A practical reference manual Treatment of children and adolescents with diabetes Dr. Birthe S Olsen, Consultant Paediatric...
Childhood diabetes <ul><li>90% Type 1 diabetes </li></ul><ul><li>Absolute or relative insulin deficiency </li></ul><ul><li...
Aetiology <ul><li>Genetic susceptibility: </li></ul><ul><ul><li>HLADR3, HLADR4: risk increased </li></ul></ul><ul><ul><li>...
Epidemiology <ul><li>Most common endocrine disease in childhood </li></ul><ul><li>Highest incidence in Finland and Sardini...
Pre-diabetes phase <ul><li>Gradual destruction of beta-cells  </li></ul><ul><li>Development of auto-antibodies: </li></ul>...
Prevention <ul><li>Primary intervention: </li></ul><ul><ul><li>aim: reducing the prevalence of a given condition in suscep...
Management – primary goals <ul><li>To ensure that insulin is available for all children </li></ul><ul><li>To ensure that t...
Early diagnosis <ul><li>Symptoms and signs: </li></ul><ul><ul><li>polydipsia </li></ul></ul><ul><ul><li>polyuria </li></ul...
Early diagnosis <ul><li>Diagnosis: </li></ul><ul><ul><li>fasting blood-glucose concentration > 7.7 mmol/l </li></ul></ul><...
The multi-disciplinary team <ul><li>The cornerstone in childhood  diabetes management: </li></ul><ul><ul><li>a paediatric ...
The multi-disciplinary team <ul><li>The team should… </li></ul><ul><ul><li>have common attitudes and philosophy </li></ul>...
Diabetes education 1 <ul><li>Initial ‘survival’ education: </li></ul><ul><ul><li>the causes of diabetes </li></ul></ul><ul...
Diabetes education 2 <ul><li>aetiology and pathology </li></ul><ul><li>injection devices and methods </li></ul><ul><li>blo...
Diabetes education 3 <ul><li>The knowledge and skills of the child should be regularly assessed </li></ul><ul><li>Re-educa...
Treatment <ul><li>At diagnosis </li></ul><ul><li>Remission phase </li></ul><ul><li>Long-term </li></ul>Initial treatment
Non-ketotic child <ul><li>Insulin: </li></ul><ul><ul><li>subcutaneous </li></ul></ul><ul><ul><li>multiple dose rapid-actin...
Non-ketoacidotic child <ul><ul><li>hospital stay as short as possible </li></ul></ul><ul><ul><li>in paediatric setting </l...
The remission phase <ul><li>Duration from weeks to months </li></ul><ul><li>Shorter in young children </li></ul><ul><li>Bl...
Long-term management <ul><li>Twice daily or multiple insulin injections </li></ul><ul><li>Regular blood glucose measuremen...
Insulin <ul><li>All children with Type 1 diabetes  must have insulin </li></ul><ul><li>Consequences of long-term insulin o...
Insulin types and duration  of action <ul><li>Insulin   </li></ul><ul><li>preparation </li></ul><ul><li>Short-acting </li>...
Short-acting insulin <ul><li>Clear solution </li></ul><ul><li>Indications for use: </li></ul><ul><ul><li>daily management ...
Intermediate-acting insulin <ul><li>Cloudy solution (should be thoroughly mixed before use) </li></ul><ul><li>Indications ...
Pre-mixed insulin <ul><li>Cloudy solution (should be thoroughly mixed before use) </li></ul><ul><li>Indications for use: <...
Rapid-acting insulin (Insulin Aspart) <ul><li>Clinical   benefits </li></ul><ul><ul><li>improved metabolic control compare...
Rapid-acting insulin (Insulin Aspart) <ul><li>Patient targeting: </li></ul><ul><ul><li>newly diagnosed children and  adole...
Storage of insulin <ul><li>Stable at room temperature for weeks </li></ul><ul><li>Should not be exposed to temperatures > ...
Injection sites <ul><li>Short acting insulin: </li></ul><ul><ul><li>injected subcutaneously into the abdomen at a 45° angl...
Insulin absorption <ul><li>Factors influencing insulin absorption: </li></ul><ul><ul><li>injection site </li></ul></ul><ul...
Insulin requirements <ul><li>Remission period </li></ul><ul><ul><li>< 0.5 IU/kg/24 hours </li></ul></ul><ul><li>Pre-pubert...
Insulin regimens <ul><li>Insulin regimens should be: </li></ul><ul><ul><li>adjusted to age, maturity and motivation </li><...
Insulin regimens <ul><li>Most widely used insulin regimens: </li></ul><ul><ul><li>twice-daily injections, mixture short an...
Insulin distribution <ul><li>Twice daily injection regimen: </li></ul><ul><ul><li>2/3 of daily dose before breakfast, </li...
Insulin adjustments <ul><li>Twice-daily injection regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of insulin to in...
Insulin adjustments <ul><li>Three-times daily injection regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of insulin...
Insulin adjustments <ul><li>Basal-bolus (multiple injection) regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of in...
Diet <ul><li>Nutritional advice should take into   consideration: </li></ul><ul><ul><li>individual requirements </li></ul>...
Diet: principles <ul><li>Number of meals: </li></ul><ul><ul><li>3 main meals </li></ul></ul><ul><ul><li>3 snacks </li></ul...
Carbohydrates <ul><li>Glycaemic index (GI): </li></ul><ul><ul><li>carbohydrate ranking system </li></ul></ul><ul><ul><li>b...
Carbohydrates <ul><li>Carbohydrate exchange system: </li></ul><ul><ul><li>based on the carbohydrate content and not the we...
Effects of exercise <ul><li>Increases insulin sensitivity </li></ul><ul><li>Improves the physical state </li></ul><ul><li>...
Food adjustments Exercise from 2nd hour  25-50 g/h 10-15 g 10-15 carb rich meal after 2 hrs 25-50 g/h 25-50 g 7-10 50 g wi...
Guidelines <ul><li>Measure blood glucose before, during and after physical exercise </li></ul><ul><li>Increased risk of hy...
Definition and causes <ul><li>Blood glucose < 3 mmol/l </li></ul><ul><ul><li>Mild (Grade 1): recognised and treated orally...
Symptoms <ul><li>Neurogenic : </li></ul><ul><ul><li>sweating </li></ul></ul><ul><ul><li>hunger </li></ul></ul><ul><ul><li>...
Treatment <ul><li>Mild hypoglycaemia  (Grade 1): </li></ul><ul><li>10–20 g glucose tablets, juice or sweet drinks </li></u...
Definition and aetiology <ul><li>Severity degree: </li></ul><ul><ul><li>Mild ketoacidosis bicarbonate > 16 and   < 22 mmol...
Symptoms and signs <ul><li>Dehydration </li></ul><ul><li>Vomiting </li></ul><ul><li>Loss of weight </li></ul><ul><li>Kussm...
