3/19/2010

1

Leslie K Scott PhD, PNP-BC, CDEUniversity of Kentucky

Review diabetes as it occurs in children Discuss the diagnosis of diabetes in children

d h d ff b 1 dand the differentiation between type 1 and type 2 diabetes

Discuss current treatment of diabetes in children---medications, monitoring, and other factors influencing its management.

3/19/2010

2

23.6 million Americans with diabetes57 illi A i ith di b t 57 million Americans with pre-diabetes

1 per 400-600 children in the U.S. have diabetes.

2 million adolescents with pre-diabetes

(12-19 years)

Fasting Plasma Glucose (FPG) > 126 mg/dl. Plasma Glucose (PG) > 200 mg/dl 2-hr. post CHO load

in a glucose tolerance test (OGTT). Casual Blood Glucose > 200 mg/dl with classic

symptoms (polyuria, polydipsia, polyphagia). A1c > 6.5%

“ b ”“Pre-Diabetes” Impaired Fasting Glucose– FPG 100-125mg/dl. Impaired Glucose Tolerance– PG 140-199 mg/dl 2-hr.

post CHO load. A1c 5.7%-6.4%

3/19/2010

3

Auto-immune process. Requires insulin injections. More common type of diabetes in children More common type of diabetes in children. Accounts for 5% of all diabetes. Overweight - Rare Family history - Rare Acute onset of symptoms

Ri k f DKA–Risk for DKA

Diagnosed by: FPG, Random glucose, A1c, Ketones, Islet cell Ab, GAD ab, IA2 Ab, Insulin AutoAb. (perhaps c-peptide)

3/19/2010

4

3/19/2010

5

More commonly seen in adults yet rates in children are rising.

Accounts for up to 45% of new diabetes i hildcases in children.

Insidious onset Overweight– Common Family History- Common Insulin Resistance- Common Treatment: Weight maintenance/loss,

exercise, Medical Nutritional Therapy (MNT), Insulin, and oral agents.

Diagnosed by: FPG, 2-hr OGTT (75 gm), A1c, (perhaps c-peptide)

Average age of onset 18-21 years Shares features of type 1 and type 2

diabetes– fibrosis causes scarring and destruction of the islet cells—but not all cells—lead to insulin deficiency

Weight loss/fatigue Weight loss/fatigue ↓ PFT’s (up to 4.5 years prior to Dx)

Diagnosed via OGTT. Screening begins at 8 years, repeated annually.

Treatment. Insulin—usually basal initially.

3/19/2010

6

MODY (Maturity Onset of Diabetes in Youth)Mutation in autosomal dominant gene(monogenic)Mutation in autosomal dominant gene(monogenic)

(2010) 6 loci on 12 chromosomes identified, MODY 2/MODY 3 most common types

–Diagnosed via genetic testing ($1500+)

MODY type determines treatment modalityyp y

Neonatal Diabetes (<6 month of age)Diagnosed via genetic testing ($600+)

MODYNon-obeseFirst-degree relatives with similar diabetesNo family history of autoimmune diseasePersistent low insulin dosing (after honeymoon)g ( y )

Neonatal DiabetesAny infant who developed diabetes prior to 6 months of age– May be able to be treated with OHA

3/19/2010

7

No prevalence data available in childrenRisk Factors Associated with Type 2 Diabetes

in Children Overweight Ethnicity Family History of Diabetes Gender Insulin Resistance

H t i Hypertension Dyslipidemias Acanthosis nigricans

ADA and AAP have established guidelines for screening “at-risk” youth.

10 years of age:BMI > 95th percentileBMI > 85th percentile with 2 additional

risk factors (ethnicity, family history, evidence of insulin resistance, maternal gestational diabetes)gestational diabetes)

Screening: FPG and/or 2-H OGTT (75 gm load; 1.75 gm/kg up to 75 gm), A1c

Evaluate B/P, Lipid Profile, and Liver Functions

3/19/2010

8

DCCT-Diabetes Control and Complication Trial (1993).Type 1 Diabetes: 42%-76% risk reduction in complications

with ‘near normal control’ UKPDS—United Kingdom Diabetes Prospective Study

(2002) Type 2 Diabetes: 1% reduction in A1c=35% risk reduction

complications (macrovascular) DPP—Diabetes Prevention Program (2002)Pre-Diabetes: 58% risk reduction for DM with lifestyle

changes ALONE!!

