Improved Glycemic Outcomes With Diabetes Technology Use Independent of Socioeconomic Status in Youth With Type 1 Diabetes.

OBJECTIVE: Technology use in type 1 diabetes (T1D) is impacted by socioeconomic status (SES). This analysis explored relationships between SES, glycemic outcomes, and technology use. RESEARCH DESIGN AND METHODS: A cross-sectional analysis of HbA1c data from 2,822 Australian youth with T1D was undertaken. Residential postcodes were used to assign SES based on the Index of Relative Socio-Economic Disadvantage (IRSD). Linear regression models were used to evaluate associations among IRSD quintile, HbA1c, and management regimen. RESULTS: Insulin pump therapy, continuous glucose monitoring, and their concurrent use were associated with lower mean HbA1c across all IRSD quintiles (P < 0.001). There was no interaction between technology use and IRSD quintile on HbA1c (P = 0.624), reflecting a similar association of lower HbA1c with technology use across all IRSD quintiles. CONCLUSIONS: Technology use was associated with lower HbA1c across all socioeconomic backgrounds. Socioeconomic disadvantage does not preclude glycemic benefits of diabetes technologies, highlighting the need to remove barriers to technology access.

Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models.

Background: Technology use, including continuous glucose monitoring (CGM) and insulin pump therapy, is associated with improved outcomes in youth with type 1 diabetes (T1D). In 2017 CGM was universally funded for youth with T1D in Australia. In contrast, pump access is primarily accessed through private health insurance, self-funding or philanthropy. The study aim was to investigate the use of diabetes technology across different socioeconomic groups in Australian youth with T1D, in the setting of two contrasting funding models. Methods: A cross-sectional evaluation of 4957 youth with T1D aged <18 years in the national registry was performed to determine technology use. The Index of Relative Socio-Economic Disadvantage (IRSD) derived from Australian census data is an area-based measure of socioeconomic status (SES). Lower quintiles represent greater disadvantage. IRSD based on most recent postcode of residence was used as a marker of SES. A multivariable generalised linear model adjusting for age, diabetes duration, sex, remoteness classification, and location within Australia was used to determine the association between SES and device use. Results: CGM use was lower in IRSD quintile 1 in comparison to quintiles 2 to 5 (p<0.001) where uptake across the quintiles was similar. A higher percentage of pump use was observed in the least disadvantaged IRSD quintiles. Compared to the most disadvantaged quintile 1, pump use progressively increased by 16% (95% CI: 4% to 31%) in quintile 2, 19% (6% to 33%) in quintile 3, 35% (21% to 50%) in quintile 4 and 51% (36% to 67%) in the least disadvantaged quintile 5. Conclusion: In this large national dataset, use of diabetes technologies was found to differ across socioeconomic groups. For nationally subsidised CGM, use was similar across socioeconomic groups with the exception of the most disadvantaged quintile, an important finding requiring further investigation into barriers to CGM use within a nationally subsidised model. User pays funding models for pump therapy result in lower use with socioeconomic disadvantage, highlighting inequities in this funding approach. For the full benefits of diabetes technology to be realised, equitable access to pump therapy needs to be a health policy priority.

Outcomes and experiences of families with children with type 1 diabetes on insulin pumps through subsidised pump access programs in Western Australia.

Introduction: In Australia, access to insulin pump therapy for children with type 1 diabetes (T1D) is predominantly restricted to families with private health insurance. In an attempt to improve equity, additional subsidised pathways exist which provide pumps to families with reduced financial resources. We aimed to describe the outcomes and experiences of families with children commenced on pumps through these subsidised pathways in Western Australia (WA). Methods: Children with T1D in WA who did not have private health insurance and received pumps from the subsidised pump programs between January 2016 and December 2020 were included. Study 1 was designed to review glycaemic outcome. A retrospective analysis of HbA1c was conducted in the whole cohort and in children who commenced pump after the first year of diagnosis to exclude the impact of the partial clinical remission phase following diagnosis. HbA1c at baseline, and six, 12, 18 and 24 months after pump initiation were collected. Study 2 was designed to review experiences of families commenced on pumps through subsidised pathway. A questionnaire designed by the clinical team was distributed to parents via an online secure platform to capture their experiences. Results: Of the 61 children with mean (SD) age 9.0 (4.9) years who commenced pump therapy through subsidised pump programs, 34 children commenced pump therapy after one year of diagnosis of T1D. The median (IQR) HbA1c (%) in 34 children at baseline was 8.3 (1.3), with no statistically significant change from baseline at six months [7.9 (1.4)], 12 months [8.0 (1.5)], 18 months [8.0 (1.3)] or 24 months [8.0 (1.3)]. The questionnaire response rate was 56%. 83% reported intention to continue pump therapy, however 58% of these families did not have avenue to acquire private health insurance. Families expressed inability to procure private health insurance due to low income and unreliable employment and remained largely unsure about the pathway to obtain the next pump. Discussion: Children with T1D who commenced insulin pump therapy on subsidised pathways maintained glycaemic control for two years, and families favored pumps as a management option. However, financial limitations persist as a significant barrier to procure and continue pump therapy. Pathways for access need to be assessed and advocated.

