This document discusses insulin management for type 1 diabetes mellitus. It provides information on diabetic ketoacidosis, goals of treatment, criteria for diabetes diagnosis, the treatment team, intensive insulin therapy including different insulin preparations and regimens, goals for blood sugar and HbA1c levels, and home blood glucose monitoring. The standard treatment involves multiple daily insulin injections or insulin pump therapy to closely mimic normal insulin secretion and intensive education to allow patients to lead normal lives.

1. INSULIN MANAGEMENT
OF
TYPE I
DIABETES MELLITUS
DR.NEVA JAY
PG - MD PAEDIATRICS , VMKVMC

2. DIABETIC KETOACIDOSIS - LIFE THREATENING
COMPLICATION OF DIABETES
DKA – MAY BE THE FIRST PRESENTING SYMPTOMS OF
TYPE I DM CHILD
ONCE DKA HAS RESOLVED IN A NEWLY DIAGNOSED CHILD
THERAPY IS TRANSITIONED TO THAT OF NON-KETOTIC ONSET
CHILDREN WITH PREVIOUSLY DIAGNOSED DIABETES WHO DEVELOP DKA
ARE USUALLY TRANSITIONED TO THEIR PREVIOUS INSULIN REGIMEN

3. CRITERIA FOR DIAGNOSIS DIABETES MELLITUS
Symptoms of Diabetes &
Random blood glucose
> 11.1 mmol /l ( 200 mg/dl )
OR
Fasting blood sugar > 7 mmol /l ( 126 mg/dl )
OR
Two hour plasma glucose > 11.1 mmol /l ( 200 mg/dl ) during an
oral glucose tolerance test
ORAL GLUCOSE TOLERANCE TEST IS
CONTRAINDICATED

4. GOALS
Eliminate symptoms related to hyperglycemia
Reduce & Delay complications
Achieve a normal lifestyle & normal emotional &
social development
Achieve normal physical growth & development
Detect associated diseases early

5. PEDIATRICIAN
PEDIATRIC ENDOCRINOLOGIST
EXPERIENCED NURSING STAFF
DIETITIAN AS DIABETES EDUCATOR &
SOCIAL WORKER
A COMPREHENSIVE APPROACH WITH A
COMPLETE TEAM STAFFING

6. CURRENT THERAPEUTIC REGIMEN
INTENSIVE INSULIN THERAPY
 FREQUENT BLOOD SUGAR MONITORING &
 MULTIPLE INSULIN INJECTIONS or
 CONTINUOUS SUBCUTANEOUS INJECTION INFUSION
 ALONG WITH DIETARY MODIFICATIONS
INTENSIVE INSULIN THERAPY RESULTS IN BETTER BLOOD SUGARS &
REDUCED LATE COMPLICATIONS OF DIABETES BY 39 – 60 %

7. GOALS OF BLOOD SUGAR & GLYCATED HEMOGLOBIN (HBA1c)
TODDLERS & PRESCHOOLERS (0-6 YR)
Pre –meal glucose : 100 – 180 mg/dl
Bedtime & overnight glucose : 110 – 200 mg/dl
HbA1c < 8.5 %
SCHOOL AGE (6-12 YR)
Pre –meal glucose : 90 – 180 mg/dl
Bedtime & overnight glucose : 100 – 180 mg/dl
HbA1c < 8.0%
ADOLESCENTS & YOUNG ADULT
Pre –meal glucose : 90 – 130 mg/dl
Bedtime & overnight glucose : 90 – 150 mg/dl
HbA1c < 7.5 %

8. FEATURES OF DIFFERENT INSULIN PREPARATION
PREPARATION PROPERTIES ONSET PEAK EFFECTIVE DURATION
RAPID – ACTING :
LISPRO , ASPART
GLULISINE
FASTER ONSET; SHORTER DURATION 15 mins 0.5 – 1.5 hr 3 – 4 hr
SHORT – ACTING :
REGULAR 30 mins 2 hr 3 – 6 hr
INTERMEDIATE :
NPH INSULIN (protamine) SLOWER ONSET; LONGER DURATION 2-4 hr 6 – 10 hr 10 - 16 hr
LENTE (no longer used) SLOWER ONSET; LONGER DURATION 3-4 hr 6 – 12 hr 12 - 18 hr
LONG – ACTING :
ULTRA LENTE (no longer used) SLOWER ONSET; LONGER DURATION 6 – 10 hr 10 – 16 hr 18– 20 hr
GLARGINE (LANTUS) SLOWER ONSET; LONGER DURATION 4 hr NO PEAK 24 hr
LEVEMIR 3-4 hr Relatively
peakless
12 – 24 hr