Diagnosis <ul><li>Clinical appearance </li></ul><ul><li>Hyperglycaemia </li></ul><ul><li>Ketonuria </li></ul><ul><li>Keton...
Treatment : fluid <ul><li>Due to the risk for overhydration: </li></ul><ul><ul><li>fluid volume in the first 24 hours shou...
Treatment : insulin <ul><li>Low-dose insulin regimen: </li></ul><ul><ul><li>short-acting insulin </li></ul></ul><ul><ul><l...
Treatment : potassium <ul><li>DKA is always accompanied by severe potassium deficiency </li></ul><ul><li>Treatment: </li><...
Treatment <ul><li>Sodium: </li></ul><ul><ul><li>measured level low due to dilution </li></ul></ul><ul><ul><li>only correct...
Cerebral oedema <ul><li>Aetiology: </li></ul><ul><ul><li>rapid fluid correction </li></ul></ul><ul><ul><li>hyperglycaemia ...
Sick-day management <ul><li>Basis for sick-day management at home: </li></ul><ul><ul><li>insulin should never be omitted <...
Sick-day management <ul><li>Situations with high fever, high blood-glucose and ketonuria: </li></ul><ul><ul><li>most often...
Sick-day management <ul><li>Situations with low-grade fever, low blood-glucose and ketonuria </li></ul><ul><ul><li>most of...
M inor surgery (duration < 3h) <ul><li>Insulin: </li></ul><ul><ul><li>in the morning intermediate-acting insulin, 1/2 to 2...
Major surgery (duration > 3h) <ul><li>Insulin and fluid: </li></ul><ul><ul><li>infusion solution containing 5% glucose and...
Tests <ul><li>HbA 1c : </li></ul><ul><ul><li>average blood glucose over last 4–6 weeks </li></ul></ul><ul><ul><li>should b...
Goals <ul><li>Well-adjusted children/adolescents with normal growth and development </li></ul><ul><li>HbA 1c  between 7–9%...
Microvascular complications <ul><li>Microvascular complications in kidneys, eyes and nerves: </li></ul><ul><ul><li>closely...
Diabetic nephropathy <ul><li>Leading cause of increased morbidity and mortality in Type 1 diabetes </li></ul><ul><li>Prece...
Diabetic nephropathy <ul><li>Annual screening: </li></ul><ul><ul><li>after 5 years’ diabetes duration in pre-pubertal chil...
Diabetic retinopathy  <ul><li>Leading cause of visual loss and blindness in working-age population </li></ul><ul><li>Preva...
Diabetic retinopathy <ul><li>Annual screening: </li></ul><ul><ul><li>after 5 years’ diabetes duration in pre-pubertal chil...
Diabetic neuropathy <ul><li>Peripheral and autonomic </li></ul><ul><li>Rare in childhood and adolescence </li></ul><ul><li...
Diabetic neuropathy <ul><li>Annual screening: </li></ul><ul><ul><li>from puberty </li></ul></ul><ul><li>Screening method: ...
Adolescence <ul><li>Insulin insensitivity </li></ul><ul><li>Poor metabolic control </li></ul><ul><li>Insulin omission </li...
Treatment strategies <ul><li>Non-threatening open-minded atmosphere </li></ul><ul><li>Patience </li></ul><ul><li>Respect <...
Risk-taking behaviour <ul><li>Alcohol: </li></ul><ul><ul><li>impairs gluconeogenesis </li></ul></ul><ul><ul><li>associated...
Risk-taking behaviour <ul><li>Smoking: </li></ul><ul><ul><li>harmful to the health of all people </li></ul></ul><ul><ul><l...
Gynaecological issues <ul><li>Menstruation: </li></ul><ul><ul><li>may be irregular due to poor metabolic control </li></ul...
School <ul><li>All children should be attending school </li></ul><ul><li>Academic expectations should be the same </li></u...
Travelling <ul><li>Appointment in the out-patient clinic 4–6 weeks before travel </li></ul><ul><li>Improve metabolic contr...
Travelling <ul><li>Bring: </li></ul><ul><ul><li>introduction letter </li></ul></ul><ul><ul><li>sufficient insulin, needles...
Psychosocial problems <ul><li>Psychosocial problems in childhood diabetes: </li></ul><ul><ul><li>imposes major demands on ...
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Childhood diabetes Practical Reference Manual

  1. 1. A practical reference manual Treatment of children and adolescents with diabetes Dr. Birthe S Olsen, Consultant Paediatrician Dr. Henrik Mortensen, Chief Physician, Senior Paediatric Endocrinologist Department of Paediatrics, Glostrup University Hospital, Copenhagen, Denmark
  2. 2. Childhood diabetes <ul><li>90% Type 1 diabetes </li></ul><ul><li>Absolute or relative insulin deficiency </li></ul><ul><li>Auto-immune process </li></ul><ul><li>Pancreatic beta-cell destruction </li></ul>Definition
  3. 3. Aetiology <ul><li>Genetic susceptibility: </li></ul><ul><ul><li>HLADR3, HLADR4: risk increased </li></ul></ul><ul><ul><li>HLADR2 : risk reduced </li></ul></ul><ul><li>Environmental factors: </li></ul><ul><ul><li>viral factors </li></ul></ul><ul><ul><li>nutritional factors </li></ul></ul>Definition
  4. 4. Epidemiology <ul><li>Most common endocrine disease in childhood </li></ul><ul><li>Highest incidence in Finland and Sardinia </li></ul><ul><li>Highest incidence in males </li></ul><ul><li>Highest incidence at 10–12 years and 5–7 years </li></ul><ul><li>Increasing incidence in very young children (0–4 years) </li></ul><ul><li>Seasonality </li></ul><ul><li>More common in families where father has diabetes </li></ul>Definition
  5. 5. Pre-diabetes phase <ul><li>Gradual destruction of beta-cells </li></ul><ul><li>Development of auto-antibodies: </li></ul><ul><ul><li>ICA </li></ul></ul><ul><ul><li>IAA </li></ul></ul><ul><ul><li>GADA </li></ul></ul>Definition
  6. 6. Prevention <ul><li>Primary intervention: </li></ul><ul><ul><li>aim: reducing the prevalence of a given condition in susceptible individuals </li></ul></ul><ul><ul><ul><li>Example: cow's milk exclusion in infancy </li></ul></ul></ul><ul><li>Secondary intervention: </li></ul><ul><ul><li>aim: early detection of a given disease and stopping or slowing further progression </li></ul></ul><ul><ul><ul><li>Example: ENDIT study </li></ul></ul></ul><ul><li>Tertiary intervention: </li></ul><ul><ul><li>aim: preventing complications associated with a disease </li></ul></ul><ul><ul><ul><li>Example: improvement in glycaemic control, screening for complications </li></ul></ul></ul>Definition
