CHILDREN WITH DIABETES

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CHILDREN WITH DIABETES

• Donna LaFrate, MS, RN, CPNP, CDE
• Joslin Diabetes Center
• Childrens Diabetes Program

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Statistics

• 23.6 Million people
• diagnosed with diabetes
• 7.8 of population
• Diagnosed 17.9 Million
• Undiagnosed 5.7 Million
• New/over age 20 1.6 Million
• New/under age 20 186,300

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Statistics

• 2011 25.8 Million people
• diagnosed with diabetes
• 8.3 population
• Diagnosed 18.8 million
• Undiagnosed 7.0 million
• New/over age 20 1.9 million
• New/under age 20 215,000

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Type 1 diabetes

• 15,000 adults and 15,000 children
• Diagnosed with T1D annually
• (80 per day)
• T1D incidence under age 20 rose by 23 between
  2001-2009
• T1D incidence worldwide among children under 14
  increases 3 annually

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Rising Incidence of Diabetes
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Types of Diabetes

• Type 1 (formerly juvenile diabetes)
• Pancreas stops making insulin all together( beta
  cell destruction)
• Usually diagnosed in youth, although some people
  develop type 1 well into their 30s
• Type 2
• Pancreas makes some insulin, but either cant
  make enough or the insulin made doesnt work
  very well
• Traditionally described as adult-onset, more
  youth are being diagnosed with type 2

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What is diabetes?

• Type 1 diabetes
• The pancreas stops making insulin entirely.
  (autoimmune response)
• Without insulin, the glucose cant travel from
  the blood into the cells.
• Two things happen
• The cells begin to starve.
• The level of glucose in the blood rises to
  unhealthy levels.

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• In a healthy body
• the stomach and digestive system break down much
  of the food we eat into glucose (or blood sugar).
• This glucose is released into the blood stream.
• The pancreas secretes the hormone insulin, which
  acts as a key, unlocking the cells and enabling
  glucose to enter and provide fuel and energy to
  the cells and tissues.

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Diagnosis

• Random plasma glucosegt200mg/dl on 2 separate
  occasions symptoms (polyuria, polydipsia,
  unexplained weight loss.
• 2. Fasting plasma glucose gt 126 mg/dl on 2
  separate occasions.
• 3. 2 hour plasma glucosegt200 mg/dl during glucose
  tolerance test.

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Meghan 7 years
Megan is in 2nd grade. She likes to draw, color
and collect Bratz dolls. She takes dancing
lessons and is in Brownies.
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Luis 10
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• Luis moved from Puerto Rico three years ago.
• He loves to play basketball.
• Luis wants to be a lawyer when he grows up so he
  can continue to argue in English and Spanish.

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Hakim 3
Diagnosed at 15 months, Hakim has never known
life without diabetes. He likes to play with
cars and trucks. He loves to tease his 6 month
old baby sister.
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Diabetes ManagementBlood Glucose Testing

• Tools
• Glucose meter
• Glucose test strips
• Lancet (with lancet device)

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Diabetes Management Blood Glucose Testing

• Use glucose reading to determine
• Food (carbohydrates)
• Insulin (injection or pump)
• Whether intervention is required
• Whether exercise or sleep are safe

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Blood glucose monitoring

• Test at least 4 times a day, usually before meals
  and bedtime
• Periodically test after eating, before and after
  exercise and middle of the night.
• Use insulin to carbohydrate ratios and correction
  doses for high and low glucose levels

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Diabetes ManagementMedication

• Insulin
• Syringe
• Insulin Pen
• Insulin Pump

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Basal Insulin

• Lantus given once a day and lasts up to 24
  hrs
• Levimir given once a day and lasts 12 up to 24
  hrs
• Neither has a peak
• Novolog, Humalog and Apridra are used in pumps
  for basal insulin.

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Definitions
Bolus

• Delivered as needed for carbohydrate intake

Includes blood glucose, correction factor
(insulin sensitivity) and target blood glucose
Amounts can vary during the day
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Bolus Insulin

• Novolog
• Humalog
• Apidra
• All are rapid acting, start to work in 10-15
  minutes, start to peak at 1 hr and last
  approximately 3 hours.

