managing-pediatric-diabetes

# Managing Pediatric Diabetes

Guides comprehensive management of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in children and adolescents, including insulin regimen selection, dose adjustment algorithms, continuous glucose monitoring (CGM) interpretation, DKA management, school/504 plan creation, and transition planning. Aligned with ADA Standards of Care and ISPAD guidelines.

## Why This Skill Exists

Pediatric T1DM incidence continues to rise, and T2DM in youth has emerged as a growing epidemic, particularly in racial/ethnic minority populations. Unlike adult diabetes management, pediatric diabetes requires: physiologic insulin dosing adjusted for growth spurts and puberty, carbohydrate counting with unpredictable eating patterns, school accommodations under Section 504 or IDEA, psychosocial screening for diabetes distress, and age-specific DKA management protocols. This skill ensures all elements of comprehensive diabetes care are documented and addressed.

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## Checkpoint A — Intake Verification

### Required Intake Questions
1. What type of diabetes does the child have (T1DM, T2DM, monogenic/MODY)?
2. What is the child's age, weight, and Tanner stage?
3. What is the current insulin regimen (MDI or insulin pump)? What are the specific doses?
4. What is the current HbA1c? What was the trend over the last 3-4 values?
5. Is the child using a CGM? What is the time-in-range (TIR), time-below-range (TBR), and GMI?
6. How many hypoglycemic episodes in the last month? Any severe (requiring assistance)?
7. How many DKA episodes since diagnosis?
8. Does the child have a 504/school plan? When was it last updated?
9. Has the child been screened for celiac disease and thyroid disease?

### Required Documents
- Current insulin regimen with doses (basal, bolus, correction factor, I:C ratios)
- HbA1c history (at least 3 prior values)
- CGM download or blood glucose log (14+ days preferred)
- Most recent comprehensive metabolic panel and lipid panel
- Thyroid function (TSH), celiac screen (tTG-IgA + total IgA)
- Ophthalmologic exam results (if ≥ 5 years diabetes duration or age ≥ 10)
- Current 504/school plan (if exists)

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## Step 1 — Glycemic Targets and HbA1c Interpretation

### ADA-Recommended Targets for Pediatric Diabetes
| Metric | Target |
|--------|--------|
| HbA1c | < 7% for most; individualize (< 7.5% acceptable if hypoglycemia risk) |
| Time in range (70-180 mg/dL) | > 70% |
| Time below range (< 70 mg/dL) | < 4% |
| Time below range (< 54 mg/dL) | < 1% |
| Time above range (> 250 mg/dL) | < 5% |
| GMI (glucose management indicator) | Should approximate HbA1c ± 0.5% |

### HbA1c Discordance
- If HbA1c and CGM-derived GMI differ by > 0.5%, investigate:
  - Hemoglobin variants (sickle cell trait, thalassemia) affecting HbA1c accuracy
  - Anemia, recent transfusion
  - CGM wear time < 70% (unreliable GMI)

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## Step 2 — Insulin Regimen Management (T1DM)

### Total Daily Dose (TDD) Estimation
| Age/Stage | TDD (units/kg/day) |
|-----------|-------------------|
| Honeymoon phase | 0.3-0.5 |
| Pre-pubertal | 0.5-0.8 |
| Pubertal | 0.8-1.2 |
| Post-pubertal | 0.7-1.0 |

### Multiple Daily Injections (MDI) Setup
- **Basal insulin**: approximately 40-50% of TDD (glargine U-100 once daily or detemir BID)
- **Bolus insulin**: approximately 50-60% of TDD divided across meals using insulin-to-carb ratio (I:C)
- **Insulin-to-carb ratio**: 450-500 / TDD = grams of carb covered per 1 unit (starting estimate)
- **Correction factor (ISF)**: 1700 / TDD = mg/dL drop per 1 unit (starting estimate)

### Dose Adjustment Algorithm
| Pattern | Adjustment |
|---------|------------|
| Fasting BG consistently high (> 150) | Increase basal by 10-20% |
| Fasting BG consistently low (< 70) | Decrease basal by 10-20% |
| Post-meal BG high (> 180 at 2 hours) | Decrease I:C ratio (more insulin per carb) by 10-20% |
| Post-meal BG low (< 70 within 3 hours of meal) | Increase I:C ratio (less insulin per carb) by 10-20% |
| Overnight lows | Decrease basal OR bedtime snack |
| Dawn phenomenon (rising BG 3-8 AM) | Increase basal or split basal timing |