  7. 7. Management – primary goals <ul><li>To ensure that insulin is available for all children </li></ul><ul><li>To ensure that the child gradually takes over the responsibility for the disease (self-care) </li></ul><ul><li>To ensure optimum glycaemic control </li></ul><ul><li>To ensure freedom from diabetic complications </li></ul><ul><li>To ensure normal growth and development </li></ul>The newly diagnosed child
  8. 8. Early diagnosis <ul><li>Symptoms and signs: </li></ul><ul><ul><li>polydipsia </li></ul></ul><ul><ul><li>polyuria </li></ul></ul><ul><ul><li>night-time incontinence </li></ul></ul><ul><ul><li>loss of weight </li></ul></ul><ul><ul><li>irritability </li></ul></ul><ul><ul><li>abdominal pain </li></ul></ul><ul><ul><li>visual disturbances </li></ul></ul><ul><ul><li>frequent infections </li></ul></ul>The newly diagnosed child
  9. 9. Early diagnosis <ul><li>Diagnosis: </li></ul><ul><ul><li>fasting blood-glucose concentration > 7.7 mmol/l </li></ul></ul><ul><ul><li>random blood-glucose concentration > 11 mmol/l </li></ul></ul><ul><ul><li>glucosuria </li></ul></ul><ul><ul><li>ketonuria </li></ul></ul><ul><ul><li>ketoacidosis </li></ul></ul><ul><li>Differential diagnosis: </li></ul><ul><ul><li>inflamed appendix </li></ul></ul><ul><ul><li>pneumonia </li></ul></ul><ul><ul><li>urinary tract infection </li></ul></ul>The newly diagnosed child
  10. 10. The multi-disciplinary team <ul><li>The cornerstone in childhood diabetes management: </li></ul><ul><ul><li>a paediatric endocrinologist </li></ul></ul><ul><ul><li>a specialised nurse </li></ul></ul><ul><ul><li>a specialised dietician </li></ul></ul><ul><ul><li>a chiropodist </li></ul></ul><ul><ul><li>a specialised social worker </li></ul></ul><ul><ul><li>a childhood psychologist </li></ul></ul><ul><ul><li>close collaboration with other relevant departments </li></ul></ul>The team
  11. 11. The multi-disciplinary team <ul><li>The team should… </li></ul><ul><ul><li>have common attitudes and philosophy </li></ul></ul><ul><ul><li>meet regularly for discussion and education </li></ul></ul><ul><ul><li>develop written material dealing with daily-life and emergency issues </li></ul></ul><ul><ul><li>encourage research into childhood diabetes </li></ul></ul><ul><ul><li>attend in-service training </li></ul></ul>The team
  12. 12. Diabetes education 1 <ul><li>Initial ‘survival’ education: </li></ul><ul><ul><li>the causes of diabetes </li></ul></ul><ul><ul><li>insulin management </li></ul></ul><ul><ul><li>injection technique </li></ul></ul><ul><ul><li>blood glucose measurements </li></ul></ul><ul><ul><li>acceptable blood glucose values </li></ul></ul><ul><ul><li>advice about hypo- and hyperglycaemic episodes </li></ul></ul><ul><ul><li>dietary advice </li></ul></ul>Diabetes education
  13. 13. Diabetes education 2 <ul><li>aetiology and pathology </li></ul><ul><li>injection devices and methods </li></ul><ul><li>blood-glucose monitoring </li></ul><ul><li>diet </li></ul><ul><li>insulin adjustments </li></ul><ul><li>hypoglycaemia </li></ul><ul><li>insulin-treatment </li></ul><ul><li>hyperglycaemia </li></ul><ul><li>sick-day management </li></ul><ul><li>sport </li></ul><ul><li>alcohol </li></ul><ul><li>drug abuse </li></ul><ul><li>travelling </li></ul><ul><li>gynaecological issues </li></ul><ul><li>complications </li></ul>Over the next months and years a more comprehensive education programme, adjusted to the age and maturity of the child: Diabetes education
  14. 14. Diabetes education 3 <ul><li>The knowledge and skills of the child should be regularly assessed </li></ul><ul><li>Re-education should be performed accordingly </li></ul>Diabetes education
  15. 15. Treatment <ul><li>At diagnosis </li></ul><ul><li>Remission phase </li></ul><ul><li>Long-term </li></ul>Initial treatment
  16. 16. Non-ketotic child <ul><li>Insulin: </li></ul><ul><ul><li>subcutaneous </li></ul></ul><ul><ul><li>multiple dose rapid-acting insulin before meals, or </li></ul></ul><ul><ul><li>combination of rapid- and intermediate-acting insulin twice daily </li></ul></ul><ul><ul><li>insulin requirements may exceed 1.5–2 IU/kg/24 hours </li></ul></ul><ul><li>Potassium: </li></ul><ul><ul><li>< 12 years 750 mg KCl for 3–4 days </li></ul></ul><ul><ul><li>> 12 years 1500 mg KCl for 3–4 days </li></ul></ul>Initial treatment
  17. 17. Non-ketoacidotic child <ul><ul><li>hospital stay as short as possible </li></ul></ul><ul><ul><li>in paediatric setting </li></ul></ul><ul><ul><li>frequent visits to out-patient clinic </li></ul></ul><ul><ul><li>24-hour hot-line service </li></ul></ul><ul><ul><li>home and institution visits </li></ul></ul><ul><li>Always managed at hospital in case of: </li></ul><ul><ul><li>ketoacidosis </li></ul></ul><ul><ul><li>severe dehydration </li></ul></ul><ul><ul><li>very young age </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>psychosocial problems </li></ul></ul><ul><ul><li>language and cultural difficulties </li></ul></ul>Initial treatment
  18. 18. The remission phase <ul><li>Duration from weeks to months </li></ul><ul><li>Shorter in young children </li></ul><ul><li>Blood glucose values between 4–8 mmol/l </li></ul><ul><li>Decreasing insulin requirements < 0.5 IU/kg/24 hours </li></ul><ul><li>One daily insulin injection is often sufficient </li></ul><ul><li>Insulin injections should not be abandoned </li></ul>Partial remission phase
  19. 19. Long-term management <ul><li>Twice daily or multiple insulin injections </li></ul><ul><li>Regular blood glucose measurements </li></ul><ul><li>At least 4 visits to out-patient clinic every year </li></ul><ul><li>Instant HbA 1c measurements at every visit </li></ul><ul><li>Height and weight measurements at every visit </li></ul><ul><li>Physical examination with pubertal staging every year </li></ul><ul><li>Regular screening for diabetes related complications </li></ul>Partial remission phase
  20. 20. Insulin <ul><li>All children with Type 1 diabetes must have insulin </li></ul><ul><li>Consequences of long-term insulin omission: </li></ul><ul><ul><li>growth retardation </li></ul></ul><ul><ul><li>delayed puberty </li></ul></ul><ul><ul><li>poor metabolic control </li></ul></ul><ul><ul><li>microvascular complications </li></ul></ul><ul><ul><li>short life expectancy </li></ul></ul><ul><ul><li>poor quality of life </li></ul></ul>Insulin
