Ruqaiya Khokhawala reviews the evidence around factors that influence the nutritional assessment and management of young children with T1DM.
Key points
- Young children with type 1 diabetes mellitus need ongoing insulin therapy and regular blood glucose monitoring, with dietary intake and carbohydrate counting playing crucial roles in their daily management. Multidisciplinary support and education for families and carers are essential for effective care.
- Parents often face significant difficulties in accurately counting carbohydrates for their children, which can impact blood glucose control. Structured, age-appropriate education and frequent dietetic reviews are recommended to address these challenges and improve nutritional management.
- Incorporating low-GI foods is encouraged to help stabilise blood glucose levels and reduce hyperglycaemic episodes. Individualised nutrition advice and education on the timing and composition of meals and snacks are highlighted as critical components of effective diabetes management in young children.
Type 1 diabetes mellitus (T1DM) is an autoimmune disorder characterised by the destruction of pancreatic beta cells, leading to insufficient insulin production and subsequent hyperglycaemia (high blood glucose levels, >11.1 mmol/L) (Los and Wilt, 2023).
Although T1DM can occur at any age, it most frequently manifests in childhood and adolescence, with incidence peaking between six months and five years of age and again during puberty. In the UK, approximately 90% of children and young people diagnosed with diabetes have T1DM (NICE, 2015). Notably, around one-third of these individuals present with diabetic ketoacidosis (DKA) at the time of diagnosis. Over the past 25 years, the incidence of T1DM has risen significantly, with an estimated annual increase of 2%–3%. The most substantial increases have been observed among children under the age of five (DiMeglio, Evans-Molina and Oram, 2019). According to data from the National Paediatric Diabetes Audit (NPDA) covering the period from April to December 2024, there were 30,276 children and young people living with T1DM in England, with 2,217 newly diagnosed cases during that timeframe (RCPCH, 2019).
T1DM is a chronic condition that requires ongoing insulin replacement therapy to manage hyperglycaemia while concurrently minimising the risk of hypoglycaemia (low blood glucose levels, <3.9 mmol/L). Achieving this delicate balance in blood glucose regulation is influenced by a range of factors – dietary intake, insulin dosing, physical activity, physiological stress, hormonal fluctuations, environmental influences and more (Los and Wilt, 2023). While not all contributing factors can be controlled, comprehensive support from an integrated multidisciplinary team (MDT) is essential to mitigate both short- and long-term health risks associated with prolonged hyperglycaemia to enhance overall quality of life.
Blood glucose levels in individuals with T1DM are typically monitored either through multiple daily fingerprick tests or via a continuous glucose monitoring (CGM) system, which provides real-time data on glucose levels throughout a 24-hour period. Insulin administration may be managed through multiple daily injections (MDI) or by using an insulin pump (IP).
Regardless of the delivery method, insulin must always be administered in relation to meals and snacks, with dosages determined by the carbohydrate content of the food and the individual’s current blood glucose levels (Los and Wilt, 2023; Annan et al., 2022). Current dietary guidelines for children diagnosed with T1DM align with those recommended for the general population, with no evidence to support increased energy or protein requirements. Nutritional recommendations typically aim for carbohydrates to provide approximately 40% 50%, fat to contribute less than 35% (with saturated fat comprising less than 10%), and protein to account for 15%–25% of total energy intake (Annan et al., 2022).
According to the latest NICE guidelines, families and carers of young children diagnosed with T1DM should be provided with an ongoing education programme beginning at the time of diagnosis, supported by an integrated MDT. These guidelines highlight the importance of enhancing understanding around dietary management and physical activity in relation to their blood glucose levels. Educational content should be individualised to the child’s age, integrating social, cultural and food security considerations. For those managing T1DM with MDI or IP, a structured education in Level 3 Carbohydrate Counting should be offered from the point of diagnosis. The guidelines also emphasise the need to address the timing of snacks and the benefits of adhering to a low glycaemic index (GI) diet, with the aim of minimising the risk of hyperglycaemic episodes. Additionally, it is recommended that children with T1DM receive frequent dietetic reviews to ensure their evolving nutritional needs are met and to support effective diabetes management (NICE, 2015).
PICO question
The aim of this review is to evaluate the evidence available for the factors that influence the nutritional assessment and management in young children with T1DM. This review focuses on two aspects:
1 Challenges to effective carbohydrate counting among parents managing blood glucose levels
2 The impact of low-GI foods on blood glucose regulation.
Search strategy
A computerised literature search was conducted between April and May 2025 using PubMed and the Cochrane Library.
