The Ins and Outs of Care for the Child with Type 1 Diabetes

1
The Ins and Outs of Care for the Child with Type
1 Diabetes

• The 31st Annual School Health Conference
• Thursday, May 14, 2009

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Overview

• History of Diabetes
• Epidemiology
• Pathogenesis
• Diagnosis
• Treatment
• Blood glucose monitoring
• Nutrition
• Insulin regimens (syringes, pens, pumps)
• Continuous glucose sensors
• Hyperglycemia
• Hypoglycemia
• Scenarios
• Final remarks/questions

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The History of Diabetes

• Diabetes was first diagnosed by Greek physician
  Aretaeus of Cappodocia in the 1st Century A.D.
• He deemed it a wonderful affection . . . Being
  meltdown of the flesh and limbs into urine. For
  the afflicted, life is disgusting and painful
  thirst unquenchable . . . And one cannot stop
  them from drinking or making water.

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The History of Diabetes

• Aretaeus referred to the disease state as
  Diabetes. It is from the Greek word meaning to
  siphon or passing through.
• In 1675, Thomas Willis added mellitus to the word
  diabetes. Mellitus stems from the Latin word
  meaning honey.

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The History of Diabetes

• 1870s French physician notices the
  disappearance of glycosuria in his patients with
  diabetes during rationing of food in Paris while
  under siege by Germany during the Franco-Prussian
  war formulates idea of individualized diets for
  his patients with diabetes.

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The History of Diabetes

• Oskar Minkowski and Joseph von Mering remove the
  pancreas from a dog to determine the effect of an
  absent pancreas on digestion in 1889.
• 1900-1915 Fad diabetes diets included

• Oat cure
• Milk diet
• Rice cure
• Potato therapy
• Opium

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The History of Diabetes

• Fredrick Allen publishes Studies Concerning
  Glycosuria and Diabetes and Total Dietary
  Regulation in the Treatment of Diabetes.
  Recommended drastically restricting caloric
  intake.
• Establishes the Physiatric Institute in New
  Jersey in 1919 and treated patients with diabetes
  and hypertension there.

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Patient prior to Insulin Therapy
13 year old female weighing 45 lbs.
9
Development of Insulin

• 1920 Fredrick Banting removes the pancreas
  from dogs.
• Summer 1921 Insulin used to successfully treat
  a dog whose pancreas was removed.
• Banting presents The Beneficial Influences of
  Certain Pancreatic Extracts on Pancreatic
  Diabetes in December 1921.

10
Dr. Banting and Dr. Best
With Marjory (one of the experimental dogs).
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What about the patient?
12
Bad Old Days of Diabetes
(Before 1980)

• 1 or 2 insulin injections a day
• Urine tests for glucose
• Aggressive therapy unsafe and of unknown benefits
• Hemoglobin A1Cgt10
• Eye and kidney complications

13
Early 1980s

• Intensive insulin therapy was made
• possible by the introduction of
• Self Monitoring of Blood Glucose
• Hemoglobin A1c assays
• Multiple daily injections (MDI) and Continuous
  Subcutaneous Insulin Infusions (CSII)

14
Type 1 Diabetes Mellitus

• Previously referred to as insulin-dependent or
  juvenile diabetes
• Polygenic, multifactorial, autoimmune disease
• Most commonly occurs in the young

15
Epidemiology

• In 2004, 3 million Americans were estimated to
  have type 1 diabetes.
• There is a 3 increase in incidence per year.
• Approximately 1 in every 400-500 children has
  type 1 Diabetes.
• Diabetes is second most common chronic disease in
  childhood after asthma.

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Epidemiology

• Peak ages at onset 5-7 and early puberty
• 30 of cases onset 18 - 40 years of age
• There is a genetic association in regards to the
  risk of developing diabetes.

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Risk for Type 1 DiabetesBy Family Member with
Diabetes
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Pathogenesis of T1DM

• T-cell mediated process directed at pancreatic ?
  cell.
• Pancreatic islet cell destruction results in
  absence of insulin.
• Absence of insulin causes chronic hyperglycemia.

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Natural History of Type 1 Diabetes
Genetic Predisposition
Immunological Abnormalities
Beta-cell Mass ( max)
Normal insulin release
Impaired insulin release
100
Overt diabetes
50
Honeymoon period
0
Birth
Time (years)
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What does insulin do?