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FUEL   BLOOD GLUCOSE
FOOD   CARB 100
PROTEIN minimal   FAT
minimal
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Protein and Fat Raise Blood Sugar
Minimally ?They may affect the rate of
digestion, delaying entry of sugar into the
blood ?They require insulin for
metabolism ?Protein and fat have calories and
affect general health so choose them wisely
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Carbohydrate Raises Blood Sugar the Most
?Almost 100 shows up as glucose in the
blood stream ?Starts showing up in
within 15 minutes almost all is
glucose by 2 hours after eating ?Most
carbohydrates raise blood sugar to about
the same degree but can vary in time
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Insulin to Carbohydrate Ratio
Individualized!!!
Based on weight and/or daily insulin needs
Early grades (small child) 1unit insulin 25-
40 grams carbohydrate at meals Different ratios
for snack, exercise, bedtime
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Insulin to Carbohydrate Ratio

• Adolescent
• May be 15, 18, or 110 at meals
• Might have strong insulin resistance

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How do you count carbohydrates?
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• The secret to carb counting
• 1. Note the serving size
• 2. Read the Total Carbohydrate

T
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Carbohydrate and Label Claims

• 1 Oatmeal Raisin Cookie
• 17 grams carbohydrate
• 1 Sugar Free Oatmeal Cookie
• 16 grams carbohydrate
• 1 FF Oatmeal Raisin Cookie
• 25 grams carbohydrate

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Fat
Protein
Carbohydrate
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Correction Factor

• A formula to calculate a plus or minus
• dose when BG is higher or lower than
• pre-meal target
• Correction Factor (CF)
• the amount one unit of insulin will
• lower or raise the BG.

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Target BG Ranges

• Usually, 80 180 mg/dl range
• Before meals, 80-150 mg/dl
• 2 hours after meals, 180 mg/ dl
• Variation for grades K to 3 or 4
• 100-200 mg/dl (MD or PCP decides)

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• Insulin to carbohydrate ratio 115
• Correction factor/ insulin sensitivity factor
  150
• Target 120 mg/dl.
• Carbs 60 (1 unit per 15) 4 units
• BG220(1 unit lowers BG 50)2 units
• Total bolus dose 6 units
  
  

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Hyperglycemia (High BG)

• Can be caused by
• Skipping an insulin dose or not enough insulin
• Eating more than or exercised less than planned
• Stress of an illness like cold or flu
• Growing
• Other stress
• Can be serious if extremely elevated (can lead to
  ketoacidosis), or if consistently elevated (poor
  control which can lead to complications)

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Hyperglycemia

• Symptoms
• Frequent urination
• Extreme thirst
• Lethargy
• Nausea/vomiting
• Unusual hunger
• Blurry vision
• Stomachache
• Hyperactivity
• Irritability

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Treating Hyperglycemia

• Exercise can usually lower blood glucose.
• If consistently elevated, meal plan and/or
  insulin regimen may be altered.
• If substantially elevated (usually gt250 mg/dl),
  need to test for ketones in the urine.
• DO NOT exercise if ketones are present (glucose
  and ketones will increase).

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Hypoglycemia

• Symptoms
• Shakiness
• Nervousness
• Impatience
• Sweating
• Irritability, sadness, anger
• Fast heartbeat
• Lack of coordination
• Headache
• Confusion

• Chills and cold sweat
• Hunger
• Stubbornness or combativeness
• Tingling or numbness of lips or tongue
• Strange behavior
• Light-headed or dizziness
• Lose consciousness

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Treating Hypoglycemia

• Check blood sugar
• Quickest way to treat is with 15 grams of simple
  carbohydrate ½ cup fruit juice, 4-6 oz regular
  (not diet) soda, 4-6 glucose tabs or glucose gel,
  Skittles
• Wait 15 minutes and check blood sugar again
• Repeat the treatment if BS is still low and still
  having symptoms

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Diabetes ManagementGlucagon
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Exercise

• Children and adolescents with Type 1 DM should
  adhere to the CDC and American Academy of Sports
  Medicine recommendations of minimum of 30-60 min
  of moderate physical activity daily.

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Physical Activity Guidelines

• Blood glucose monitoring before exercise is
  recommended .
• If blood sugar less than 100, administer 15 grams
  of CHO for every 30 minutes of activity.
• These goals can vary for each child, parents will
  know best.

