HELP ON DIABETES

INSULIN THERAPY FOR CHILDREN

Adjusting Insulin Doses

Insulin dosages are based on weight of your child in kilograms (1 kg is equal to 2.2 pounds). The doses vary based on whether the child is in the honeymoon phase or not and whether he or she is going through puberty.

• During the honeymoon phase, your child will need very little insulin, and a simple insulin regimen with two or three injections a day may suffi ce. The basal insulin needs may be as low as 0.125 units per kilogram. The ratio for carbohydrate might be 1 unit of insulin for 60 to 75 grams carbohydrate, and your child may not need any insulin for corrections. 
• Once the honeymoon phase is over, your child’s basal insulin needs may go up to 0.25 units per kilogram, and the insulin to carbohydrate ratio may go up to 1 unit for 15 to 60 grams carbohydrate. He or she may also need insulin for correction, for example, 1 unit for every 50 to 200 mg/dl blood glucose over her target. 
• When your child goes through puberty, the insulin needs go up substantially—this is principally because of the growth hormone pulses. Now the basal insulin requirements might be as much as 0.5 to 0.75 units per kilogram, the ratio for carbohydrate might be 1 unit for 8 to 10 grams carbohydrate, and the corrections for high sugars might be about 1 unit for 30 mg/dl blood glucose over target. Let your child know that this increase in dose is normal. 

The dose ranges I have quoted are general guidelines; every child is different, and the doses your child’s doctor will prescribe will depend on his or her age and size.

Working with Small Insulin Doses

Giving the small doses of insulin can be challenging. Eli Lilly and Novo Nordisk make pens that will deliver in half units, but the minimum dose is 1 unit. Becton, Dickinson and Company makes an ultrafine short-needle insulin syringe with half-unit markings. You can also ask your pharmacy to dilute the insulin. Eli Lilly makes a diluent for NPH, regular, and Humalog insulin. Similarly, Novo Nordisk makes a diluent for Novolin regular, and this can also be used for NovoLog. For U50 insulin, the insulin is diluted by 50 percent, so 1 ml contains 50 units of insulin. If you draw up 1 unit on an insulin syringe, you are giving 0.5 units. For U10 insulin, the insulin is diluted by 90 percent, so 1 ml contains 10 units of insulin. If you draw up 1 unit on an insulin syringe, you are giving 0.1 units.

The diluted insulin does not last as long, and you may need a new diluted batch every two weeks. If you use diluted insulin for your child, it is very important that all caregivers are aware of this to avoid giving the same amount of undiluted insulin.

Managing the Decreased Duration of the Action of Injected Insulin

Very young children need tiny amounts of insulin, and because the volumes of insulin are so small, the insulins work for shorter periods. Thus insulin glargine does not last for twenty-four hours and usually has to be given twice a day for basal coverage.

Injection Sites

Inject the insulin in the abdomen (avoid the two-inch area in the center—one inch either side of the umbilicus). Alternative places to inject include the front and side of thighs (top and outside is best), buttocks, and side of arms. Do not inject in the same spot again and again because it can cause lipohypertrophy, a thickening of the tissues that interferes with the absorption of insulin. After injecting with a pen, count to ten before removing the needle to avoid insulin leakage.

Limiting the Number of Injections

Children have multiple meals and snacks throughout the day, but insulin is not usu­ally given for all the meals (this is especially true for babies). Usually, a basal insu­lin is given and then corrections made by giving extra doses as needed. If a child is unwilling to get an insulin injection at lunchtime at school, then a mixture of fast-acting insulin analog with NPH injected in the morning will cover breakfast and the lunchtime meal, provided the child is willing to eat a consistent amount of carbohy­drate at lunch. The next injection can be fast-acting insulin with the after-school snack and/or dinner, and then an NPH injection at bedtime.

If your child needs her insulins to be mixed, use the following guidelines for mixing insulins:

• Draw up regular insulin or the fast-acting insulin analog fi rst—then draw up the NPH (that is, “clear insulin before cloudy”). To prevent the formation of a vacuum in the vial, you are supposed to put an equal amount of air into the vial as the amount of insulin you are going to draw up. So, if you are going to draw up 3 units of Lispro and 7 units of NPH, you first put 7 units of air in the NPH bottle and then put 3 units of air in the Lispro bottle; next draw up 3 units of Lispro and then 7 units of NPH. You do not have to put air into vials if you use only a small amount of insulin in a vial every month before discarding it and opening a new vial. 
• Even though mixing insulin glargine with the fast-acting insulin analogs is not recommended, you can do this provided it is done immediately before injecting—draw up the fast-acting insulin (lispro or insulin aspart) and then draw up the insulin glargine. The mixture does go cloudy, but go ahead and inject it anyway. 
• Do not mix insulin detemir with insulin aspart: this reduces the effect of insulin aspart by 40 percent. 

Using Small Needles

Use short needles for children because they do not have much fat. Inject at an angle to avoid giving intramuscular insulin, which would get absorbed much faster.

Handling a Fear of Needles

If your child has a fear of seeing the needle going into his or her skin during the injection, you can use a device called Inject-Ease, which hides the insulin syringe and needle. You place the device tip on the skin and press a button to give an injec­tion (see Resources). There are also covers available that hide the needles within the pens—examples include the NovoPen 3 PenMate and NeedleAid.

Using Insulin Pumps

Insulin pumps are an increasingly popular alternative to injections in children. The main disadvantage of pumps is that if the infusion set gets kinked or dislodged or there is a pump malfunction, the child can go into ketoacidosis within a few hours. Pumps are great for children and families who are proactive in managing the diabetes.