A combination of the above search terms was used to identify relevant studies, which were initially screened based on their titles and abstracts. Studies were included if they were published in English and available as full-text articles free of charge. To ensure relevance, a publication date limit was applied, restricting the selection to studies published within the last 22 years due to the lack of current evidence in the last five years. Additionally, the reference lists of the selected articles were reviewed to identify and include further relevant literature. All included studies were critically appraised using the Critical Appraisal Skills Programme (CASP) tools. This report incorporates evidence from randomised controlled trials (RCTs), systematic reviews and prospective observational studies.
1 – Challenges to effective carbohydrate counting among parents managing blood glucose levels
Carbohydrate counting is a method used to track the amount of carbohydrates you eat in your meals and snacks. It is often used to manage blood glucose levels in individuals with T1DM. A prospective observational study conducted between 2014 and 2016 investigated the variation of carbohydrate intakes (CI) in children.
It found that significant CI variation rates were 30% at the daily level – 34% for breakfast, 44% for lunch and dinner and 53% for snacks. It concluded that in children with T1DM and diet variability, matching insulin doses with carbohydrate counting offers flexibility and a better quality of life (Robart et al., 2019; Annan et al., 2022).
Due to limited cognitive development and immature communication skills, young children may be unable to articulate symptoms associated with hypoglycaemia or hyperglycaemia (Robart et al., 2019). As a result, despite the well-established benefits of carbohydrate counting and pre-prandial insulin administration, parents of very young children with T1DM encounter a unique set of challenges in managing their condition (Olinder et al., 2022). This review explores three specific challenges commonly reported by parents, as identified in the literature.
Challenge 1: Fear of hypoglycaemia
A study conducted by DiMeglio et al. (2020) reported that, on average, children with T1DM spent the majority of the day, approximately 13 hours, in a hyperglycaemic state, with a median duration of around one hour per day in hypoglycaemia. The study highlighted that parental fear of hypoglycaemia was particularly evident among parents of younger children at the time of diagnosis and those from minority racial and ethnic backgrounds.
Likewise, The Sensor Evaluation in Newborns and Children with Type 1 Diabetes (SENCE) study explored the complexities of achieving optimal glycaemic control in children aged two-six years with T1DM. The study integrated the use of CGM with a structured family behavioural intervention (FBI) designed to enhance glycaemic outcomes. Recognising that children in this age group are unable to manage their diabetes independently, the study underscored the substantial burden placed on parents in managing the condition. Despite its contributions, the study presents certain methodological limitations. Notably, it relied on self-reported parental questionnaires, which may introduce response bias, and it did not control for key confounding variables such as parental educational background or prior experience with CGM technology.
These factors may have influenced both parental perceptions and glycaemic outcomes. Nevertheless, the findings demonstrated significant improvements in glycaemic control, alongside reductions in parental anxiety, particularly concerning undetected hypoglycaemic episodes.
Parents also reported improvements in quality of life, especially regarding sleep and worry, which are often compromised in the caregiving context. Importantly, the intervention appeared to reduce the uncertainty commonly associated with carbohydrate estimation, potentially leading to more accurate carbohydrate counting and insulin dosing (Van et al., 2022).
Challenge 2: Erratic eating behaviours
It is often observed that children of young age tend to have erratic eating behaviours due to sudden appetite changes, picky eating, grazing on snacks, irregular meal timings and high carbohydrate variability in their foods (Annan et al., 2022).
Patton, Dolan and Powers (2006) conducted a six-month prospective observational study to investigate the influence of mealtime interactions on dietary adherence and glycaemic control in young children with T1DM. The study included 60 children aged two-five years and emphasised the often-underappreciated role of family dynamics and behavioural factors in diabetes management. Findings indicated that the effective application of parental strategies and targeted behavioural interventions was positively associated with improved dietary adherence and better glycaemic outcomes. Despite its valuable insights, the study has limitations that affect its broader applicability. The sample was drawn from a specific demographic and geographic population, which may limit generalisability.
Additionally, the study did not account for potential confounding variables such as socioeconomic status, parental education levels or the psychological wellbeing of caregivers, all of which could significantly influence both parental behaviours and diabetes outcomes in children.