Physical Activity Management for Youth With Type 1 Diabetes: Supporting Active and Inactive Children.

Regular physical activity and exercise are important for youth and essential components of a healthy lifestyle. For youth with type 1 diabetes, regular physical activity can promote cardiovascular fitness, bone health, insulin sensitivity, and glucose management. However, the number of youth with type 1 diabetes who regularly meet minimum physical activity guidelines is low, and many encounter barriers to regular physical activity. Additionally, some health care professionals (HCPs) may be unsure how to approach the topic of exercise with youth and families in a busy clinic setting. This article provides an overview of current physical activity research in youth with type 1 diabetes, a basic description of exercise physiology in type 1 diabetes, and practical strategies for HCPs to conduct effective and individualized exercise consultations for youth with type 1 diabetes.

CGM accuracy: Contrasting CE marking with the governmental controls of the USA (FDA) and Australia (TGA): A narrative review.

The National Institute for Clinical Excellence updated guidance for continuous glucose monitoring (CGM) in 2022, recommending that CGM be available to all people living with type 1 diabetes. Manufacturers can trade in the UK with Conformité Européenne (CE) marking without an initial national assessment. The regulatory process for CGM CE marking, in contrast to the Food and Drug Administration (FDA) and Australian Therapeutic Goods Administration (TGA) process, is described. Manufacturers operating in the UK provided clinical accuracy studies submitted for CE marking. Critical appraisal of the studies shows several CGM devices have CE marking for wide-ranging indications beyond available data, unlike FDA and TGA approval. The FDA and TGA use tighter controls, requiring comprehensive product-specific clinical data evaluation. In 2018, the FDA published the integrated CGM (iCGM) criteria permitting interoperability. Applying the iCGM criteria to clinical data provided by manufacturers trading in the UK identified several study protocols that minimized glucose variability, thereby improving CGM accuracy on all metrics. These results do not translate into real-life performance. Furthermore, for many CGM devices available in the UK, accuracy reported in the hypoglycaemic range is below iCGM standards, or measurement is absent. We offer a framework to evaluate CGM accuracy studies critically. The review concludes that FDA- and TGA-approved indications match the available clinical data, whereas CE marking indications can have discrepancies. The UK can bolster regulation with UK Conformity Assessed marking from January 2025. However, balanced regulation is needed to ensure innovation and timely technological access are not hindered.

Evaluation of real-life clinical outcomes in Australian youth with type 1 diabetes on hybrid closed-loop therapy: A retrospective study.

AIM: To determine the clinical outcomes and evaluate the perspectives of children with Type 1 diabetes (T1D) and their parents managing their child on hybrid closed-loop (HCL) therapy. METHODS: Children with T1D on HCL attending a tertiary diabetes centre between April 2019 and July 2021 were included. A retrospective analysis of glycaemic data was conducted to determine the clinical outcomes. Time spent in closed loop, time in target glucose range (TIR 3.9-10 mmol/L), hypoglycaemia and hyperglycaemia were collected at baseline, 4 weeks, 3 and 6 months post-HCL. User experience was assessed by questionnaires administered to parents of children with T1D. RESULTS: Seventy-one children, mean (SD) age of 12.2 (3.2) years were commenced on HCL. Ten (14%) discontinued HCL use, with 60% discontinuing within the first 6 months. Glycaemic outcomes were analysed in 52 children. Time spent in closed loop was 78 (21) % at 4 weeks, declined to 69 (28) % at 3 months (P = 0.037) and 63 (34) % at 6 months (P = 0.001). The mean %TIR increased from 59.8 at baseline to 67.6 at 3 months and 65.6 at 6 months with a mean adjusted difference of 7.8% points [95% CI 3.6, 11.9] and 5.5% points [95% CI 1.4, 9.5], respectively. There was a reduction in time > 10 mmol/L and time < 3.9 mmol/L from baseline to 6 months. Although families faced challenges with technology, better glucose control with reduced glycaemic fluctuations were reported. CONCLUSIONS: HCL therapy is associated with improved glycaemia; however, adequate support and education are required for best outcomes.