### Insulin Pump Therapy
- Preferred for children with frequent hypoglycemia, high HbA1c on MDI, or very young children
- Basal rates programmed hourly; bolus via pump calculator using I:C and ISF
- Hybrid closed-loop systems (Tandem Control-IQ, Medtronic 780G, Omnipod 5): automatically adjust basal and deliver correction boluses
- Download pump data at every visit: review basal pattern, bolus frequency, override rate

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## Step 3 — Hypoglycemia Management

### Severity Classification
| Level | Definition | Treatment |
|-------|-----------|-----------|
| Level 1 | BG 54-69 mg/dL | 15g fast-acting carbs; recheck in 15 min (Rule of 15) |
| Level 2 | BG < 54 mg/dL | 15-30g fast-acting carbs; recheck; may need repeat |
| Level 3 (severe) | Altered consciousness, seizure, requiring assistance | Glucagon: 0.5 mg IM/SC (< 25 kg) or 1 mg IM/SC (≥ 25 kg); OR nasal glucagon 3 mg; OR dasiglucagon 0.6 mg SC |

### Hypoglycemia Prevention
- Review every hypoglycemia event: timing, preceding activity, insulin dose, carb intake
- Recurrent pattern at same time → adjust insulin
- Exercise-induced: reduce bolus before exercise by 25-50%, or provide 15-30g carb pre-exercise
- Hypoglycemia unawareness: raise BG targets temporarily to restore awareness; consider CGM with low alert set to 80 mg/dL

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## Step 4 — DKA Management (Pediatric Protocol)

### DKA Diagnosis
- BG > 200 mg/dL (may be lower in known diabetics on SGLT2 inhibitors or partially treated)
- Venous pH < 7.3 OR bicarbonate < 15 mmol/L
- Ketonemia (beta-hydroxybutyrate > 3 mmol/L) or ketonuria

### Severity
| Severity | pH | Bicarbonate |
|----------|-----|-------------|
| Mild | 7.2-7.3 | 10-15 |
| Moderate | 7.1-7.19 | 5-9 |
| Severe | < 7.1 | < 5 |

### Fluid Management (ISPAD/PECARN Protocol)
- Initial bolus: 10-20 mL/kg NS over 1-2 hours (only if hemodynamically compromised; otherwise start maintenance rate)
- Maintenance + deficit replacement over 24-48 hours
- Do NOT exceed 1.5-2× maintenance rate (cerebral edema risk)
- Switch to D5 + 0.45-0.9% NS when BG < 300 mg/dL (maintain insulin infusion)

### Insulin
- Start insulin infusion at 0.05-0.1 units/kg/hour (do NOT bolus insulin in pediatric DKA)
- Goal: BG decline of 50-100 mg/dL/hour
- Do not decrease BG faster than 100 mg/dL/hour (cerebral edema risk)
- Continue insulin drip until: pH ≥ 7.3, bicarbonate ≥ 15, AG closed, patient tolerating PO

### Cerebral Edema Monitoring
- Most feared DKA complication in children; mortality 20-25% when it occurs
- Risk factors: young age, new-onset diabetes, severe acidosis, over-aggressive fluid resuscitation, rapid BG drop
- Signs: headache, altered mental status, hypertension, bradycardia, pupil changes
- Treatment if suspected: hypertonic saline 3% (5-10 mL/kg over 15-30 minutes) OR mannitol 0.5-1 g/kg IV; elevate head of bed; reduce IV fluids

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## Step 5 — Complication Screening

