Diabetes Mellitus in Children and Adolescents

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Diabetes Mellitus in Children and Adolescents

• Maureen McGrath, PNP-BC, CDE
• Emory-Childrens Center
• Division of Endocrinology and Diabetes

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DIABETES Defect in Energy Utilization

• Glucose is primary energy source of all cells
• Insulin is necessary to transport glucose into
  most cells
• Insufficient insulin results in inadequate
  glucose for energy inside cell, need alternative
  energy source (fat)
• Insufficient insulin results in high
  extracellular or blood glucose (hyperglycemia)

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How the Body Uses Food as Fuel
Digestion of Macronutrients (CHO, FAT, PRO)
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GLUCOSE
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Pancreas (Insulin)
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Insulin
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Blood Stream
Cell
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PATHOPHYSIOLOGY HYPERGLYCEMIA

• Blood glucose increasing above the renal
  threshold (180 mg/dL) results in glycosuria
• Glucose urinated out polyuria
• Decreased extracellular water stimulates thirst
  polydipsia
• Lost glucose is lost calories and stimulates
  hunger polyphagia

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InsulinBefore and After
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TYPE 1 DIABETES

• Most common presentation in children and
  adolescents
• Autoimmune pathophysiology
• Prevalence 1 of 350 children
• 3-5 risk in siblings 30 for identical twins
• Risk of ketoacidosis
• Dependent on insulin for survival

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Type 1 diabetes insulin deficiency
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Glucose
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Pancreas (Insulin)
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Blood Stream
Cell
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TYPE 2 DIABETES
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TYPE 2 DIABETES

• 30 of children gt 10 y.o. present with type 2
  diabetes
• African-Americans, Latinos, Native Americans,
  Pacific Islanders
• Insulin resistance associated with obesity and
  acanthosis nigricans
• Prevalence increasing
• Very strong family history
• May also have ketonuria and ketosis
  (ketosis-prone type 2 DM)
• Treatment lifestyle, metformin, insulin

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Type 2 diabetes insulin resistance
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GLUCOSE
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Pancreas (Insulin)
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Insulin
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Cell
Blood Stream
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ACANTHOSIS NIGRICANS
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PRESENTING SYMPTOMS
Symptoms Type 1 Type 2 P
(n48) (n40)
value Abdominal Pain 46
33 gt.10 Dizziness
15 33
gt.10 Headache 33
43 gt.10 Nocturia
71 65
gt.10 Polydipsia 96
85 gt.10 Polyphagia
69 60
gt.10 Polyuria 94
88 gt.10 Visual Problem
17 20 gt.10
Weight loss 71
40 .005
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PRESENTING SYMPTOMSand SIGNS

• Vulvovaginitis, severe candida diaper rash
• Vomiting
• Dehydration
• Difficulty breathing (Kussmaul respirations)
• Fruity odor to breath (ketones)
• Altered mental status

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PATHOPHYSIOLOGY ofDIABETIC KETOACIDOSIS (DKA)

• Low insulin ? hyperglycemia and glycosuria,
• insufficient suppression of lipolysis and
  ketogenesis
• Glycosuria ? osmotic diuresis ? polyuria ?
  dehydration ? polydipsia
• Dehydration ? increase in counter-regulatory
  hormones, which leads to further hyperglycemia
  and ketosis
• Hyperosmolarity ? altered mental status

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DIABETIC KETOACIDOSIS

• Hyperglycemia
• Blood Sugar gt300
• Acidosis
• pH lt7.3 or Bicarb lt15
• Mortality
• 2-10

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DIAGNOSIS of DIABETES MELLITUS

• Symptoms of diabetes and random glucose greater
  than 200 mg/dl
• Fasting lab plasma glucose (not fingerstick) of
  gt 126 mg/dL (2 separate occasions)
• OGTT 2 hour plasma glucose gt 200 mg/dl
  - fasting, 1.75 gm/kg, max 75 gm glucose load
• HbA1c of 6.5 or greater (lab verified)
• 5.7- 6.4 considered sign for increased risk

