Insulin Therapy For Children

Introduction

Insulin therapy is an essential part of managing diabetes for many children. Insulin helps regulate blood glucose levels by allowing cells throughout the body to absorb and utilise glucose from the bloodstream".¹ For children with type 1 diabetes and some cases of type 2 diabetes, insulin therapy is necessary to achieve glycaemic control and reduce complications related to prolonged high blood sugar.

Parents and caregivers of children using insulin therapy must have a comprehensive understanding of the several types of insulin, delivery methods, dosage adjustments, and other key aspects of care. By equipping themselves with the knowledge of insulin therapy principles and techniques, parents can provide optimal at-home diabetes management while children are under their supervision. Establishing consistency also helps ease potential anxiety children may initially feel towards insulin treatment.

The purpose of this article is to provide parents and caregivers with the key information needed to understand insulin therapy protocols, work closely with healthcare teams to initiate and adjust therapy for their child, and feel empowered to make insulin therapy a normal part of life for the entire family.²

Types of diabetes in children

There are two main types of diabetes which occur in children - type 1 and type 2. Understanding the causes and characteristics of each type gives important context for insulin therapy requirements.³

Type 1 diabetes

Type 1 diabetes, formerly called juvenile diabetes, accounts for most diabetes cases in children. It is an autoimmune disease where the body destroys the insulin-producing beta cells in the pancreas. This leaves the child dependent on external insulin.⁴

Causes and risk factors

The exact cause or combination of triggers leading to type 1 diabetes is still under some debate. However, these factors are all believed to play a role:

Genetics

Having a first-degree relative with type 1 diabetes significantly raises risk. Certain HLA genotypes make a child more susceptible.

Environmental

Potential triggers under investigation include early infant diet, exposure to viruses, and gut bacteria imbalances.

Immune system dysregulation

The body's immune defences start attacking normal healthy beta cells, severely lowering insulin production over time".⁵

Regardless of what initiates the onset of type 1 diabetes, all children afflicted with the condition then rely completely on outside insulin administration for survival once beta cell loss reaches a critical point".⁶

Insulin dependence

"Exogenous insulin therapy becomes an absolute necessity for children with type 1 diabetes. Without ongoing insulin doses that mimic physiologic insulin levels, children experience hyperglycaemia that can turn into life-threatening diabetic ketoacidosis (DKA)".⁷ DKA is a medical emergency that can lead to coma or death.

Type 2 diabetes

While still less common in youth than type 1 diabetes, rates of type 2 diabetes in children are rising, fuelled by increasing childhood obesity levels. Unlike type 1 diabetes, which requires insulin supplementation for survival, some children with type 2 diabetes can achieve glycaemic control via lifestyle modifications, oral medications, or a combination of treatments. However, many paediatric type 2 diabetes patients do utilise some form of insulin therapy for management at diagnosis or eventually require insulin to reach HbA1c goals as the disease progresses.⁸

According to the latest CDC reports, around 3,700 children and adolescents in the United States under age 20 receive a new diagnosis of type 2 diabetes annually - a significant rise over previous decades. Obesity plays a significant role in the growing epidemic of youth-onset type 2 diabetes. Close to 40 per cent of U.S. children have a body mass index (BMI) qualifying in the overweight or obese range. Carrying excess weight raises insulin resistance and diabetes risk dramatically during childhood.

Role of insulin in type 2 diabetes management

At diagnosis, changes in nutrition and physical activity may help some children succeed with oral medications or no pharmacological intervention. However, youth often have trouble sustaining intensive lifestyle changes. Within a few months to years of diagnosis, many children require supplemental insulin or insulin alone to control type 2 diabetes as pancreas function declines. Using insulin as needed alongside other treatments can help prevent complications of prolonged hyperglycaemia during vulnerable childhood and adolescent developmental windows.

Overview of insulin and its function

Insulin is an anabolic hormone produced in the beta cells located in the pancreas. It plays an indispensable regulatory role in allowing glucose to be used inside most cells throughout the body. Insulin levels spike after meals when blood glucose levels rise.

This triggers increased glucose uptake from the blood into the liver, muscle and fat cells for immediate energy or storage for later energy needs. Insulin also controls various genes and enzymes involved in glucose, lipid, and protein metabolism. Balancing food intake with just the right amount of insulin release keeps blood glucose levels tightly maintained - deviations from the normal range result in diabetes and its health consequences.¹

When children have insulin deficits, providing external sources of insulin helps restore this homeostasis. Today, we can supplement or replace missing insulin via injections and pumps with short-acting and long-acting insulin analogues that closely mimic natural pancreatic insulin output.²

Different types of insulin

There are several varieties of insulin used in paediatric therapy. They differ in on-set, peak action time, and duration. Some mirror natural bolus secretions that handle mealtime glucose spikes, while others provide steady basal coverage. Common insulins utilised include:

Rapid-acting insulin

Examples are insulin lispro (Humalog), insulin aspart (Novolog) and insulin glulisine (Apidra). Onset begins within 15 minutes following injection, peaks from 1-2 hours, and remains active for 2 to 4 hours total. These are taken at mealtimes and rapidly counter the glucose surge during digestion.³

