LONG TERM MANAGEMENT OF

DIABETES MELLITUS IN
CHILDREN
Presenter- Dr. Nawarajendra Munakarmi
Guide- Associate prof. Dr. Srijana Basnet

1
Objectives
• To discuss goals of management of diabetes mellitus in children
• To discuss components of management of diabetes mellitus in
children
• To discuss the physiology and practical aspects of insulin therapy for
the management of diabetes
• To discuss the various long term complications and comorbidities of
diabetes in children and their management.

2
Goals of diabetes treatment

• maintain blood glucose and HbA1c levels as close to normal without

causing hypoglycemia
• To prevent acute symptoms- eliminate polyuria, nocturia and prevent
ketoacidosis
• Minimize the risk of long term micro- and macrovascular complications
while minimizing impact in lifestyle of child
• Permit normal growth and development of the child

3
Components of management of diabetes in children
• Insulin therapy- initiation and adjustment
• Regular monitoring of blood sugar and monitoring for complication
• Nutritional management
• Physical activity /lifestyle factors
• Diabetes self care behaviors
• Management of diabetes in special situations e.g sick day management, surgery
• Detection and management of microvascular and macrovascular complications
• Detection and management of other complication/conditions associated with DM
• Psychological care of children and adolescent and the family members

4
Insulin treatment for diabetes
• Insulin therapy is the mainstay of treatment for type 1 diabetes
mellitus.
• Aim- improved glycemic control by intensive insulin treatment
and prevent the risks of acute and long-term complications
• Insulin treatment must be started as soon in children with
hyperglycemia to prevent metabolic decompensation and
diabetes ketoacidosis.
• Insulin treatment should be as physiological as possible.

5
6
7
Commonly Used Insulin Preparations
Insulin Onset of action Peak Duration of action

Rapid acting
Lispro 15-30 min 30-90 min 3-6 hr
Aspart 10-20 min 40-50 min 3-5 hr
Glulisine 20-30 min 30-90 min 3-4 hr

Short acting
Regular 30 min – 1 hr 2-5 hr 5-8 hr

Intermediate-acting
NPH 2-4 hr 4-12 hr 12-18 hr

Long-acting
Glargine 1-1.5 hr No peak 20-24 hr
Detemir 1-2 hr No peak 14-24 hr
Glargine U300* 2-6 hr 30- 36 hour
Degludec 0.5-1.5 >42 hour

8
Outpatient Management of Pediatric Type 1 Diabetes; Beck, J Pediatr Pharmacol Ther 2015 Vol20
9
 Insulin regimen
The two most common regimens used are:
• Twice-daily insulin using both short-acting and also intermediate-
acting insulin. (If these insulins are not always available, pre-mixed insulin
can be used as an alternative regimen).
• Basal bolus regimen (the preferred option) - with shortacting insulin
given with main meals (usually three times per day) and intermediate-
acting insulin given once or twice daily (evening, or morning and evening).

10
Starting insulin dose
• prepubertal children presenting without DKA can be started on a dose
of 0.4-0.5 units/kg/day.
• Overweight pubertal adolescents presenting with DKA may need up
to 1-1.2 units/kg/day.
• Insulin requirements in infancy vary from <0.2 units/kg/day to >1
unit/kg day

11
Basal-bolus regimen

• Of total daily insulin requirement, 50% total daily dose by long acting insulin and
remainder by bolus of short acting insulin at meal times.

• Injection of regular insulin 20-30 min before each main meal(breakfast, lunch and
the main evening meal)

• Intermediate acting insulin or basal/long acting analog at bedtime or twice

daily(mornings and evenings)
Adapted from Nelson textbook of pediatrics 21 st edition
Split/mixed regimens
• Are the basic two- or three-injection regimens based on intermediate insulin (NPH).

• A 3-injection regimen combine NPH with a rapid analog bolus at breakfast, a rapid-acting analog
bolus at supper, and glargine at bedtime may provide fair glucose control and eliminate the need for
an injection at school. Further

2 injection regimen
• About 70% of their total dose in the morning and 30% in the evening.

