pediatric diabetes pediatric diabetes by jeanne fenn rn, bc, med, cde clinical nurse educator,...
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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 [email protected]
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.