Short-acting insulin

Regular or neutral protamine Hagedorn (NPH) insulin takes effect within 30 minutes to 1 hour, peaks anywhere from 2 to 8 hours based on dose and lasts for up to 16 hours. NPH is sometimes used as a mealtime insulin but is also utilised to provide baseline insulin between meals and overnight.⁴

Intermediate-acting insulin

An example is NPH insulin, especially when given twice daily as opposed to once a day. This provides more stable coverage for controlling glucose outside mealtimes".⁵

Long-acting insulin

Examples include insulin detemir (Levemir) and insulin glargine (Lantus). Onset is 1 to 2 hours, and the duration is flat for 24 hours, without a pronounced peak. This gives steady, non-peaking coverage to control fasting blood glucose levels.⁶

Insulin delivery method

There are three common methods for administering insulin therapy in children - injections, pumps, and closed-loop systems. The latter automatically adjusts background insulin delivery via continuous glucose monitoring.⁷

Insulin injections

Injected insulin is absorbed into local subcutaneous tissue and then enters the bloodstream to take effect. This route is simple, accessible, and allows for reasonable accuracy in dosing. Children receive either multiple daily injections, known as MDI, or one single daily long-acting insulin shot combined with oral medicines.

Physical discomfort, inconvenience, needle anxiety, lipodystrophies, and compliance issues are the biggest downsides to long-term injections. Still, modern needles are exceedingly small to minimise pain, and innovative self-applied patch pumps are also now available.⁸

Insulin pumps

Insulin pumps continuously infuse rapid or short-acting insulin under the skin 24/7 via a catheter placed on different body areas each day. Some portion serves as mealtime bolus insulin and the rest provides adjustable background basal support. Pumps allow children to receive more precise, customisable insulin tailored to their needs. However, wearing pumps can cause discomfort and require diligence. Pumps also carry the risk of site infection or diabetic ketoacidosis if they malfunction or catheter dislodgement occurs.

Continuous glucose monitoring (CGM)

CGM utilises a sensor inserted under the skin to constantly measure interstitial fluid glucose levels which correlate closely to blood glucose. Readings are transmitted to receivers, phones, pumps, and even watch devices, and some new models provide alerts for pending highs and lows. Combining CGM glucose data with automatically adjusting pump insulin delivery allows a closed-loop system that functions as an artificial pancreas. This emerging hybrid approach has tremendous promise.¹

Initiating insulin therapy in children 

The process for determining appropriate initial insulin regimens for children involves blood glucose monitoring, thorough medical assessments, selecting an insulin plan, and extensive teaching for caregivers on administration techniques and diarrhoea management at home. It also requires emotional support for the profound lifestyle change a diabetes and insulin therapy diagnosis precipitates.²

Diagnosis and assessment

Confirming the diagnosis of diabetes and determining its underlying type and severity guides health providers on when to start prescribing insulin therapy or what combination therapy to recommend.³

Blood glucose monitoring 

Checking blood sugar classifications gives insight into how severely insulin-deficient the child may be. Symptoms are also assessed. Polydipsia (intense thirst), polyphagia (increased hunger), polyuria (frequent urination), weight fluctuations, and fatigue often emerge as glucose control worsens. Finger-stick home blood glucose meters are utilised for initial and ongoing daily monitoring.⁴

HbA1c levels

This lab value indicates average blood glucose over a 2 to 3-month stretch. Freshly diagnosed children with severely uncontrolled diabetes often have HbA1c levels at 14.⁵

Educating parents and caregivers 

Extensive teaching is provided to parents and other caregivers who will oversee administering insulin and managing the child’s diabetes. Topics include:

Insulin administration techniques

Nurses demonstrate how to prepare and administer insulin injections and operate pumps. Supervised return demonstrations help ensure comfortable proficiency. Common injection sites and infusion set placement are reviewed along with site rotation importance. Hands-on practice checking blood glucose levels is also included.⁶

Recognition of hypoglycaemia and hyperglycaemia symptoms 

Parents must understand how to interpret symptoms of insulin excess causing blood sugar drops (hypoglycaemia) and insulin inadequacy leading to high blood sugar (hyperglycaemia). This assists with taking appropriate actions for out-of-range levels once insulin therapy commences. Suspending insulin infusion or giving rescue glucose for hypoglycaemic emergencies is covered. Never rationing or skipping insulin doses is strongly emphasised, even when families struggle financially.⁷

Adjusting insulin dosages

Achieving tight glycaemic control in children involves frequent adjustments to insulin doses. Numerous factors impact how much insulin a child needs daily or week to week. Maintaining vigilance through blood glucose testing and tracking patterns is necessary for dosing titration.⁸

Factors influencing insulin requirements

Insulin plans never stay entirely static because a child’s endogenous and exogenous daily insulin necessities rise and fall in response to:

Growth spurts

Growth spurts evolve insulin demands as muscle tissue expands and metabolism accelerates. Parents may witness appetite changes or unexplained high blood sugars as clues that growth is spurring insulin needs upward.

