Leslie K Scott PhD, PNP-BC, CDE University of Kentucky

Transcription

1 Leslie K Scott PhD, PNP-BC, CDE University of Kentucky Review diabetes as it occurs in children Discuss the diagnosis of diabetes in children and the differentiation between type 1 and type 2 diabetes Discuss current treatment of diabetes in children---medications, monitoring, and other factors influencing its management. 1

2 23.6 million Americans with diabetes 57 million Americans with pre-diabetes 1 per 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% Pre-Diabetes Impaired Fasting Glucose FPG mg/dl. Impaired Glucose Tolerance PG mg/dl 2-hr. post CHO load. A1c 5.7%-6.4% 2

3 Auto-immune process. Requires insulin injections. More common type of diabetes in children. Accounts for 5% of all diabetes. Overweight - Rare Family history - Rare Acute onset of symptoms Risk for DKA Diagnosed by: FPG, Random glucose, A1c, Ketones, Islet cell Ab, GAD ab, IA2 Ab, Insulin AutoAb. (perhaps c-peptide) 3

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5 More commonly seen in adults yet rates in children are rising. Accounts for up to 45% of new diabetes cases 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 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 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. 5

6 MODY (Maturity Onset of Diabetes in Youth) 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 modality Neonatal Diabetes (<6 month of age) Diagnosed via genetic testing ($600+) MODY Non-obese First-degree relatives with similar diabetes No family history of autoimmune disease Persistent low insulin dosing g( (after honeymoon) Neonatal Diabetes Any infant who developed diabetes prior to 6 months of age May be able to be treated with OHA 6

7 No prevalence data available in children Risk Factors Associated with Type 2 Diabetes in Children Overweight Ethnicity Family History of Diabetes Gender Insulin Resistance Hypertension Dyslipidemias Acanthosis nigricans ADA and AAP have established guidelines for screening at-risk youth. 10 years of age: BMI > 95 th percentile BMI > 85 th percentile with 2 additional risk factors (ethnicity, family history, evidence of insulin resistance, maternal 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 7

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. 8

9 Medical Stabilization Type 1 vs. Type 2 Medication Administration Insulin Oral Agents Glucose/ Urine monitoring Hypoglycemia management Sick-day management Physical Activity/Exercise Medical Nutrition Therapy Developmental Issues Hyperglycemia (glucose > 300 mg/dl) Evidence of significant ketosis (urine acetoacetate, blood betahydroxybutyrate) Acidosis (ph < 7.30 or HCO 3 < 15) 9

10 Correct the dehydration (PRIORITY) Correct the hyperglycemia Hydration Start with cc/kg NS 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/m 2 / 24 hrs (usually 1.5 x Maintenance) Add dextrose when BG < mg/dl OR decrease in glucose is too rapid Goal: decrease BG by mg/dl/ hour Continually re-evaluate status of hydration 10

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 quickly 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 the clinical status after initial hydration When adding glucose decrease to ½ NS Add potassium when K< 5 and with urination K >5.5 5 no potassium in IVF K meq/l K+ K < meq/l K+ 11

12 ph > 7.30 and HCO 3 > 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 insulin resistance after DKA New patient units/kg/ day: Type 1 diabetes Initiate insulin therapy-- Basal-Bolus Therapy 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. 12

13 Goal of insulin therapy is to provide for physiologic needs (mimic normal physiology). Very Rapid Acting Aspart (Novolog)/Lispro (Humalog)/Apidra Rapid Acting Regular Intermediate Acting NPH Long Acting Glargine (Lantus) Detemir (Levemir) 75 Breakfast Lunch Dinner 50 Plasma Insulin (µu/ml) 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 =insulin administration. Time 13

14 Conventional BID/TID dosing Intensive Insulin Therapy Basal/Bolus insulin dosing Insulin Pump Therapy Conventional BID Dosing (NPH/Reg) TID Dosing (NPH/Reg) Intensive Therapy Basal Bolus Therapy (Glargine/Detemir) Basal (Novolog/Humalog/Apidra)---Bolus 14