Goal should be individualized.

3/19/2010

9

Medical StabilizationT 1 T 2Type 1 vs. Type 2

Medication AdministrationInsulinOral Agents

Glucose/ Urine monitoring Hypoglycemia management Hypoglycemia management Sick-day management Physical Activity/Exercise Medical Nutrition Therapy Developmental Issues

Hyperglycemia (glucose > 300 mg/dl) Evidence of significant ketosis Evidence of significant ketosis

(urine acetoacetate, blood beta-hydroxybutyrate)

Acidosis (pH < 7.30 or HCO3 < 15)

3/19/2010

10

Correct the dehydration (PRIORITY)Correct the hyperglycemia

Hydration Start with 10-20 cc/kg NS bolus Do not give more than 40 cc/kg as bolus Do not give more than 40 cc/kg as bolus Goal is to replace deficits over 48 hours Continually re-evaluate status of hydration

Hydration (cont’d) Replacement therapy

Will need 3,000 mL/m2/ 24 hrs(usually 1.5 x Maintenance)

Add dextrose when BG < 250 -300 mg/dl OR decrease in glucose is too rapid

Goal: decrease BG by 50-100 mg/dl/ hour Continually re-evaluate status of hydration

3/19/2010

11

Insulin Do NOT give initial bolus of insulin (IV) IV insulin drip at 0.1 units/ kg/ hour May decrease to 0.05 u/kg/hr if BG decreasing

too quicklyq y To get control of balance with IV fluids Prevent hypoglycemia

Monitor BG at least q 1 hr

Initial hydration with NS May decrease to ½ to ¼ NS depending upon May decrease to ½ to ¼ NS depending upon

the clinical status after initial hydration When adding glucose decrease to ½ NS

Add potassium when K< 5 and with urinationK >5 5 t i i IVF K >5.5 – no potassium in IVF

K 4.5 – 5.5 – 20 meq/L K+ K <4.5 – 40 meq/L K+

3/19/2010

12

pH > 7.30 and HCO3 > 15-18 Patient able to eat Subcutaneous insulin:

Give sq injection, D/C IV insulin / IV dextrose, feed child

Known diabetes patient Previous dosing May need additional rapid acting insulin to overcome y p g

insulin resistance after DKA New patient 0.5 – 1.0 units/kg/ day:

Type 1 diabetes—Initiate insulin therapy-- Basal-Bolus Therapy

Type 2 diabetes Type 2 diabetes—A1c < 8%-- may consider lifestyle (2-3 mo)

and/or monotherapy. Re-evaluate therapy every 3 mo. ‘Til A1c goals achieved.

A1c 8%-10%-- consider insulin in addition to insulin sensitizer.

A1c > 10%-- initiate insulin therapy. May alter

therapy as glucose toxicity resolves.

Pre-diabetes—Initiate lifestyle modification. Consider insulin sensitizer.

3/19/2010

13

Goal of insulin therapy is to provide for physiologic needs (mimic normal physiology).

Very Rapid ActingAspart (Novolog)/Lispro (Humalog)/Apidra

Rapid ActingRegular

Intermediate Acting Intermediate ActingNPH

Long ActingGlargine (Lantus)Detemir (Levemir)

7575BreakfastBreakfast LunchLunch DinnerDinner

2525

5050PlasmaPlasma

Insulin (Insulin (µU/mL)U/mL)

4:004:00 16:0016:00 20:0020:00 24:0024:00 4:004:00 8:008:0012:0012:008:008:00

TimeTime=insulin administration.