• The doses usually are split between one-third intermediate-acting/rapid-acting insulin and
two thirds NPH to one-half/one-half (e.g 30:70 or 50:50)

14
Utilization of ingested carbohydrate
Insulin: Carbohydrate ratio
– It represents how many grams of carbohydrate are covered
by 1 unit of insulin
– Depends upon individual’s sensitivity to insulin, can vary
according to time and affected by physical activity and
stress
– 500/total daily insulin dose
– Eg. For 20 kg child without ketosis
– Insulin requirement=10 units
– I:C ratio= 500/10=50 (1 unit insulin covers 50gm)
Correction of elevated blood glucose
• An insulin correction factor can be used to select an insulin
dose to correct hyperglycemia before meals or between
meals.
• For rapid-acting insulin, divide 1500 by the total daily insulin
dose. This calculation estimates the decrease in blood glucose
from one unit of a rapid-acting insulin.
• As an example, if the total daily insulin dose is 10 units

– 1 unit of rapid acting insulin will drop the blood sugar

– 1500/total insulin requirement
– Eg. 1500/10= 150mg/dl
– 1 unit of rapid acting insulin will drop the blood sugar by
150 mg
 Calculating insulin dosage
• For 15yr boy of 40 kg with diabetic ketoacidosis
• Total insulin required=1.2*40=48 units=50 units
• Basal insulin:40-50%=25 units(e.g. Glargine)
• I:C ratio=500/50=10 gm of carbohydrate
• Correction factor=1800/50=36mg/dl
– If carbohydrate consumed is 100 gm, then Insulin to cover
carbohydrate is 10 units
– E.g if premeal blood sugar is 202mg/dl, and the target blood sugar is
130
– Difference=202-130=72mg/dl
– Total bolus insulin=8+2=10 units
• Calculation for split/mixed regimen- total 24 hour insulin required=48 units
• 30:70 mixtard(regular + NPH) insulin, before breakfast-32 unit(2/3 rd of
total insulin)
• Before dinner- 16 unit( 1/3 of total insulin requirement)
Administration of insulin
• Multiple daily injection(MDI)
– Insulin syringes- thinner needles that are 4 to 8 mm long (30-32 G) using two finger pinch
technique at a 45 oangle( A 90o angle can be used if the s.c. fat is thick enough ) is recommended
to ensure a strict subcutaneous injection.

– Pen injector devices- make injections easier and more flexible, eliminate the need for drawing up
from an insulin vial; the dose is dialed up on a scale , useful for insulin administration away from
home, at school or on holidays

• Subcutaneous indwelling catheters

• Automatic injection devices
• Jet injectors
• Continuous subcutaneous insulin infusion
• Sensor-augmented pump therapy and ‘closed loop’
18
Insulin Pen

19
Injection sites
• Usual injection sites are
– Abdomen(preferred site, less affected
by muscle activity or exercise)
– Front of thigh/lateral thigh(preferred
site for slower absorption of longer
acting insulin)
– Lateral upper quadrant of the buttocks
– Lateral aspect of arm
– Rotation of injection sites are
important also within the same area of
injection

20
21
Problems with injections
• Local hypersensitivity reactions
• Lipohypertrophy
• lipoatrophy
• Painful
• Leakage
• Bruising, bleeding
• Due to insulin- edema, weight
gain

22
Factors affecting insulin absorption
• Age
• Fat mass
• Dose of injection (larger dose- slower absorption)
• Site and depth of s.c injection
• S.c vs i.m. injection (i.m- faster)
• Exercise
• Insulin concentration, type and formulation(Insulin analogue-less
affected)
• Ambient and body temperature
23
Insulin Adjustments
• Adjustments until target BG levels and target HbA1c are achieved.

• ↑ BG before breakfast - ↑ pre-dinner or pre-bed intermediate/long acting

insulin.

• ↑ BG after meal - ↑ pre-meal rapid/regular insulin.

• ↑ BG before lunch/dinner - ↑ pre-breakfast basal insulin or ↑ pre-breakfast

rapid-acting insulin.