### Annual Screening Schedule (ADA Standards of Care)
| Complication | Screen | When to Start |
|-------------|--------|---------------|
| Retinopathy | Dilated eye exam or retinal photography | Age ≥ 11 and ≥ 2 years T1DM duration; OR ≥ 5 years duration regardless of age |
| Nephropathy | Urine albumin-to-creatinine ratio (UACR) | ≥ 10 years old and ≥ 5 years T1DM duration |
| Neuropathy | Foot exam, monofilament testing | ≥ 10 years old and ≥ 5 years duration |
| Dyslipidemia | Fasting lipid panel | At diagnosis (after glucose stabilization), then every 5 years if normal; annually if abnormal |
| Thyroid | TSH | At diagnosis, then every 1-2 years (T1DM associated with autoimmune thyroiditis) |
| Celiac | tTG-IgA + total IgA | At diagnosis, then within 2 years and as symptoms warrant |
| Blood pressure | Every visit | Every visit from diagnosis |

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## Step 6 — School/504 Plan and Psychosocial Support

### 504 Plan (Section 504 of Rehabilitation Act)
Every child with diabetes is eligible. The plan must include:
- Unrestricted access to blood glucose monitoring and CGM use in classroom
- Permission to eat snacks as needed for hypoglycemia prevention
- Unrestricted access to water and bathroom
- Trained staff member to assist with insulin administration (if age-appropriate delegation)
- Protocol for hypoglycemia treatment including glucagon administration
- Accommodations for testing (extended time if BG is out of range)
- Field trip and extracurricular activity accommodations
- Emergency contact information and physician orders

### Psychosocial Screening
- Screen for diabetes distress at every visit (Diabetes Distress Scale or PAID)
- Screen for depression (PHQ-A) annually
- Screen for disordered eating behaviors (insulin omission for weight loss = "diabulimia")
- Assess family functioning: caregiver burnout, parent-child conflict around management
- Refer to diabetes-experienced mental health provider when indicated

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## Checkpoint B — Diabetes Management Review

- [ ] Diabetes type confirmed and documented
- [ ] HbA1c obtained and trended with prior values
- [ ] CGM data reviewed: TIR, TBR, TAR, GMI documented
- [ ] Insulin regimen documented with all doses, I:C ratios, ISF, and correction targets
- [ ] Dose adjustments made based on identified patterns
- [ ] Hypoglycemia events reviewed with pattern analysis
- [ ] DKA prevention education provided (sick day rules documented)
- [ ] Annual complication screening current (eyes, kidneys, thyroid, celiac, lipids)
- [ ] 504/school plan reviewed or created/updated
- [ ] Psychosocial screening completed (distress, depression, eating behaviors)
- [ ] Transition planning discussed (if age ≥ 16)
- [ ] All [VERIFY] flags resolved or escalated

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## Quality Audit

| Item | Requirement | Pass? |
|------|-------------|-------|
| HbA1c monitoring | Obtained at least every 3 months | |
| CGM utilization | Data downloaded and reviewed; TIR documented | |
| Insulin optimization | Pattern-based adjustments documented | |
| Hypoglycemia review | Events counted, patterns identified, glucagon prescribed | |
| DKA education | Sick day rules provided in writing | |
| Complication screening | All age-appropriate screens current | |
| Thyroid/celiac | Screening per schedule | |
| 504 plan | Current plan on file and reviewed | |
| Psychosocial screen | Distress and depression screening done | |
| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |

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## Guidelines

- Follow ADA Standards of Care in Diabetes (updated annually) — Pediatric-specific chapter
- Follow ISPAD (International Society for Pediatric and Adolescent Diabetes) Clinical Practice Consensus Guidelines
- Apply PECARN/ISPAD DKA fluid management protocol for pediatric DKA
- CGM targets: ADA/ISPAD consensus on time-in-range goals
- Insulin adjustment: use the 450/500 rule (I:C) and 1700 rule (ISF) as starting points; individualize
- Closed-loop systems: follow manufacturer and endocrinology guidance for settings
- Glucagon prescribing: ensure every family has a current glucagon kit (IM, nasal, or SC formulation)
- Section 504: federally mandated; schools must comply with physician-directed diabetes management plan
- T2DM in youth: metformin first-line (if not in DKA); insulin if HbA1c ≥ 8.5% or symptomatic; GLP-1 RA emerging per ADA
- Transition planning: begin at age 16; complete transfer to adult endocrinology by 18-22
- This skill produces clinical documentation; it does not replace clinical judgment