  21. 21. Insulin types and duration of action <ul><li>Insulin </li></ul><ul><li>preparation </li></ul><ul><li>Short-acting </li></ul><ul><li>Intermediate-acting </li></ul><ul><li>Premixed insulin 10/90 </li></ul><ul><li>Premixed insulin 20/80 </li></ul><ul><li>Premixed insulin 30/70 </li></ul><ul><li>Premixed insulin 40/60 </li></ul><ul><li>Premixed insulin 50/50 </li></ul><ul><li>Rapid-acting insulin analogue </li></ul>Onset of action (h or min) 30 min. 1–2 h 0.5–1 h 0.5–1 h 0.5–1 h 0.5–1 h 0.5–1 h 10–20 min. Peak action (h) 1–3 4–12 2–8 5–10 5–9 1–3 1–3 1–3 Maximal duration (h) 6–8 18–24 18–24 18–24 18–24 18–24 18–24 3–5 Insulin
  22. 22. Short-acting insulin <ul><li>Clear solution </li></ul><ul><li>Indications for use: </li></ul><ul><ul><li>daily management of diabetes, alone or in combination with intermediate-acting insulin </li></ul></ul><ul><ul><li>hyperglycaemia </li></ul></ul><ul><ul><li>sick-day management </li></ul></ul><ul><ul><li>intravenous therapy </li></ul></ul>Insulin
  23. 23. Intermediate-acting insulin <ul><li>Cloudy solution (should be thoroughly mixed before use) </li></ul><ul><li>Indications for use: </li></ul><ul><ul><li>daily management of diabetes, alone or in combination with short-acting insulin </li></ul></ul>Insulin
  24. 24. Pre-mixed insulin <ul><li>Cloudy solution (should be thoroughly mixed before use) </li></ul><ul><li>Indications for use: </li></ul><ul><ul><li>daily management of diabetes, alone or in combination with short-acting insulin </li></ul></ul>Insulin
  25. 25. Rapid-acting insulin (Insulin Aspart) <ul><li>Clinical benefits </li></ul><ul><ul><li>improved metabolic control compared with human soluble insulin </li></ul></ul><ul><ul><li>fewer hypoglycaemic episodes </li></ul></ul><ul><ul><li>no post-prandial hypoglycaemia </li></ul></ul><ul><ul><ul><ul><ul><li>rapid onset of action </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>short duration of action </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>better quality of life and improved convenience </li></ul></ul></ul></ul></ul>Insulin
  26. 26. Rapid-acting insulin (Insulin Aspart) <ul><li>Patient targeting: </li></ul><ul><ul><li>newly diagnosed children and adolescents with diabetes </li></ul></ul><ul><ul><li>children and adolescents currently on basal/bolus regimens </li></ul></ul><ul><ul><ul><ul><ul><li>children and adolecents with poorly controlled diabetes on twice daily therapies </li></ul></ul></ul></ul></ul>Insulin
  27. 27. Storage of insulin <ul><li>Stable at room temperature for weeks </li></ul><ul><li>Should not be exposed to temperatures > 25ºC or under freezing point </li></ul><ul><li>Unused vials and cartridges should be stored in the refrigerator </li></ul><ul><li>Should never be exposed to sunlight </li></ul><ul><li>Should never be frozen </li></ul>Insulin
  28. 28. Injection sites <ul><li>Short acting insulin: </li></ul><ul><ul><li>injected subcutaneously into the abdomen at a 45° angle </li></ul></ul><ul><li>Intermediate-acting and pre-mixed insulins: </li></ul><ul><ul><li>injected subcutaneously in the front of the thighs or into the buttocks at a 45° angle </li></ul></ul>Insulin
  29. 29. Insulin absorption <ul><li>Factors influencing insulin absorption: </li></ul><ul><ul><li>injection site </li></ul></ul><ul><ul><li>injection depth </li></ul></ul><ul><ul><li>insulin type </li></ul></ul><ul><ul><li>insulin dose </li></ul></ul><ul><ul><li>physical exercise </li></ul></ul><ul><ul><li>skin temperature </li></ul></ul>Insulin
  30. 30. Insulin requirements <ul><li>Remission period </li></ul><ul><ul><li>< 0.5 IU/kg/24 hours </li></ul></ul><ul><li>Pre-pubertal period </li></ul><ul><ul><li>0.6–1.0 IU/kg/24 hours </li></ul></ul><ul><li>Pubertal period </li></ul><ul><ul><li>1.0–2.0 IU/kg/24 hours </li></ul></ul>Insulin
  31. 31. Insulin regimens <ul><li>Insulin regimens should be: </li></ul><ul><ul><li>adjusted to age, maturity and motivation </li></ul></ul><ul><ul><li>as simple as possible </li></ul></ul><ul><li>Children for multiple injection therapy should: </li></ul><ul><ul><li>be selected carefully </li></ul></ul><ul><ul><li>understand the relationship between insulin, food and physical exercise </li></ul></ul><ul><ul><li>be motivated and have family support </li></ul></ul><ul><ul><li>be willing to measure blood glucose several times each day </li></ul></ul><ul><ul><li>be willing to inject insulin at school </li></ul></ul>Insulin
  32. 32. Insulin regimens <ul><li>Most widely used insulin regimens: </li></ul><ul><ul><li>twice-daily injections, mixture short and intermediate, before breakfast and the evening meal </li></ul></ul><ul><ul><li>three daily injections, mixture short and intermediate before breakfast, short-acting before the evening meal and intermediate-acting before bed </li></ul></ul><ul><ul><li>short-acting insulin before main meals, intermediate before bed </li></ul></ul>Insulin
  33. 33. Insulin distribution <ul><li>Twice daily injection regimen: </li></ul><ul><ul><li>2/3 of daily dose before breakfast, </li></ul></ul><ul><ul><li>1/3 before supper </li></ul></ul><ul><ul><li>both 2/3 intermediate-acting and 1/3 short-acting insulin </li></ul></ul><ul><li>Three-times daily injection regimen: </li></ul><ul><ul><li>40–50% before breakfast (2/3 intermediate- and 1/3 short-acting) </li></ul></ul><ul><ul><li>10–15% short-acting before supper </li></ul></ul><ul><ul><li>40% intermediate-acting before bed. </li></ul></ul><ul><li>Multiple injection regimen: </li></ul><ul><ul><li>30–40 % (intermediate) before bed </li></ul></ul><ul><ul><li>the rest (short-acting) before main meals </li></ul></ul>Insulin