24
Honeymoon phase

• A few weeks after the diagnosis and initiation of insulin therapy, a period of
decreasing exogenous insulin requirement occurs, commonly referred to as the
"honeymoon" or remission phase of diabetes.

• Duration variable - several months to several years.

• Rising blood glucose levels, A1C, and increasing exogenous insulin need indicates
the end of this phase.
Dawn phenomenon and Somogyi phenomenon
• Blood glucose levels tend to rise in the hours of the morning prior to waking - dawn
phenomenon.

• Fasting hyperglycemia is caused by waning insulin levels, thus exaggerating the dawn
phenomenon.

• Morning hyperglycemia can in some cases be preceded by nighttime

hypoglycemia(rebound hyperglycemia) – Somogyi phenomenon

• Correction of fasting hyperglycemia - an adjustment of the insulin regimen to provide

effective insulin levels throughout the night and the early morning by the use of:
– Intermediate acting insulin later in the evening or at bedtime a longer acting evening insulin/basal
insulin analog.
– Change to insulin pump treatment.

26
Insulin storage
• Insulin must never be frozen.
• Unused insulin should be stored in a refrigerator(4-8°C)
• Direct sunlight or warming(in hot climates) damages insulin
• Insulin that have changed in appearance(clumping, frosting, precipitation or
discoloration) should not be used
• After 1st usage, an insulin vial should be discarded after 3 months(if kept at 2-8°C) or
4 weeks(if kept at room temperature)
• In hot climates where refrigeration is not available , cooling jars, earthenware
pitcher (matka), or a cool wet cloth around the insulin will help to preserve insulin
activity

27
Target premeal and 30 day average blood glucose
ranges and the HbA1C

28
Monitoring of blood glucose level
• Self monitoring of blood glucose- an
essential component of managing
diabetes
• Assessed by quarterly hemoglobin A1c
(HbA1c) and by regular home glucose
monitoring.
• Helps in prescribing appropriate
adjustments in insulin doses, and teaching
the family

29
Timing of self-monitoring of glucose(SMBG)
• BG is best measured: 6-10 times a day ideally, at least 4 times.
• During the day- before meals and snacks
• At other times (e.g, 2-3 hours after food intake) to determine appropriate insulin
doses and show levels of BG in response to the action profiles of insulin

• At bedtime, during the night and on awakening to detect and prevent nocturnal
hypoglycemia and hyperglycemia.
• Current recommended blood glucose targets are 90-130 mg/dL before meals and
90-150 mg/dL before bedtime
• glycemic goals must be individualized to the patient based on age, hypoglycemia
risk, and other factors.

30
Advanced Blood glucose monitoring
• Continuous glucose monitoring system
– Records data from subcutaneous sensor every 5 min upto 72 hrs
– Continuous profile of tissue glucose level is obtained
– Helps in adjustment of insulin regimen and nutritional plan to
improve glycemic control
– Helps in detecting nocturnal hypoglycemia
– Disadvantages- suboptimal compliance, human error, incorrect
technique, sensor failure

31
Glycosylated hemoglobin
• Reliable index of long term glycemic control
• Fraction of hemoglobin to which glucose is non enzymatically
attached in blood stream
• Reflects average blood glucose concentration from the preceding 2-3
months
• Measured 3-4 times/year
• Lower the level, lower is the microvascular complications
The HbA1c target for all children with diabetes is <7.5% and for those over 18 yr it
is ≤7.0%.

32
Hypoglycemia
• Clinical hypoglycemia alert- a glucose value ≤3.9 mmol/L (70 mg/dL) is used as
the clinical alert or threshold value for initiating treatment for hypoglycemia in
diabetes because of the potential for glucose to fall further.