Identifying Suicide Risk in Adolescents and Young Adults With Type 1 Diabetes: Are Depression Screeners Sufficient?

OBJECTIVE: Examine the utility of suicide-risk items embedded within depression screeners for identifying the presence of suicide risk in adolescents and young adults (AYA) with type 1 diabetes. RESEARCH DESIGN AND METHODS: Sensitivity, specificity, and predictive value of self-report of suicide risk on the Patient Health Questionniaire-9 (PHQ-9) were compared with the pediatric psychologist-administered Columbia-Suicide Severity Rating Scale (C-SSRS) as the reference standard for AYA with type 1 diabetes seen in a multidisciplinary AYA Diabetes Program clinic. RESULTS: Of 133 participants, 9.8% and 11.3% reported suicide risk on the PHQ-9 and C-SSRS, respectively. Sensitivity of the PHQ-9 risk item was 53.3% (95% CI 27.4%-77.7%), specificity was 95.7% (95% CI 89.9%-98.4%), positive predictive value was 61.5% (95% CI 32.3%-84.9%), and negative predictive value was 94.2% (95% CI 87.9-97.4%). CONCLUSIONS: Depression screeners appear to under-identify AYA with type 1 diabetes who may otherwise be at risk for suicide.

Hypoglycaemia avoidance behaviour and exercise levels in active youth with type 1 diabetes.

AIMS: The primary goal of this exploratory study was to examine the association between fear of hypoglycaemia (FOH), hypoglycaemia avoidance behaviours and exercise in active youth with type 1 diabetes (T1D). METHODS: 30 youth with T1D who participate in some physical activity (PA), age 15.0 ± 2.4 years, on insulin pump therapy completed the 'Type 1 Diabetes Report of Exercise Practices Survey (T1D-REPS)' and parent and child hypoglycaemia fear surveys (HFS). Twenty-eight participants completed the 3-day PA recall survey. Clinical data and pump downloads were obtained at the time of the survey collection. RESULTS: Higher child HFS behaviour and total scores were associated with higher PA levels (P = .003, P = .027), and higher parent HFS behaviour score was associated with higher youth PA levels (P = .031), after adjusting for age, sex, duration of diabetes and BMI. Higher child HFS behaviour score was associated with a higher exercise hypoglycaemia avoidance score on T1D-REPS (r = .38, P = .043). Higher child HFS worry and total scores were associated with higher HbA1c (r = .48, P = .008; r = .46, P = .012). CONCLUSIONS: This study demonstrated that, in a generally active cohort of youth with T1D, increased hypoglycaemia avoidance behaviour was associated with higher PA levels. Higher overall FOH scores were associated with PA level, driven by higher behaviour subscale scores, while worry subscales were not correlated with PA level. Those with more FOH intervene more to specifically avoid exercise-associated hypoglycaemia and appear to have worse overall glycaemic control. Thus, improved education is required to improve glycaemic control around exercise while maintaining avoidance of hypoglycaemia.

Alcohol consumption patterns in young adults with type 1 diabetes: The SEARCH for diabetes in youth study.