Additionally, Dovc et al., (2021) conducted an observational study, examining the use of CGM in children aged 1–7 years with T1DM and collecting data from 15 centres across nine countries. Although the study did not explicitly focus on eating behaviours as a central variable, it identified unpredictable eating patterns as a significant contributor to glycaemic variability in this age group, obscuring the maintenance of stable blood glucose levels. The findings highlighted that CGM use allowed parents to make real-time insulin adjustments based on immediate glucose readings and meal responses, enabling possibly splitting insulin doses (a fraction given before and the remainder during the meal). This facilitated more accurate monitoring of postprandial glycaemic trends, improved time in target glucose range, and reduced the likelihood of carbohydrate underestimation. While the study effectively demonstrated the benefits of CGM in supporting glycaemic stability, it did not account for behavioural or psychosocial factors that may also influence dietary habits and insulin management, limiting the depth of conclusions that can be drawn about eating behaviours specifically.
Challenge 3: Changing insulin requirements
Although not explicitly stated, an additional challenge that emerged during the literature review was the difficulty parents face in managing insulin dosing in young children, particularly during the early stages following diagnosis. Due to their small body size and variable activity levels, young children often require minimal insulin doses initially. A prospective study by Abdul-Rasoul, Habib and Al-Khouly (2006), involving 103 children under the age of 12 newly diagnosed with T1DM, found that 69% entered a partial remission phase, commonly referred to as the honeymoon phase.
During this period, insulin requirements were substantially reduced, averaging 0.65U/kg/day, in contrast to 1.75 U/ kg/day in those not undergoing remission. The study also identified age (with higher remission rates in children over five years) and the absence of DKA at diagnosis as significant predictive factors for remission. As remission wanes, insulin needs tend to increase, presenting new challenges in glycaemic management. A longitudinal study by Nwosu et al. (2018) involving 123 children with T1DM found that individuals who had experienced partial clinical remission required significantly lower insulin doses at six months postdiagnosis (0.22U/kg/day) compared to four to five years later (0.64U/kg/day). This increase in insulin demand was associated with a corresponding rise in HbA1c levels, suggesting a deterioration in glycaemic control over time. These findings underscore the dynamic nature of insulin management in paediatric T1DM and the ongoing need for parental education and clinical support throughout different disease phases. Moreover, a qualitative study highlighted that, beyond the variability in insulin needs, ongoing physical growth and social development further contributed to the complexity of diabetes management. Parents reported that these evolving factors significantly impacted glycaemic control and often heightened the burden of diabetes care. This emphasises the importance of tailored, ongoing support for families to navigate the dynamic nature of T1DM in early childhood (Lawson et al., 2014).
Furthermore, a multicentre RCT conducted by Battelino et al. (2012), involving 153 participants across eight centres, evaluated the efficacy of CGM in individuals with T1DM receiving IP therapy. The study demonstrated that the integration of CGM significantly facilitated more frequent and precise insulin adjustments. This was attributed to the enhanced ability to administer additional boluses and utilise temporary basal rates and extended bolus options, thereby contributing to more accurate insulin dosing and improved glycaemic control. Despite its strengths, the study had notable limitations. The participant cohort included both paediatric and adult populations, which may limit the applicability of the findings to specific age groups. Additionally, the study duration was limited to 12 months, potentially insufficient to assess long-term outcomes and the evolving nature of insulin requirements over time. Nevertheless, the capability for micro-dosing with IPs, when guided by CGM data, may enhance parental confidence in carbohydrate counting at mealtimes and support more precise and adaptive insulin management in young children.
2 – The impact of low-GI foods on blood glucose regulation
In children with T1DM, maintaining a healthy lifestyle is essential to prevent prolonged postprandial hyperglycaemic spikes. Glycaemic index and glycaemic load (GL) are key measures used to evaluate the quality and quantity of carbohydrate-containing foods
and their impact on blood glucose levels (Annan et al., 2022). A systematic review by Quarta et al. (2023) examined the influence of low-GI diets on glycaemic control in children with T1DM. It explored various aspects, including the physiological rationale behind low-GI diets and their potential benefits. It found that such dietary patterns significantly enhance glycaemic stability and reduce postprandial hyperglycaemic peaks.
However, the review lacked practical guidance on how to enhance adherence or evaluate the practicality of adopting low-GI diets across diverse populations considering social and cultural contexts, leaving the persistent challenge of poor dietary compliance among children unaddressed.
Likewise, Gilbertson et al. (2003) conducted an RCT to examine the impact of low-GI dietary guidance on food choices and overall dietary quality in children with T1DM. Participants were randomised to follow either a conventional carbohydrate-exchange (CHOx) diet or a more flexible low-GI dietary approach. Dietary intake was monitored using detailed three-day food diaries, offering valuable insights into the participants’ food selection and eating patterns. Statistical analyses were appropriately conducted, and findings revealed no significant differences between the two groups in terms of macronutrient consumption (protein, fat, carbohydrates), dietary fibre intake or diversity of food group intake.