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MANAGEMENT of TYPE 1 DIABETES

• Insulin
• Glucose monitoring
• Nutrition
• Exercise
• Sick Day management
• Psychosocial

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MANAGEMENT of TYPE 2 DIABETES

• Eliminate symptoms of hyperglycemia
• Weight stabilization
• Improve cardiovascular risk factors
• Hypertension
• Hyperlipidemia
• Hyperglycemia
• Psychosocial
• Oral meds/insulin

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DIABETES SELF MANAGEMENT EDUCATION

• Basic pathophysiology
• Short and long term complications
• Meal planning
• Exercise guidelines
• Blood glucose monitoring
• Patient-centered goal setting

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INSULIN
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Insulin Action
Normal insulin delivery
This is a 24 hour representation of the insulin
profile for someone who does not have diabetes.
The pancreas releases insulin for each meal, but
there is always a constant background or basal
amount present that has nothing to do with food.
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INSULINSU-100 Human Recombinant DNA or Analog
Insulin Onset Peak
Duration
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Basal/Bolus Regimens (physiologic/MDI/BBT)
This shows the basal/bolus regimen with the
background or basal insulin as the thick black
line at the bottom. Meal or bolus doses are
delivered in varying amounts and times according
to meals.
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INSULINSMixed

• Novolog 70/30
• Humalog 75/25
• Humalog 50/50

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Two or three injections/day

• People on this injection regimen would be getting
  shots at breakfast and
• supper.
• The breakfast shot combines a short-acting
  insulin which covers just that meal.
• The intermediate-acting insulin mixed in the same
  shot covers lunch
• and the hours until supper.
• The supper shot covers the evening meal and the
  nighttime hours.

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Why only two or three injections per day?

• School issues
• Injection avoidance
• Possibly non-specialty care
• Adherence issues
• Lack of parental supervision
• Developmental issues
• Age-inappropriate expectations
• Teenagers (away from parental support and
  supervision)

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Ways to Give Insulin- Injections
Insulin can be injected with a standard vial and
syringe or by using a pre-filled insulin pen.
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Ways to Give Insulin- Insulin Pumps
Insulin pumps are computers that deliver insulin
continuously instead of taking multiple
injections.

• Deliver programmed insulin (bolus)
• Deliver pre-programmed insulin delivery (basal)
• Do not measure glucose levels

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Pump Sites
Catheter- small plastic tube that remains under
the skin.

• Pump sites generally changed every 3 days
• Pumps can be disconnected
• for activities and/or showers
• Sites may have to be changed more frequently as
  the catheter falls out, becomes untaped

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Real-time Continuous Glucose Monitoring
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TREATMENT of TYPE 2 DIABETES - DRUGS

• INSULIN
• Initial Rx if DKA, FBS gt 250 mg/dl or if
  symptomatic
• Large dose may be needed because of insulin
  resistance
• Often use 70/30
• Used in combination with oral agent

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TREATMENT of TYPE 2 DIABETES- DRUGS

• Biguanide - metformin
• Sulfonylurea - Glipizide, Glyburide, Glimepiride
• Meglitinide - Repaglinade (Prandin)
• a-Glucosidase inhibitor - Acarbose
• Thiazolidinedione - Avandia, Actos

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METFORMIN (Glucophage)

• Inhibits hepatic glucose production, also
  decreases elevated androgens
• No hypoglycemia
• Doesnt cause weight gain
• Anorexia, gastrointestinal symptoms
• Helpful if taken with food
• Risk of Lactic Acidosis

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USUAL INITIATION OF THERAPY

• Education and Monitoring
• - If ketotic or FBS gt300 start insulin
• Nutrition and Exercise Guidelines
• Evaluation over 3 months,
• If on insulin and meeting guidelines, progress
  to Metformin and decrease insulin
• If not on insulin and not meeting guidelines,
  progress to Metformin

