DAY CARE MANAGEMENT OF DIABETES IN CHILDREN

Dr. C. KannanDepartment of pediatricsMGMCRI

QUESTIONS• A child with newly diagnosed type 1 diabetes mellitus• How will you train the parents/care takers ?• How will you train the teachers ?

• Name the long acting Insulins ?• What is basal bolus regimen ?• What is the ability middle school children in SMBG ?• Signs/symptoms of moderate hypoglycemia ?• Glucagon dose and route ?

DIAGNOSTIC CRITERIA

• Symptoms with random blood glucose of >200mg/dl (or)• Fasting plasma glucose > or = 126mg/dl (or)• 2hr blood glucose during the OGTT > or = 200mg/dl (or)• HbA1c > or= 6.5%

DIAGNOSIS

• Typical symptoms of DM

• By diagnostic criteria based on blood sugar/ HBA1C• Never from finger test method• Never from single plasma value• Never with underlying stress(infection/injury)

• Molecular genetic testing for monogenic DM

• Check for associated ketoacidosis

• Suspect Type II DM if child is obese

• Associated autoimmune diseases• Auto immune thyroiditis (30%)• Celiac disease (5 – 10%)

MONITORING

Education of care taker

• Pathophysiology of diabetes• Symptoms and when to anticipate hypoglycemia• Regular monitoring of • Insulin administration technique/sites

• Various situations requiring various insulin doses• Dietary deviations• Minor intercurrent illness• Unusual physical activity

MONITORING

• Frequency of RBS/HBA1C• Prebreakfast• Prelunch• Presupper • Bedtime• If required 2 hours of postprandial • During initial period/if nocturnal hypoglycemia anticipated

• At 12 am• At 3 am

MONITORING

• Dose adjustments• 10-15% of insulin can be adjusted according RBS variations

• Target blood sugar

Age in years Pre meal 30 day average HBA1C

<5 100-200 180-250 7.5-9.0

5-11 80-150 150-200 6.5-8.0

12-15 80-130 120-180 6.0-7.5

16-18 70-120 100-150 5.5-7.0

MONITORING

Interpretation of SMBG

ABILITY OF CHILDREN

Preschool child• Unable to do anything

Elementary school child• By 8 years able to do finger test• By 10 years able to administer insulin under supervision

Middle school child• Administers insulin under supervision• Self monitors blood glucose under usual circumstances

High school child• Administers insulin without supervision• Self monitors blood glucose under usual circumstances

MONITORING

Education for school teachers/school workers

• All teachers who are teaching him and 1 or 2 school workers

• Clearly explain about the • Nature of illness• Insulin requirement• Importance of frequent monitoring/diet plan

• Acute complications

• Teacher should maintain a log and hand over it to parents

MONITORING• Child should be allowed • To have snacks• To do finger test Any time in the class room• To administer insulin

• Child should allow to miss school any day with doctor’s note

• If needed school should provide privacy area for • Finger test • Insulin administration

• Special attention during • Field trips• Extra curricular activities• Sports events

MONITORING

Rationale behind monitoring

• Accuracy of glycaemic control

• Prevent both acute and chronic complications of diabetes

• Effects on cognitive function

INSULIN• Started as soon as possible to avoid metabolic decompensation and DKA

• Maintain dynamic relationship between • Physical activity• Insulin administration• Carbohydrate intake

• Basal bolus insulin regimen preferred (units/kg/day)

Age No DKA DKA

Pre pubertal 0.25-0.50 0.75-1.0

pubertal 0.50-0.75 1.0-1.2

Post pubertal 0.25-0.50 0.8-1.0

INSULINRapid Acting Insulins• Lispro• Aspart

Short acting• Insulin Glulisine• Regular Insulin

Intermediate acting• NPH- Neutral Protamine• Hagedorn• Pre mixed Insulins

Long Acting• Glargine• Detemir

INSULIN

BASAL BOLUS INSULIN REGIMEN

• Longer acting form of insulin

• To keep blood glucose levels stable• Through periods of fasting

• Separate injections of shorter/rapid acting insulin

• To prevent rises in blood glucose resulting from meals

BASAL BOLUS INSULIN REGIMEN

• A long acting insulin (Glargine) • Basal insulin- preferably morning/bedtime with

• Rapid acting insulin ( Aspart, Lispro) • Given before each meal and snack.