9. LISPRO (L) AND ASPART (A) INSULIN ANALOGS :
 Absorbed much quicker because they do not form hexamers
 Has a Discrete pulses and short tail effect
 BETTER CONTROL OF POST-MEAL GLUCOSE &
 REDUCED BETWEEN-MEAL OR NIGHTTIME HYPOGLYCEMIA
REGULAR INSULIN :
 Conversion of Hexamers to Monomers Thus onset of action is 30 min slower
 Has a wide peak and a long tail for bolus insulin
 Limits postprandial glucose control ,
 Excessive hypoglycemic effects between meals &
 Increases the risk of nighttime hypoglycemia
 Feeding the insulin with snacks

14. PATHOGENESIS
FOLLOWING MEAL:
Energy released from ingested food
for immediate use or
stored as glycogen in Liver or Muscle &
any excess is deposited as adipose tissue
Anabolic steps are carried through insulin secretion & action
FASTING : Sleeping at night
Insulin level falls
Catabolic state
Mobilization of energy from the stores

15. TYPE 1 DM
Absence of Insulin
Peripheral utilisation of Glucose is halted
&
Post prandial hyperglycemia results
Low plasma insulin
Catabolic activity in liver by
Glycogenolysis & Gluconeogenesis
Endogenous glucose production
Fasting hyperglycemia
Counter-regulatory hormones induces glycogenolysis & gluconeogenesis, lipolysis & ketogenesis
Epinephrin , cortisol & growth hormones oppose the action of insulin &
Decrease the peripheral tissue utilization of glucose & glucose clearance
Elevated blood glucose level

16. INTERMEDIATE OR LONG-ACTING INSULIN
To provide background insulin to maintain
glycemic control during the
FASTING STATE
SHORT-ACTING INSULIN
To provide glycemic control in the
POST-PRANDIAL STATE

17. INSULIN STORAGE
Insulin has a “use by date” & a “expiry date”
Stored inside the Fridge – 2 – 8 C
Unopened Insulin – Stored until expiration date
Open vials :
stored in fridge at 2-8 C – used for 3months
Controlled room temperature - 28 days
PENS
Pen should not be stored in fridge
Controlled room temperature-used for 7–28 dys
depending the pen you use
NEVER TO BE FROZEN
Hot places / Hot cars / Sunlight / light
Never use insulin if expired
INSPECT YOUR INSULIN :
Clumps/solid white particles/crystals in bottle or
pen
Clear insulin should be clear & never cloudy
In use insulin
Discard after 28 days whether vial or cartridge
DO DON’T

18. INSULIN INJECTION
Preferred for Split mix regimen
40 units /ml vial = 40 U syringe
100 units/ml vial = 100 U syringe
Insulin syringe:
30 G -31 G -Pain free
Re – usable till bent
Never clean with spirit

19. INSULIN PEN
Preferred for Basal Bolus regimen
Used Multiple times - Pain free

20. Continuous subcutaneous insulin (CSII)
via battery-powered pump

21. INSULIN PUMP

23. SUB-CUTANEOUS INSULIN
INJECTION SITE
Insulin kept in fridge should be allowed to reach
room temperature before injection
Abdominal Injection sites – Best
Followed by outer arm
Followed by Thigh &
then Buttocks

24. Preventing FATTY LUMP
LIPOHYPERTROPHY
Retards uniform distribution of Insulin
Poor Glycemic control
FATTY LUMP
LIPOHYPERTROPHY
LIPOATROPHY
 SUB CUTANEOUS INJECTION - Different sites
Always rotated regularly
Not given in the same site in the morning & evening