AIMS: The objective of this study is to describe alcohol consumption behaviors of young adults with T1D and to examine associations between alcohol consumption and diabetes-related clinical markers. METHODS: Data from 602 SEARCH for Diabetes in Youth Study participants age ≥ 18 yrs. with T1D were collected from 12/2011 to 6/2015 (50% female, mean age 21.3(SD 2.4), 22% race/ethnic minority). Participants were characterized as alcohol non-drinkers (n = 269), drinkers but non-binge drinkers (n = 167), or binge drinkers (n = 166) based on reported consumption in the past 30 days. Analyses were conducted using one-way ANOVAs, chi-square tests, and logistic regression modeling to examine associations between drinking and clinical markers. RESULTS: Fifty-five percent of participants reported alcohol consumption; 27.6% of participants reported binge drinking. After adjusting for demographic characteristics, neither binge drinking nor non-binge drinking were associated with HbA1c or severe hypoglycemic events relative to non-drinkers. Binge drinking was associated with higher HDL (p = 0.008), lower systolic blood pressure (p = 0.011), and a lower waist:height ratio compared to non-drinkers (p = 0.013). CONCLUSIONS: Young adults with T1D in the SEARCH cohort reported similar alcohol use but higher rates of binge drinking compared to the general United States population and previously reported rates in adults with T1D.

Feasibility of Routine Assessment of Exercise Knowledge and Safety in Youth With Type 1 Diabetes.

PURPOSE: This pilot study assessed the feasibility and satisfaction of an electronic clinical tool to survey management of exercise in youth with type 1 diabetes (T1DM) for use in an outpatient diabetes clinic setting. METHODS: Fifty youth with T1DM were recruited (ages, 10-18 years; mean ± SD, 14.8 ± 2.4) and 11 diabetes providers. Prior to a clinic visit and with an electronic tablet, participants completed the Type 1 Diabetes Report of Exercise Practices Survey, which included 9 primary exercise management guidelines. Responses were flagged if contrary to guidelines, and automated individualized reports with personalized evidence-based recommendations were produced for providers prior to seeing the patient. Postclinic assessment surveys were completed by patients and providers. RESULTS: Out of the 9 guidelines, a mean of 4 ± 0.9 responses per patient were flagged as potentially unsafe. Ninety-one percent of providers took <10 minutes to review and discuss the report with their patients. Ninety-one percent of providers rated the tool as highly useful in facilitating patient education regarding exercise guidelines at that clinic visit. Fifty-six percent of youth rated the tool highly when asked whether its use altered their planned behavior around exercise. When participants were asked if such a tool should be used routinely in diabetes clinic, 64% of provider responses and 60% of patient responses were highly positive. CONCLUSIONS: This electronic tool identified deficits in exercise management in youth with T1DM and improved education in the clinic visit regarding exercise, and a majority felt it feasible and desirable to include in routine outpatient diabetes care.

Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program.

Purpose The purpose of this study was to examine the feasibility and efficacy of the Diabetes Community Care Ambassador (DCCA) Program, a novel medical-legal community intervention designed to support high-risk youth with type 1 diabetes. Methods Study eligibility criteria: ages 3-19 years, A1C ≥8.5% (≥69 mmol/mol) and/or recent diabetic ketoacidosis hospitalization, type 1 diabetes duration ≥1 year, and English- or Spanish-speaking. Eighty-nine youth and their caregivers participated in the 9- to 12-month intervention, which included diabetes education and support through 3 home visits, 1 to 2 school visits, and phone support from a lay health worker, as well as legal support from a medical-legal partnership attorney. Feasibility was assessed; change in A1C was compared in a linear mixed model. Results Of the 89 DCCA Program participants, 80% completed the program, with the majority of participants rating their DCCA favorably. Sixty-two percent reported ≥1 unmet legal need, of whom 29% accepted legal counsel. Youth enrolled in the DCCA Program demonstrated an improvement in glycemic control as their mean A1C decreased from 9.71% (83 mmol/mol) at the start of the program to 9.40% (79 mmol/mol) at the end of the intervention period ( P = .03). Participants with public health insurance experienced the greatest differential A1C reduction (9.79% to 9.11%, 83 mmol/mol to 76 mmol/mol). Conclusions The DCCA Program represents a promising intervention for improving care of high-risk youth with type 1 diabetes. A significant proportion of caregivers of youth reported having an unmet legal need. Participants remained highly engaged and demonstrated improved glycemic control, particularly youth with public health insurance.

Exercise management in type 1 diabetes: a consensus statement.

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.

Do youth with type 1 diabetes exercise safely? A focus on patient practices and glycemic outcomes.