Physical activity

Exercise lowers blood glucose, so insulin reductions may prevent hypoglycaemia. Long-term activity levels improve insulin sensitivity, but doses need alignment when children are less active, like summer break.

Illness

Illness suppresses appetite and physical activity. Insulin adjustments prevent hypoglycaemia during sick days and allow children to keep ingesting carbs and fluids. Infections directly impact blood sugars as well.

Individualising insulin regimens for children

The highly variable nature of type 1 diabetes coupled with differing lifestyles makes utilising general insulin guidelines inadequate for achieving optimal outcomes in children. Insulin regimens need to be individually customised. For example, recently diagnosed children under age 12 often receive twice daily mixes of short-acting and intermediate-acting insulins.

Older, more independent youth transition towards basal-bolus regimens with mealtime rapid-acting coverage. Still, overall doses account for pubertal status, gender, food preferences and age-appropriate activities rather than strict calculations alone. Customising insulin for the child prevents problematic rigid standardisation.¹

Despite best intentions and medical support, children and families invariably face both practical and psychological barriers complicating insulin therapy. Being aware of hurdles that potentially arise helps parents prepare themselves and their children for the realities of managing diabetes long-term.²

Psychological impact on children and parents 

Dealing with diabetes and daily insulin management has profound effects on emotional well-being and mental health for children and parents or guardians. Supportive interventions can make coping easier in the face of added life stresses.³

Coping strategies

Children benefit when parents first deal with their fears and sadness stemming from diagnosis. Masking feelings teaches unhealthy repression. Support groups connect families with others traversing similar terrain who understand unique diabetes issues. Therapy aids in processing diagnosis emotions. Mindfulness, relaxation techniques and maintaining self-care help prevent parental burnout since childhood diabetes requires round-the-clock vigilant oversight.⁴

Support networks

Children themselves also need coping outlets like journaling feelings, diabetes summer camps with specialised staff, or finding online groups and blogs where they feel less alone with tough diabetes routines. Age-appropriate counselling explores their losses and tackles self-image issues like weight changes or insulin delivery visibility among peers.⁵

School and social considerations

Diabetes, and new insulin regimens impact school attendance along with peer relationship dynamics. Children deserve proper support in both areas.⁶

Communicating with teachers and school staff

Section 504 educational plans, individualised health plans and emergency care plans are important accommodations that provide health support protecting children’s consistent school access and ability to learn. Parent and school nurse diabetes training ensures proper illness and low blood sugar identification and response. This alleviates text anxiety kids may have managing diabetes tasks like testing and eating without negative peer attention. Plans also include accommodating frequent bathroom privileges.⁷

Empowering children to self-manage 

As children mature into preteens and teens, they require changes to gradually take charge of their own glucose testing, insulin administration and adjusting to physical activity and dietary choices. This allows appropriate adolescent autonomy development despite dealing with diabetes. Educators and providers emphasise actions supporting self-efficacy and confidence. Peer insensitivity gets addressed through sensitivity training promoting inclusiveness and anti-bullying.⁸

Future developments in paediatric insulin therapy

Both extensive research and promising innovations for improving paediatric insulin therapy outcomes are rapidly evolving. Scientific exploration also continues to prevent or reverse type 1 diabetes.

Research advancements

Many investigators devote careers to paediatric endocrinology queries, given youth are vulnerable to diabetes health threats during critical growth stages. Both pharmaceutical and government-funded research programs actively pursue discoveries that better children’s diabetes health such as:

Closed-loop systems

Automated pumps adapting insulin doses utilising connected continuous glucose monitor data will soon revolutionise care. Hybrid closed-loop devices showed improved glycaemic control over conventional pumps in paediatric studies. Fully automated artificial pancreas-like systems are reaching clinical trials. These technologies should assist diabetes self-management.

Novel insulin formulations 

Rapid-acting insulins are undergoing enhancements in bioavailability and timing of peak action. Concentrated and consistently absorbed forms requiring less volume for equivalent glucose-lowering potency are in development. Once commercialised, adjusting mealtime coverage should prove easier with extended and more predictable tailored insulin activity profiles.

Summary 

Insulin therapy forms a cornerstone in effective diabetes management starting from the point of diagnosis. Various insulin formulations and delivery approaches now help restore missing or inadequate insulin levels children need to regulate energy flow into cells. Dynamic insulin regimens require customisation to match each youth’s changing lifestyle patterns.

Mastering self-monitoring paired with seamless team collaboration allows frequent insulin dose titrations in anticipation of fluctuating requirements or unanticipated needs. Paediatric insulin therapy also warrants appreciation for strong psychological elements interplaying with physiological ones. Smooth initiation and adjustment of insulin treatment combine both medical and emotional support.

Ongoing research foreshadows exciting progress, reducing complication risks and self-management burdens for children living with diabetes through most of childhood. Continual communication with children’s healthcare providers as partners optimises insulin therapy safety and efficacy on the journey to eventual cure.