25. INSULIN REQUIREMENT
CURRENT INSULIN - generated using recombinant DNA technology
DOSAGE :
During DKA : 0.1U/kg/hr of Short acting insulin
During Recovery : 2-3 U/kg/day
Honey moon phase : 0.5U/kg/day or Less or Virtually no insulin
Intensification phase : Infection – 0.7 to 1 U /kg/day
Puberty - 1 – 1.5 U/kg/day
INSULIN RQUIREMENT IS HIGHER IN PUBERTAL CHILDREN
Insulin sensitivity reduces during puberty – Insulin dose is increased upto 1.5 units/kg/day
Insulin sensitivity normalises at the End of puberty - Insulin dose reverted to 1unit/kg/day

26. Honey moon Period
New – onset diabetes have some residual  - cell function
Reduces exogenous insulin need
Insulin may needed to be stopped temporarily
Thus avoiding Hypoglycemia
Residual  - cell function usually fades within a few months and is reflected as a
steady increase in insulin requirement & wider glucose excursions
Newly Diagnosed children in Honey moon require 60 – 70 % of full replacement

27. Diabetes in Toddlers (1-3 yrs)
Present with more acute & severe symptoms of
Insulinopenia compared to older children
Goals of therapy is relaxed as they eat unpredictability
Hence Hypoglycemia
Goals in TODDLERS (0-3 yr):
High Target of Blood glucose levels : 110 – 220 mg/dl
HbA1c : 8 - 8.5 %
MANIFESTATION :
Pale , cranky, sweating,
let out a particular cry, become clumsy,
develop bluish tinge of lips & fingers,
Temper tantrum may be the chief symptoms
REPEATED HYPOGLYCEMIC EPISODES:
Affects the developing brain by resulting in
PERMANENT COGNITIVE , INTELLECTUAL &
LEARNING DEFECTS
MRI : MESIAL TEMPORAL SCLEROSIS
a defect that is never observed in normal children

28. INSULIN REGIMEN
2 DOSE SPLIT - MIX Regime
(NPH) Intermediate acting + Short Acting (Regular)
BASAL - BOLUS INSULIN Regime
Long-acting insulin typically insulin Glargine (Lantus) + Rapid Acting

29. 2 DOSE SPLIT - MIX Regime
COMMOMLY USED CONVENTIONAL INSULIN PLAN
(NPH) Intermediate acting + Short Acting (Regular)
2 Injections are given daily
DAILY CALCULATED DOSE OF INSULIN IS DIVIDED
2/3rd 1/3rd
MORNING PRIOR TO BREAKFAST & EVENING PRIOR TO DINNER
2/3 NPH + 1/3 Short acting 1/2 - 2/3 NPH + 1/3 - 1/2 Short acting
(At Dinner or Bedtime)

30. Insulin injection is given 20 – 30 mins before meal
as the onset of action of Regular Insulin is 30 minutes after Injection
as the hexamers must dissociate into monomers subcutaneously
before being absorbed into the circulation
Delaying the meal 30-60 min after the injection for optimal effect
a delay rarely attained in a busy child’s life
REGULAR + NPH OR LENTE
POORLY MIMICS NORMAL
ENDOGENOUS INSULIN SECRETION

31. 2 DOSE SPLIT - MIX Regime

32. DRAWING UP A MIXED DOSE OF INSULIN
SHORT - ACTING INSULIN IS DRAWN BEFORE INTERMEDIATE ACTING INSULIN
CLEAR THEN CLOUDY
accidental introduction of longer-acting insulin in short-acting insulin can result in
increasing the duration of effect of short-acting insulin

33. Disadvantages of 2 DOSE SPLIT - MIX Regime
• Peaking in blood sugar following lunch is not covered adequately by
morning short-acting insulin as it is nearly over by then
Adolescents & Children without optimal blood sugar control
Extra dose of Short-acting insulin at Lunch time is added to the regimen
Peak action of the morning NPH falls between lunch & dinner Late Evening snacks
NPH insulin peaks around the middle of the night
leading to increasing risk of night time hypoglycemia &
NPH insulin is not sufficient to prevent the rise of hyperglycemia before breakfast

34. MEAL PLAN
3 MEALS and 2 or 3 SNACKS
[Mid-morning , in the afternoon & late evening]
IN REGULAR INTERVAL &
EQUAL IN CARBOHYDRATE & CALORIE CONTENT
Big meal = Hyperglycemia
Delayed or Reduced intake = Hypoglycemia