  34. 34. Insulin adjustments <ul><li>Twice-daily injection regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of insulin to increase </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate-acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Morning intermediate-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul><ul><ul><li>Blood glucose low: Dose of insulin to decrease </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate- acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Morning intermediate-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul>Insulin
  35. 35. Insulin adjustments <ul><li>Three-times daily injection regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of insulin to increase </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate- acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Morning intermediate-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul><ul><ul><li>Blood glucose low: Dose of insulin to decrease </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate- acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Morning intermediate-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul>Insulin
  36. 36. Insulin adjustments <ul><li>Basal-bolus (multiple injection) regimen: </li></ul><ul><ul><li>Blood glucose high: Dose of insulin to increase </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate-acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Lunch time short-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul><ul><ul><li>Blood glucose low: Dose of insulin to decrease </li></ul></ul><ul><ul><li>Before breakfast or overnight Evening intermediate-acting </li></ul></ul><ul><ul><li>Before lunch Morning short-acting </li></ul></ul><ul><ul><li>Before dinner Lunch time short-acting </li></ul></ul><ul><ul><li>Before bed Evening short-acting </li></ul></ul>Insulin
  37. 37. Diet <ul><li>Nutritional advice should take into consideration: </li></ul><ul><ul><li>individual requirements </li></ul></ul><ul><ul><li>local customs </li></ul></ul><ul><ul><li>family dietary habits </li></ul></ul><ul><li>General recommendations: </li></ul><ul><ul><li>eat a broad variety of food </li></ul></ul><ul><ul><li>eat plenty of bread, cereals, vegetables and fruit </li></ul></ul><ul><ul><li>eat only small amounts of sugar </li></ul></ul><ul><ul><li>in young children fat intake should not be restricted </li></ul></ul><ul><ul><li>older children and adolescents should eat a low fat diet </li></ul></ul><ul><ul><li>choose food with small amounts of salt </li></ul></ul><ul><ul><li>encourage breast-feeding at least until six months of age </li></ul></ul>Diet
  38. 38. Diet: principles <ul><li>Number of meals: </li></ul><ul><ul><li>3 main meals </li></ul></ul><ul><ul><li>3 snacks </li></ul></ul><ul><ul><li>adapted to age, physical activity and insulin regimen </li></ul></ul><ul><li>Energy intake: </li></ul><ul><ul><li>1000 calories (4180 Kj) + 100 calories/year of age </li></ul></ul><ul><ul><li>50–55% of energy from carbohydrates </li></ul></ul><ul><ul><li>30% of energy from fat </li></ul></ul><ul><ul><li>15–20% of energy from protein </li></ul></ul>Diet
  39. 39. Carbohydrates <ul><li>Glycaemic index (GI): </li></ul><ul><ul><li>carbohydrate ranking system </li></ul></ul><ul><ul><li>based on post-prandial blood glucose response </li></ul></ul><ul><ul><li>low GI = slow, sustained blood glucose response (e.g. rice, pasta) </li></ul></ul><ul><ul><li>high GI = rapid and high blood-glucose response (e.g. white bread, candy/sweets, cornflakes, honey, sugar) </li></ul></ul>Diet
  40. 40. Carbohydrates <ul><li>Carbohydrate exchange system: </li></ul><ul><ul><li>based on the carbohydrate content and not the weight of the food </li></ul></ul><ul><ul><li>makes it easy to exchange carbohydrate containing food elements (e.g. 15 g carbohydrates in candy for 15 g carbohydrates in fruit) </li></ul></ul><ul><ul><li>one exchange usually contains 10–15 g carbohydrate </li></ul></ul>Diet
  41. 41. Effects of exercise <ul><li>Increases insulin sensitivity </li></ul><ul><li>Improves the physical state </li></ul><ul><li>Reduces the risk of cardiac diseases </li></ul><ul><li>Reduces the risk of hypertension </li></ul><ul><li>Does not improve metabolic control </li></ul><ul><li>Increases the risk of hypoglycaemia </li></ul>Exercise
  42. 42. Food adjustments Exercise from 2nd hour 25-50 g/h 10-15 g 10-15 carb rich meal after 2 hrs 25-50 g/h 25-50 g 7-10 50 g within the 1 st hour 25-50 g/h 50 g below 7 Strenuous exercise (football, basketball, running, swimming, aerobics) carb rich meal after 2 hrs from 2nd hour 15-25 g/h nothing 10-15 15-25 g/h 10-15 g 7-10 50 g within the first hour 15-25 g/h 25-50 g below 7 Moderate exercise (tennis, jogging, golf, cycling) nothing above 7 if necessary 10 g from 2nd hour 10-15 g/h 0-15g below 7 Mild exercise (walking, slow speed cycling) After During exercise Before Before exercise Carbohydrate intake Blood glucose (mmol/L) Type of activity
  43. 43. Guidelines <ul><li>Measure blood glucose before, during and after physical exercise </li></ul><ul><li>Increased risk of hypoglycaemia 12–40 hours after strenuous physical exercise </li></ul><ul><li>Reduce short-acting insulin accordingly </li></ul><ul><li>Blood glucose before bedtime should be > 10–12 mmol/l </li></ul>Exercise
  44. 44. Definition and causes <ul><li>Blood glucose < 3 mmol/l </li></ul><ul><ul><li>Mild (Grade 1): recognised and treated orally by the patient </li></ul></ul><ul><ul><li>Moderate (Grade 2): treated orally, with help from someone else </li></ul></ul><ul><ul><li>Severe (Grade 3): unconscious or having fits – nothing by mouth </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><li>strenuous exercise </li></ul></ul><ul><ul><li>missed meals </li></ul></ul><ul><ul><li>injection errors </li></ul></ul>Hypoglycaemia
  45. 45. Symptoms <ul><li>Neurogenic : </li></ul><ul><ul><li>sweating </li></ul></ul><ul><ul><li>hunger </li></ul></ul><ul><ul><li>tremor </li></ul></ul><ul><ul><li>pallor </li></ul></ul><ul><ul><li>restlessness </li></ul></ul><ul><li>Neuroglycopenic : </li></ul><ul><ul><li>weakness </li></ul></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>change in behaviour </li></ul></ul><ul><ul><li>tiredness </li></ul></ul><ul><ul><li>visual and speech disturbances </li></ul></ul><ul><ul><li>vertigo </li></ul></ul><ul><ul><li>lethargy </li></ul></ul><ul><ul><li>confusion </li></ul></ul><ul><ul><li>fits and unconsciousness </li></ul></ul>Hypoglycaemia