OBJECTIVE: Insulin adjustments have been shown to reduce glycemic excursions during and after exercise, but little is known about their use in youth with type 1 diabetes (T1D). We aimed to assess practices in youth with T1D around exercise, assess factors that influence practices, and examine associations between key behaviors and glycemic outcomes. RESEARCH DESIGN AND METHODS: We developed the 'Type 1 Diabetes Report of Exercise Practices Survey (T1D-REPS)' and piloted this tool in 100 youth with T1D on an insulin pump. Participants completed a 3-day physical activity recall and 30 days of pump/glucose data were collected. Chart review was conducted for key clinical measures. RESULTS: Eighty-four percent of participants modified their insulin regimen around exercise; only 40% reported adjusting prandial insulin immediately before exercise while 68% reported some modification (suspension or decrease) of basal insulin during exercise. Following exercise, only 10% reported reducing overnight basal insulin. Those who performed ≥ 5 glucose checks/day adjusted basal insulin during exercise more frequently than those with fewer daily glucose checks (33% vs. 13%, p = 0.05, chi-squared = 3.7), and were more likely to report decreasing insulin dose for the bedtime snack following exercise (50% vs. 17%, p = 0.004, chi-squared = 8.2). CONCLUSIONS: Despite several studies showing the frequency of hypoglycemia during and after exercise, many youth are not adjusting insulin for exercise. A tool designed to capture patient practices and provide clinicians with a framework for patient education may lead to improved safety around exercise in youth with T1D.

Exercise in Youth with Type 1 Diabetes.

Exercise is important in the management of type 1 diabetes mellitus (T1DM). Modern diabetes care includes the goal that all youth meet guidelines for regular physical activity. Evidence suggests regular physical activity improves cardiovascular health, lipid profiles, psychosocial wellbeing and, possibly, glycemic control in youth with T1DM. However, exercise is especially problematic for children and adolescents because wide glycemic excursions commonly occur during and after exercise and may increase the risk of severe hypoglycemia. In addition, youth with T1DM have abnormal counterregulatory hormone responses, further increasing the risk of exercise-associated hypoglycemia. Recent studies have demonstrated that this risk is present during, and many hours after exercise, and have tested strategies to prevent exercise-induced hypoglycemia in youth. Despite these recent studies, the fear of hypoglycemia remains a major impediment to achieving target glycemic control in youth, targets that have recently been tightened. Equally, data suggests fear of hypoglycemia is the major impediment to participation in regular daily exercise in T1DM. Recent advances in insulin delivery systems and in real time continuous glucose monitoring have improved care for youth with T1DM, allowing safer participation in exercise programs. The impending development and approval of "closed loop" insulin delivery systems (the artificial pancreas) holds great promise for the safe participation in exercise for all youth with T1DM.

Current perspectives on physical activity and exercise for youth with diabetes.

Regular physical activity (PA) for youth with diabetes improves cardiorespiratory fitness, body composition, bone health, insulin sensitivity, and psychosocial well-being. However many youth with diabetes or pre-diabetes fail to meet minimum PA guidelines and a large percentage of youth with diabetes are overweight or obese. Active youth with type 1 diabetes tend to have lower HbA1c levels and reduced insulin needs, whereas activity in adolescents at-risk for type 2 diabetes improves various measures of metabolism and body composition. Insulin and nutrient adjustments for exercise in type 1 diabetes is complex because of varied responses to exercise type and because of the different times of day that exercise is performed. This review highlights the benefits of exercise and the established barriers to exercise participation in the pediatric diabetes population. A new exercise management algorithm for insulin and carbohydrate intake strategies for active youth with type 1 diabetes is presented.

Thyroid-related neurological disorders and complications in children.