• Clinically important or serious hypoglycemia: A glucose value of <3.0 mmoL/L (54

mg/dL) indicates serious, clinically important hypoglycemia

• Severe hypoglycemia is defined as an event associated with severe cognitive

impairment (including coma and convulsions) requiring external assistance by
another person to actively administer carbohydrates, glucagon, or take other
corrective actions
(ISPAD-2018)

33
Hypoglycemia clinical features

• Autonomic Cerebral glucopenia

– Pallor - drowsiness
– Sweating -personality changes
– Apprehension -mental confusion
– Tremor -impaired judgement
– Palpitation -coma
-seizure
• Non specific signs
– Hunger, headache, nausea, tiredness

• Hypoglycemia unawareness- recurrent hypoglycemic episodes with

tight metabolic control aggravates partial counter-regulatory
deficiencies

• Older patients with long standing hypoglycemia, lose ability to

secrete glucagon in response to hypoglycemia

• Epinephrine deficiency may be part of autonomic neuropathy

Management of hypoglycemia
• Teaching patients and family of the signs and symptoms of hypoglycemia
• A source of glucose should be available at all times and places(eg candies)(0.3gm/kg of oral glucose
or equivalent)
• Administration of glucagon if child cannot take glucose orally
– Intramuscular dose 0.5mg if child <25kg, 1mg if >25kg

• In a hospital setting, intravenous glucose or glucagon

• Intravenous glucose - administered over several minutes to reverse hypoglycemia.
– Dextrose 10% to 20%, for a total of 200 to 500 mg/kg of glucose.

• Rapid administration or excessive concentration (ie, glucose 50%) may result in an excessive rate of
osmotic change with risk of hyperosmolar cerebral injury

• Recurrent hypoglycemia- additional oral carbohydrates and/or intravenous infusion of 10% glucose,
2 to 5 mg/kg/min

36
Nutritional Management
Age Kcal required/kg body weight
Children:
0-12 months 120
1-10 years 100-75

Young women
11-15 years 35
≥16 years 30

Young men
11-15 years 80-55(65)
16-20 years
Average activity 40
Very physically active 50
sedentary 30

American Diabetes Association and The American Dietetic Association, 1988

37
• A guide to the distribution of macronutrients
– Carbohydrate 45% to 55% energy
– Moderate sucrose intake (up to 10% total energy)
– Fat 30% to 35% energy
– <10% saturated fat + trans fatty acids
– Protein 15% to 20% energy

38
Nutritional recommendations and distribution
Nutrient (%) of calories Recommended daily intake
carbohydrates Will vary High fiber, soluble fiber
Fiber 14 g/4184 kJ (1000 kcals)
1 year or greater 3.3 g/MJ
Alternative formula Age in years +5 = grams of fiber per day
Children >2 years old
Protein 12-20 childhood from approximately 2 g/kg/day in early infancy
to 1 g/kg/day for a 10-year-old and
to 0.8 to 0.9 g/kg/day in later adolescence
Fat <30
Saturated <10
Polyunsaturated 6-8
Monounsaturated Remainder of
fat allowance
Cholesterol 300mg
Sodium Avoid excessive, limit to 3000-4000 mg if hypertensive 39
Exercise and Type 1 DM
• No form of exercise should be forbidden to the child with diabetes
• Major complication of exercise- hypoglycemia during or within hours of
exercise
• If no hypoglycemia occurs with exercise, no need for change in diet or insulin
• Regular exercise improves glucoregulation by increasing insulin receptor
number
• In patients with poor metabolic control, vigorous exercise precipitates
ketoacidosis due to exercise induced increase in counterregulatory hormones

40
Exercise guidelines
• No form of exercise should be forbidden
to the child with diabetes
• Major complication of exercise-
hypoglycemia during or within hours of
exercise
• If no hypoglycemia occurs with exercise,
no need for change in diet or insulin
• Regular exercise improves glucoregulation
by increasing insulin receptor number
• In patients with poor metabolic control,
vigorous exercise precipitates ketoacidosis
due to exercise induced increase in
counter-regulatory hormones

41
Behavioral/Psychological aspects and eating disorder

• Cognitive function
• Coping styles
• Nonadherence
• Anxiety and depression
• Fears of self injecting and self testing
• Eating disorders

42
Sick Day Guidelines
• Principles:
– More frequent BG and ketone (urine or blood) monitoring
– Do no stop insulin even when oral intake limited, supplemental doses of rapid acting insulin
should be given to correct hyperglycemia or suppress ketogenesis
– Monitor and maintain salt and water balance
– Treat the underlying precipitating illness
– Vomiting – insulin deficiency until proven other wise
• Sick day guidelines including insulin adjustment should be taught soon after diagnosis and reviewed
at least annually with patients and family members with a goal of minimizing and/or avoiding DKA
and similarly minimizing and/or avoiding illness associated hypoglycemia.

