Background: Our practice is to commence newly diagnosed children and young people (CYP) with diabetes, over 5 years old, on multiple daily insulin (MDI), using fixed Insulin to Carbohydrate ratios (ICRs) with meals across the day. ICRs are subsequently adjusted according to blood glucose response, individualising insulin treatment. We know intensified insulin therapy includes use of varied ICRs, reflecting varying insulin sensitivity at different times of day. We do not know whether glycaemic outcomes are better if varying ICRs are introduced from diagnosis, or subsequently.
Aims: To retrospectively audit ICRs in children with newly diagnosed diabetes at diagnosis, 6 weeks and 3 months to identify evidence for individualised treatment.
Methods: Case note review of consecutive CYP presenting with diabetes, commenced on MDI between August 2010 and 2012, recording ICRs for each mealtime at diagnosis, 6 weeks and 3 months.
Results: MDI was commenced in 55 of 93 CYP presenting with diabetes, of which 48 records were retrieved for analysis (87%). Median age was 11.2 years (range 1.8616.9 years). Carbohydrate counting and fixed ICRs were commenced in 45 CYP from diagnosis. Of three commenced on fixed mealtime doses, two were carbohydrate counting before 6 weeks. Two children had mealtime insulin temporarily discontinued by 6 weeks. One third of CYP were on the same ratios at 6 weeks and 3 months as they were at diagnosis, and the same ICR across the entire day.
Conclusion: Up to one third of our CYP had evidence of inadequately intensified or individualised insulin therapy at 6 weeks and 3 months. We are concerned this limits our ability to improve outcomes. We have adjusted our approach, utilising variable ICRs from diagnosis to avoid losing this important educational element, placing a greater focus on post-prandial glucose testing, frequent clinical reviews and greater emphasis on patient education.
13 Nov 2013
British Society for Paediatric Endocrinology and Diabetes