Summary: In young children with Type 1 diabetes mellitus treated with multiple daily insulin injections (MDI), bedtime snacking prior to the nocturnal period demonstrated significantly impaired nocturnal glycemic control with reduced time in range (TIR) compared to no bedtime snack (going to sleep without additional food intake after dinner), with no reduction in hypoglycemia frequency, negating its primary intended benefit.
| PICO | Description |
|---|---|
| Population | Young children diagnosed with Type 1 diabetes mellitus treated with multiple daily insulin injections (MDI), representing the population most commonly given bedtime snacks due to parental hypoglycemia concerns. |
| Intervention | Bedtime snacking prior to the nocturnal period, following typical bedtime snack practices. |
| Comparison | No bedtime snack, with the child going to sleep without additional food intake after dinner/evening meal. |
| Outcome | Bedtime snacking significantly impaired nocturnal glycemic control, reducing time in range (TIR). Critically, bedtime snacking did not reduce hypoglycemia frequency, negating its primary intended benefit. |
Clinical Context
Bedtime snacks have been a longstanding tradition in pediatric Type 1 diabetes management, originally intended to prevent overnight hypoglycemia when NPH insulin with its peak action during sleep was the standard basal insulin. Parents understandably fear nocturnal hypoglycemia, which can occur undetected while children sleep and carries risks of seizures, cognitive impairment, and even death in rare cases.
However, modern basal insulins (glargine, detemir, degludec) have flatter pharmacokinetic profiles without the pronounced overnight peaks of NPH. This raises the question: do bedtime snacks remain necessary with contemporary insulin regimens, or do they now cause more glycemic harm than benefit by contributing to overnight hyperglycemia?
Young children present unique challenges: their small body size means even modest snacks represent significant carbohydrate loads, their activity and food intake are unpredictable, and their insulin pharmacokinetics may differ from older children and adults.
Clinical Pearls
1. Bedtime Snacks Worsen Glycemia Without Preventing Hypoglycemia: The fundamental rationale for bedtime snacks is hypoglycemia prevention. This trial found no hypoglycemia reduction with snacking, while nocturnal glycemic control worsened. The practice provides no benefit while causing harm.
2. Time in Range Decreased: TIR is the primary CGM-era metric for glycemic control. Reduced overnight TIR means more time in hyperglycemia, contributing to higher HbA1c and increased long-term complication risk.
3. Crossover Design Strengthens Conclusions: Each child served as their own control, eliminating individual variation in insulin sensitivity, activity patterns, and metabolism that would confound between-subject comparisons.
4. Practice Change Needed: The traditional bedtime snack recommendation may be outdated for children on modern insulin regimens. Clinicians should individualize based on CGM data.
Practical Application
Review overnight CGM data for pediatric T1D patients currently receiving bedtime snacks. If overnight hyperglycemia predominates without significant hypoglycemia, trial eliminating the bedtime snack. Monitor for any increase in nocturnal hypoglycemia and adjust basal insulin if needed.
Counsel families that bedtime snacks were originally designed for older insulin regimens with different overnight profiles. Modern basal insulins generally do not require routine bedtime snacking. When bedtime glucose is already trending low, a targeted snack remains appropriate based on real-time data.
Broader Evidence Context
This trial aligns with evolving understanding that many traditional T1D dietary rules developed in the NPH era may not apply to modern insulin analogs. Similar reconsideration has occurred for rigid meal timing, carbohydrate distribution requirements, and strict snack schedules. CGM has enabled personalization that replaces one-size-fits-all rules.
The shift toward automated insulin delivery systems (hybrid closed-loop) further reduces bedtime snack necessity, as these systems adjust basal delivery based on predicted glucose trends.
Study Limitations
The specific ages of children, snack composition, and snack timing were not detailed. Results may not apply to children on hybrid closed-loop systems or those with specific hypoglycemia-prone patterns. Long-term outcomes of eliminating bedtime snacks were not assessed.
Bottom Line
Bedtime snacking in young children with Type 1 diabetes on multiple daily injections worsens nocturnal glycemic control without reducing hypoglycemia. For children on modern insulin regimens, routine bedtime snacks should be reconsidered in favor of individualized approaches based on CGM data.
Source: Gokce T, et al. “Bedtime Snacking and Glycemic Deterioration in Young Children with Type 1 Diabetes on Multiple Daily Injections: A Randomized Controlled Crossover Trial.” 2025. Read article.