ISPAD Clinical Practice Consensus Guidelines 2018 Compendium

Sick day management in children and adolescents with diabetes
43
 Management during infections
Urine ketone status Glucose testing and extra rapid
acting insulin
Comment
Correction doses
Insulin

Negative or small Q2hr Q2hr for glucose Check ketones every

>250mg/dl other void

Moderate or large Q1hr Q1hr for glucose Check ketones each void,
>250mg/dl go to hospital if emesis
occurs

44
 Indications for seeking urgent medical advice
• Age <5 years
• Vomiting >2 hours
• Child appears exhausted or confused
• Child is hyperventilating or has abdominal pain
• Blood glucose persistently low (<70 mg/dL) or continues to
rise despite supplemental insulin doses
• Blood ketones remain elevated (>1.5 mmol/L) or urine
ketones remain "large" despite extra insulin and hydration
• Child has a comorbid condition that complicates home care

45
Management during Surgery
Blood glucose level(mg/dl) Insulin infusion(units/kg/hr) Blood glucose monitoring

<120 0.00 1hr

121-200 0.03 2hr
200-300 0.06 2hr
300-400 0.08 1hr*
400 0.10 1hr*

An infusion of 5% glucose and 0.45% saline solution with 20mEq/L of potassium acetate is given at
1.5 times maintenance rate
* Check urine ketones

46
Diabetes education

• Therapy consists not only of initiation and adjustment of insulin dose but also education to
the patient and family
• “Basics” during acute phase includes
– Monitoring the child’s blood glucose and urine or blood ketones
– Preparing and injecting the correct insulin dose subcutaneously at the proper time,
– recognizing and treating low blood glucose reactions,
– having a basic meal plan
• Psychological issues during acute phase hinders limited ability to retain new information
• Written materials to be provided
• Advanced self management classes
– Implementation of flexible insulin management
– Helps patients and parents acquire skills for managing diabetes during athletic activities
and sick days
Management of type 2 DM
• Lifestyle changes should be recommended at the time of diagnosis of T2DM
• Initial pharmacologic treatment of youth with T2DM should include metformin and insulin alone or in combination.
a. Metabolically stable patients (HbA1c < 8.5 and no symptoms) - metformin.
b. In patients with ketosis/ketonuria/ketoacidosis,- subcutaneous or intravenous insulin should be
initiated to rapidly correct the metabolic abnormality.
i. Once a day intermediate-acting or basal insulin (0.25-0.5 units/kg starting dose) is effective in
attaining metabolic control
ii. Metformin can be started along with insulin, once acidosis is resolved
iii. Transition onto metformin monotherapy over 2 to 6 weeks
• The goal of treatment should be an HbA1c < 7.0%
• If target is not attained on the combination metformin and basal insulin (up to 1.5 U/kg), prandial insulin should be
initiated and titrated to reach target HbA1c < 7%
• Self-monitored blood glucose (SMBG) should be performed regularly.
• Assessment and management of comorbidities like obesity, hypertension, dyslipidemia and complications

ISPAD Clinical Practice Consensus Guidelines 2018: Type 2 diabetes mellitus in youth

48
Long term complications
• Microvascular complications:
– Retinopathy
– Nephropathy

• Macrovascular complications:
– coronary artery disease
– cerebrovascular disease
– peripheral vascular disease
– Neuropathies-both peripheral and autonomic

• Life expectancy remains 8–13 years shorter and cardiovascular disease

continues to be the leading cause of morbidity and mortality in type 1 diabetes
Type 1 diabetes mellitus and cardiovascular disease: a scientific statement from the American
Heart Association and American Diabetes Association. Circulation 2014; 130: 1110–30.
49
Diabetes Control and Complications Trial (DCCT)

• Conducted from 1983 to 1993

• Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.