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GLUCOSE MONITORING

• BG should be checked before all meals and bedtime
• Additional checks as needed
• Physical activity
• Driving
• Sick days
• Snacks

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GLUCOSE MONITORING Meters

• Memory for 30-120 days (3-4xdaily)
• Small blood volumes (0.3, 0.6, 1.0, 1.5µl)
• Rapid results (5-10 seconds)
• Use of sites other than fingers
• Serum ketone monitoring
• Measurement of serum ß hydroxybutyrate

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American Diabetes Association- BG and HbA1c goals
for T1DM by age group
Age Before Meals Bedtime/ Overnight HbA1c
lt 6 years 100-180 110-200 7.5-8.5
6-12 years 90-180 100-180 lt8
13-19 years 90-130 90-150 lt7.5
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SPECIFIC TREATMENT GOALS for TYPE 2 DIABETES

• FBS lt 140 mg/dl, HgbA1C lt 7
• LDL cholesterol lt 100 mg/dl
• BP lt 90 for age

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Annual Screening

• TIDM
• Family history of hypercholesterolemia If LDL
  lt 100 screen every 5 years.
• Annual microalbumin/creatinine ratio age 10 and
  TIDM for 5 years,
• Annual ophthalmologic exam age 10 and 3-5 years
  of TIDM
• Screen for Thyroid Peroxidase and Thyroglobulin,
  Transglutaminase or Endomysial Abs at diagnosis
• TSH q 1-2 yrs
• TC gt240 and/or Cardiac Event lt 55 Screen age gt2
  otherwise begin screen at gt 12.

• T2DM
• Lipid Panel yearly
• Microalbumin/creatinine ratio at diagnosis and
  yearly
• Dilated eye exam at diagnosis and yearly
• Liver function every 6 months if on metformin

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NUTRITION
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Why Carbohydrate Counting?

• More Precise Meal Planning Method
• Greater Flexibility with Food Choices
• Only One Main Nutrient Counted
• Better Blood Glucose Control

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NUTRITION PRINCIPLES

• 50-55 carbohydrates, 15-20 protein, 30 fat
• Sufficient calories for growth
• Pattern of food distribution
• -Exchanges
• -Carbohydrate counting
• Distributed as 3 meals and 2-3 snacks
• Individualize plan

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CARBOHYDRATE COUNTING

• Insulin dose is tied to amount of carbohydrate
• Read total carbohydrates on food label, not sugar
• Most children dont need to eat a particular
  number of carbs per meal
• Those on basal/bolus regimens or insulin pumps
  can vary insulin dose with amount of carbohydrate

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Carbohydrates These are examples of 15 gram
portions

• ½ cup pasta
• 3 oz. Baked potato
• 1 slice bread
• ½ cup cereal
• 1 cup milk
• 3 cups popcorn

• 1 sm. apple, orange or peach
• 15 grapes
• ½ large banana
• ½ cup (4 oz.) juice

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The Misconception About Sweets
A Carb is a Carb is a Carb - but there are
Healthy Carbs fruits, vegetables, whole grains
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MANAGEMENT of TYPE 2 DIABETES - NUTRITION

• Prevent further weight gain
• Decrease energy intake
• to 65-80 if BMI gt 40
• or 90 if BMI gt30 and lt40
• CHO 50-55,fat 30, protein 10-15

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EXERCISE
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EXERCISERecommendations

• More monitoring, better control
• Extra carbohydrates if BG normal-low
• 15gm per 30 min intense exercise
• No exercise if BG gt300 or ketonuria
• Goal for people with diabetes is 150 minutes per
  week of moderate-intensity aerobic exercise

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MANAGEMENT of TYPE 2 DIABETES - EXERCISE

• Increase physical activity
• Decrease sedentary behavior

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MANAGEMENT of HYPOGLYCEMIA

• Prevention
• -Meals on time
• -Exercise pre-treatment
• Monitoring Blood Glucose
• Treatment give 15 g CHO, wait 15 min.
• -Glucose tabs, glucose gel
• -Glucagon Emergency Kit