15 Insulin to Carbohydrate Ratio Rule of TDD Insulin Correction Factor (Sensitivity Factor) Rule of 1500/1600/ TDD Pump Emergency Kit Insulin to CHO ratio: 1:10 Correction Factor: 1:50>150mg/dl BS: 210 CHO: 60 Calculated dose: 15

16 Insulin to CHO ratio 60 Gm 10 = 6 units Correction Factor = = 1.2 units Total Dose: 6 units 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). 16

17 Keep refrigerated degrees until expiration date (unused) Keep at room temperature 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 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 line medication, only medications approved dfor < 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) 17

18 Blood glucose levels are monitored at least four times per day--before bf meals and bedtime. Incorporate postprandial checks. Also should be checked anytime child feels/displays symptoms of hypoglycemia. Check before recess/ PE class. Any time blood glucose levels > 240 mg/dl on two separate occasions. During illness. Pump Therapy blood glucose levels > 240 mg/dl on any occasion. 18

19 Low blood sugar is defined as a blood sugar less than mg/dl with symptoms. Check blood sugar if less than 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 15 minutes--rule of 15 s--15 grams of CHO and recheck blood sugar in 15 minutes. 19

20 If longer than one hour before next meal or 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. 20

21 Hyperglycemia is blood sugar greater than 240 mg/dl for two blood glucose tests in a row. Check urine ketones If ketones are moderate to large, parents to call healthcare provider ASAP Increase fluids--caffeine free Do not increase activity 21

22 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 Intake Intensive 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. 22

23 Pros Improves insulin sensitivity Can reduce hyperglycemia* Mental Boost Weight management Life Experience/Increased confidence 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 levels Adjust insulin schedule/dose/administration location Adjust food intake Wear medical ID 23

24 Ben is a 12 year old who presents to your clinic with complaints of fatigue. Dad just Dx d w/ T2DM; 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 loss since beginning of school year. Clinic FSBS: 302 mg/dl What other labs would you like? Fasting glucose: 283 mg/dl A1c: 10.1% 1% C-peptide:.8 (.7-3.8) Was started on Metformin 500 mg daily and referred to Endocrine for evaluation and management of T2DM 24

25 Labs? Glucose: 238 mg/dl A1c: 10.3% CO2: 21 TSH: 2.74 urine ketones (negative) GAD Ab: (positive) I-A2 Ab: (positive) Insulin Ab: (negative) (Antibodies- 1 week) 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 her last check-up. Mom reports polydipsia and bedwetting. Height: 86 cm (34 in) Weight: 13 kg (29 lbs) BMI: 17 Clinic FSBS: 316 mg/dl What labs would you obtain? Refer?? 25

26 Plasma Glucose: 317 mg/dl CO2: 9 Potassium: 3.5 A1c: 13.4% Serum Ketones: Positive GAD Ab: Positive IA-2 Ab: Positive Insulin Auto Ab: Negative Admitted to KCH Therapy?? NS bolus, Insulin gtts ( unit/kg/hr), K+ replacement Medications?? Insulin---Basal/bolus Therapy Determine Basal dose ( units/kg/day) Determine Bolus doses Insulin to CHO ratio Correction Factor 26

27 Jamie is a 14 year old who comes to your clinic 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 post A1c: 6.6% TSH: 3.78 GAD Ab: negative IA-2 Ab: negative Insulin Ab: negative Suggested Treatment???? 27

28 Toddler (1-3 years) Parents must differentiate misbehavio from hypoglycemia Encourage child to report funny feelings 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 tasks Teach child to report lows to an adult Teach child what to eat when low 28

29 School Age (6-12 years) Educate school personnel about diabetes Encourage age-appropriate independence--all Activities Must Be Supervised Encourage extra-curricular activities and participation p in social groups year olds able to perform an occasional injection Remember Chronological age may not correspond with developmental readiness Adolescence More capable of performing self-care activities Know which foods fit into meal plan and how to adjust More willing to perform multiple injections Needs continued parental involvement and support 29

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