• Insulin is a hormone secreted by the ?-cells of
  the pancreas in response to rising glucose
  levels.
• Insulin is a key that allows peripheral tissues
  to open and allow glucose to enter.

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What does insulin do?
22
Absence of Insulin

• Absence of insulin causes the body to act in
  fasting state, despite being fed.
• Serum glucose cannot be used by peripheral
  tissues because of dependence on insulin.
• Stimulation of hepatic glycogenolysis and
  gluconeogenesis cause further hyperglycemia.
• All of the above cause serum glucose levels to
  exceed the renal threshold (180 mg/dl) and
  glucose is spilled into the urine.

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Osmotic Diuresis

• Once the renal threshold of 180mg/dL is exceeded
  glucose is spilled into the urine. Water is
  dragged out along with the glucose due to the
  molecular weight of glucose in a process known as
  osmotic diuresis.
• Polyuria persists and the body struggles to
  maintain homeostasis by taking in more fluid.
• Without glucose cells resort to lipolysis and
  proteolysis (breakdown of fatty acids and amino
  acids for energy) leading to an accumulation of
  ketone bodies.
• Weight loss results.

24
New Onset Patients

• Symptoms
• Polydipsia
• Polyuria
• Weight loss
• Vomiting
• Nocturia
• Abdominal Pain
• Decreased energy
• Fatigue, General Malaise

25
New Onset Patients

• Started on subcutaneous insulin.
• Instructed on basics of diabetes care including
• How to check blood glucose
• Basic nutrition guidance
• How to administer insulin injection
• Basic understanding of different types of insulin
• Treatment of low bloods sugars
• What to do in case of high blood sugars

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Treatment Goals

• Monitoring of blood glucose levels at least four
  times a day
• Nutrition sufficient for growth
• Insulin to achieve near normal blood glucose
  levels
• Activity and exercise
• Quarterly HbA1c levels
• Support child and family psychologically
• Prevent complications

27
Blood Glucose Monitoring

• Meters require a small amount of blood
  (0.3microliters for freesytle flash)
• Most meters allow for alternate site testing
  (forearm or finger)
• When to test
• At least 4 times a day (before meals and before
  bed)
• As needed for symptoms of low and high blood
  sugars
• Before and after exercise
• Prior to driving

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Meal Planning for Type 1 DM

• All carbs (except fiber) are absorbed in the form
  of glucose molecules
• The total amount of carbs eaten has a greater
  effect on blood glucose rise than does the type
  or the source of carb.
• Keep carb intake consistent during meals from day
  to day if on fixed doses or adjust insulin dose
  to food intake (bolus).

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Carbohydrate Counting

• Allows for more flexibility
• Only grams of carbohydrate are counted
• Insulin dose is varied based on amount of carb
  and blood sugar level
• However, it is important to note serving size!

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What About Sugar?

• Carbohydrates are carbohydrates no matter what
  the source of the carb is.
• Table sugar, sweets, and candy will be broken
  down into glucose.
• As long as someone with diabetes counts the
  carbohydrate they are eating or follows a
  pre-specified amount of carbohydrates daily, it
  is okay to eat such foods.

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Free foods No need to bolus

• Non-starchy vegetables
• Low-fat cheese and lean meats
• Pickles, eggs
• Unsalted nuts and seeds, peanut butter
• Artificially sweetened drinks with Nutrasweet or
  Splenda
• Sugar-free jello, popsicles and syrup

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Meal Planning for T1DM

• Remember to Treat Children with Diabetes
• like all other Children
• Adjust insulin regimen and doses to
• their lifestyle and eating habits
• Flexibility is important!

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Glycemic Controlin Type 1 Diabetes
34
Changes in Diabetes Management
The Effect of Intensive Treatment of Diabetes on
the Development and Progression of Long Term
Complications in Insulin Dependent Diabetes
Mellitus The Diabetes Control and Complications
Trial Research Group NEJM 1993 Sep
30329(14)977-86.
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Diabetes Control and Complications Trial (DCCT)
10.0
9.5
9.0
8.5
Hemoglobin
Conventional
8.0
Intensive
A1c
7.5
7.0
6.5
6.0
Adults
Adolescents
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Risks Benefits of Intensive Diabetes Therapy
(DCCT)

• Decreased Risk ()
• Progressive retinopathy 60
• Microalbuminuria 40
• Neuropathy 60
• Increased Risk ()
• Severe hypoglycemia 300

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Glycemic Control in Pediatrics

• Controversy remains about the level of glycemic
  control that should be targeted for children
  despite the findings of fewer complications with
  better control.
• Concerns exists given the high risk of
  hypoglycemia and what hypoglycemia can do to the
  developing brain.