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MANAGEMENT of ILLNESS KETOSIS

• Prevention
• - Never omit insulin even if vomiting or NPO
• - Monitoring blood glucose
• - Monitor urine or blood for ketones if
• BG gt300 or if ill
• Treatment
• - Consultation with diabetes team may use
  Zofran or phenergan if vomiting
• -Fluids and insulin

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COMPLICATIONS of HYPERGLYCEMIA

• Diabetic Nephropathy- majority of kidney failure
  and transplants
• Diabetic Retinopathy- majority of blindness
• Diabetic Neuropathy- painful or decreased
  sensation (contributes to foot disease), abnormal
  stomach function (gastroparesis), impotence
• Increased risk for coronary heart disease and
  stroke
• Huge expense!

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PREVENTION OF COMPLICATIONS

• DCCT-1993
• Control of hyperglycemia prevents or delays
  retinopathy, nephropathy
• Treatment of microalbuminuria
• ACE inhibitor prevents progression and may
  decrease protein excretion

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PSYCHOSOCIAL
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DEVELOPMENTAL ISSUES

• Toddler/Preschooler
• At initial diagnosis, often fearful
• Struggles over control, including food
• Behavior can be reflected in glucose levels
• School Age
• Very concrete and task-oriented
• Often want to do own BG checks, may be more
  hesitant with self-injections

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DEVELOPMENTAL ISSUES

• Teens
• increasing age associated with decreased
  adherence to exercise, injection regularity, diet
  and monitoring
• external interests (peers, school, sports) take
  precedence over diabetes

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ADOLESCENT DEVELOPMENT

• Social/Behavioral Development
• 25 of teens surveyed falsify BG results so as
  not to be judged
• 25 of teens surveyed miss injections due to
  forgetting

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ADOLESCENT DEVELOPMENT Health Belief Model

• Adolescents with diabetes who perceived high
  benefits to regimen were more likely to adhere to
  it
• Adherence was highest when benefits/costs were
  high and threat was low
• When perceived threat is too powerful, adherence
  decreases

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ADOLESCENT PSYCHOSOCIAL ISSUES

• Depression is more common
• Eating disorders at higher incidence
• Insulin omission for weight loss very common

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MAJOR ROLES of the PNP

• Recognition of signs and symptoms and risk groups
  of diabetes in children
• Reinforcing the prescribed plan and regular f/u
  with specialists
• Helping parents understand normal developmental
  issues (i.e. adolescents decrease in adherence
  to regimen is related to normal developmental
  issues and is not pathologic)

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MAJOR ROLES of the PNP

• Addressing the grief involved in a new diagnosis
  (up to 40 of mothers are clinically depressed
  in the first 2 years after diagnosis)
• Advocating for parents with school
• Normalizing childs daily life as much as
  possible (i.e. encouraging parents to allow
  normal activities)

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MAJOR ROLES of the PNPFocus on Type 2 DIABETES

• Weight stabilization
• Improve cardiovascular risk factors
• Hypertension/microalbuminuria
• Hyperlipidemia
• Hyperglycemia
• Smoking

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IDENTIFYING CHILDREN AT RISK for TYPE 2 DIABETES

• Obesity- BMI gt85 for age
• weight gt120 for height
• Family history in 1st or 2o relative
• Race/ethnicity (American Indian, African
  American, Hispanic, Asian/Pacific Islander)
• Condition associated with insulin resistance
  Acanthosis Nigricans
• Hypertension
• Dyslipidemia
• Polycystic Ovary Syndrome

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TESTING at RISK CHILDREN

• How- Fasting Blood Sugar
• Who- 8 years old or pubertal child
• When- every 2 years
• Type 1 DM TrialNet natural history study for
  1st degree relatives of people with type 1
  diabetes

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PREVENTION of TYPE 2 DIABETES in CHILDREN

• Anticipatory Guidance
• - Breast feeding, Nutrition
• Healthcare Maintenance
• Community Involvement
• - Nutrition and Exercise in Schools