MANAGEMENT OF

T1DM
Presenter – Saurabh Agarwal (8th Semester, AIIMS, Jodhpur)
Goals
• Strict glycemic control and avoiding hypoglycemia
• To eliminate polyuria and nocturia
• To prevent ketoacidosis
• To permit normal growth and development with minimal effect on lifestyle
• Parent & patient education – disease, treatment, insulin administration, charting
of daily blood glucose results, detection of hypoglycemia and its immediate
management
• Insulin therapy
• Physical activity
• Nutritional counselling
• Psychosocial support
Insulin therapy
• Prolonged hyperglycemia impairs neurological development
• Dosing – depends on body weight and pubertal stage of child
• Dose adjustments are made until the target BG levels & HbA1c are not achieved.
Insulin regimens
A. Intensive (Basal bolus regimen)
 more closely mimics physiologic insulin secretion
 suppresses lipolysis and hepatic glucose production
 dose can be adjusted as per meal glucose content and BG levels more stable
glycemic control and fewer episodes of hypoglycemia
 cons – frequent BG monitoring & insulin injections, calculation of dietary
carbohydrates.
 Types -
i. multiple daily injections
ii. continuous insulin pumps
Multiple daily injections
• Use once a long acting insulin e.g., glargine along with pre-snack or pre-meal short
acting insulin (adjustable dose based on dietary content and current BG levels)
• E.g.,
1. short (70%) + intermediate (30%)
2. short (50%) + long (50%)
Insulin pumps
• Can be recommended in following cases:-
1. Recurrent severe hypoglycemia
2. Wide fluctuations of blood glucose levels
3. Micro/macrovascular complications
4. Young children & infants
5. Adolescents with eating disorders
6. Pregnant adolescents
B. Conventional (twice-daily infusion)
 using intermediate acting insulin twice and short-acting 2-3 times a day

 fixed regimen & patient should adjust as per the regimen

 For a 36 kg child who is started on 0.5 U/kg/d, the total dose is 18 U. Two-thirds of it
is given bbf -12U and one-third before evening meal – 6U. At each inj 1/3 is short-
acting and 2/3 is intermediate acting.
Blood glucose monitoring
• Ideally should be checked 4-6 times a day
• But it can be modified as per the patient’s need and affordability

(2016) (2018) (2018)

Therapies under development….
• Artificial pancreas or closed loop insulin pump devices
• Adjuncts – metformin, amylin analogues (pramlintide), GLP-1 receptor agonist
(e.g., exenatide)
• Islet cell transplantation
Hypoglycemia
• When BG levels <70 mg/dL or symptoms at a level close to this
• Causes – improper nutrition, physical activity, too much insulin

Mild Severe
Patient can recognize the symptoms and Associated with loss of consciousness or
is able to self-treat seizure
• Management
 Give fast acting glucose (e.g., sugar, honey, sweet drink) immediately – 0.3 g/kg

 Re-test BG 10-15 minutes later to confirm if the levels are in normal limits (> 100
mg/dL). If the BGL remains low or symptoms persist, repeat the above step.
 Severe hypoglycaemia with loss of consciousness ± convulsions (or if the child is
vomiting)
1. Glucagon (prefer) – im or sc <12y 0.5 mg
>12y 1.0 mg or 10-30mcg/kg of bw
2. If glucagon not available – iv dextrose 10% or 25%
 Nutritional management
• A dietitian should be consulted so that the meals are planned as per the insulin regimen.
• Growth monitoring every 6 months to check for adequate calorie intake
• 45-55% calories – CHO (70% complex CHO, low glycemic index foods e.g., whole-grain breads, pasta,
temperate fruits and dairy products)
• Use of sucrose is not forbidden, but it should be kept up to 10% of total energy
Protein requirement
• High fiber diet (for >2 y old age in years + 5 = g/day)
1y 2 g/kg
• Restricted salt intake if hypertensive
10 y 1 g/kg
• 30-35% calories – fats (<10% saturated fats, 10 % PUFA ω-3 & 6 FA, no trans-fats)
Adolescence 0.8-0.9 g/kg
• 15-20% calories - Protein (restriction, if microalbuminuria develops)
• Sweeteners may be used if necessary
• “Diabetic” foods are also not recommended because they are expensive, often high in fat and may
contain sweeteners with laxative effects. These include the sugar alcohols such as sorbitol.
• Routine vitamin & mineral supplements not required
Physical activity
• 30-60 min of moderate to vigorous intensity exercise daily
• But pre-exercise BG levels should be >100 mg/dL, can consume 1-1.5 g CHO/kg of
body weight during strenuous exercise
• If BG >250 mg/dL with ketonuria/ketonemia, exercise should be avoided.
Psychosocial support
• Affects lifestyle and interpersonal relationships of entire family
• Feelings of anxiety & guilt with denial & rejection are common
• Shared responsibility by both patient and parents has better outcomes
Sick day care
• Many illnesses with fever raise blood glucose levels d/t stress hormones
• Illnesses with GI symptoms can cause hypoglycemia d/t poor food intake, poor absorption &
changes intestinal motility
• Management –
1. do not stop insulin, but dose can be titrated as per BG levels
2. evaluate & treat acute illness
3. monitor BG levels 3-4 hourly & ketones 1-2 times/day
4. antipyretics, adequate fluid intake, easily digested foods
5. avoid strenuous exercise
6. admission – young dehydrated child, n/v, ketonuria, acute illness is severe
DKA management
Follow-up
• Weight should be measured at each visit, and Height every six months. Pubertal status should be
noted at relevant ages.
• HbA1c is ideally measured every three months. Target level is <7.5%.
• Blood pressure should be measured at least annually.
• After two years duration of diabetes, eyes should be checked for visual acuity, cataracts and
retinopathy annually.
• Peripheral and autonomic neuropathy should be assessed by history, physical examination and
sensory tests for vibration, thermal sensation or light touch.
• Urinary protein (and also serum creatinine if possible) should be measured after two years diabetes
duration, and annually thereafter.
• Fasting blood lipids should be performed when diabetes is stabilised in children aged over 12 years.
• Other conditions may occur with diabetes including hypothyroidism or hyperthyroidism, coeliac
disease, and Addison’s disease (rare) – screening for these may be appropriate.
Bibliography
• ISPAD. Pocketbook for Management of Diabetes in Childhood and Adolescence in
Under-resourced Countries, 2017.
• DiMeglio LA, Acerini CL, Codner E, et al. ISPAD Clinical Practice Consensus
Guidelines 2018: Glycemic control targets and glucose monitoring for children,
adolescents, and young adults with diabetes. Pediatr Diabetes. 2018;19(Suppl.
27):105–114.
• Smart CE, Annan F, Higgins LA, Jelleryd E, Lopez M, Acerini CL. ISPAD Clinical
Practice Consensus Guidelines 2018: Nutritional management in children and
adolescents with diabetes. Pediatr Diabetes. 2018;19 (Suppl. 27):136–154.
• Levitsky LL, et al. Management of Type 1 DM in Children & Adolescents.
UpToDate.com, 2019.
• Nelson Textbook of Pediatrics, 20e (2016)
THANK YOU