Premeal insulin treatment during basal-bolus regimen in young children with type 1 diabetes.

The introduction of insulin analogs in clinical practice suggests updating therapeutic schemes in subjects with type 1 diabetes. We read with interest the recent article by Alemzadeh et al. (1), which was designed to determine the feasibility of a flexible multiple daily insulin regimen in preschool children. Rapid-acting insulin analogs offer unquestionable advantages due to their pharmacokinetics and pharmacodynamic properties. However, when used in a basal-bolus regimen, they also need great accuracy in determining the carbohydrate content of the meal. A small mistake could generate a significant problem, including hyperglycemia or hypoglycemia. The meal carbohydrate count system seems to be effective and safe in controlling postmeal hyperglycemia in children treated with continuous subcutaneous insulin infusion (2), but when rapid-acting analogs are associated with glargine at bedtime, they could leave a “window” of low plasma insulin levels during the first portion of the night. Indeed, glargineinsulin plasma levels could not yet be consistently stable (3). Moreover, when using rapid-acting insulin analogs, children need an additional insulin shot to control the carbohydrate intake of their afternoon snack, which is a common practice among children living in the Mediterranean area. The object of the present study was to evaluate fasting and postmeal metabolic effects in prepuberal children treated with glargine and regular or rapid-acting insulin using the carbohydrate counting system.