pediatric diabetes pediatric diabetes by jeanne fenn rn, bc, med, cde clinical nurse educator,...

Pediatric Diabetes By

Jeanne Fenn RN, BC, MEd, CDEClinical Nurse Educator, Pediatrics

University Medical CenterTucson, Arizona

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.

Definition

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

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-diabetes

CDC, 2008

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

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

Types of Diabetes

Type 1 Type 2 Cystic Fibrosis Related Diabetes

(CFRD) Gestational Diabetes Mellitus (GDM) Others; steroid induced

hyperglycemia

Diabetes Management

Oral Hypoglycemics/Insulin Therapy:• Insulin Injections• Blood glucose monitoring

Nutritional guidelines Prevention of:

• Hypoglycemia• Hyperglycemia

Stress/sick day management• Urine ketone testing

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?

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.

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

Type 1 Diabetes Therapy

Insulin

Type 2 Diabetes

Insulin resistance• Subnormal response to a given

concentration of insulin Inadequate insulin response Increased hepatic glucose

Hyperglycemia

Metabolic Defects in Type 2 DiabetesMetabolic Defects in Type 2 Diabetes

PancreasPancreas

LiverLiver Muscle and AdiposeMuscle and Adipose

Hepatic Glucose Insulin Production - Resistance Glucose

UptakeInsulin

Resistance-

ProgressiveInsulin SecretoryDefect

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

Factors Related to the Onset of Obesity

Altered dietary intake

Decreased physical activity

Increased inactivity

Altered dietary intake

Nutritional content Portion size

Decreased physical activity

Not as much participation in physical activities; walking, active play, recess

Increased inactivity

Look at time spent watching TV, playing electronic games

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:

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)

Acanthosis Nigricans

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

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

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)

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

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)

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)

Diabetic KetoAcidosis(DKA) & Hyperosmolar Hyperglycemic

Syndrome (HHS) The two most serious acute

metabolic complications of diabetes.

Mortality rate:• DKA < 5%• HHS about 15%

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

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

Diabetic Ketoacidosis

Dehydration Tachycardia Weight loss Hypotension Abdominal pain Vomiting Decreased level of consciousness

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

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.

Treatment of HHNK

Careful fluid rehydration Insulin therapy Monitor labs Treat underlying cause Assess for complications

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

Insulin Therapy

Indicated for patients with:• Type 1 diabetes/DKA• CFRD • Type 2 diabetes if other therapy is

inadequate• secondary diabetes; pancreatitis,

steroid therapy

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) ®

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

Different AnaloguesDifferent Profiles

Insulin Therapy

Dosing regimens:• Glargine & Lispro or Aspart

(Basal/Bolus) • Regular/NPH• Insulin pump therapy (Lispro/Aspart)

Food intake and insulin regimen should correlate

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

Insulin Administration

Syringes: short needle, mixing insulins

Pen injectors: flexibility Insulin Pumps; Continuous

subcutaneous insulin infusion (CSII) devices

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

Goals for Diabetes Management: Adults

Glycemic control:

FPG (preprandial) 70 - 130 mg/dl PPG (2-h postprandial) <180 mg/dl

ADA, 2009

Blood Glucose Testing

Frequency (varies) Issues(school, availability of

meters,alternate site testing,) Documentation (despite monitor

memory)

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

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

Nutritional Guidelines

Eat a well-balanced diet (there is no one ADA or diabetic diet)

Eat meals(3) and snacks at the same time each day

Use appropriate snacks for hypoglycemia Carbohydrates cause the greatest rise in

blood glucose; avoid concentrated sugars Referral to diabetes nutritionist once/year

Nutritional Guidelines

Carbohydrate Counting

• 1 carbohydrate choice = 15 grams carbohydrate

• 1 carbohydrate choice = 1 starch exchange(15g) or 1 fruit exchange(15g) or 1 milk exchange(15g)

Definition: blood glucose (bg) level of <60 mg/dl

False reaction: Symptomatic with rapid fall in blood sugar even though blood sugar is not low.

Low Blood Sugar Hypoglycemia or Insulin

Reaction

Not enough food

Too much insulin

Extra exercise

Causes of Hypoglycemia

Treatment of Hypoglycemia If person is alert, cooperative and able to swallow:

Give 1/2 cup of juice or regular soda, glucose tabs, soft candy, sugar (15 grams)

Wait 15 minutes, check bg, if still low, repeat

If person is uncooperative, but able to swallow: Give glucose gel (may need to rub into gums)

If seizure, unconscious or cannot swallow without choking: Provide safety, administer glucagon

Glucagon

Counterregulatory hormone to insulin (raises blood sugar)

Indicated for severe hypoglycemia

Hyperglycemia

Blood Glucose levels > 240 mg/dl

Refer to person’s blood glucose goals based on age.