INSULIN PUMP THERAPY

AUTOMATED CLOSED LOOP SYSTEM

DOSAGE

Day 1

• <5 years - 0.1U/kg

• 5 years/above - 0.2U/kg

• Regular insulin every 2 hours until blood glucose <120mg/dl

• Then 4th hourly

DOSAGE

Day 2

• 0.5 to 1U/Kg/day

• Twice daily regimen• More dose in the mornings and less in the evening

• Basal bolus regimen• 50% as rapid acting + 50% as long acting • 70% as regular insulin + 30% as long acting • Given as 3-4 pre meal boluses• With night time/breakfast intermediate or long acting insulin

HYPOGLYCEMIA

• More common in infancy and toddlers

• Unpredictable/wide swings in glucose levels

• Result from unbalanced insulin effect

• Longstanding DM Neuropathy Low catecholamines

Hypoglycemia No early response

Mild hypoglycemia

• Once in a weak

• Pallor Sweating Apprehension

• Tremors Hunger Irritability and tachycardia

HYPOGLYCEMIA

Moderate hypoglycemia• Few times a year• Drowsiness personality changes, • mental confusion impaired judgement

Severe hypoglycemia• Once in few years• Inability to seek help• Seizures• coma

MANAGEMENT OF HYPOGLYCEMIA

• Avoid tighter glucose control

• Explain parents when to anticipate hypoglycemia

• Sports/gym activities

• Document/maintain blood glucose log

• Emergency glucose source in hand - candy/ juice

• Glucose 5-10 g can be given

• Check CBG 15-20 min later

• Minidose Glucagon can be given IM

• 0.5 mg <20 kg/1 mg >20 kg

DAWN PHENOMENON

Early morning• Increase in blood glucose levels due to decline in insulin levels.

Overnight • Growth hormone secretion • Increased insulin clearance

Normal child• Physiological compensation by more insulin output • which does not happen in a diabetic child

SOMOGYI PHENOMENON

• Rebound hyperglycemia from an exaggerated counter regulatory response

SICK DAY PATHOPHYSIOLOGY

• Infections disrupt the glucose control

• Hyperglycemia osmotic diuresis dehydration

• DKA ketosis-emesis dehydration

Anorexia

Hypoglycemia

SICK DAY MANAGEMENT

Management during intercurrent illnesses

• Adequate hydration (ORS)

• More frequent monitoring

• Adequate glycaemic control by dose adjustment

• Prompt management of fever

• Underlying illness should be detected early and managed

• Detection of ongoing dehydration and Ketoacidosis

SICK DAY MANAGEMENT

If ketones (-)• 5-10% of total daily insulin (or) 0.5-1U • Short acting every 2-4 hours based on blood glucose levels

If ketones (+)• 10- 20% of total insulin (or) 1 U of insulin• Every 1 hour.

NUTRITIONAL GUIDELINESAge KCAL required / Kg Body weight

• Children • 0-12 months 120• 1-10 years 100 – 75

• Young women• 11-15 years 35• >/= 16 years 30

• Young men • 11-15 80-55• 16-20

• Sedentary 30• Average activity 40• Very physical activity 50

NUTRITIONAL GUIDELINES

• Carbohydrate 55%• Fat 30%• Protein 15%• 75% of carbohydrates should come from complex starch• Avoid glucose from refined sugars• Avoid sweetened carbonated beverages • Fibre rich diets are advised • Fats derived from plants are advised• Select diet based on personal taste

NUTRITIONAL GUIDELINES

• Carbohydrate Vary (depends upon fibre content)• Fibre >20 g/day• Protein 12-20 • Fat <30• Saturated <10• Polyunsaturated 6-8• Monounsaturated Remainder of fat allowance

• Cholesterol 300 mg• Sodium 3-4 g

NUTRITIONAL GUIDELINES

• Prevent overweight and starvation

• Periodic growth monitoring

• High protein may leads to Diabetic nephropathy

• 3 snacks/day for younger children

• Adolescents- include mid-afternoon and bedtime snacks

SCREENING FOR COMPLICATIONS

REFERENCES• Nelson textbook of pediatrics

• Articles from ISPAD (international society for pediatrics and adolescent diabetes)

• Care of Children With Diabetes in the School and Day Care Setting from American diabetes association.