Aim and objectives. The aim of this study was to examine insulin initiation practice across the UK in relation to children with newly diagnosed type 1 diabetes. Objectives of this study were to explore practices surrounding insulin initiation in children and nurses' perceptions of associated decision-making.Background. There are comparative studies of insulin treatments and regimens for children but few that describe the insulin initiation process or associated decision-making. The literature suggests a heavy workload for nurses working in practice and insufficient resources for home initiation of insulin.Design. A survey design.Method. A questionnaire regarding insulin initiation was distributed to 247 diabetes specialist nurses working with children from all four UK countries.Results. One hundred and twelve responses (45%). Only 37 (33%) started clinically well, newly diagnosed children on insulin at home, but most would do so with adequate resources. The most common insulin regimen at diagnosis was twice daily injections, with 86% (n = 96) using re-usable pens to deliver the insulin. As expected, no one commenced children on pump therapy at diagnosis. Analogue insulin was seen as the drug of choice by over a quarter of the nurses (29%, n = 32). Doctors appeared to be the main decision-makers, supplemented by other members of the paediatric diabetes multi-disciplinary team and decision-making aids.Conclusion. Approaches to treatment at onset of type 1 diabetes in children remain relatively traditional. Nurses expressed a desire to stabilise clinically well children at home but were restricted by lack of resources. Decision-making in most domains was largely medically dominated.Relevance to clinical practice. The study provides an insight into current insulin initiation practice in childhood diabetes and offers a useful comparator as practices change in the light of advances in treatment (medication and equipment), changes in professional roles (e.g. independent prescribing) and policy shifts (the move away from hospitals and resource constraints).