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CSIIInsulin pump therapy
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CSII Benefits

• Decreases hypoglycemia
• Increases flexibility in lifestyle
• Sleeping in
• Eating with friends
• Improves control for preconception and pregnancy

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CSII Benefits

• Improves blood glucose control
• Decreases incidence and progression of
  complications
• Provides precise dosage delivery
• Can adjust for hormonal changes in glucose levels
• Improves control during exercise

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• Simulates normal insulin delivery
• Pump automatically delivers programmed basal
• User delivers a specific insulin dose (bolus)
  when food (carbohydrate) is eaten or bg is high
• The user may increase, decrease, or stop insulin
  delivery as situations demand
• Pumper learns to think like a pancreas

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Pump Myths

• Easy, no more injections EVER!
• Less time consuming
• Less BG monitoring
• Perfect blood glucose
• No complications
• Hospital stay required
• Surgical procedure needed

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Pump Facts

• Pager sized Mini-computer
• Pre-programmed insulin delivery
• Uses an cartridge and infusion set
• Short-acting or fast acting insulin only
• No surgery necessary
• Glucose levels are not measured by pump

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Definitions

• Basal rate

Constant delivery of pre-programmed insulin to
meet metabolic needs when not eating
Rates will vary during the day
Rates will change periodically
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Insulin Delivery With the Pump
Basal Rates

• 12mn - 0.175 units / hour
• 3am - 1.125 units / hour
• 6am - 0.25 units / hour
• 6pm - 0.35 units / hour

3am
6pm
12 am
6am
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Calculating Basal Doses

• For example
• Long acting 10 units Lantus/Levemir
• (subtract 20) divided by 24 hours/day.
• This is 8 divided by 24 equals 0.35 units per
  hour for the initial basal rate.

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Bolus
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Meal Time Insulin
Bolus The insulin required at meal or snack times
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Animas Ping
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Medtronic Minimed
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OmniPod
                                                                                          
 
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Tandem tslim
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An infusion set is the link between your insulin
pump and your body.
Reservoir
Cannula Housing
Cannula
Adhesive
Serter Device
Tubing
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Infusion set cannulas
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Connected
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Disconnected
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Advanced features

Extended Bolus You can give some insulin now as
a bolus and program the remainder of insulin to
be delivered over a set amount of time. Can be
helpful for high fat foods- Pizza
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Advanced features

Temporary Basal Set Duration and of Basal
Adjustment Example Decrease of basal for
activity
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Advanced features
Basal Pattern Monday-Friday vs
Weekend Different Basal requirements for
different days
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Current Monitoring Tools
Continuous Glucose Monitoring (CGM)
HbA1c
Blood Glucose Meter (Fingerstick)
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Intensive Management and A1c
Intensive management attempts to decrease blood
glucose variability A1c test alone is not enough
to measure good blood glucose control
Target Blood Glucose Range
Patient A A1c of 7
Patient B A1c of 7
Patient C A1c of 7
Illustrative purposes only
A1C Test American Diabetes Association
http//www.diabetes.org/type-1-diabetes/a1c-test.j
sp Sept 2007
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Reveals Overall Pattern
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Effect of Real-time Sensing
SA
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Continuous Glucose Monitoring (CGM)
Personal Products
Seven System
GlucoWatch
MiniMed Paradigm REAL-Time System
Guardian RT Continuous Glucose Monitoring System
Abbott Navigator
GlucoWatch is a registered Trademark of Animas
Corporation Seven System is a registered
Trademark of DexCom , Inc Corporation
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How the System Works

• Glucose sensor is inserted in subcutaneous tissue
  and can be worn for up to 3 days
• Glucose sensor is connected to the transmitter
• Glucose sensor sends glucose values to the
  transmitter
• Transmitter then sends these values wirelessly to
  the insulin pump every 5 minutes, where data can
  be viewed and acted on in real-time

Fingerstick measurements are required for
sensor calibration (every 12 hours) and prior to
therapy adjustments
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Value of CGM

• Ability to see interaction between medication,
  food choices, exercise, etc
• Ability to view overnight trends
• Download historical data
• Improved communication with the Health Care
  Provider
• Audible high and low blood sugar alerts
• Better control and piece of mind

Priceless!
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Whats in the Future?
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Questions???
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HAVE A PURR-FECTLY WONDERFUL
DAY!!