35. BASAL - BOLUS INSULIN Regime
Long-acting insulin typically Glargine (Lantus) + Short / Rapid Acting insulin
Long-acting analog glargine (G) with rapid bolus (L or A) on top of the basal insulin
More physiologic pattern of insulin effect
Insulin Glargine is steadily absorbed & acts over 24 hours provides a constant background level of insulin
without definite peak of action - FLATTER 24-HR PROFILE
Given once daily before bedtime
ADVANTAGES :
Postprandial glucose elevations are better controlled
Between-meal hypoglycemia and nighttime hypoglycemia are reduced

36. BASAL - BOLUS INSULIN Regime
Long-acting insulin typically Glargine (Lantus) + Short Acting insulin

37. SUBCUTANEOUS INSULIN DOSING
AGE
(yr)
TARGET GLUCOSE
(mg/dl)
TOTAL DAILY INSULIN
(U/kg/Day)
BASAL INSULIN
% OF TOTAL DAILY
DOSE
BOLUS INSULIN
UNITS ADDED PER 100
mg/dl above Target
UNITS ADDED
PER 15 g AT MEAL
0-5 100 - 200 0.6 – 0.7 25 - 30 0.50 0.50
5-12 80 - 150 0.7 – 1.0 40 - 50 0.75 0.75
12-18 80 – 130 1.0 – 1.2 40 – 50 1.0 - 2.0 1.0 - 2.0
Example 6 yr old child x 20 kg :
0.7 U/kg/24hr x 20 kg = 14 U / day
= 7 U (50 %) as Basal + 7 U as Total daily bolus
Subtract 1 U if below target
Add 0.75 U for each 100 mg/dl above target (round the dose to the nearest 0.5 U)

38. Dose of the short-acting insulin = amount of carbohydrate intake &
level of blood sugar
UNITS OF INSULIN PER G OF CARBOHYDRATE INGESTED
Most infants and young children : 1 unit of insulin per 20-30 g of carbohydrates
Older children : 1 unit per 10-15 g of carbohydrate
Adolescents : 1 unit of insulin per 5 g of carbohydrate
Insulin to carbohydrate ratio = 500 Total daily dose of insulin g/unit
 Example 6 yr old child x 20 kg :
1 U/kg/24hr x 20 kg = 20 U / day = 500 20 = 25 g of carbohydrates
1 U = 25 g of carbohydrate = 1 U is added

39. UNABLE TO ADMINISTER 4 DAILY INJECTIONS
COMPROMISE
3-INJECTION REGIMEN
NPH + RAPID ANALOG BOLUS AT BREAKFAST RAPID-ACTING ANALOG BOLUS AT SUPPER & NPH AT BEDTIME
FURTHER COMPROMISE
2-INJECTION REGIMEN
NPH + RAPID ANALOG AT BREAKFAST AND SUPPER
POOR COVERAGE FOR LUNCH AND EARLY MORNING &
INCREASE RISK OF HYPOGLYCEMIA AT MID-MORNING & EARLY NIGHT

40. GOAL
TO ACHIEVE A NEAR NORMAL BLOOD SUGAR
AT ALL TIMES WITH MINIMAL HYPOGLYCEMIA
THUS DELAYING LONG TERM
COMPLICATIONS OF DM

41. HOME BLOOD GLUCOSE MONITORING
provides a basic idea of Correctness of insulin doses used
& fine tuning to control blood sugar
DONE 3 or AT LEAST 2 CONSECUTIVE DAYS
4 TIMES A DAY :
PRE- BREAKFAST
2 HOURS AFTER BREAKFAST
PRE-DINNER
2 HOURS AFTER DINNER
Frequent blood glucose monitoring & insulin adjustment are necessary in the 1stweeks
as the child returns to routine activities & adapts to a new nutritional schedule &
as the total daily insulin requirements are determined

42. MODEL DIABETES DIARY or LOG BOOK
NAME :
AGE (DOB):
ADDRESS :
PHONE / MOBILE NO (PATIENT) :
PHONE / MOBILE NO (PARENTS) :
CLINIC NUMBER :
WEIGHT:
HEIGHT:
INSULIN REGIMEN & INSULIN DOSE
DATE FASTING PRE-
LUNCH
PRE-
DINNER
BED TIME 2-3 AM OTHER
TIME
INSULIN
ADJUSTED
REMARKS