  46. 46. Treatment <ul><li>Mild hypoglycaemia (Grade 1): </li></ul><ul><li>10–20 g glucose tablets, juice or sweet drinks </li></ul><ul><li>1–2 slices of bread </li></ul><ul><li>Moderate hypoglycaemia (Grade 2): </li></ul><ul><li>10–20 g glucose tablets </li></ul><ul><li>1–2 slices of bread </li></ul><ul><li>Severe hypoglycaemia (Grade 3): </li></ul><ul><li>Outside hospital: </li></ul><ul><ul><li>children < 10 years: 0.5 mg glucagon i.m. </li></ul></ul><ul><ul><li>children > 10 years: 1.0 mg glucagon i.m. </li></ul></ul><ul><li>In hospital: </li></ul><ul><ul><li>bolus glucose (20%) 1 ml/kg over 3 min followed by </li></ul></ul><ul><ul><li>glucose (10%), 0.2 ml/kg/min </li></ul></ul>Hypoglycaemia
  47. 47. Definition and aetiology <ul><li>Severity degree: </li></ul><ul><ul><li>Mild ketoacidosis bicarbonate > 16 and < 22 mmol/l </li></ul></ul><ul><ul><li>Moderate ketoacidosis bicarbonate > 10 and < 16 mmol/l </li></ul></ul><ul><ul><li>Severe ketoacidosis bicarbonate < 10 mmol/l </li></ul></ul><ul><li>Characterised by: </li></ul><ul><ul><li>absolute insulin deficiency </li></ul></ul><ul><ul><li>increased level of counter regulatory hormones </li></ul></ul><ul><li>Aetiology: </li></ul><ul><ul><li>newly diagnosed </li></ul></ul><ul><ul><li>infections </li></ul></ul><ul><ul><li>insulin omission </li></ul></ul>Diabetic ketoacidosis
  48. 48. Symptoms and signs <ul><li>Dehydration </li></ul><ul><li>Vomiting </li></ul><ul><li>Loss of weight </li></ul><ul><li>Kussmaul respirations </li></ul><ul><li>Acetone smell </li></ul><ul><li>Impaired sensorium </li></ul><ul><li>Shock </li></ul>Diabetic ketoacidosis
  49. 49. Diagnosis <ul><li>Clinical appearance </li></ul><ul><li>Hyperglycaemia </li></ul><ul><li>Ketonuria </li></ul><ul><li>Ketonaemia </li></ul><ul><li>Plasma bicarbonate < 22 mmol/l </li></ul>Diabetic ketoacidosis
  50. 50. Treatment : fluid <ul><li>Due to the risk for overhydration: </li></ul><ul><ul><li>fluid volume in the first 24 hours should not exceed 4 l/m 2 </li></ul></ul><ul><ul><li>rehydration over 24–36 hours </li></ul></ul><ul><li>Initiate treatment with isotonic 0.9 % saline: </li></ul><ul><ul><li>1st hour: 20 ml/kg body weight (previous) </li></ul></ul><ul><ul><li>2nd hour: 10 ml/kg body weight </li></ul></ul><ul><ul><li>3rd hour onwards: 5 ml/kg body weight </li></ul></ul><ul><li>When blood glucose levels are below 12 mmol/l: </li></ul><ul><ul><li>5–10 % glucose solution </li></ul></ul>Diabetic ketoacidosis
  51. 51. Treatment : insulin <ul><li>Low-dose insulin regimen: </li></ul><ul><ul><li>short-acting insulin </li></ul></ul><ul><ul><li>intravenously </li></ul></ul><ul><ul><li>bolus or continuous infusion </li></ul></ul><ul><ul><li>0.1 IU/kg/hour </li></ul></ul><ul><li>Ideal blood-glucose reduction: </li></ul><ul><ul><li>maximal 4–5 mmol/l </li></ul></ul><ul><li>Until acidosis is corrected: </li></ul><ul><ul><li>adjust insulin and fluid to blood glucose level between 5–15 mmol/l </li></ul></ul>Diabetic ketoacidosis
  52. 52. Treatment : potassium <ul><li>DKA is always accompanied by severe potassium deficiency </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>initially add 20 mmol KCl to 500 ml fluid </li></ul></ul><ul><ul><li>adjust potassium replacements to plasma potassium level: </li></ul></ul><ul><ul><li>plasma potassium potassium chloride (mmol/l) (mmol/kg/h) </li></ul></ul><ul><ul><li>< 3 0.5 3–4 0.4 4–5 0.3 5–6 0.2 > 6 nothing </li></ul></ul>Diabetic ketoacidosis
  53. 53. Treatment <ul><li>Sodium: </li></ul><ul><ul><li>measured level low due to dilution </li></ul></ul><ul><ul><li>only correction if values are below 120 mmol/l </li></ul></ul><ul><ul><li>if values are above 160 mmol/l (hypernatriaemic state) </li></ul></ul><ul><ul><li>rehydrate over 48–72 hours </li></ul></ul><ul><li>Bicarbonate: </li></ul><ul><ul><li>only in very sick children with severe ketoacidosis (pH < 7.0) </li></ul></ul><ul><ul><li>recommended dose 1–2 mmol/kg </li></ul></ul><ul><ul><li>½ of the dose over 30 minutes and ½ over 1–2 hours </li></ul></ul><ul><li>Hazards of bicarbonate treatment: </li></ul><ul><ul><li>precipitation of hypokalaemia </li></ul></ul><ul><ul><li>paradoxical exacerbation of CNS acidosis </li></ul></ul><ul><ul><li>cerebral oedema </li></ul></ul>Diabetic ketoacidosis
  54. 54. Cerebral oedema <ul><li>Aetiology: </li></ul><ul><ul><li>rapid fluid correction </li></ul></ul><ul><ul><li>hyperglycaemia </li></ul></ul><ul><ul><li>bicarbonate treatment </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>fluid restriction </li></ul></ul><ul><ul><li>hyperventilation </li></ul></ul><ul><ul><li>mannitol infusion 1–2 g/kg over 20–30 minutes </li></ul></ul><ul><li>Prognosis: </li></ul><ul><ul><li>very poor </li></ul></ul>Diabetic ketoacidosis
  55. 55. Sick-day management <ul><li>Basis for sick-day management at home: </li></ul><ul><ul><li>insulin should never be omitted </li></ul></ul><ul><ul><li>frequent blood glucose measurements </li></ul></ul><ul><ul><li>frequent urine testing for ketone bodies </li></ul></ul><ul><ul><li>close contact with the diabetes team </li></ul></ul><ul><li>Situations where admittance to hospital is indicated: </li></ul><ul><ul><li>persistant vomiting </li></ul></ul><ul><ul><li>increasing ketone bodies in the urine </li></ul></ul><ul><ul><li>increasingly sick child </li></ul></ul><ul><ul><li>abdominal pain </li></ul></ul><ul><ul><li>non-compliance and psycho-social problems </li></ul></ul><ul><ul><li>language and cultural difficulties </li></ul></ul><ul><ul><li>very young age (< 2 years) </li></ul></ul>Sick-day management
