Because of the complexity of a diabetic diet, the American Diabetes Association recommends that individuals (especially growing children) consult yearly with a registered dietician who is experienced with diabetes.

Changing lifestyles, as children grow, require changes in the approach to diet and to the insulin schedule. Nutritionists who are aware of the nutritional and lifestyle needs of different age children can offer invaluable help for improving diabetes control.

Studies have shown that improved blood sugar control leads to fewer diabetes complications, and slows the rate with which complications develop. Complications of diabetes include eye, kidney, nerve, and heart effects.

The American Diabetes Association recommends blood sugar tests at least 3 or more times a day for diabetics who take insulin. Frequent blood sugar testing is especially important for young children (children below age 5) to help avoid severe low blood sugar attacks. Usually 5-6 blood sugar tests and 2 urine tests (to measure glucose and ketones) per day are recommended.

A blood sugar test later in the evening, at the parents bedtime, is especially important since "silent" low blood sugar attacks (hypoglycemia) occur commonly in very young children.

The accuracy of blood sugar testing depends on good technique. Have your clinician observe and evaluate your technique regularly to make sure that your measurements are accurate.

Newer, short-acting insulins are very convenient and useful, especially for young children. They can be given 0-15 minutes before or after a meal compared to regular insulin which is given 30-45 minutes before a meal.

The fact that rapid-acting insulin can be given after the meal means that parents can wait to see how much a child eats before determining the insulin dose. This can be of great advantage since children are often unpredictable in the amounts of food that they eat.

Rapid-acting insulins are also useful for preteens who may require large amounts of insulin for a short time (after eating a big meal).

Rapid-acting insulins provide great flexibility in meal schedules but require the tradeoff of more frequent injections.

Insulin pumps are devices that continuously deliver insulin through a small tube (or catheter) that is embedded under the skin. A new tube through which the insulin is pumped is inserted into the skin every 3 days.

Insulin pumps represent an alternative to multiple, daily insulin injections. Studies show that they provide better blood sugar control and decrease the risk of low blood sugar (hypoglycemia) attacks.

They are expensive, can get clogged or malfunction which may lead to attacks of high blood sugar. They sometimes cause irritation and infection at the site where the tube is placed under the skin.

Insulin pumps are being used with increasing frequency for children with diabetes with the assumption that the better blood sugar control that they offer will decrease the risk of diabetes complications.

Annual eye exams with dilation (widening the pupils with medicine to offer a better view of the blood vessels inside of the eye) are recommended for all individuals who have diabetes.

For children with type I diabetes, an initial eye exam is recommended within the first 3-5 years of the initial diagnosis, or once the child has reached the age of 10; and yearly after that.

More frequent dosing (more than 2 injections a day) allows people with diabetes to eat meals at varying times of day and provides better blood sugar control.

Typically, one injection of long-acting (ultralente) insulin is taken at night and 3 more rapid- or short-acting (lispro or regular) injections are taken during the day, with one injection before each meal.

Alternatively, instead of the one long-acting injection at bedtime, two doses of intermediate insulin can be taken - one in the morning and one at bedtime (in addition to the short-acting doses taken with meals). This approach is useful for people whose blood sugar dips too low at night with the long-acting (ultralente) insulin, or for those who have high morning blood sugars.

Another alternative is combining an intermediate and short-acting insulin with breakfast, a short-acting drug at dinner, and another intermediate-acting drug at bedtime (10-11 PM). A short-acting dose can be added as well at bedtime if blood sugar levels are high. Another short-acting dose can be added during the day if lunch or snack-time insulin levels are high.

Regular insulin is a short-acting insulin that is typically taken 30-45 minutes before meals. When taken before breakfast, its effects usually last until lunch time. When taken before dinner, it tends to last until bedtime.

The advantage of a short-acting (regular) insulin in contrast to a rapid-acting (lispro) insulin is that its effects last longer; the disadvantage is that it doesn't take effect as quickly and must be administered before meals while the rapid-acting insulins can be taken with or right after meals when dose requirements can be more accurately estimated.

