadian Diabetes Association

have failed to demonstrate an improvement in glycated hemoglobin
(A1C) compared with MDI. However, almost all clinic-based
studies of CSII in school-aged children and
adolescents have shown a significant reduction in A1C with
reduced hypoglycemia 12 to 24 months after initiation of CSII
when compared to pre-CSII levels (15).
Most, but not all, pediatric studies of the extended longacting
insulin analogues detemir and glargine have demonstrated
improved fasting BG levels and fewer episodes of
nocturnal hypoglycemia with a reduction in A1C (16-18).
GLUCOSE MONITORING
Self-monitoring of blood glucose (SMBG) is an essential part
of management of type 1 diabetes (19). Subcutaneous continuous
glucose sensors have demonstrated good accuracy except
when BG levels are in the hypoglycemic range (20-22).
Continuous glucose sensors may be a useful tool for improving
glycemic control in individuals on intensive therapy (23).
NUTRITION
All children with type 1 diabetes should receive counselling
from a registered dietitian experienced in pediatric diabetes.
Children with diabetes should follow a healthy diet, as recommended
for children without diabetes in Eating Well with
Canada’s Food Guide (24).This involves consuming a variety of
foods from the 4 food groups (grain products, vegetables and
fruits, milk and alternatives, meat and alternatives). There is
no evidence that one form of nutrition therapy is superior
to another in attaining age-appropriate glycemic targets.
Appropriate matching of insulin to carbohydrate content may
allow increased flexibility and improved glycemic control
(25,26), but the use of insulin to carbohydrate ratios is not
required.The effect of protein and fat on glucose absorption
must also be considered. Nutrition therapy should be individualized
(based on the child’s nutritional needs, eating habits,
lifestyle, ability and interest) and must ensure normal growth
and development without compromising glycemic control.
This plan should be evaluated regularly and at least annually.
HYPOGLYCEMIA
Hypoglycemia is a major obstacle for children with type 1 diabetes
and can affect their ability to achieve glycemic targets.
Significant risk of hypoglycemia often necessitates less stringent
glycemic goals, particularly for younger children. Severe
hypoglycemia should be treated with pediatric doses of intravenous
(IV) dextrose in the hospital setting, or glucagon in
the home setting. In children, the use of mini-doses of
glucagon has been shown useful in the home management of
mild or impending hypoglycemia associated with inability or
refusal to take oral carbohydrate. A dose of 20 µg per year of
age up to a maximum of 150 µg is effective at treating and
preventing hypoglycemia, with an additional doubled dose
given if the BG has not increased in 20 minutes (27,28).
CHRONIC POOR METABOLIC CONTROL
Diabetes control may worsen during adolescence. Factors
responsible for this deterioration include adolescent adjustment
issues, psychosocial distress, intentional insulin
omission and physiologic insulin resistance. A careful multidisciplinary
assessment should be undertaken for every child
with chronic poor metabolic control (e.g. A1C >10.0%) to
identify potential causative factors such as depression and eating
disorders and to identify and address barriers to improved
control (29,30).
DKA
DKA occurs in 15 to 67% of children with new-onset diabetes
and at a frequency of 1 to 10 episodes per 100 patient
years in those with established diabetes (31). As DKA is the
leading cause of morbidity and mortality in children with
diabetes (32), strategies are required to prevent the development
of DKA. In new-onset diabetes, DKA can be prevented
Table 1. Recommended glycemic targets for children and adolescents with
type 1 diabetes
Age
(years)
*Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available
† In adolescents in whom it can be safely achieved, consider aiming toward normal PG range (i.e. A1C ≤6.0%, fasting/preprandial
PG 4.0-6.0 mmol/L, and 2-hour postprandial PG 5.0–8.0 mmol/L)
A1C = glycated hemoglobin
PG = plasma glucose
A1C (%) Fasting/
preprandial
PG (mmol/L)