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Glycemic Control in Pediatrics

• Consensus Statement from the American Diabetes
  Association targets the following goals

Diabetes Care 2009 32 S13-S62.
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How is glycemic control achieved?

• Insulin Therapy

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Action Profiles of Insulins
Aspart, glulisine, lispro 45 hours
Regular 68 hours
Plasma insulin levels
NPH 1216 hours
Detemir 14 hours
Ultralente 1820 hours
Glargine 24 hours
Hours
Burge MR, Schade DS. Endocrinol Metab Clin North
Am. 199726575-598 Barlocco D. Curr Opin Invest
Drugs. 200341240-1244 Danne T et al. Diabetes
Care. 2003263087-3092
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Insulin Profiles
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3 Injections a day
Aspart, glulisine, or lispro
?U/mL
NPH at bedtime
100
NPH
B
L
D
80
60
Normal pattern
40
20
Time of day
Bbreakfast Llunch Ddinner
43
3 injections a day
Aspart, glulisine, or lispro
?U/mL
100
Levemir
B
L
D
80
NPH
60
Normal pattern
40
20
Time of day
Bbreakfast Llunch Ddinner
44
4 Injections a day
Aspart, glulisine, or lispro
?U/mL
100
Glargine or Levemir
B
L
D
80
60
Normal pattern
40
20
Time of day
Bbreakfast Llunch Ddinner
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How can insulin be delivered?

• Draw up from vial and administer with syringe
• Insulin pens
• Insulin pumps

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Insulin via Syringe

• Insulin is drawn from a vial into a 28-31 gauge
  insulin syringe
• Used for all patients who are newly diagnosed
  with diabetes as insulin doses are being adjusted
  daily

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Insulin Pens

• Doses are dialed up
• Administer like insulin injection via syringe and
  hold down back of pen
• Benefits Faster than syringe injections
• Drawbacks Less fine tuning of doses due to
  increments and pre-mixed pens come in specified
  dosages (70/30 or 75/25)

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The Development of the Insulin Pump

• Initially, subcutaneous infusion pump being used
  by Howard Pearson for patients with thalessemia
  major.
• Decision made to try insulin delivery with pump
  to children with type 1 diabetes.

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First Outcome Study of Pumps in Pediatrics
Reduction to normal of plasma glucose in juvenile
diabetes by subcutaneous administration of
insulin with a portable infusion pump WV
Tamborlane, RS Sherwin, M Genel, and P Felig
NEJM 1979 300573-8
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NEJM 1979 300573-8
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The Development of the Insulin Pump
Autosyringe AS2C Used 50mL syringe Had only one
basal rate No memory Slightly noticeable when
worn
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Advances to Pumps

• Smaller size (roughly the size of a pager)
• Multiple basal rates
• Temporary basal rates
• Direct glucose entry from meter or continuous
  monitor
• Able to check history
• Reminders and alerts
• Ability to disconnect infusion sets
• Bolus wizard availability
• Preprogrammed carbohydrate ratios and correction
  factors
• Glucose targets
• Duration of insulin action

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New Insulins for Use in Pumps

• Insulin analogs become available in 1996. Pumps
• transition from use with regular insulin to use
  with
• insulin analogs allowing the pump to work more
• physiologically.

Insulin analogs 45 hours
Regular 68 hours
Plasma insulin levels
Available Insulin Analogs Aspart Lispro Glulisine
Hours
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Insulin pumps versus multiple daily injections
(MDI)

• Advantages of pumps
• More reliable insulin action
• Greater precision in dosages
• Automatic dose calculation with smart pumps
• Flexible mealtimes
• Flexible schedule (exercise, shift work, skipping
  meals)
• Increased sense of well being

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Pump Basics

• Target Blood Glucose glucose to which your pump
  will correct your blood glucose using correction
  factor. May have multiple target blood glucose
  based on time of day.
• Daytime target blood glucose 100mg/dL
• Overnight target blood glucose 120mg/dL

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Pump Basics

• Bolus a quick release or burst of insulin
• Carbohydrate Ratio - the ratio of how many grams
  of carbohydrates are covered by each unit of
  insulin
• Example 1 unit for 10 grams of carbs
• Correction Factor - the mg/dL that each unit of
  insulin will drop your blood glucose.
• Example 1 unit for 50mg/dL

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Pump Basics
Basal rates background insulin released slowly
throughout the day.