43. INSULIN ADJUSTMENTS IN SPLIT- MIX REGIMEN
SMBG INSULIN TO BE ALTERED
Fasting Night NPH (SOMOGYI PHENOMENON)
Pre- Lunch Morning regular
Pre-Dinner Morning NPH
Bed Time Night regular
SMBG INSULIN TO BE ALTERED
Fasting & Pre-meals Long acting analog
Post meal Rapid or Regular before that meal
INSULIN ADJUSTMENTS IN BASAL BOLUS REGIMEN

44. SOMOGYI PHENOMENON
Rebound hyperglycemia - rare
DAWN PHENOMENON
Nocturnal secretion of growth hormones
Early morning hyperglycemia
(usually recurrent)
shifting the timing of evening dose of
intermediate acting insulin from pre-
dinner to 2 hours after dinner or at
bedtime
evening short- acting insulin dose is given
at pre-dinner
Excess Exogenous insulin
[evening dose of intermediate – acting ]
SILENT HYPOGLYCEMIA DURING THE NIGHT
Release of counter-regulatory hormones in the night
[Glucagon , cortisol , growth hormone & adrenaline]
Early morning hyperglycemia
Appropriate reduction in the evening dose of
intermediate – acting insulin

45. Diagnosis of Dawn & Somogyi phenomenon
Check for hypoglycemic event during middle of night
periodically at the same time
Hypoglycemia Blood sugar normal
Somogyi phenomenon Dawn phenomenon

46. EXERCISE & PHYSICAL ACTIVITY
 Important aspect in the management of Type 1 DM
 Improves glycemic control , Physical fitness , muscle strength , Psycological well-being
 Children participating in Sports or programmed exercises should be supervised & have access to sweetened
drinks & snacks
 Blood glucose should be monitored before , during & after physical activity
 Do not inject insulin into muscle – heavily involved in muscular activity
 Extra carbohydrate intake and /or reduced insulin dose is necessary
 Every 30 mins of of moderate exercise to intensive sports or physical activity = 15 g or extra serving of
Carbohydrate is added
 If Blood glucose < 100 mg/dl at bedtime = extra Carbohydrate is taken
 Check blodd glucose at 3 am
 Avoid Streneous physical activity = If Blod glucose > 250 mg/dl ,especially if ketones are present = Insulin

47. INFORMING SCHOOL AUTHORITIES
 Staff members & some close schoolmates of the child should be familiar with the special needs of the
child :
 Type 1 DM is not contagious disease
 They need to take 2 – 4 injections of insulin each day , Check blood glucose , Eat healthy food at fixed
timings and take precautions prior to physical activities
 Should not be treated differenly from other children
 Diabetes doe not affect academic performance , provided it is well controlled
 Teachers & close friends should be familiar with symptoms of high blood sugar - Parents should be altered
and
 Needs to consume extra snacks before , during & after exercise
 School nurse should supervise /administer Insulin
 Staff needs to have the Telephone number of the Child’s parent & the medical team in case of Emergency

48. HYPOGLYCEMIA
Need to know the early symptoms & first aid management of Hypoglycemia
If child complaints of Hypoglycemia or
found drowsy , confused or behaving in an erratic manner
Rx: 3 teaspoon of glucose powder or powered sugar is given ,
followed by snacks in the form of fruits, sandwich or biscuits
Administer glucagon (0.3-0.5 – young children & 1 mg for older children SC) shot
if severe hypoglycemia occurs (Blood Glucose < 70 mg/dl)

49. COMPLETELY
AUTOMATED
CLOSED LOOP
INSULIN PUMP
Currently being evaluated
INHALED INSULIN
Under clinical trials

50. O.P.Ghai 8th Edition
Nelson Textbook of Pediatrics -19th
Edition
IAP Textbook of Pediatrics 5th Edition
Achar’s Txtbk of Pediatrics
ISPAE Guidelines
ADA Guidelines
REFERENCE

51. THANK YOU
HAPPY LEARNING
DR.NEVA.JAY