Diabetes Mellitus in Children and Adolescents

Maureen McGrath, PNP-BC, CDE

Emory-Children’s Center

Division of Endocrinology and Diabetes

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)

How the Body Uses Food as Fuel

I

GLUCOSE

Blood Stream Cell

G

G

G

GG

G

Digestion ofMacronutrients

(CHO, FAT, PRO)

Pancreas

(Insulin) I I

I

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I Insulin

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

Insulin:Before and After

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

Type 1 diabetes: insulin deficiency

Glucose

Blood Stream Cell

G

G

G

Pancreas

(Insulin)XXXXX

TYPE 2 DIABETES

TYPE 2 DIABETES• ~ 30% of children > 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

Type 2 diabetes: insulin resistance

I

GLUCOSE

Blood Stream Cell

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G

G

Pancreas

(Insulin) I I

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I InsulinI

ACANTHOSIS NIGRICANS

PRESENTING SYMPTOMS

Symptoms %Type 1 %Type 2 P (n=48) (n=40) value

Abdominal Pain 46 33 >.10Dizziness 15 33 >.10Headache 33 43 >.10Nocturia 71 65 >.10Polydipsia 96 85 >.10Polyphagia 69 60 >.10Polyuria 94 88 >.10Visual Problem 17 20 >.10 Weight loss 71 40 .005

PRESENTING SYMPTOMSand SIGNS

• Vulvovaginitis, severe candida diaper rash

• Vomiting

• Dehydration

• Difficulty breathing (Kussmaul respirations)

• Fruity odor to breath (ketones)

• Altered mental status

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

DIABETIC KETOACIDOSIS• Hyperglycemia

Blood Sugar >300

• Acidosis

pH <7.3 or Bicarb <15

• Mortality

2-10%

DIAGNOSIS of DIABETES MELLITUS

• Symptoms of diabetes and random glucose greater than 200 mg/dl

• Fasting lab plasma glucose (not fingerstick) of > 126 mg/dL (2 separate occasions)

• OGTT 2 hour plasma glucose > 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

MANAGEMENT of TYPE 1 DIABETES

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

MANAGEMENT of TYPE 2 DIABETES

• Eliminate symptoms of hyperglycemia• Weight stabilization• Improve cardiovascular risk factors

HypertensionHyperlipidemiaHyperglycemia

• Psychosocial• Oral meds/insulin

DIABETES SELF MANAGEMENT EDUCATION• Basic pathophysiology

• Short and long term complications

• Meal planning

• Exercise guidelines

• Blood glucose monitoring

• Patient-centered goal setting

INSULIN

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.

INSULINSU-100 Human Recombinant DNA or Analog

Humalog (Lispro)

5 min 1-2 hrs 3-4 hrs

Novolog (Aspart)

5 min 1-2 hrs 3-4 hrs

Apidra (glulisine)

30 min 2-4 hrs 4-6 hrs

NPH 1 hour 6-8 hrs 10-12 hrs

Levemir (Detemir)

1-2 hours 6-8 hrs Dose-dep

Lantus (Glargine)

1-3 hrs None 24 hrs

Insulin Onset Peak Duration

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.

INSULINSMixed

• Novolog 70/30

• Humalog 75/25

• Humalog 50/50

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.

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)

Ways to Give Insulin- Injections

Insulin can be injected with a standard

vial and syringe or by using a pre-filled

insulin pen.

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

Pump Sites

• 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

Catheter- small plastic tube that remains under the skin.