3/19/2010

14

ConventionalBID/TID d iBID/TID dosing

Intensive Insulin TherapyBasal/Bolus insulin dosing

Insulin Pump Therapy

C i l Conventional BID Dosing (NPH/Reg) TID Dosing (NPH/Reg)

• Intensive TherapyB l B l ThBasal Bolus Therapy(Glargine/Detemir)—Basal(Novolog/Humalog/Apidra)---Bolus

3/19/2010

15

Insulin to Carbohydrate Ratio‘Rule of 500’----500 ÷TDD

Insulin Correction Factor (Sensitivity Factor)‘Rule of 1500/1600/1800’----- 1500÷TDD

Pump Emergency KitPump Emergency Kit

Insulin to CHO ratio: 1:10 Correction Factor: 1:50>150mg/dl

BS: 210 CHO: 60

Calculated dose:_______

3/19/2010

16

Insulin to CHO ratio60 Gm ÷ 10 = 6 units

Correction Factor210 – 150 = 60 ÷ 50 = 1.2 units

Total Dose: 6 units + 1.2 units = 7.2 ~ 7 units

Administered Sub-Q at 90° No aspiration necessary If using pen device remember to prime

needle with 2 unit “air-shot” Insulin vial/pen in use is good for 28 days

only. Remaining must be discarded. (Every 3 days in insulin pump).

3/19/2010

17

Keep refrigerated 36-46 degrees until expiration date (unused)

Keep at room temperature 59-86 degrees for 30 days

Don’t leave in a car dashboard or trunk Don’t leave on a window

ledge, next to the stove, or in a steamy or in a steamy bathroom medicine chest

Sulfonylureas: Stimulate the beta cells in the pancreas to make more insulin. Some of them appear to also make body cells more sensitive to insulin.

Meglitinides: Stimulate the beta cells in the pancreas to make more insulin. In contrast to the sulfonylureas, it has a short duration and no known effect on insulin sensitivity.

Biguanides: Decrease the amount of sugar produced by the liver and increase insulin sensitivity both in the liver and muscle cells. They do not have a direct effect on insulin-producing cells. (First l d l d d f 10 ld )line medication, only medications approved for < 10 year olds)

Glucosidase inhibitors: Work in the intestines to slow down the conversion of ingested carbohydrates to sugar.

Thiazolidinediones: Increase insulin sensitivity at the cellular level and improve glucose usage by the cells. (Should not be used in children)

3/19/2010

18

Blood glucose levels are monitored at l t f ti d b f l least four times per day--before meals and bedtime. Incorporate post-prandial checks.

Also should be checked anytime child feels/displays symptoms of hypoglycemiahypoglycemia.

Check before recess/ PE class.

Any time blood glucose levels > 240 mg/dl on two separate occasions.p

During illness. Pump Therapy–blood glucose levels > 240 mg/dl on any occasion.

3/19/2010

19

Low blood sugar is Low blood sugar is defined as a blood sugar less than 70-80 mg/dL with symptoms.

Check blood sugar—if less than 65 70 mg/dL treatif less than 65-70 mg/dL--treat

Treat with 15 of FAST-ACTING CHO--1/2 cup of juice or regular soft drink, 1 cup of milk, glucose tablets, cake icing (gel)

After treating, recheck blood sugar in g g15 minutes--rule of 15’s--15 grams of CHO and recheck blood sugar in 15 minutes.

3/19/2010

20

If longer than one hour before next meal or snack follow with small snack (1/2 sandwich snack, follow with small snack (1/2 sandwich or cheese & crackers)

DO NOT USE CAKES, COOKIES, OR CANDY--Contains fat which will not increase blood glucose.

If unable to swallow, use Glucagon Emergency Kit. -- Dose 1 mg.

Inject into sub-Q or muscle--once given must turn on side to prevent aspiration. After awake, must feed.

Glucagon has an expiration date.

3/19/2010

21

Hyperglycemia is blood sugar h /d fgreater than 240 mg/dL for two

blood glucose tests in a row.

Check urine ketonesIf k t d t t l If ketones are moderate to large, parents to call healthcare provider ASAP

Increase fluids--caffeine free Do not increase activity

3/19/2010

22

Carbohydrates main food Carbohydrates main food source that increases blood sugar

Fat can increase blood sugar later Don’t restrict CHO--but have a specific amount for

meals and snacks Develop CHO goals—

Conventional Consistent CHO IntakeConventional– Consistent CHO IntakeIntensive– Insulin to CHO ratio

ADA updated position statement on diabetes & exercise

….Becoming increasingly clear that exercise may be a therapeutic tool in a variety of patients with diabetes, or a risk for diabetes….