  56. 56. Sick-day management <ul><li>Situations with high fever, high blood-glucose and ketonuria: </li></ul><ul><ul><li>most often caused by bacterial infections </li></ul></ul><ul><ul><li>seek and treat the infection focus </li></ul></ul><ul><ul><li>give frequent subcutaneous injections of short-acting insulin </li></ul></ul><ul><ul><li>continue treatment until ketone bodies have disappeared </li></ul></ul><ul><ul><li>give glucose containing food or drinks to maintain acceptable blood glucose values </li></ul></ul><ul><ul><li>encourage the child to drink plenty of fluids </li></ul></ul>Sick-day management
  57. 57. Sick-day management <ul><li>Situations with low-grade fever, low blood-glucose and ketonuria </li></ul><ul><ul><li>most often caused by viral infections </li></ul></ul><ul><ul><li>associated with anorexia, vomiting and diarrhoea </li></ul></ul><ul><ul><li>reduce short- and intermediate- acting insulin according to blood glucose values </li></ul></ul><ul><ul><li>give glucose containing food or drinks to maintain acceptable blood glucose values </li></ul></ul><ul><ul><li>encourage the child to drink plenty of fluids </li></ul></ul>Sick-day management
  58. 58. M inor surgery (duration < 3h) <ul><li>Insulin: </li></ul><ul><ul><li>in the morning intermediate-acting insulin, 1/2 to 2/3 of total daily dose </li></ul></ul><ul><ul><li>if blood glucose is above 20 mmol/l supply with a small dose short-acting insulin </li></ul></ul><ul><ul><li>in the evening give intermediate-acting insulin, 1/3 of daily dose </li></ul></ul><ul><li>Fluid: </li></ul><ul><ul><li>glucose 5% intravenously, volume according to age </li></ul></ul><ul><li>Blood glucose monitoring: </li></ul><ul><ul><li>every 1–2 hours </li></ul></ul><ul><ul><li>values between 10–14 mmol/l </li></ul></ul>Surgery
  59. 59. Major surgery (duration > 3h) <ul><li>Insulin and fluid: </li></ul><ul><ul><li>infusion solution containing 5% glucose and 20 mmol/l sodium chloride (maintenance volume) </li></ul></ul><ul><ul><li>50 IU short-acting insulin in 500 ml 0.9 % saline by separate drip infusion 0.5 ml = 0.05 IU/kg/hour </li></ul></ul><ul><li>Blood glucose monitoring: </li></ul><ul><ul><li>every 1–2 hours </li></ul></ul><ul><ul><li>values between 6–14 mmol/l </li></ul></ul><ul><ul><li>if < 5 mmol/l reduce infusion rate </li></ul></ul><ul><ul><li>continue infusion therapy until food intake is re-established </li></ul></ul>Surgery
  60. 60. Tests <ul><li>HbA 1c : </li></ul><ul><ul><li>average blood glucose over last 4–6 weeks </li></ul></ul><ul><ul><li>should be measured and available at every out-patient clinic visit </li></ul></ul><ul><li>Home blood glucose (HBG) measurement: </li></ul><ul><ul><li>ideally before breakfast, lunch, evening meal and bedtime </li></ul></ul><ul><ul><li>before, during and after physical exercise </li></ul></ul><ul><ul><li>during intercurrent illnesses </li></ul></ul><ul><ul><li>if hypo- or hyperglycaemia is suspected </li></ul></ul><ul><ul><li>following hypoglycaemia </li></ul></ul><ul><ul><li>after changing insulin dose </li></ul></ul><ul><ul><li>frequency of HBG should be adjusted to age, insulin regimen and acceptance of the child </li></ul></ul><ul><li>Urine testing: </li></ul><ul><ul><li>ketone testing in case of fever and high blood glucose </li></ul></ul>Glycaemic control
  61. 61. Goals <ul><li>Well-adjusted children/adolescents with normal growth and development </li></ul><ul><li>HbA 1c between 7–9% </li></ul><ul><li>Less than 10–20 severe hypoglycaemia episodes and ketoacidosis per 100 patient years </li></ul><ul><li>Post-prandial blood glucose values below 10–12 mmol/l </li></ul><ul><li>Pre-prandial blood glucose values between 4–8 mmol/l </li></ul><ul><li>Glycaemic goals less strict for very young children </li></ul><ul><li>Goals realistic and individualised in puberty </li></ul>Glycaemic control
  62. 62. Microvascular complications <ul><li>Microvascular complications in kidneys, eyes and nerves: </li></ul><ul><ul><li>closely related to poor long-term metabolic control </li></ul></ul><ul><ul><li>occur from puberty </li></ul></ul><ul><ul><li>preceded by subclinical changes </li></ul></ul><ul><ul><li>can be delayed or prevented by good metabolic control </li></ul></ul>Complications
  63. 63. Diabetic nephropathy <ul><li>Leading cause of increased morbidity and mortality in Type 1 diabetes </li></ul><ul><li>Preceded by microalbuminuria (albumin excretion rate > 20 µg/min) </li></ul><ul><li>Prevalence in adolescence 5–20% </li></ul><ul><li>Correlated with long-term metabolic control </li></ul><ul><li>Long diabetes duration </li></ul><ul><li>Elevated arterial blood pressure </li></ul><ul><li>Genetic susceptibility </li></ul>Complications
  64. 64. Diabetic nephropathy <ul><li>Annual screening: </li></ul><ul><ul><li>after 5 years’ diabetes duration in pre-pubertal children </li></ul></ul><ul><ul><li>after 2 years’ diabetes duration in adolescents </li></ul></ul><ul><li>Screening method: </li></ul><ul><ul><li>albumin excretion rate calculated from night-time urine collections </li></ul></ul><ul><li>Microalbuminuria treatment: </li></ul><ul><ul><li>improved long-term metabolic control </li></ul></ul><ul><ul><li>normalising arterial blood pressure </li></ul></ul><ul><ul><li>smoking discouraged </li></ul></ul><ul><ul><li>ACE-inhibition </li></ul></ul>Complications
  65. 65. Diabetic retinopathy <ul><li>Leading cause of visual loss and blindness in working-age population </li></ul><ul><li>Prevalence in adolescence: 10–80% </li></ul><ul><li>Correlated with long-term metabolic control </li></ul><ul><li>Long diabetes duration </li></ul><ul><li>Elevated arterial blood-pressure </li></ul><ul><li>Genetic susceptibility </li></ul><ul><li>Background retinopathy: </li></ul><ul><ul><li>not vision threatening </li></ul></ul><ul><ul><li>stable for many years </li></ul></ul><ul><li>Proliferative retinopathy: </li></ul><ul><ul><li>vision-threatening </li></ul></ul><ul><ul><li>new vessels </li></ul></ul><ul><ul><li>retinal retraction </li></ul></ul>Complications
