Susan Phillips, MD TCOYD
Newsletter, Vol. 23, 2007

Caring for Infants and Toddlers

The management of type 1 diabetes mellitus (T1DM) in infants and toddlers is a complex set of problems. Optimal management of these issues requires close cooperation between the patient, family and health care team.

All very young children are hospitalized following the diagnosis of diabetes in order to correct acidosis, rapidly stabilize the diabetes, and initiate an outpatient insulin treatment regimen. The key components of diabetes management, such as insulin administration, blood sugar monitoring, treatment of hypo- and hyper- glycemia and a basic meal plan are taught so that the family understands these components thoroughly. After leaving the hospital families remain in close contact with the diabetes team to review blood sugars and insulin dose adjustments. Outpatient visits are scheduled four times per year, but the complexity of diabetes management in the very young may initially require more frequent visits. During the first of these visits the family meets with all members of the multidisciplinary team for a comprehensive assessment, and a plan is established. The diabetes team consists of a pediatric endocrinologist, a diabetes nurse educator, a dietician and a clinical social worker or pediatric psychologist. During subsequent visits the patient and family are seen by the physician and other members of the team as needed to ensure optimal blood sugar control, ongoing education and support.

The American Diabetes Association recommends a fasting blood sugar goal of 100-180 mg/dl and an HbA1c of < 8.5 (but >7.5) % in toddlers and preschoolers with T1DM. The higher targets reflect the high risk and vulnerability to hypoglycemia seen in this group. It is important to note that there is no established formula to achieve these targets and a variety of insulin regimens can be used successfully in this group.

Finger Sticks & Insulin Shots

In general, blood sugars are monitored at the finger-tips, toes, or heels before meals and at bedtime, and insulin is administered as a combination of a rapid- and intermediate- acting (NPH) or a long-acting (glargine) to achieve glycemic control. Because children are so sensitive to insulin, they need to have highly precise insulin dosing. Continuous subcutaneous administration of rapid acting insulin through an insulin pump capable of very low infusion rates works well. The Animas 2020, for example, currently offers the lowest delivery increments (0.025 units per hour basal, and 0.05 unit bolus increments). In addition, several devices such as insulin pens that deliver rapid acting analog in 0.5 unit increments and catheter devices such as the Insuflon™ that allow multiple insulin injections through the same injection port over several days, permits intensive regimens of diabetes management in the very young. In our practice, we generally start a rapid acting analog in combination with NPH at breakfast and in combination with glargine (Lantus) or detemir (Levemir) at dinner. In theory, the use of a peakless longacting insulin at dinner would reduce the risk for nocturnal hypoglycemia. Importantly, with regard to this regimen, Peter Chase, MD (Children’s Diabetes Foundation, Denver) and colleagues have reported that mixing the longacting insulin analog glargine with a rapid acting analog, as opposed to injecting these insulins separately, is safe and effective. Insulin injections are generally tolerated but may initially cause fear and anxiety in the toddler. The inability of the child to communicate and cooperate with the treatment regimen can create increased stress and uncertainty for the family. With time, however, the child’s anxiety lessens and frequently they willingly participate in both injection site selection and skin preparation.

The Challenge of Dosing

Among the factors unique to the care and management of the very young with diabetes is insulin dosage. Although newly diagnosed children and adults with T1DM require similar weight based doses of insulin (0.5-1.0 units of insulin/kgday), in infants and toddlers this translates to very small doses of insulin. Typically such doses are less than one unit and dose increments are frequently as little as 0.1 units. Such small doses require the use of diluted insulin (U-10, U-25 or U-50) in preference to the standard U-100 formulation. For the families, this presents the challenge of identifying local pharmacies willing to dilute insulin. For the providers, it means ensuring that the family understands the insulin dose conversions to accurately communicate insulin dose information and avoid inadvertent administration of U-100 insulin.

The Challenge of Getting Little Ones to Eat

Another factor unique to this population is the difficulty of adhering to a meal plan. Meal plans are developed by a dietician in collaboration with the family and generally call for three meals and three snacks. Adequate protein and starches are incorporated at each meal to ensure sufficient calories and nutritional content for normal growth. Toddlers are notoriously finicky eaters and may frequently refuse meals or snacks. Given that insulin doses are based on the carbohydrate intake, the finicky toddler is at increased risk for hypoglycemia. Add to this their variable physical activity and limited ability to recognize and/or communicate symptoms of hypoglycemia and one can easily empathize with the anxiety associated with the care of a toddler with diabetes.

The Challenge of Hypoglycemia

To address the real risk of hypoglycemia in this population a number of accommodations can be made. First, we strongly advise families to test the blood sugars frequently, particularily if activity level increases or if they suspect a low. In children prone to hypoglycemia we recommend testing at times when insulin is peaking, although this may sometimes interrupt sleep. The recent availability of continuous glucose sensors with hypoglycemia alarms, although not approved for use in this population, may be the best potential solution to this problem. We also recommend delaying mealtime insulin administration by 5-10 minutes after the meal in order to assess how much of the meal the youngster actually eats. If necessary, a reduced insulin dose can then be made to accommodate for changes in food intake to lower the risk of subsequent hypoglycemia.

The Challenge of Other Illness

Of course, kids get sick, and intercurrent illnesses pose additional challenges to the families of young children with diabetes and account for many of the calls made by the family to the diabetes care team. The effect of a given illness on blood sugar levels is variable. Blood sugars and urinary ketones need to be checked more frequently and dose adjustments made accordingly. Lows may be treated with popcicles or juice if tolerated and high blood sugars should be treated with increased insulin. Close follow up with the family is critical to ensure appropriate treatment and emergency room referral if necessary.

Diabetic complications resulting from poor glycemic control, such as retinopathy, nephropathy, and neuropathy, are rarely seen in the very young with T1DM. However, the earlier the age of onset suggests a greater exposure to higher blood sugars with a potentially higher risk for long term complications. Alternatively, overly aggressive management of diabetes, together with the inability of the very young to recognize and communicate their hypoglycemic symptoms, places them at increased risk of recurrent hypoglycemia and possible developmental impact.

In summary, TIDM among the very young is increasing worldwide and their management requires a specialized approach via a multidisciplinary team experienced in the treatment of childhood diabetes. Nurse educators, dieticians and clinical social workers are essential members of this team who, along with the endocrinologist, help the family learn to manage diabetes and the stress of caring for a very young child with this condition. In distinction to the care of older children with diabetes, very young children with diabetes are unable to communicate hypoglycemic symptoms and thirst associated with hyperglycemia placing them at greater risk of complications. They frequently require specialized insulin regimens, including the dosing of insulin after eating and increased frequency of blood sugar testing.

New technologies such as insulin pumps capable of delivering very small doses of insulin and continuous glucose sensors have the potential to both improve diabetes control and reduce the risk of hypoglycemia and its complications.

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