3/19/2010

23

Pros Improves insulin sensitivity Can reduce hyperglycemia* Can reduce hyperglycemia* Mental Boost Weight management Life Experience/Increased confidence

Cons Cons Hypoglycemia* Extensive TV time is associated with poor metabolic control in

children with type 1 diabetes. Significant increase in A1c for every hour of TV time—adjusted for age, BMI, and insulin dosing. (computer???)

Monitor blood glucose levelsg Adjust insulin schedule/dose/administration

location Adjust food intake Wear medical ID

3/19/2010

24

Ben is a 12 year old who presents to your clinic with complaints of fatigue. Dad just Dx’d w/ T2DM; mom has hypothyroidismT2DM; mom has hypothyroidism

Height: 152 cm (60 in)Weight: 78 kg (172 lbs.)BMI: 34.8 (> 97%)ROS: + nocturia 1-2 times per night, 4 lbs. weight p g g

loss since beginning of school year.Clinic FSBS: 302 mg/dl

What other labs would you like?

Fasting glucose: 283 mg/dlA1 10 1% A1c: 10.1%

C-peptide: .8 (.7-3.8)

Was started on Metformin 500 mg daily and referred to Endocrine for evaluation and management of T2DM

3/19/2010

25

Labs? Glucose: 238 mg/dl A1c: 10.3%g/CO2: 21 TSH: 2.74urine ketones (negative)GAD Ab: (positive) I-A2 Ab: (positive)Insulin Ab: (negative) (Antibodies- 1 week)

d ? Medications?

Insulin: Basal/Bolus (.5 units/kg/day)

Sara is a 4 year old brought to your clinic with vomiting No fever She has lost 3 pounds since vomiting. No fever. She has lost 3 pounds since her last check-up. Mom reports polydipsia and bedwetting.

Height: 86 cm (34 in) Weight: 13 kg (29 lbs)

BMI 17 BMI: 17 Clinic FSBS: 316 mg/dl

What labs would you obtain? Refer??

3/19/2010

26

Plasma Glucose: 317 mg/dlCO2 9 CO2: 9

Potassium: 3.5 A1c: 13.4% Serum Ketones: Positive GAD Ab: Positive IA-2 Ab: Positive Insulin Auto Ab: Negative

Admitted to KCHTh ?? Therapy??

NS bolus, Insulin gtts (.05-.1 unit/kg/hr), K+ replacement

Medications?? Insulin---Basal/bolus TherapyDetermine Basal dose (.25-.5 units/kg/day)Determine Bolus doses

Insulin to CHO ratioCorrection Factor

3/19/2010

27

Jamie is a 14 year old who comes to your clinic for runny nose You notice she has gained 40 for runny nose. You notice she has gained 40 lbs. since the school year began.

Height: 155 cm (61 in)Weight: 95 kg (208 lbs)BMI: 39

Clinic FSBS: 143 mg/dl

What labs would you obtain?

FBS: 116 mg/dl 2-hr OGTT: 116 mg/dl baseline

203 mg/dl 2-hour postA1c: 6.6%TSH: 3.78GAD Ab: negativeIA 2 Ab tiIA-2 Ab: negativeInsulin Ab: negative

Suggested Treatment????

3/19/2010

28

Toddler (1-3 years)Toddler (1-3 years) Parents must differentiate misbehavio

from hypoglycemia Encourage child to report “funny”

feelings Expect “food jags” Expect food jags Give choices regarding SBGM, injectio

site and food choices.

Preschool (3-6 years) Reassure child who views diabetes

tasks as punishment for behavior Encourage child to participate in simple

diabetes tasksdiabetes tasks Teach child to report “lows” to an adult Teach child what to eat when “low”

3/19/2010

29

School Age (6-12 years) Educate school personnel about Educate school personnel about

diabetes Encourage age-appropriate

independence--ALL Activities Must Be Supervised

Encourage extra-curricular activities and participation in social groupsp p g p

11-12 year olds able to perform an occasional injection

Remember Chronological age maynot correspond with

developmental readiness

Adolescence More capable of performing self-care

activities Know which foods fit into meal plan and Know which foods fit into meal plan and

how to adjust More willing to perform multiple

injections Needs continued parental involvement

and support

3/19/2010

30