Managing Pediatric Diabetes

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)

Step 1 — Glycemic Targets and HbA1c Interpretation

ADA-Recommended Targets for Pediatric Diabetes

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)

Step 2 — Insulin Regimen Management (T1DM)

Total Daily Dose (TDD) Estimation

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

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

Step 3 — Hypoglycemia Management

Severity Classification

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

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

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

Step 5 — Complication Screening

Annual Screening Schedule (ADA Standards of Care)

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

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

Quality Audit

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