• The DCCT involved 1,441 volunteers, ages 13 to 39, with type 1 diabetes and 29 medical centers in
the United States and Canada.

• The study compared the effects of standard control of blood glucose versus intensive control on the
complications of diabetes . Intensive control meant keeping hemoglobin A1C levels as close as
possible to the normal value of 6 percent or less.

50
DCCT Study Findings
• Intensive blood glucose control reduces risk of
• eye disease
76% reduced risk
• kidney disease
50% reduced risk
• nerve disease
60% reduced risk

51
EDIC study(1994-2006)

• After the DCCT ended in 1993, researchers continued to study more than 90 percent
of participants.
• The follow-up study, Epidemiology of Diabetes Interventions and Complications
(EDIC),
• To assess the incidence and predictors of cardiovascular disease events such as
heart attack, stroke, or needed heart surgery, as well as diabetic complications
related to the eye, kidney, and nerves.
• The EDIC study also examined the impact of intensive control versus standard
control on quality of life.
EDIC Study Findings

• Intensive blood glucose control reduces risk of

– any cardiovascular disease event
42% reduced risk
– nonfatal heart attack, stroke, or death from cardiovascular causes
57% reduced risk
Diabetic retinopathy
• Risk of diabetic retinopathy after 15 yr duration of diabetes is 98% for T1DM
patients and 78% for those with T2DM
• Rates of diabetic retinopathy range from 15-30%
• Types
– Non proliferative
– Background diabetic retinopathy-microaneurysms, dot and blot hemorrhages,
hard and soft exudates, venous dilation and beading, intraretinal microvascular
abnormalities
– Proliferative diabetic retinopathy- neovascularization, fibrous proliferation and
preretinal and vitreous hemorrhage

54
Management of Diabetic retinopathy
• Once sight-threatening retinopathy- laser photocoagulation and/or anti-VEGF
therapy(For PDR, intravitreal injection of anti-VEGF (ranibizumab, aflibercept,
bevacizumab)

• In advanced diabetic eye disease: severe vitreous hemorrhage or fibrosis, with

retinal detachment- vitrectomy

55
Diabetic nephropathy
• Major cause of morbidity and mortality amongst young adults with type 1 diabetes
• Affects 20-30% of patients with T1DM and 15-20% of patients with T2DM patients 20 year after
onset
• Risk of nephropathy increases with duration of diabetes, degree of metabolic control, and genetic
predisposition to essential hypertension
• Only 30-40% of patients affected by T1DM eventually experience ESRD
• Stages
– Earliest - glomerular hypertrophy, hyperfiltration, and hyperperfusion.
– Stage of prealbuminuria- of subclinical morphological changes and increases in albumin
excretion rates (AER) within the normal range.
– Albuminuria - Further increases in albumin excretion, with an ACR between 30 and 300 mg/24 h
or 20 and 200 μg/min in a 24-hour or timed urine collection (stage 3)
– Overt proteinuria (formerly “macroalbuminuria)” (AER >200 μg/min or >300 mg/24 h) (stage
4)
– End-stage renal disease (ESRD) (stage 5).

56
 Management
• Once albuminuria is diagnosed, number of factors attenuate the effect of hyperfiltration on
kidneys:
– Meticulous control of hyperglycemia
– Aggressive control of systemic blood pressure
– Selective control of arteriolar dilation by use of ACE inhibitors
– Better lipid control
• Yearly screening for individuals with T2DM and yearly screening for those with T1DM
after 5 yr duration of disease

57
 Diabetic neuropathy
• Polyol pathway, nonenzymatic glycation and or disturbances of
myoinositol metabolism affect the peripheral nerves

• Heat induced pain threshold in the hand is correlated with the

duration of diabetes

• Subclinical motor nerve impairment is manifested by reduced

sensory nerve conduction velocity and sensory nerve action
potential amplitude can be detected during late puberty and after
puberty in approx. 10% of adolescents