• Lantus or Levemir

Pump
200
1600
2000
2400
700
1200
700
Time
Basal insulin delivery from a pump provides a
better and faster match for lifes needs
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Temporary Basal Rate

• Temporary adjustment to basal pattern
• Set in response to change in usual activity
• Exercise (lower the usual basal pattern)
• Sick Day (increase the usual basal pattern)
• Programmed by
• Duration
• of Basal
• Example Temporary rate at 200 for 3 hrs
• Pump automatically returns to usual basal pattern
  at completion of temporary rate

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Basals And Boluses
Bolus
bolus
basal
Suspend pump for exercise
Basal Rate

• A pump more easily matches the realities of daily
  life.

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Who is a Pump Candidate?

• Hemoglobin A1C of lt8.
• Testing blood glucose 4 times a day.
• Logs blood glucose.
• Counts carbs.
• Comes to clinic for follow up. Knows how to
  contact diabetes team.
• Realistic expectations.

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Insulin Pump Brands

• Accu-check Spirit
• One Touch Ping by Animas
• Deltec CozMore 1800
• Insulet Omnipod
• Medtronic Paradigm x22

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Accu- Check Spirit

• Bolus based on BG
• Holds 300 units
• 0.1 unit basal rates bolus increments
• Reversible display
• Side mounted tactile buttons
• Accu-Check Pump Configuration Software
• IR (direct line) control from optional Palm PDA
  or smart phone
• Database of 1,000 Calorie King foods in PDA

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One Touch Ping by Animas

• Bolus can be delivered from One Touch meter up to
  10 feet away
• High contrast color screen for easy viewing
• Smallest mainstream pump
• Smallest basal rate increment 0.025 u
• Waterproof 12 ft for 24 hrs
• ezCarb meal bolus calculator
• ezCarb stores 500 foods
• ezBG correction bolus calculator
• ezBolus shortcut to give bolus

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Deltec CozMore 1800

• Most features HypoManager, Weekly Schedule,
  Missed Meal Bolus, Disconnect Bolus, Basal Test,
  Meal Maker with CozFoods, Therapy Effectiveness
• Most flexible setup
• Direct BG entry from attachable Freestyle meter
• 300 units
• 0.05 unit basal and bolus increments
• Accurate bolus calculations
• IR download
• Best for blind or visually impaired

RECENTLY DISCONTINUED!!!
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Insulet Omnipod

• No tubing for easy wear
• Automatic cannula insertion and priming
• 200 units
• Limited to 72-80 hrs use
• Watertight
• Controlled by PDM or smartphone
• 1000 food database

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Medtronic Paradigm

• Simple interface, less scrolling
• One Touch meter transmits BG directly
• Proprietary infusion sets
• History of carbs, TDD, basal, carb,
  correction
• CareLink online software
• CGM displays BG, 3 hr trend, trend arrow, and
  advance warning of lows and highs
• Considered least accurate CGM for detection of
  lows

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Infusion Sets

• Inserted under the skin in subcutaneous tissue.
• Cannulas can be 6mm-17mm in length.
• Can use Emla Cream prior to insertion.
• Changed every 2-3 days.
• Placed in abdomen or buttocks.

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Infusion Sets

• Five varieties
• Self-contained (Omnipod)
• Slanted Teflon
• Straight-in Teflon
• Slanted metal
• Straight-in metal
• Three connections
• Luer lock pumps 25 varieties
• Paradigm 4 varieties
• Omnipod 1, auto-inserted

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Infusion Sets

• Tubing may be disconnected without removing
  insertion site
• Should be removed for swimming or bathing
• Should be removed for contact sports
• May be removed for other sports
• If disconnecting for more than 2 hours, patients
  should check their blood sugars, reconnect, and
  give a bolus to prevent hyperglycemia

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Bad Infusion Sets

• Infusion set may go bad (pulled out, kinked, or
  blocked).
• Because the pump only uses rapid-acting insulin
  if the site is not changed may end up with
  hyperglycemia or Diabetic Ketoacidosis.
• So, if someone on a pump has a high blood sugar
• 1- A correction is given through the pump.
• 2- Re-test blood sugar in 2 hours. If still
  high, then change infusion set and give injection
  of insulin.
• 3- Check urine for ketones.

