BNF for Children (BNFC) 2018-2019

resulting tissue damage has both short-term and long-term

adverse effects on health; this can result in retinopathy,

nephropathy, premature cardiovascular disease, and

peripheral artery disease.

Typical features in children presenting with type 1

diabetes are hyperglycaemia, polyuria, polydipsia, weight

loss, and excessive tiredness.

Aims of treatment

Treatment is aimed at using insulin regimens to achieve as

optimal a level of blood-glucose control as is feasible, while

avoiding or reducing the frequency of hypoglycaemic

episodes, in order to minimise the risk of long-term

microvascular and macrovascular complications. Disability

from complications can often be prevented by early

detection and active management of the disease (Diabetic

complications p. 449 ).

gThe target for glycaemic control should be

individualised for each child, considering factors such as

daily activities, aspirations, likelihood of complications,

adherence to treatment, comorbidities, and history of

hypoglycaemia. Tighter control of blood-glucose is now

recommended for children with type 1 diabetes and

treatment should attempt to reach near normal HbA 1 c and

blood-glucose concentration. A target HbA 1 c concentration

of 48 mmol/mol ( 6. 5 %) or lower is recommended in children

to minimise the risk of long-term complications. The

optimal plasma glucose targets for children are:

.fasting blood-glucose concentration of 4 – 7 mmol/litre on

waking;

.a blood-glucose concentration of 4 – 7 mmol/litre before

meals at other times of the day;

.a blood-glucose concentration of 5 – 9 mmol/litre after

meals;

.a blood-glucose concentration of at least 5 mmol/litre in

young people when driving.h

Overview

gType 1 diabetes requires insulin replacement,

supported when necessary by active management of other

associated cardiovascular risk factors such as hypertension.

Tight glycaemic control may be achieved by intensive insulin

management (multiple daily injections or insulin pump

therapy) from diagnosis, accompanied by carbohydrate

counting.

The effectiveness of metformin in combination with

insulin is not yet known in children, and so should not be

used; other oral antidiabetic drugs should not be used in

combination with insulin as their use may increase the risk

of hypoglycaemia.

Dietary control is important in both type 1 and type 2

diabetes and children (with their families) should be

encouraged to develop good knowledge of nutrition and how

it affects their diabetes and insulin requirements. Healthy

eating, regular exercise, and control of body-weight can

reduce cardiovascular risk and help improve glycaemic

control.

Children with type 1 diabetes over the age of 6 months

should receive immunisation against influenza and

pneumococcal infection (in children treated with

antidiabetic drugs)—see Vaccines p. 777 .h

Management of type 1 diabetes with insulin

gAll children with type 1 diabetes require insulin therapy

(see also Insulin p. 447 ). Treatment should be initiated and

managed by clinicians with relevant expertise; there are

three basic types of insulin regimen, although each regimen

should be individualised.

Children should also be offered carbohydrate-counting

training as part of a structured education programme.h

Multiple daily injection basal-bolus insulin regimens

One or more separate daily injections of intermediate-acting

insulin or long-acting insulin analogue as the basal insulin;

alongside multiple bolus injections of short-acting insulin

before meals. This regimen offersflexibility to tailor insulin

therapy with the carbohydrate load of each meal.

Mixed (biphasic) regimen

One, two, or three insulin injections per day of short-acting

insulin mixed with intermediate-acting insulin. The insulin

preparations may be mixed by the patient at the time of

injection, or a premixed product can be used.

Continuous subcutaneous insulin infusion (insulin pump)

A regular or continuous amount of insulin (usually in the

form of a rapid-acting insulin analogue or soluble insulin),

delivered by a programmable pump and insulin storage

reservoir via a subcutaneous needle or cannula.

Recommended insulin regimens

gChildren should be offered multiple daily injection

basal-bolus regimens initiated at diagnosis, considering

personal and family circumstances, and personal

preferences. Children and their carers should be encouraged

to adjust the insulin dose as appropriate after each blood-

glucose measurement, and to inject rapid-acting insulin

analogues before eating (rather than after eating); this

reduces blood-glucose concentrations after meals and helps

to optimise blood-glucose control.

If a multiple daily injection basal-bolus insulin regimen is

unsuitable, or the child does not have optimal blood-glucose

control, it may be necessary to offer an alternative insulin

regimen (either continuous subcutaneous insulin infusion or

once-, twice- or three-times daily mixed injections) as well

as additional support (such as increased contact with their

specialist diabetes team).

Continuous subcutaneous insulin infusion (or insulin

pump) therapy may be considered under the care of a

specialist team. It should only be offered to children over

12 years who suffer disabling hypoglycaemia, or, who have

high HbA^1 c concentrations (^69 mmol/mol [^8.^5 %] or above)

with multiple daily injection therapy (including, if

appropriate, the use of long-acting insulin analogues)

despite a high level of care. Children under 12 years may be

offered insulin pump therapy if a multiple daily injection

regimen is impractical or inappropriate, but they should

undergo a trial of a multiple dose injection regimen between

the ages of 12 and 18 years.

If the chosen regimen is a twice daily injection regimen,

the insulin dose should be adjusted according to the general

trend in pre-meal, bedtime and occasional night-time blood-

glucose concentration.h

Insulin requirements

gThe dosage of insulin must be determined individually

for each child and should be adjusted as necessary according

to the results of regular monitoring of blood-glucose

concentrations.

Prescribers and patients should be aware that initiation of

insulin may be followed by atemporarypartial remission

phase or‘honeymoon period’when lower doses of insulin

are required than are subsequently necessary to maintain

glycaemic control with an HbA 1 c concentration of less than

48 mmol/mol ( 6. 5 %).h

gInsulin doses should be reviewed after puberty

(around 1 year after menarche or after the growth spurt in

boys) as insulin resistance falls after puberty, and

maintenance of pubertal doses may increase the risk for

excessive weight gain.l

gPersistent poor glucose control, leading to erratic

insulin requirements or episodes of hypoglycaemia, may be

due to many factors, including adherence, injection

technique, injection site problems, blood-glucose

monitoring skills, lifestyle issues (including diet and

exercise), psychological issues, and organic causes such as

446 Diabetes mellitus and hypoglycaemia BNFC 2018 – 2019

Endocrine system

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