These results suggest that low-GI dietary strategies can be integrated into diabetes management without negatively affecting nutritional variety or quality, which is an important consideration in children where growth and nutrition are critical. While the study employed robust dietary assessment methods, it was limited by the absence of information regarding blinding procedures and an unclear follow-up duration for all participants after the 12-month dietary intake reports. These methodological omissions may introduce risk of bias and limit the interpretability of long-term adherence and effectiveness.
Additionally, an RCT was conducted evaluating the effect of a low-glycaemic diet versus a standard diet on blood glucose levels and macronutrient intake in children with T1DM. The study involved a small sample size of 23 children as each participant consumed both diets on separate days, with the order counterbalanced. Blinding was not feasible due to the nature of dietary interventions, so participants were aware of the diet they were consuming, which could influence their behaviour and reporting.
The study did find that the low-GI diets resulted in significantly lower mean daytime blood glucose levels compared with the usual meals, with a p-value <0.001.
Moreover, the high blood glucose index was significantly reduced on the low-GI day and led to healthier macronutrient intake (e.g., increased fibre, reduced fat). However, although the results are promising and likely applicable to children with T1DM, confirmation through larger, randomised, long-term studies is required for effective integration in clinical practice (Rovner, Nansel and Gellar, 2009).
Moreover, Nansel, Gellar, and McGill (2008) conducted a randomised crossover study to evaluate the short-term glycaemic effects of high glycaemic index (HGI) versus low glycaemic index (LGI) meals in children with T1DM using CGM and basal-bolus insulin therapy. The study involved 20 participants, each of whom completed both dietary interventions on separate days in a randomised sequence, allowing for direct within-subject comparisons.
Results demonstrated that LGI meals were associated with significantly lower mean daytime blood glucose levels compared with HGI meals, suggesting a beneficial effect on glycaemic stability. However, the study also noted a higher incidence of mild hypoglycaemic events with LGI meals, highlighting the need for close monitoring and potential insulin dose adjustments when implementing such dietary strategies.
From a clinical perspective, while the study design was appropriate for assessing acute effects, it was limited by its short duration and small sample size. Importantly, it did not evaluate long-term clinical outcomes such as HbA1c, growth parameters or quality of life, which are essential for a comprehensive understanding of the clinical utility of LGI diets in T1DM management. Therefore, while the findings are promising, further research involving larger cohorts and extended follow-up is warranted to validate the safety and efficacy of LGI dietary interventions.
The reviewed literature collectively concludes the beneficial role of low-GI diets in the management of T1DM in children, particularly in enhancing postprandial glycaemic control and promoting favourable macronutrient profiles. However, methodological limitations underscore the need for caution in generalising these findings. Additionally, practical barriers to adherence, adaptability to various populations and the potential for hypoglycaemic episodes highlight the importance of individualised dietary planning and insulin adjustment.
Future research involving larger diverse cohorts and extended intervention periods is warranted to establish the long-term safety, efficacy and feasibility of integrating low-GI dietary strategies into clinical practice for the management of T1DM in young children.
Experience, reflection, action
According to the Jasper ERA model of reflection (2013), there are three key stages: experience, reflection and action. This model was selected for use due to its simplicity, suitability for healthcare environments and cyclical structure, which emphasises the ongoing process of learning and reflective practice (Ryder and Downs, 2022).
Emotionally challenging
As part of my role as a general paediatric and diabetes dietitian in a secondary care setting, I frequently work with young children who are admitted to the hospital with a new diagnosis of T1DM. Often, these children are referred directly from primary care with limited background information beyond elevated blood glucose levels.
For parents, particularly those of young children, such admissions can be overwhelming and emotionally challenging. I have encountered multiple cases where parents reported – prior to their diagnosis – noticing behavioural changes in their child, such as increased irritability, reduced activity levels and a generally quieter demeanour. Many parents already face additional difficulties managing their child’s behaviour, and the added complexity of a new diagnosis often heightens their stress and anxiety.
A common concern among parents is the unpredictable eating habits and changing insulin requirements. These factors complicate meal planning, making it difficult to establish consistent routines, and in turn this affects insulin dosing accuracy. One key observation I have made is that, out of fear of hypoglycaemia, parents often prefer to maintain their child’s blood glucose levels above the recommended target range of 4–7mmol/L (NICE, 2015).
Over time, even as they come out of their honeymoon phase and insulin requirements change due to growth spurts, this fear persists and often hinders parents from carbohydrate counting with confidence. Additionally, young children naturally incline towards sweeter foods, many of which have a high GI. This preference further complicates blood glucose management, contributing to frequent fluctuations that are difficult to stabilise.
