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Pediatric Diabetes

Pediatric Diabetes . By Jeanne Fenn RN, BC, MEd, CDE Clinical Nurse Educator, Pediatrics University Medical Center Tucson, Arizona. Objectives. Discuss diagnosis of of type 1 and type 2 diabetes, and cystic fibrosis-related diabetes (CFRD).

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Pediatric Diabetes

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  1. Pediatric Diabetes By Jeanne Fenn RN, BC, MEd, CDE Clinical Nurse Educator, Pediatrics University Medical Center Tucson, Arizona

  2. Objectives • Discuss diagnosis of of type 1 and type 2 diabetes, and cystic fibrosis-related diabetes (CFRD). • Identify current management issues in dealing with diabetes. • Discuss responsibilities of multidisciplinary staff in providing basic diabetes education and care.

  3. Definition • Diabetes Mellitus is a chronic disorder in which the body cannot properly use glucose. The body also has difficulty using fats and proteins.

  4. Diabetes affects 24 million people in the U.S. • 90 - 95% have Type 2 • 1/3 of these people do not know they have diabetes • 57 million people in the U.S. have pre-diabetesCDC, 2008

  5. Diabetes Diagnostic CriteriaAmerican Diabetes Association • Each test must be confirmed on a subsequent day: • Symptoms plus a random plasma glucose > 200 mg/dL • Fasting plasma glucose >126 mg/dL • Two-hour plasma glucose > 200 mg/dL during an oral glucose tolerance test

  6. Diagnosis of pre-diabetes • Impaired fasting glucose: • FPG 100 – 125 mg/dl • Impaired glucose tolerance: • 2-hour plasma glucose 140 – 200 mg/dl after the OGTT

  7. Types of Diabetes • Type 1 • Type 2 • Cystic Fibrosis Related Diabetes (CFRD) • Gestational Diabetes Mellitus (GDM) • Others; steroid induced hyperglycemia

  8. Diabetes Management • Oral Hypoglycemics/Insulin Therapy: • Insulin Injections • Blood glucose monitoring • Nutritional guidelines • Prevention of: • Hypoglycemia • Hyperglycemia • Stress/sick day management • Urine ketone testing

  9. Care of the patient with diabetes • Does the pt/family(p/f) understand the reason for the diabetes care plan? • Can the p/f perform all the self care skills? • Have appropriate f/u and supplies been provided?

  10. Psycho-social Issues • Feelings of shock, denial, and sadness are common reactions for people who learn they have diabetes. • Ongoing support necessary in dealing with a chronic care issue.

  11. Type 1 Diabetes • Autoimmune destruction of the beta cells of the pancreas • Insulin deficiency • Insulin is necessary for survival • Diabetic Ketoacidosis (DKA) • Usually an acute onset

  12. Type 1 Diabetes Therapy • Insulin

  13. Type 2 Diabetes • Insulin resistance • Subnormal response to a given concentration of insulin • Inadequate insulin response • Increased hepatic glucose

  14. Type 2 Diabetes • The rise in incidence of type 2 diabetes is commensurate with the increase in obesity. • Characteristics: • obesity • ethnicity • acanthosis nigricans (insulin resistance) • family history of type 2 diabetes

  15. Factors Related to the Onset of Obesity • Altered dietary intake • Decreased physical activity • Increased inactivity

  16. Altered dietary intake • Nutritional content • Portion size

  17. Decreased physical activity • Not as much participation in physical activities; walking, active play, recess

  18. Increased inactivity Look at time spent watching TV, playing electronic games

  19. Screening for Type 2 Diabetes in Children • Criteria: • overweight (BMI > 85th %ile for age and sex, weight for height > 85th %ile, or weight > 120% of ideal for height) • Plus any two of the following risk factors:

  20. Risk Factors for Type 2 Diabetes • family history of type 2 diabetes in first- or second-degree relative • race/ethnicity (American Indian, African-American, Hispanic, Asian/Pacific Islander) • signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome)

  21. Acanthosis Nigricans

  22. Type 2 Diabetes Therapy • Weight loss • Exercise • Oral agents • Biguanides • Metformin, FDA approved for use in children • Insulin Secretagogues • Alpha-glucosidase Inhibitors (AGI) • Thiazolidinediones (TZD) • Insulin

  23. N Engl J Med 346:393-403, 2002.

  24. Cystic Fibrosis-Related DiabetesCFRD • Becoming a common complication of cystic fibrosis (CF) • Prevalence rates: • 5-9 yo: 9% • 10 -20 yo: 26% • By age 30 yo: 50% • Peak age of onset: 18 – 24 years (O’Riordan, et al., 2009)

  25. Pathophysiology of CFRD • Genetics • Those with the most severe CF mutations develop CFRD • Pancreatic pathology • Excess mucus; obstruction, fibrosis, and fatty infiltration • Insulin deficiency • Insulin resistance • Frequent infections, inflammation

  26. Significance of CFRD • The diagnosis of CFRD has been associated with increased risk of morbidity and mortality related to influence on: • Pulmonary function • Nutritional status (Mohan, Miller, Burhan, Ledson, & Walshaw, 2008)