Causes of Hyperglycemia

Too much food

Not enough insulin orMedication

Illness

Stress

Treating Hyperglycemia

Increase fluid intake; water Check for ketones Extra insulin May need to increase appropriate

insulin

Exercise Management Check blood glucose before, during and

after exercise. Eat before heavy exercise. Always carry a fast acting carbohydrate Have extra carbohydrate snacks available. Reduce the insulin dosage. Change the injection site. Be sure others know. Do not exercise if ketones are present. Be aware of delayed hypoglycemia

Sick Day Management

Insulin Management• Insulin therapy must always be

continued• Provide usual doses if eating• Provide extra short acting

insulin(regular/humalog) if glucose is >300 or > trace ketones.

• Estimate 10% - 15% of total daily insulin dose for regular/humalog insulin dose

Refer to Emergency Care Vomiting Unable to eat or drink. Illness with mod/large ketones Symptoms of DKA

Long Term Complications of Diabetes

http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm

Long Term Complications of Diabetes

Macrovascular• Heart and blood vessels:

High cholesterol Hypertension Atherosclerosis

Microvascular• Retinopathy• Nephropathy• Neuropathy

ADA Recommendations for ongoing care:

Exercise daily 30 – 60 minutes (mod) Thyroid Function monitored every 1 – 2 yrs Microalbuminuria annual screening at age

10 yo or 5 years after dx. Blood pressure every visit, treat if elevated Fasting lipid profiles: family history Opthalmic annual exam at 10 yo or 3 – 5

years after dx.

ADA Recommendations:

Foot exams annually begin at puberty

Psychosocial function/family coping routinely.

Depression screening annually at 10 yo

ADA, 2009

Summary of Diabetes Care

Does the person/family:• Know rationale for diabetes care• Have appropriate supplies and

know how to use• Know when to call for help• Have follow-up care

Resources

www.diabetes.org www.childrenwithdiabetes.com www.jdfcure.org www.cdc.gov http://care.diabetesjournals.org/ www.barbaradaviscenter.org

• “Understanding Diabetes”

Questions?

Contact information:

Jeanne Fenn RN, BC, MEd, CDE University Medical Center Tucson, AZ 85274 520.694.2475 jfenn@umcaz.edu

ReferencesAmerican Association of Clinical Endocrinologists (2007). AACE Diabetes Mellitus Guidelines,

Diabetes Management in the Hospital Setting, Endocrine Practice, 13, Suppl 1, 59-61. 

American Diabetes Association (2009). “Standards of Medical Care in Diabetes-2009”, Clinical Practice Recommendations, Diabetes Care, 32, Suppl1, S12-49.

Center for Disease Control (2008). Number of people with diabetes increases to 24 million. Accessed 9/26/08 at http://www.cdc.gov/media/pressrel/2008/r080624.htm

Chase, P. (2006) Understanding Diabetes: A handbook for people who are living with diabetes, 11 th edition, Children’s Diabetes Foundation at Denver.

Chirico, M., Cherian, S., Anderson, S., Taylor, J. (2007). New Agents for the Treatment of Diabetes, Review of Endocrinology, 1, 42-46.

Clement, S., et al (2004). Management of Diabetes and Hyperglycemia in Hospitals. Diabetes Care, 27. 553-591.

References

DeLuca, M. (2007). PDR Concise Prescribing Guide, 1 Thomson Healthcare.

Gates, G. Onufer, C., Setter, S. (2006). Your Complete Type 2 Meds Reference Guide, Diabetes Health.

McCance, K., Huether, S.(2006). Pathophysiology the Biologic Basis for Disease in Adults and Children, 5th edition, Elsevier Mosby.

Mohand, K., Miller, H., Burhan, H., Ledson, M. J., & Walshaw, M. J. (2008). Management of cystic fibrosis related diabetes: a survey of UK cystic fibrosis centers. Pediatric Pulmonology, 43, 642-647.

O’Riordan, S. M., Robinson, P. D., donaghue, K. C., & Moran, A. (2009). ISPAD clinical practice consensus guidelines 2009 management of cystic fibrosis-related diabetes in children and adolescents. Pediatric Diabetes, 10 (Suppl. 12), 43-50.