Overview
Definition:
Inpatient glycemic management in pediatrics aims to maintain blood glucose within a target range to prevent complications
Two primary insulin regimens are commonly used: insulin sliding scales and basal-bolus therapy
Insulin sliding scales use rapid-acting insulin based on current blood glucose levels
Basal-bolus therapy involves long-acting insulin to cover basal needs and rapid-acting insulin to cover meals (bolus) and correct hyperglycemia (correction doses).
Epidemiology:
Hospitalized children, especially those with diabetes mellitus (Type 1 or Type 2), critical illness, or receiving glucocorticoid therapy, are at risk of hyperglycemia
The prevalence of hyperglycemia in hospitalized children varies widely based on the underlying condition, with rates reported between 15-40% in general pediatric wards and higher in intensive care units
The choice of insulin regimen significantly impacts glycemic control and patient outcomes.
Clinical Significance:
Effective inpatient glycemic control in pediatrics is crucial to prevent short-term complications like dehydration, infections, and electrolyte imbalances, and long-term microvascular and macrovascular complications
Inadequate management can lead to prolonged hospital stays, increased resource utilization, and poorer patient outcomes
Understanding the nuances of sliding scales versus basal-bolus therapy is essential for resident physicians preparing for board examinations like DNB and NEET SS.
Introduction And Indications
Background:
Historically, sliding scale insulin (SSI) was the predominant method for managing inpatient hyperglycemia
However, evidence suggests that SSI alone is often insufficient for achieving optimal glycemic control and can lead to significant glucose variability and frequent hypoglycemic or hyperglycemic excursions
Basal-bolus therapy, mimicking physiological insulin secretion, has emerged as a preferred approach for many pediatric patients.
Indications For Insulin Therapy:
Insulin therapy is indicated in hospitalized children for: established diabetes mellitus (Type 1 or Type 2) requiring inpatient management
hyperglycemia related to critical illness (e.g., sepsis, trauma, burns)
hyperglycemia secondary to medications (e.g., corticosteroids, calcineurin inhibitors)
acute complications of diabetes (e.g., Diabetic Ketoacidosis - DKA, Hyperosmolar Hyperglycemic State - HHS)
and children requiring parenteral nutrition with glucose infusion.
Indications For Basal Bolus Therapy:
Basal-bolus therapy is generally recommended for pediatric patients with Type 1 diabetes or Type 2 diabetes who are on insulin therapy at home, have established diabetes requiring inpatient management beyond transient hyperglycemia, or are expected to have prolonged hospital stays
It is also considered for children requiring consistent glycemic control, such as those with significant steroid-induced hyperglycemia or in the perioperative period.
Indications For Sliding Scale Insulin:
SSI may be considered for transient hyperglycemia in otherwise well patients, such as those experiencing short-term stress hyperglycemia from illness or medications, or as an adjunct to basal-bolus therapy for correction doses
It is generally not recommended as the sole method of insulin delivery for patients with established diabetes or those with prolonged hyperglycemia.
Insulin Regimens In Detail
Sliding Scale Insulin Ssi:
SSI typically involves administering doses of rapid-acting insulin (e.g., lispro, aspart, glulisine) based on pre-prandial or random blood glucose readings according to a predetermined scale
For example, a scale might dictate 0 units for glucose < 70 mg/dL, 2 units for 70-120 mg/dL, 4 units for 121-180 mg/dL, and so on
This approach is reactive and does not provide basal insulin coverage, leading to glucose fluctuations.
Basal Bolus Therapy:
Basal-bolus therapy consists of: 1
Basal insulin: Administered once or twice daily using an intermediate-acting (NPH) or long-acting (glargine, detemir) insulin to provide continuous background insulin coverage
2
Bolus insulin: Administered before meals using rapid-acting insulin to cover carbohydrate intake
3
Correction doses: Administered with bolus insulin or separately using rapid-acting insulin to correct pre-meal or random hyperglycemia, based on the patient's insulin sensitivity factor.