• Early sign of autonomic neuropathy such as decreased heart rate

variability may present in adolescents with a history of long standing
disease and poor metabolic control
Modalities of treatment of diabetic neuropathy
• Improvement in metabolic control
• Use of aldose reductase inhibitors to reduce by products of the polyol pathway
• Use of alpha lipoic acid(antioxidant) which enhances tissue nitric oxide and its
metabolites
• Use of anticonvulsants for neuropathic pain
• Antidepressants
• antiarrhythmics

59
ISPAD Clinical Practice Consensus Guidelines 2018:
Microvascular and macrovascular complications in children and adolescents
60
 Screening Guidelines

American Diabetes Association: Children and adolescents: standards of medical care

in diabetes—2018. Diabetes Care 41(Suppl 1):S126–S136, 2018.
Challenges in diabetes care in children
• Diabetes is an expensive condition to manage for families
• Physiological-increased sensitivity to insulin and risk of hypoglycemia
• Developmental challenges
– Rapid period of physical growth and development
– Engage in frequent, inconsistent bursts of physical activity
– Difficulty verbalizing symptoms, thought, feelings
– Fear of injections, hospital, doctors, resistance to BG monitoring
– Diet control is problem
• Availability of insulin, insulin injection technology and monitoring facility
• Limited expertise centers

62
63
Recent advances in type 1 Diabetes management

Non insulin treatment

• Metformin might help prevent cardiovascular disease in T1D. This hypothesis is
being tested in the REducing with Metformin Vascular Adverse Lesions in type 1
diabetes (REMOVAL) study currently underway in Europe, Canada and Australia
• Pramlintide –a synthetic analogue of amylin approved for improving glycemic
control in type 1 DM
• Sodium–glucose cotransporter 2 inhibitor dapagliflozin achieved a dose-related
(but non-significant) reduction of glycaemic excursions and insulin requirement
• Glucagon-like peptide-1 analogue liraglutide suppresses glucagon levels and
reduces insulin requirements
• Dipeptidyl peptidase-4 inhibitor sitagliptin showed a trend to reducing
hyperglycaemia in a subset of patients
64
• Artificial pancreas – "Closed-loop" insulin pump devices, which deliver
insulin based on real time glucose concentrations and are controlled by
a computer driven algorithm
• Immunologic vaccination - against Glutamic acid decarboxylase
• T1D cure with pancreas or islet transplantation- are only offered to
individuals with diabetes and renal failure (pancreas) or severe
hypoglycaemia unawareness (islet cell transplants).

• Insulin gene therapy

• Stem cell therapy
65
Summary
• Risks of diabetes complications can be decreased with improved glycemic control and improved
management of associated risk factors— eg, hypertension and hyperlipidaemia .
• Insulin analogs, glucose monitoring, and delivery device technology leads to improved
management of disease and quality of life of affected individuals
• Basal bolus insulin should be prescribed over premixed insulin for better glycemic control if feasible.
• Screening for retinopathy (fundal examination), nephropathy (urine albumin/creatinine ratio) and
neuropathy (clinical examination) should be done annually. Child also screened for commonly
associated conditions such as thyroid and celiac disease .
• Nutritional management, Exercise, healthy diet and psychosocial support is essential.
• Diabetes education both to the patient and the caregivers allows better management in diabetes.
• In long term management of diabetes, a multidisciplinary team based approach allows improved
patient and caregiver involvement ,required for success in reaching management goals in children.

66
References
• Nelson Textbook of Pediatrics, 20 th edition.
• Type 1 Diabetes . Lancet. 2018, Lancet 2018; 391: 2449–62
• ISPAD Clinical Practice Consensus Guidelines 2018 Compendium; Pediatric
Diabetes 2018.
• Type 1 Diabetes Mellitus, Pediatrics in Review Vol.34 No.5 May 2013
• The Diabetes Control and Complications Trial Research Group. The Effect of
Intensive Treatment of Diabetes on the Development and Progression of Long-
term Complications in Insulin-dependent Diabetes Mellitus. N Eng J Med. 1993;
329(14):977–986.
• The Diabetes Control and Complications Trial/Epidemiology of Diabetes
Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive
Diabetes Treatment and Cardiovascular Disease in Patients with Type 1 Diabetes.
N Eng J Med. 2005; 353(25):2643–2653.

67
• Thank you

68