  27. CFRD Therapy • Early identification of CFRD and management of blood glucose with insulin administration stabilizes lung function and improves nutritional status. • Insulin therapy • Optimal nutrition O’Riordan et al., 2009)

  28. Diabetic KetoAcidosis(DKA) & Hyperosmolar Hyperglycemic Syndrome (HHS) • The two most serious acute metabolic complications of diabetes. • Mortality rate: • DKA < 5% • HHS about 15%

  29. Diabetic Ketoacidosis • Caused by an absolute or relative insulin deficiency and an increase in insulin counterregulatory hormones: catecholamines, cortisol, glucagon, and growth hormone. • Individuals with type 1 are more at risk. • Precipitated by illness, infection, trauma, surgery, and stress

  30. DKA Clinical Presenting Symptoms: • Hyperglycemia > 250 mg/dL • Ketonemia (ketone bodies in the blood) • Ketonuria • Kussmaul respirations (deep/rapid) • Metabolic Acidosis • pH < 7.20 • Bicarbonate < 15 mEq/L

  31. Diabetic Ketoacidosis • Dehydration • Tachycardia • Weight loss • Hypotension • Abdominal pain • Vomiting • Decreased level of consciousness

  32. DKA • Management: • Fluid replacement • Insulin drip: Regular Insulin only per IV • Monitor glucose/electrolytes/ketones/labs • *Rapid correction of fluids/electrolytes may lead to development of cerebral edema in young patients. • Assess/treat causes of DKA • Monitor for complications

  33. Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNK)(HHS) • Characterized by a lack of ketosis, extremely high blood glucose levels, and increased fluid deficiency. • Type 2 and elderly more at risk. • Similar presenting symptoms.

  34. Treatment of HHNK • Careful fluid rehydration • Insulin therapy • Monitor labs • Treat underlying cause • Assess for complications

  35. Insulin • Insulin is a hormone produced in the beta cells of the Islets of Langerhans in the pancreas. • Administration of insulin requires frequent blood glucose monitoring necessary to monitor insulin therapy

  36. Insulin Therapy • Indicated for patients with: • Type 1 diabetes/DKA • CFRD • Type 2 diabetes if other therapy is inadequate • secondary diabetes; pancreatitis, steroid therapy

  37. Types of Insulin • Rapid Acting: • Insulin lispro (Humalog) ® • Insulin aspart (Novolog) ® • Insulin glulisine (Apidra) ® • Short-acting: • regular • Intermediate-acting: • NPH • Long-acting: • Insulin glargine (Lantus) ® • Insulin detemir (Levemir) ®

  38. Insulins by Relative Comparative Action Curves Insulin Type Onset Peak Usual Effective Usual Maximum (hours) Duration (hours) Duration (hours) Aspart (Novolog) 5-10 minutes 1-3 3-5 4-6 Lispro (Humalog) <15 minutes 0.5-1.5 2-4 4-6 Glulisine (Apidra) <15 minutes Similar to apart/lispro regular 0.5-1 hour 2-3 3-6 6-10 NPH 2-4 hours 4-10 10-16 14-18 Glargine (Lantus) 3 - 4 hours -- 24 24 Detemir (Levemir) similar to glargine

  39. Different AnaloguesDifferent Profiles

  40. Insulin Therapy • Dosing regimens: • Glargine & Lispro or Aspart (Basal/Bolus) • Regular/NPH • Insulin pump therapy (Lispro/Aspart) Food intake and insulin regimen should correlate

  41. Intensive Diabetes Management • Insulin to Carbohydrate ratio • Unit: Grams of CHO • Example: 1 unit : 15 grams of CHO • Correction Factor: Units of insulin needed to correct a blood sugar level. • Example: 1 unit of lispro/50 mg/dl > 150 mg/dl

  42. Insulin Administration • Syringes: short needle, mixing insulins • Pen injectors: flexibility • Insulin Pumps; Continuous subcutaneous insulin infusion (CSII) devices

  43. Blood Glucose Goals Age Desired Range Before Meals Bedtime < 6 yo 100-180 110-200 6 - 12 yo 90 – 180 100 - 180 13 -19 yo 90 – 130 90 - 150 ADA, 2009

  44. Goals for Diabetes Management: Adults • Glycemic control: • FPG (preprandial) 70 - 130 mg/dl • PPG (2-h postprandial) <180 mg/dl ADA, 2009

  45. Blood Glucose Testing • Frequency (varies) • Issues(school, availability of meters,alternate site testing,) • Documentation (despite monitor memory)

  46. Hemoglobin A1C(HbA1c) • hemoglobin protein with attached glucose • Reflects how often the blood glucose has been >150 mg/dl over the past 3 months. • Non diabetes: 4 – 6 % • Goals: (ADA) • < 6 yo 7.5-8.5 % • 6 - 12 yo < 8% • 13-19 yo < 7.5 % • > 19 yo < 7% (ADA) < 6.5% (AACE) ADA, 2009

  47. Goals for Diabetes Management • Blood pressure • Systolic: <130 mm Hg • Diastolic: <80 mm Hg • Cholesterol: Lipids • LDL-C <100 mg/dL • HDL-C >40 mg/dL (men) > 50 mg/dL (women) • Triglycerides < 150 mg/dL

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