Special Report: Preserving beta-cell function and early insulin use

In episode 4 of the Special Report: Advances in Type 1 Diabetes Management, Contemporary Pediatrics continued its expert discussion on how preserving beta-cell function influenced both short- and long-term outcomes in children with type 1 diabetes. Moderated by Herbert Bravo, MD, the conversation focused on C-peptide as a marker of residual insulin production and its relationship to hypoglycemia risk, disease stability, and quality of life.

Bravo opened by asking how preservation of beta cells affected pathologic hypoglycemia in insulin-treated children. Marian Rewers, MD, PhD, explained that age at diagnosis and timing of intervention strongly influenced disease trajectory. Adults, he noted, were often diagnosed later, retained more endogenous insulin production, and therefore required lower insulin doses per kilogram of body weight. In contrast, young children diagnosed after extensive beta-cell loss frequently experienced wide glycemic variability and little to no measurable C-peptide, a pattern historically described as brittle diabetes. Rewers emphasized that earlier diagnosis, independent of age, improved the likelihood of preserving endogenous insulin secretion.

The discussion then turned to the economic and psychosocial implications of early identification. Bravo highlighted the high cost and emotional burden of pediatric intensive care unit admissions for diabetic ketoacidosis, noting that early recognition of stage 2 disease allowed for outpatient education and initiation of insulin before crisis occurred. Rewers agreed, explaining that cost-effectiveness analyses depended largely on preventing DKA and reducing hospital length of stay, as well as minimizing lost income for families. He added that DKA rates at diagnosis were increasingly viewed as a marker of primary care quality, with the United States ranking poorly compared with many other countries.

Bravo also reflected on a key shift in clinical thinking: treatment decisions were no longer based solely on glucose thresholds but on symptoms and disease stage. He described how children in stage 2 disease could begin low-dose insulin therapy to relieve symptoms such as weight loss, polyuria, or visual changes, even before marked hyperglycemia developed. Rewers reinforced this point by drawing parallels to hypertension management, arguing that waiting until disease reached extreme levels ignored well-established preventive principles.

Together, the exchange underscored how early intervention preserved beta-cell function, reduced hypoglycemia risk, lowered costs, and improved patient experience. The episode reinforced that treating type 1 diabetes earlier in its course was not only clinically sound but aligned with broader goals of preventive, value-based pediatric care.

Our experts

Herbert Bravo, MD, is a pediatrician and the president and founder of the Society for Innovation in Pediatrics. He is also the co-founder of The Pediatric Lounge Podcast.

Marian Rewers, MD, PhD, is a professor of Pediatrics and Medicine at the University of Colorado School of Medicine and executive director of the Barbara Davis Center for Diabetes.

Editor's note:

Herbert Bravo, MD, reports disclosures for Society For Innovation in Pediatrics, Sanofi, and Barbara Davis Center.