Real-time Continuous Glucose Monitoring

TREATMENT of TYPE 2 DIABETES - DRUGS

INSULIN• Initial Rx if DKA, FBS > 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

TREATMENT of TYPE 2 DIABETES- DRUGS

• Biguanide - metformin

• Sulfonylurea - Glipizide, Glyburide, Glimepiride

• Meglitinide - Repaglinade (Prandin)

• α-Glucosidase inhibitor - Acarbose

• Thiazolidinedione - Avandia, Actos

METFORMIN (Glucophage)

• Inhibits hepatic glucose production, also decreases elevated androgens

• No hypoglycemia• Doesn’t cause weight gain• Anorexia, gastrointestinal symptoms

– Helpful if taken with food

• Risk of Lactic Acidosis

USUAL INITIATION OF THERAPY

• Education and Monitoring

- If ketotic or FBS >300 start insulin• Nutrition and Exercise Guidelines• Evaluation over 3 months,

º If on insulin and meeting guidelines, progress to Metformin and decrease insulin

º If not on insulin and not meeting guidelines, progress to Metformin

GLUCOSE MONITORING

• BG should be checked before all meals and bedtime

• Additional checks as needed– Physical activity– Driving– Sick days– Snacks

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 β hydroxybutyrate

Diabetes Care, 2010

American Diabetes Association- BG and HbA1c goals for T1DM by age group

Age Before Meals

Bedtime/ Overnight

HbA1c

< 6 years 100-180 110-200 7.5-8.5%

6-12 years 90-180 100-180 <8%

13-19 years 90-130 90-150 <7.5%

SPECIFIC TREATMENT GOALS for TYPE 2 DIABETES

• FBS < 140 mg/dl, HgbA1C < 7%

• LDL cholesterol < 100 mg/dl

• BP < 90% for age

Annual ScreeningTIDM• Family history of hypercholesterolemia * If

LDL < 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 >240 and/or Cardiac Event < 55 Screen age >2 otherwise begin screen at > 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

NUTRITION

Why Carbohydrate Counting?

• More Precise Meal Planning Method

• Greater Flexibility with Food Choices

• Only One Main Nutrient Counted

• Better Blood Glucose Control

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

CARBOHYDRATE COUNTING

• Insulin dose is tied to amount of carbohydrate• Read total carbohydrates on food label, not sugar• Most children don’t 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

Carbohydrates: These are examples of 15 gram portions

• 1 sm. apple, orange or peach

• 15 grapes• ½ large banana• ½ cup (4 oz.) juice

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

The Misconception About Sweets

A Carb is a Carb is a Carb - but there are Healthy Carbs: fruits, vegetables, whole grains

MANAGEMENT of TYPE 2 DIABETES - NUTRITION

• Prevent further weight gain

• Decrease energy intake

to 65-80% if BMI > 40

or 90% if BMI >30 and <40

• CHO 50-55%,fat 30%, protein 10-15%

EXERCISE

EXERCISERecommendations

• More monitoring, better control• Extra carbohydrates if BG normal-low

15gm per 30 min intense exercise• No exercise if BG >300 or ketonuria

• Goal for people with diabetes is 150 minutes per week of moderate-intensity aerobic exercise

MANAGEMENT of TYPE 2 DIABETES - EXERCISE

• Increase physical activity

• Decrease sedentary behavior

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

MANAGEMENT of ILLNESS KETOSIS

• Prevention- Never omit insulin even if vomiting or NPO- Monitoring blood glucose- Monitor urine or blood for ketones if

BG >300 or if ill• Treatment

- Consultation with diabetes team – may use Zofran or phenergan if vomiting-Fluids and insulin

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!

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

PSYCHOSOCIAL

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

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

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

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

ADOLESCENT PSYCHOSOCIAL ISSUES

• Depression is more common

• Eating disorders at higher incidence

• Insulin omission for weight loss very common

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. adolescent’s decrease in adherence to regimen is related to normal developmental issues and is not “pathologic”)

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 child’s daily life as much as

possible (i.e. encouraging parents to allow normal activities)

MAJOR ROLES of the PNPFocus on Type 2 DIABETES

• Weight stabilization

• Improve cardiovascular risk factors

Hypertension/microalbuminuria

Hyperlipidemia

Hyperglycemia

Smoking

IDENTIFYING CHILDREN AT RISK for TYPE 2 DIABETES

• Obesity- BMI >85% for age weight >120% 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

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

PREVENTION of TYPE 2 DIABETES in CHILDREN

• Anticipatory Guidance

- Breast feeding, Nutrition

• Healthcare Maintenance

• Community Involvement

- Nutrition and Exercise in Schools