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How are the pumps worn?

• Older patients will wear the pump on a clip which
  can be attached to a belt, pants, or in a pocket.
• Pumps can also be left without a clip inside a
  pocket.
• Special pump holders are sold which can be
  attached to the thigh or inside of bra to hold
  pump for discretion.
• Younger patients may use pump packs.

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Continuous Glucose Monitoring

• Subcutaneous catheter placed.
• Measures glucose in interstitial fluid.
  Conversion done to display blood glucose in
  mg/dL.
• Glucose measured every 5 minutes.
• Must be calibrated with fingerstick blood glucose.

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Continuous Glucose Monitoring

• Increased sense of security.
• Trend arrows for real time adjustment.
• Alarms for low and high blood sugars.
• Retrospective data to adjust carbohydrate rate,
  correction factor, and basal rates.

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Medtronic Paradigm System
Continuous Glucose Monitoring
Freestyle Navigator
Dexcom
Guardian Real Time
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Continuous Glucose Monitoring
Medtronic real time continuous glucose monitor
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The highs and lows of diabetesHypo and
Hyperglycemia
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Causes of Hypoglycemia

• Too much insulin
• Inadequate food intake
• Delayed meals or snacks
• Exercise

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Symptoms of Hypoglycemia
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Moderate/Severe Hypoglycemia

• Lethargy
• Extreme weakness
• Unsteady Gait
• Combativeness
• Seizure Activity
• Unresponsiveness

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Treatment of Mild Hypoglycemia

• Child is responsive and able to swallow
• Blood sugar is lt70mg/dL
• Give 15 grams of FAST ACTING carbohydrate
• (3-4 ounces of juice, 3 glucose tablets)
• Re-test in 15 minutes if persistence of symptoms
  see if blood sugar has risen.

82
Treatment of Mild Hypoglycemia

• Children who are able, can keep this treatment in
  the classroom.
• Children should be assisted to the nurses office
  if necessary.
• Children on insulin pumps may need less glucose
  for treatment.

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Over treatment of Hypoglycemia

• More is not always better!!!
• Over treatment of lows can cause hyperglycemia in
  the next 1-3 hours
• If patterns of lows persist over days, family
  should be notified so insulin adjustments can be
  made.

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Treatment of Moderate/ Severe Hypoglycemia

• Defined as requiring assistance of an adult to
  get treatment.
• If child is able to sit and swallow, use juice or
  glucose tablets
• If unable to swallow, use glucose gel first
  squirting the tube on the buccal mucosa.
• If gel isnt bringing the glucose up, then use
  call 911 and/or use glucagon.

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Glucagon

• If altered level of consciousness or seizure
  activity consider glucagon use.
• Mix powdered glucagon with diluent.
• Draw mixture up in insulin syringe.
• Administer subcutaneously.

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Prevention of Hypoglycemia

• Child may need juice or glucose tabs before gym
  class or recess
• If necessary, the pump may be disconnected for
  gym class or recess.
• If recurrent lows inform the parents so they can
  call their clinicians to make dose adjustments.

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Hyperglycemia

• In children and teens dx with T1D, glucose levels
  over 130/140 mg/dl are considered high.
• Hemoglobin A1c target range is 6-7 for children
  and teens.
• The child may not have symptoms of a high until
  glucose level is over 250.

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Causes of Hyperglycemia

• Inadequate doses of insulin
• Additional carbohydrates
• Missed injection of insulin glucose will be
  very high with ketones
• Malfunctioning pump catheter glucose will not
  respond to corrections given via pump, ketones
  may be present
• Illness ketones may be present
• Lipohypertrophy scar tissue at injection site

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Symptoms of Hyperglycemia
90
Hyperglycemia Correction

• Correction can take 2-3 hours to normalize
  glucose
• If glucose is not decreasing after 2 hours in a
  child on pump, then insulin injection should be
  given
• If the child feels okay he/she may
• Return to class
• Participate in gym
• Sugar free liquids help with hydration
• Contact Yale if treatment plan requires
  clarification

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Hyperglycemia Correction

• Most patients will have personalized correction
  factors but the guidelines below can be helpful
  to determine a correction factor based on age.