During the typical three-day hospital admission for structured diabetes education, the environment offers regulated meal and snack times, and immediate professional support, which contributes to reassurance in management.
However, many parents report that their anxiety and confidence diminish once they return home, where real-life routines such as work, childcare, varying activity levels and diverse meals introduce new challenges.
Long-term implications
Before attending this module, I was already aware through experience of the practical challenges parents face when managing T1DM in young children. However, I had not previously explored the evidence base supporting these experiences and the longterm implications and practical recommendations for managing them. The module also highlighted that 10g over- or under-estimation of carbohydrates is okay, but in the practical world, large meals are usually underestimated and snacks overestimated.
Initially, I aimed to focus my evidence-based case study exclusively on toddlers aged 0–3 years. However, I quickly discovered a significant gap in the literature specific to this age group.
Furthermore, it became apparent that pre-school and early school-aged children often encountered similar difficulties with dietary quality, including mealtime routines, which are important to achieving optimal glycaemic targets (Annan et al., 2022). While reviewing national guidelines, I noted that the UK’s carbohydrate dietary reference values are established only for adults and children aged five.
For younger children, the guidelines focus on general dietary patterns, appropriate food choices and proportions of macronutrients instead (COMA, 1991). This leaves a gap in support for this particularly vulnerable group in terms of when parents ask for carbohydrate recommendations per day. Although the World Health Organization also does not specify gramme-based recommended dietary allowance (RDA) in children under one year, it does recommend that carbohydrates should make up 45%–65% of total daily energy from six months onward (WHO, 2015).
Reflecting on my clinical practice, I recognised that I may have overwhelmed parents by providing too much information in a short timeframe. I was keen to ensure they received all the necessary dietary education before discharge, but in doing so I may have limited opportunities for more meaningful, individualised discussions. Although I enquired about the child’s lifestyle, I realise now that I could have explored more deeply the mother’s specific fears, perceived barriers and anxieties.
Additionally, I became more aware of the cumulative effect of simultaneous education on insulin administration being delivered by nursing staff. For parents, processing complex dietary advice alongside learning how to give insulin injections – especially with each meal – can be emotionally and cognitively overwhelming. I also reflected that although we advise on carbohydrate counting and portion sizes, the practical realities of feeding young children are unpredictable. Children may refuse food, eat erratically or vary their intake significantly, which complicates insulin dosing and can add to parental stress (Annan et al., 2022).
Parental fears
Moving forward, I aim to adapt my clinical practice to more actively acknowledge and address parental fears, especially around hypoglycaemia and carbohydrate counting, preventing over- and under-estimations of carbohydrates. I aim to explore parents’ existing knowledge and take into account behavioural, food security, psychosocial and cultural influences on their concerns.
This approach will support the inclusion of scenario-based discussions and shared parental experiences, with the goal of enhancing parents’ confidence in managing unpredictable eating patterns and adapting to evolving insulin needs. I also acknowledge the need to more directly address children’s preferences for high-GI foods during dietary counselling. This should involve practical, realistic strategies to promote moderation and balance. Guiding families towards suitable substitutions with lower GI options, while monitoring long-term adherence and maintaining nutritional variety, can support healthier dietary patterns.
I also intend to collaborate more closely with the MDT, especially psychologists, so that emotional support is embedded alongside dietary education. I aim to see them separately at their first MDT outpatient appointment after discharge, to go through home management and troubleshoot real-world challenges they encounter.
Furthermore, I would highlight these important aspects in their dietetic annual reviews, individualising their evolving nutritional needs. I aim to discuss my findings from this report with my wider dietetic team to make sure the care we provide is standardised, holistic and evidence-based.
Conclusion
While considerable research is being conducted in the field of diabetes, there remains a gap in studies focusing on specific age groups and the unique challenges associated with their management. Limitations such as small and non-diverse sample sizes, methodological constraints and response bias reduce the applicability of current findings to clinical practice. Moreover, important contextual variables such as socioeconomic status, parental education and caregiver psychological wellbeing are often underrepresented in research.
Evidence underscores the importance of regular monitoring during periods of growth, ongoing education on carbohydrate counting and the incorporation of low- GI foods where appropriate.
Notably, the use of CGMs and IPs has been shown to improve glycaemic control and reduce fluctuations in blood glucose levels (Annan et al., 2022). To advance care, further targeted research is needed, along with the development of strong support networks between healthcare professionals and families managing in children.
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