  66. 66. Diabetic retinopathy <ul><li>Annual screening: </li></ul><ul><ul><li>after 5 years’ diabetes duration in pre-pubertal children </li></ul></ul><ul><ul><li>after 2 years’ diabetes duration in adolescents </li></ul></ul><ul><li>Screening method: </li></ul><ul><ul><li>ophthalmoscopy </li></ul></ul><ul><ul><li>fundus photography </li></ul></ul><ul><ul><li>fluorescein angiography </li></ul></ul><ul><li>Retinopathy treatment: </li></ul><ul><ul><li>improved long-term metabolic control </li></ul></ul><ul><ul><li>normalising arterial blood pressure </li></ul></ul><ul><ul><li>laser therapy in case of proliferative retinopathy </li></ul></ul>Complications
  67. 67. Diabetic neuropathy <ul><li>Peripheral and autonomic </li></ul><ul><li>Rare in childhood and adolescence </li></ul><ul><li>Preceded by subclinical abnormalities </li></ul><ul><li>Correlated with </li></ul><ul><ul><li>poor long-term metabolic control </li></ul></ul><ul><ul><li>long diabetes duration </li></ul></ul><ul><ul><li>older age </li></ul></ul><ul><ul><li>higher Tanner stage </li></ul></ul><ul><ul><li>male sex </li></ul></ul>Complications
  68. 68. Diabetic neuropathy <ul><li>Annual screening: </li></ul><ul><ul><li>from puberty </li></ul></ul><ul><li>Screening method: </li></ul><ul><ul><li>ankle reflexes </li></ul></ul><ul><ul><li>sensation (temperature discrimination) </li></ul></ul><ul><ul><li>non-invasive test of nerve function (biothesiometry) </li></ul></ul><ul><li>Neuropathy treatment: </li></ul><ul><ul><li>improved long-term metabolic control </li></ul></ul>Complications
  69. 69. Adolescence <ul><li>Insulin insensitivity </li></ul><ul><li>Poor metabolic control </li></ul><ul><li>Insulin omission </li></ul><ul><li>Overweight </li></ul><ul><li>Eating disorders </li></ul><ul><li>Psychosocial problems </li></ul><ul><li>Microvascular complications </li></ul>Adolescence
  70. 70. Treatment strategies <ul><li>Non-threatening open-minded atmosphere </li></ul><ul><li>Patience </li></ul><ul><li>Respect </li></ul><ul><li>Flexible appointment times </li></ul><ul><li>Opportunity to meet other adolescents with diabetes </li></ul><ul><li>Planned transition to adult setting </li></ul><ul><li>Parental involvement </li></ul>Adolescence
  71. 71. Risk-taking behaviour <ul><li>Alcohol: </li></ul><ul><ul><li>impairs gluconeogenesis </li></ul></ul><ul><ul><li>associated with severe hypoglycaemia </li></ul></ul><ul><li>Advice: </li></ul><ul><ul><li>drink in moderation </li></ul></ul><ul><ul><li>eat complex carbohydrates while drinking alcohol </li></ul></ul><ul><ul><li>if HBG is not measured always eat extra food before bedtime </li></ul></ul><ul><ul><li>make sure that your friends are aware of your diabetes </li></ul></ul><ul><ul><li>always wear your diabetes amulet when going to parties </li></ul></ul><ul><ul><li>measure HBG before going to bed </li></ul></ul><ul><ul><li>measure blood glucose (HBG) regularly </li></ul></ul>Adolescence
  72. 72. Risk-taking behaviour <ul><li>Smoking: </li></ul><ul><ul><li>harmful to the health of all people </li></ul></ul><ul><ul><li>associated with increased risk of microvascular complications </li></ul></ul><ul><ul><li>is expensive </li></ul></ul><ul><ul><li>is addictive </li></ul></ul><ul><li>Drug abuse: </li></ul><ul><ul><li>should be considered in connection with other risk-taking behaviour </li></ul></ul>Adolescence
  73. 73. Gynaecological issues <ul><li>Menstruation: </li></ul><ul><ul><li>may be irregular due to poor metabolic control </li></ul></ul><ul><ul><li>may be accompanied by high blood glucose levels </li></ul></ul><ul><li>Oral contraceptives with low-dose oestrogen: </li></ul><ul><ul><li>safe for most adolescents with diabetes </li></ul></ul><ul><ul><li>may be accompanied by insulin resistance </li></ul></ul><ul><ul><li>not to be used in cases of arterial hypertension </li></ul></ul><ul><li>Condoms: </li></ul><ul><ul><li>safe contraceptive method </li></ul></ul><ul><ul><li>protect against sexually transmitted diseases </li></ul></ul>Adolescence
  74. 74. School <ul><li>All children should be attending school </li></ul><ul><li>Academic expectations should be the same </li></ul><ul><li>Teachers and school nurse should be informed about general rules and emergency situations </li></ul><ul><li>Written material about diabetes should be handed out to school staff </li></ul><ul><li>A close communication should exist between home and school </li></ul>Camps, school and travel
  75. 75. Travelling <ul><li>Appointment in the out-patient clinic 4–6 weeks before travel </li></ul><ul><li>Improve metabolic control, if necessary </li></ul><ul><li>Make sure that the family is capable of treating hypo- and hyperglycaemic episodes </li></ul><ul><li>Make sure that the family is informed about sick-day management </li></ul><ul><li>Make sure that travel health insurance is valid </li></ul>Camps, school and travel
  76. 76. Travelling <ul><li>Bring: </li></ul><ul><ul><li>introduction letter </li></ul></ul><ul><ul><li>sufficient insulin, needles, blood glucose testing material and glucagon </li></ul></ul><ul><ul><li>blood glucose meters and extra batteries </li></ul></ul><ul><ul><li>extra food and drink </li></ul></ul><ul><li>Long flights: </li></ul><ul><ul><li>stick to the ‘home-time’ and normal routines </li></ul></ul><ul><ul><li>6-hourly injections of short-acting insulin </li></ul></ul>Camps, school and travel
  77. 77. Psychosocial problems <ul><li>Psychosocial problems in childhood diabetes: </li></ul><ul><ul><li>imposes major demands on child and family </li></ul></ul><ul><ul><li>pre-existing problems may interfere with patients compliance </li></ul></ul><ul><ul><li>different psychological problems may emerge in different age-groups </li></ul></ul><ul><li>Parents: </li></ul><ul><ul><li>in shock at diagnosis </li></ul></ul><ul><li>Young children: </li></ul><ul><ul><li>needle-phobia and eating problems </li></ul></ul><ul><li>Adolescents: </li></ul><ul><ul><li>poor compliance, insulin omission, eating disorders </li></ul></ul><ul><li>The team should: </li></ul><ul><ul><li>look for these problems from diagnosis </li></ul></ul><ul><ul><li>take care that early counselling is initiated </li></ul></ul>Psychosocial problems
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