Background: Beginning in January 2017, our institution transitioned new-onset diabetes mellitus education to the ambulatory setting for all children 5 years of age and older. During this transition, our education and practice standards were reviewed and updated. Education historically had been provided during a two-day inpatient hospitalization. With the shift to ambulatory education, teaching was spread out to three separate classes in the first month after diagnosis given that the patients were not under direct supervision. Our primary aim was to prevent hypoglycemia at home, so we introduced new standard insulin doses during the education transition. Glargine doses were reduced to 0.2 units/kg (< 5 years), 0.25 units/kg (5-10 years), and 0.3 units/kg (> 10 years) to minimize hypoglycemia risk while preventing DKA. Due to the lower basal insulin, we lowered insulin sensitivity factors (ISF) to 150 for children under 5 years, 75 for 5-10 years, and 50 for children 11 and older. Corrections were given at meal time to prevent stacking of insulin. Initial carbohydrate ratios remained the same.

Methods: We monitored incidence of high-risk events between classes by characterizing the frequency of hypoglycemia less than 70 mg/dL, hypoglycemia less than 50 mg/dL, use of glucagon, and development of ketones/DKA.

Results: From 1/3/2017 to 12/31/2018 there were 451 patients diagnosed with diabetes at our center. Hypoglycemia questionnaires were completed by 320/451 (71%) of patients/families 1 week after diagnosis. Hypoglycemic episodes with BG < 70 mg/dL occurred in 41% of patients and BG < 50 mg/dL occurred in 8% of patients. Only 1 patient required glucagon for a severe hypoglycemic episode. While 22% of patients had ketones, no patients developed DKA after initial diagnosis.

Conclusions: Conservative dosing with glargine, along with more aggressive carbohydrate and correction dosing at meals is safe and effective in preventing severe hypoglycemia and DKA for patients educated in the ambulatory setting.

Disclosure

T.S. Musick: None. R. McDonough: None.

© 2019 by the American Diabetes Association.
2019
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