In this video interview, Maureen Madden, DNP, CPNP-AC, CCRN, FCCM, FAAN, joined Contemporary Pediatrics while at the 2025 NAPNAP National Conference on Pediatric Health Care, to discuss her session on updated pediatric clinical guidelines for glycemic control for critically ill children and adults.

Madden is a pediatric critical care nurse practitioner at Bristol-Myers Squibb Children’s Hospital and professor of pediatrics at Rutgers Robert Wood Johnson Medical School.¹

In her session, Madden highlighted key updates from the 2024 American College of Critical Care Medicine's guidelines, updated from the 2012 guidelines.

"In critically ill patients under stress, the medications we use often cause a significant spike in blood glucose, leading to hyperglycemia," said Madden. "We know that hyperglycemia is associated with poor long-term outcomes, particularly in individuals with diabetes. There are many factors involved in managing blood glucose effectively."

The updated guidelines addressed 6 specific questions, with recommendations or good practice statements grading scales. Madden noted answers with strong quality of evidence are listed as "strong recommendation," where answers to the questions with less evidence are "good practice statements," and those with little evidence, answers in the updated guideline are an "in our practice" statement.

"If there's very little evidence, we'd [still] like to give you some guidance, and we'd like to tell you in our practice,' but knowing resources and cost also associated with health care, we don't want to dictate what may not be feasible to do, so long as you know that you can get the number returned in a pretty efficient manner that should be appropriate," said Madden."

Questions and recommendations in 2024 guidelines²:

1. Question:

In "pediatric critically ill patients," should we recommend initiating IV insulin therapy at a lower glucose threshold 6.1-10mmol/L (110-180 mg/dL) or higher glucose threshold > 10 mmol/L (> 180 mg/dL)?

Good practice statement:

Clinicians should initiate glycemic management protocols and procedures to treat persistent hyperglycemia ≥ 10 mmol/L (180 mg/dL) in critically ill children.

2. Question:

In “pediatric critically ill patients on insulin therapy,” should we recommend a lower blood glucose target 4.4–7.7 mmol/L (80–139 mg/dL) “or” a higher glucose target 7.8–11.1 mmol/L (140–200 mg/dL)?

Good Practice statement: Clinicians should use glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill children and should treat hypoglycemia without delay.

Strong recommendation:

We recommend against intensive BG control, 4.4-7.7 mmol/L (80-139 mg/dL) as compared to conventional BG control, 7.8-11.1 mmol/L (140-200 mg/dL) in critically ill children (defined by the pediatric panel as ≥ 42 weeks adjusted gestational age).

3. Question:

“In the acute management of pediatric critically ill patients for whom insulin therapy is being initiated,” should we recommend initiating continuous IV insulin infusion “or” intermittent subcutaneous insulin?

"In our practice statement":

We make no recommendation regarding the use of continuous IV infusion for insulin therapy over intermittent subcutaneous insulin in the acute care management of hyperglycemia in critically ill pediatric patients in whom insulin therapy is indicated. However, in our practice, our pediatric expert panel members use continuous IV infusion over intermittent subcutaneous insulin in critically ill pediatric patients with hyperglycemia.

4. Question:

“In pediatric critically ill patients on insulin infusion therapy,” should we recommend monitoring of glucose at frequent intervals (≤ 1 hr, continuous or near-continuous) “or” longer intervals (> 1 hr), during the period of glycemic instability?

"In our practice" statement:

We make no recommendation regarding frequent BG monitoring (interval ≤ 1 hr, continuous or near-continuous) "or" longer intervals (> 1 hr) in pediatric critically ill patients on insulin infusion therapy. However, in our practice we almost always use frequent or continuous or near-continuous monitoring systems (if available) in children being treated with insulin infusion therapy.

5. Question:

“In pediatric critically ill patients on insulin therapy,” should we recommend an explicit clinical decision support tool vs. a protocol with no explicit clinical support tool for insulin titration?

Conditional recommendation (quality of evidence: Low):

We suggest the use of explicit decision support tools over no such tools in critically ill pediatric patients receiving IV insulin infusions for the management of hyperglycemia.

We strongly recommend high-quality research on the use of explicit decision support tools for insulin infusion titration in pediatric patients.

6. Question:

“In critically ill patients (adult and pediatric)”, can a point of care device be used for blood glucose monitoring or a central laboratory device, using an arterial or venous specimen?

Answer:

Unable to provide a specific recommendation due to inconsistent methodologies and reporting among studies. The American College of Critical Care Medicine recognized the need for timely results in a clinical setting, and that further research is recommended.

More on NAPNAP

There are several more important and timely sessions taking place at the 2025 NAPNAP conference. Be sure to visit ContemporaryPediatrics.com for regular updates and continued coverage from Chicago.

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References:

1. Maureen A Madden, DNP, CPNP-AC,l CCRN, FCCM. PennNursing. Accessed March 10, 2025. https://www.nursing.upenn.edu/live/profiles/18828-maureen-madden

2. Madden M. Pediatric Clinical Guidelines Update. Guidelines on glycemic control and critically ill children and adults. Presented at: 2025 NAPNAP National Conference on Pediatric Health Care. March 10-13, 2025. Chicago, Illinois.