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). 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 Criteria American 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 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, AfricanAmerican, 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 Diabetes CFRD 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 • HHS < 5% 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 (hours) Usual Effective Duration (hours) Usual Maximum 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 regular 0.5-1 hour NPH Glargine (Lantus) Detemir (Levemir) 2-4 hours 3 - 4 hours Similar to apart/lispro 2-3 3-6 6-10 4-10 10-16 14-18 -- 24 24 similar to glargine Different Analogues Different 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 6 - 12 yo 13-19 yo > 19 yo 7.5-8.5 % < 8% < 7.5 % < 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) Low Blood Sugar Hypoglycemia or Insulin Reaction 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. Causes of Hypoglycemia Not enough food Too much insulin Extra exercise 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 or Medication 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 firstname.lastname@example.org References American 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, 11th 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 fibrosisrelated diabetes in children and adolescents. Pediatric Diabetes, 10 (Suppl. 12), 43-50.