In the UK and many other countries, most children are started on two injections per day. Many children will use combinations or mixtures of rapid or short-acting insulin and intermediate-acting insulins before breakfast and before tea. These doses and mixtures are adapted to the size of meals and usual activity levels. With a two-dose treatment it is essential that the last meal of the day is taken immediately before going to bed (bedtime snack) to prevent night time hypoglycaemia.
A three-dose insulin treatment usually consists of a combination of rapid- or short-acting and intermediate-acting insulin for breakfast, rapid or short-acting insulin for the afternoon snack after returning from school or at teatime, and intermediate-acting insulin at bedtime. This may be a suitable regimen for a smaller child, especially if it is difficult to find someone who can give the lunchtime dose at school or in the day nursery. A combination of rapid- or short-acting and intermediate-acting insulin at breakfast may also be a good solution for the teenager who tends to forget lunchtime insulin doses when at school or out with their peer group. In situations like this, pre-mixed insulin that can be administered with a pen may be an alternative choice.
Multiple injection treatment
In Sweden, the US and many other countries, it is common to use a multiple injection treatment with pre-meal doses of rapid-acting insulin from the onset of diabetes, even for younger children and toddlers. In some places children are started on insulin pumps from the onset of diabetes but usually this form of therapy is started later. With multiple injections, pre-meal injections will be given for the main meals of breakfast, lunch, tea and evening snack. An extra bedtime snack will usually be given only if the blood glucose level is low with this type of insulin regimen.
Insulin is adjusted in relation to the carbohydrate content of the meal. Before breakfast, higher doses of insulin are needed in relation to the size of the meal. This is due partly to increased levels of growth hormone and partly to a reduction over time in the effect of the bedtime insulin dose. In addition, breakfast usually contains a greater proportion of carbohydrates than other meals (e.g. from juice, bread, cereals).
Insulin at school and day nurseries
Sometimes it is difficult to get help with insulin injections at a day care centre or nursery, or to get the teacher to remind the child to take their insulin at school. The staff have no formal obligation to give injections when needed, but some schools have a nurse or teacher's assistant who will help. At some larger schools where several pupils have diabetes, they might meet at lunchtime to eat together, and a staff member may be able to be on hand to help them if necessary.