NPH and Lente insulins are intermediate-acting insulins that are typically taken twice a day - at night and in the morning. They cover a 12 hour period (approximately) and provide a reasonably steady dose of insulin. Lente is available in the U.S. but more commonly used in Europe.

Long-acting insulins may be taken once a day and they provide a small, steady amount of insulin in the blood stream.

The Hemoglobin A1c (HbA1c or glycohemoglobin) is a test that indicates how well blood sugar has been controlled during the past 3 months. This tests measures the amount of sugar that is attached to red blood cells. Sugar becomes attached to these cells when there is excess sugar in the blood stream (when diabetes is not well controlled).

Studies have shown, that the lower the A1c (HbA1c), the less the risk of developing diabetes complications over the long-term.

In nondiabetics, normal HbA1c levels are between 4-6% (your physician can tell you what the normal levels are in the lab that he/she uses). According to the American Diabetes Association, a good target level of A1c (HbA1c) would be below 7%. Target goals in children are sometimes higher since children are at a greater risk of hypoglycemic attacks (a severe drop in blood sugar).

Lowering A1c (HbA1c) levels even lower, to the normal range (less than 6%) decreases the risk of diabetes complications even further but increases the risk of hypoglycemic attacks (severe drop in blood sugar).

The American Diabetes Association recommends a target goal of pre-meal blood sugar between 90-130 mg/dL. Pre-meal blood sugars in nondiabetic individuals are normally below 110 mg/dL. Maintaining blood sugars that are close to normal ranges decreases the chance of developing diabetes complications.

The American Diabetes Association recommends a target goal of bedtime blood sugar between 110-180 mg/dL. Bedtime blood sugars in nondiabetic patients are normally below 120 mg/dL. Maintaining blood sugars that are close to normal ranges decreases the chance of developing diabetes complications.

With twice-a-day dosing schedules, injections are typically given in the morning, and in the late afternoon just before dinner.

The morning dose often consists of an intermediate-acting insulin (NPH or lente) either alone, or mixed with a rapid (lispro) or short-acting (regular) insulin.

The evening dose combines a short-acting and an intermediate-acting insulin that provides coverage overnight.

One problem with twice-a-day dosing is that the evening dose peaks during the middle of the night when blood sugar is typically at its lowest point, and this increases the risk of serious nighttime hypoglycemic attacks (serious drops in blood sugar).

Children and preteens are often started on a twice a day dosing schedule when they are first diagnosed.

The small doses of insulin that are required by children can be difficult to measure accurately. Studies have shown that parents tend to err on the side of giving a little too much insulin. Some experts recommend that, if different parents are administering insulin, that one give it in the morning and the other give it at night so that doses might be more consistent.

Studies have shown the use of needles that are too long increases the risk that the insulin will be injected into varying locations from day to day (too deeply - into the muscles - on one day; and less deeply - into the fat - on another). This leads to an uncertainty about the "real" dose given since insulin injected into muscle versus fatty tissue behaves very differently. Any confusion about dose increases the risk of an insulin overdose and a hypoglycemic (low blood sugar) attack.

Some experts have found that, by using short needles in young children, there is better assurance that the insulin is consistently being injected into the right location.

A single daily injection of an intermediate-acting insulin is not recommended for most people with diabetes. More frequent insulin injections provide much better blood sugar control and significantly decreases the risk of developing diabetes complications.

Since "silent" nighttime attacks of hypoglycemia (low blood sugar) are common in young children and represent a serious threat, a sensor with an alarm device that can alert parents about a low blood sugar level could be very beneficial and even life-saving.

These types of devices are being developed and may be available soon.

Devices that are able to continuously monitor blood sugar are currently being developed. When they become available, they will allow much more precise control over blood sugar and will prevent serious episodes of both high and low blood sugar.