92
Signs/Symptoms of Hyperglycemia and Ketonuria

• Extreme thirst
• Increased urination
• Abdominal pain
• Nausea/vomiting
• Weakness
• Dizziness
• Labored breathing

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Treatment of Hyperglycemia with Ketonuria.

• Parents should be contacted immediately
• Parents call Yale Pediatric Diabetes Clinic
• Increased amounts of insulin will be required via
  injection.
• Provide sugar free liquids.
• Insulin is required even with vomiting and
  hypoglycemia with ketones.
• No exercise with ketones

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• Scenarios

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Scenario 1

• A student on a pump performs a routinely
  scheduled BG test just before lunch and the
  result is 61 mg/dL. The student is asymptomatic.
  
• What is the most appropriate action to take?

96
Scenario 2

• 13 yo student on a pump. Pre-lunch blood
  glucose is 302 mg/dL. The student boluses for
  both meal coverage and a correction. You ask the
  student to come back 2 hours later for a BG
  check. At that time, the BG is 290 mg/dL.
• What is going on?

97
Scenario 3

• A 6yo student is normally quiet and follows
  directions well. One afternoon during quiet
  reading time he starts to read out loud and
  states he is tired and puts his head down on the
  desk.
• What is most likely going on?

98
Scenario 4

• 16yo patient on injection therapy comes to your
  office mid-morning saying that they are not
  feeling well. Upon questioning, you find out
  that the patient left the house that morning
  without testing the BG or taking any insulin
• What do you do now?

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Scenario 5

• A 9yo student has had BG levels gt 250mg/dl for
  at least 3-4 days per week for the last 2-3
  weeks. You have been calling the parent who has
  asked that you give the prn order for insulin.
• What is the best course of action for managing
  this patients BG levels?

100
Scenario 6

• A 12yo student come into your office shortly
  after arriving at school and states she is not
  feeling well. She indicates that she did not eat
  much this morning because her stomach hurts and
  everyone at home has the stomach bug. She
  proceeds to vomit in the office
• What is/are the first steps to take?

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Scenario 7

• One of the 6th grade teachers calls you at the
  beginning of the school day to let you know that
  a mother is bringing in cupcakes for the class.
  They will be having the cupcakes whenever the
  mother arrives. The teacher is concerned about
  the 11yo boy who was recently diagnosed w/
  diabetes. She called to ask your opinion about
  what to do.
• What is the best course of action?

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• Final Thoughts

103
Meal Planning

• Sugar is NOT a bad word
• Children with diabetes should not be excluded
  from school parties or events
• On the Pump, parties or special events may
  require additional bolusing
• With injection therapy, parties or special events
  should be planned for ahead of time

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A Parents Role

• Work with the school and healthcare team to
  design a diabetes management plan that normalizes
  the childs life as much as possible
• Supply all materials needed for BG monitoring
• Supply preferred treatments for Low blood sugars
• Supply individualized information related to
  diabetes in their child (including meal planning)
• Supply emergency contact numbers

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A Schools Role

• Train adults who will interact with the child
  about diabetes
• Identify at least 2 adults who can perform
  diabetes management tasks
• Allow for immediate access (in the classroom) to
  hypoglycemia treatments
• Communicate with parent as needed to modify
  diabetes plan
• Permission for the child to eat a snack when
  necessary wherever they may be
• Access to water and bathroom as needed
• Diabetes supplies should go with the child during
  extracurricular activities or field-trips

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The Take Home Message

• Diabetes is a complex condition.
• Children with diabetes are not sick
• Children with diabetes should be allowed to
  participate fully in all school-sponsored
  activities
• Successful diabetes management requires a team
  approach involving the child, parents, school
  personnel and healthcare providers

107
Our Philosophy

• One of the biggest things to always remember is
  our patients arent diabetic they have diabetes.
  We will educate them not to define themselves by
  their diabetes, but to live with this disease.
• Diabetic Has diabetes

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Thank you!

• Questions????