BACKGROUND: Thyroid hormones exert critical roles throughout the body and play an important and permissive role in neuroendocrine, neurological, and neuromuscular function. METHODS: We performed a PubMed search through June 2014 with search terms including "hypothyroidism," "hyperthyroidism," "neurological complications," "neuropathy," "myopathy," "congenital hypothyroidism," and "encephalopathy." Relevant publications reviewed included case series, individual case reports, systematic reviews, retrospective analyses, and randomized controlled trials. The neurological outcomes of congenital hypothyroidism were reviewed, along with the clinical features of associated neuromuscular syndromes of both hypothyroidism and hyperthyroidism, including other autoimmune conditions. Evidence for, and pathophysiological controversies surrounding, Hashimoto encephalopathy was also reviewed. RESULTS: The establishment of widespread newborn screening programs has been highly successful in attenuating or preventing early and irreversible neurological harm resulting from congenital thyroid hormone deficiency, but some children continue to display neuromuscular, sensory, and cognitive defects in later life. Acquired disorders of thyroid function such as Hashimoto thyroiditis and Graves' disease are associated with a spectrum of central nervous system and/or neuromuscular dysfunction. However, considerable variation in clinical phenotype is described, and much of our knowledge of the role of thyroid disease in childhood neurological disorders is derived from adult case series. CONCLUSIONS: Early and aggressive normalization of thyroxine levels in newborn infants with congenital hypothyroidism is important in minimizing neurological sequelae, but maternal thyroid hormone sources are also critically important to the early developing brain. A spectrum of neurological disorders has been reported in older children with acquired thyroid disease, but the frequency with which these occur remains poorly defined in the literature, and much must be extrapolated from adult data. A high index of suspicion for acquired thyroid disease is paramount in the investigation of many neurological disorders of youth, as many reported sequelae of hypothyroidism and hyperthyroidism are reversible with appropriate endocrine management.

GATA4 mutations are a cause of neonatal and childhood-onset diabetes.

The GATA family zinc finger transcription factors GATA4 and GATA6 are known to play important roles in the development of the pancreas. In mice, both Gata4 and Gata6 are required for pancreatic development. In humans, GATA6 haploinsufficiency can cause pancreatic agenesis and heart defects. Congenital heart defects also are common in patients with GATA4 mutations and deletions, but the role of GATA4 in the developing human pancreas is unproven. We report five patients with deletions (n = 4) or mutations of the GATA4 gene who have diabetes and a variable exocrine phenotype. In four cases, diabetes presented in the neonatal period (age at diagnosis 1-7 days). A de novo GATA4 missense mutation (p.N273K) was identified in a patient with complete absence of the pancreas confirmed at postmortem. This mutation affects a highly conserved residue located in the second zinc finger domain of the GATA4 protein. In vitro studies showed reduced DNA binding and transactivational activity of the mutant protein. We show that GATA4 mutations/deletions are a cause of neonatal or childhood-onset diabetes with or without exocrine insufficiency. These results confirm a role for GATA4 in normal development of the human pancreas.

Insulin therapy in children and adolescents with type 1 diabetes.

Treatment of type 1 diabetes mellitus (T1DM) requires lifelong administration of exogenous insulin. The primary goal of treatment of T1DM in children and adolescents is to maintain near-normoglycemia through intensive insulin therapy, avoid acute complications, and prevent long-term microvascular and macrovascular complications, while facilitating as close to a normal life as possible. Effective insulin therapy must, therefore, be provided on the basis of the needs, preferences, and resources of the individual and the family for optimal management of T1DM. To achieve target glycemic control, the best therapeutic option for patients with T1DM is basal-bolus therapy either with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Many formulations of insulin are available to help simulate endogenous insulin secretion as closely as possible in an effort to eliminate the symptoms and complications of hyperglycemia, while minimizing the risk of hypoglycemia secondary to therapy. When using MDI, basal insulin requirements are given as an injection of long- or intermediate-acting insulin analogs, while meal-related glucose excursions are controlled with bolus injections of rapid-acting insulin analogs. Alternatively, CSII can be used, which provides a 24-h preselected but adjustable basal rate of rapid-acting insulin, along with patient-activated mealtime bolus doses, eliminating the need for periodic injections. Both MDI treatment and CSII therapy must be supported by comprehensive education that is appropriate for the individual needs of the patient and family before and after initiation. Current therapies still do not match the endogenous insulin profile of pancreatic ß-cells, and all still pose risks of suboptimal control, hypoglycemia, and ketosis in children and adolescents. The safety and success of a prescribed insulin regimen is, therefore, dependent on self-monitoring of blood glucose and/or a continuous glucose monitoring system to avoid critical hypoglycemia and glucose variability. Regardless of the mode of insulin therapy, doses should be adapted on the basis of the daily pattern of blood glucose, through regular review and reassessment, and patient factors such as exercise and pubertal status. New therapy options such as sensor-augmented insulin pump therapy, which integrates CSII with a continuous glucose sensor, along with emerging therapies such as the artificial pancreas, will likely continue to improve safe insulin therapy in the near future.