Components Of Basal Bolus:
The basal insulin dose is typically initiated at 40-50% of the total daily insulin dose (TDD) if the patient was on insulin prior to admission, or a calculated dose based on weight (e.g., 0.2-0.3 units/kg/day) for new-onset diabetes
Bolus doses are individualized based on carbohydrate counting and the insulin-to-carbohydrate ratio (ICR)
Correction doses are adjusted using an insulin sensitivity factor (ISF), often calculated as 1800 divided by the TDD for rapid-acting insulin.
Adjusting Basal Bolus Therapy:
Inpatient basal-bolus therapy requires frequent monitoring and adjustments
Factors influencing adjustments include changes in food intake, activity levels, illness severity, and response to therapy
Close collaboration between the medical team, nursing staff, and potentially a diabetes educator is vital.
Monitoring And Targets
Frequency Of Monitoring:
For patients on SSI, blood glucose monitoring is typically performed before meals and at bedtime
For patients on basal-bolus therapy, monitoring is usually done before meals and at bedtime, with additional checks as needed for hypoglycemia or significant hyperglycemia
Continuous Glucose Monitoring (CGM) can be a valuable tool in selected pediatric inpatients for more granular data and early detection of glycemic excursions.
Target Blood Glucose Ranges:
General target blood glucose levels for hospitalized pediatric patients are typically 80-140 mg/dL before meals and 100-180 mg/dL 1-2 hours after meals
However, targets may be individualized based on the patient's age, comorbidities, severity of illness, and risk of hypoglycemia
Critically ill patients in the ICU may have a target range of 140-180 mg/dL
DKA management targets are distinct.
Hypoglycemia Management:
Hypoglycemia (blood glucose < 70 mg/dL) in pediatric inpatients requires prompt assessment and treatment
Mild hypoglycemia can be treated with oral glucose sources (e.g., juice, glucose tablets), while severe hypoglycemia may necessitate intravenous dextrose
Identifying the cause of hypoglycemia (e.g., excessive insulin, reduced food intake, increased activity) is crucial for preventing recurrence
Close monitoring after treatment is essential.
Complications And Considerations
Hypoglycemia With Ssi:
SSI alone is associated with a higher risk of glycemic variability and rebound hyperglycemia, as well as frequent episodes of hypoglycemia due to reactive dosing without adequate basal coverage
The "rollercoaster" effect of blood glucose can be particularly challenging in children.
Hyperglycemia With Ssi:
Despite aggressive SSI, prolonged periods of hyperglycemia can occur, especially if the scale is not aggressive enough or if carbohydrate intake is inconsistent
This can lead to osmotic diuresis, dehydration, and delayed wound healing.
Hypoglycemia With Basal Bolus:
While basal-bolus therapy aims for more stable glucose, hypoglycemia can still occur, particularly if basal doses are too high, meal boluses are missed, or if there is unexpected hypoglycemia unawareness or increased insulin sensitivity
Careful titration and monitoring are paramount.
Advantages Of Basal Bolus:
Basal-bolus therapy generally leads to more stable glycemic control, reduced glucose variability, fewer hypoglycemic episodes compared to SSI alone, and better physiological mimicry
It allows for more flexibility in meal timing and carbohydrate intake and is more aligned with outpatient diabetes management principles.
Key Points
Exam Focus:
Understand the principles, advantages, and disadvantages of both SSI and basal-bolus insulin regimens in pediatric inpatients
Be prepared to discuss when each is appropriate and how to initiate and adjust therapy
Differentiate between basal, bolus, and correction insulin doses.
Clinical Pearls:
For new-onset diabetes, initiating basal-bolus therapy requires careful titration
Always consider the patient's nutritional status and anticipated caloric intake
Engage parents/guardians in the management plan, especially for children with Type 1 diabetes
Hypoglycemia protocols should be readily available and staff well-trained.
Common Mistakes:
Relying solely on SSI for all pediatric inpatients, especially those with established diabetes
Underestimating the insulin needs in critically ill or steroid-treated children
Not adjusting insulin doses based on changes in oral intake or illness
Failing to have clear protocols for hypoglycemia management
Not considering continuous glucose monitoring in complex cases.