Diabetes Management in Early Childhood


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Presentation by Deborah Holtorf, NP, Pediatric Diabetes Nurse Practitioner, Joslin Diabetes Center at JDRF New England chapter's 2nd Annual “Living Well with T1D” Symposium on March 9, 2013.

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Diabetes Management in Early Childhood

  1. 1. Diabetes Management In EarlyChildhoodChasing a Moving TargetDeborah Holtorf, MPH, MSN, NPMarch 9, 20131
  2. 2. Type 1 Diabetes in Young ChildrenEpidemiological Trends Type 1 diabetes has increased in incidence andprevalence during the late 20th and early 21st centuries. During this time period there has been a shift towards ayounger age of onset.2
  3. 3. Type 1 Diabetes in Young ChildrenEpidemiological TrendsSEARCH for Diabetes in Youth StudyJAMA 2007;297:2716-27243
  4. 4. Type 1 Diabetes in Young ChildrenEpidemiological Trends4
  5. 5. EURODIAB ACE study groupLancet 2000;355:873-8765Age (yrs)IncreasedIncidence %0-4 6.35-9 3.110-14 2.4
  6. 6. Type 1 DiabetesGoals of Therapy (ADA)Plasma blood glucose range (mg/dl)Values by age before meals bedtime A1cToddler/preschooler 100-180 110-200 <8.5 but >7.5%(<6 yrs)School age (6-12 yrs) 90-180 100-180 <8%Adolescents 90-130 90-150 <7.5%*Key concepts in setting glycemic goals: Goals should be individualized and lower goals may bereasonable based on benefit-risk assessment. Goals should be higher than those listed above in children withfrequent hypoglycemia or hypoglycemic unawareness. Postprandial blood glucose should be measured when there is adisparity between pre-prandial values and A1c levels.*A lower goal (<7%) is reasonable if it can be achieved withoutexcessive hypoglycemia.
  7. 7. Type 1 DiabetesGuidelines of Therapy (ISPAD) ISPAD (International Society for Pediatric and AdolescentDiabetes) recommends A1C less than 7.5%, withhigher goals based on risk factors rather than age ofchild.7
  8. 8. Challenges of Caring for Young ChildrenWith Diabetes Unpredictable eating patterns Unpredictable activity patterns Hypoglycemic unawareness Periods of rapid growth Susceptibility to communicable illness Evolving understanding of what diabetes is and how itimpacts identity Need for age-appropriate developmental experiences8
  9. 9. Unpredictable Eating PatternsInsulin9
  10. 10. Insulin Therapy – Human Insulin/AnalogsInsulin Preparation Onset Peak DurationVery rapid-acting insulin analogsInsulin lispro (Humalog) 5-15 min 30-90 min 3-5 hInsulin aspart (Novolog) 5-15 min 30-90 min 3-5 hInsulin glulisine (Apidra) 5-15 min 30-90 min` 3-5 hRapid-acting insulinRegular 30-60 min 2-3 h 5-8 hIntermediate-acting insulinNPH 2-4 h 4-10 h 10-16 hLong-acting insulinInsulin glargine (Lantus) 2-4 h “peakless” 23-25 hInsulin detimir (Levemir) 2-4 h “peakless” 16-20 h
  11. 11. Unpredictable Eating PatternInsulin Plans11 Basal/bolus by multiple injections Insulin pump therapy Insulin plans that include NPH
  12. 12. Unpredictable Eating PatternInsulin Plans – Insulin Pumps An insulin pump has the potential to provide: Insulin delivery that more closely resembles physiologicinsulin production. Flexibility in timing and amount of food eaten, exercise, andsleep patterns. Short term dosing modifications to address unexpectedactivity, illness, and travel. Fewer “shots”.
  13. 13. Unpredictable Eating PatternInsulin PlansInsulin Pumps A pump is not “smart”. It requires accurate and regularinformation from the user, including blood glucosedata, grams of carbohydrate to be eaten, need formodified bolus patterns, and temporary basal rateadjustments. A pump uses only rapid-acting insulin to meet all insulinneeds. If insulin is not being delivered due to a pump orinfusion set failure, ketones will be produced. If thissituation is not addressed appropriately, the rise inketones will lead to ketoacidosis.13
  14. 14. Unpredictable Activity Patterns14
  15. 15. Unpredictable Activity PatternsHypoglycemia Hypoglycemia is the main risk factor when childrenare active Insulin cannot be turned off or limited once it isdelivered Young children are unaware of symptoms ofhypoglycemia, and older children miss symptomswhen focused on activity Young children are less likely to experience a bloodglucose raising adrenaline response duringvigorous activity
  16. 16. Unpredictable Activity PatternsHypoglycemia Too little carbohydrate to sustain prolonged activity Too much insulin available or “on board” Unplanned activity Swimming and sledding
  17. 17. Unpredictable Activity PatternsHyperglycemia Too little insulin before during, and/or after exercise Too much carbohydrate consumed before or duringexercise Unplanned naps Rainy days
  18. 18. Unpredictable Activity PatternsTools18
  19. 19. Unpredictable Insulin PatternsInsulin Management Program a temporary basal rate 10-30% less than usualrate, 30-90 minutes before, during, and /or 30-90 minutesafter activity Correct elevated blood glucose to a higher target (180-200mg/dL) prior to exercise Modify insulin-to-carbohydrate ratio for meal or snackbefore exercise Disconnect insulin pump for a maximum of 1-2hours, giving 50% of anticipated missed insulin as bolusbefore disconnection Consider untethered approach to pump management ifactivity requires pump to be disconnected for more than 1-2 hours during a 24-hour period19
  20. 20. Unpredictable Exercise PatternsCarbohydrate Adjustment Estimate 5-15 grams of extra carbohydrate forevery 30 minutes of vigorous activity depending onbody weight and intensity of activity Add fat and protein to help carbohydrate last longerduring activity Decrease carbohydrate and fat content of meals andsnacks on low activity days if child is not underweight
  21. 21. Hypoglycemic Unawareness
  22. 22. Hypoglycemic Unawareness Increase blood glucose monitoring during and afteractivity Increase blood glucose monitoring during episodes ofillness Consider use of continuous glucose monitoring device inconsultation with diabetes care providers
  23. 23. Periods of Rapid Growth
  24. 24. Periods of Rapid Growth Adequate insulin is needed to utilize carbohydrate forgrowth. Children with diabetes who do not get enoughinsulin will grow and gain more slowly than would bepredicted by their genetics. Children who have frequent episodes of low blood sugarand/or whose caretakers are unusually frightened byhypoglycemia may gain excess weight Hormones that accompany rapid growth cause increasedinsulin resistance Growth hormone is usually active during periods of deepsleep causing a young child to have different dailypatterns of insulin need than an older child has
  25. 25. Susceptibility to Communicable Illness25
  26. 26. Susceptibility to Communicable Illness Children’s day to day activities bring them into contactwith a variety of viral and bacterial illnesses Even mild viruses such as colds can increase insulinrequirements Gastrointestinal illnesses with vomiting and diarrhea canresult in poor absorption of carbohydrate anddehydration causing blood glucose to fall and ketones torise. Management of “sick days” requires frequent bloodglucose and ketone monitoring, assessment of fluid andcarbohydrate intake, and regular contact the child’sdiabetes team as needed.26
  27. 27. Susceptibility to Communicable Illness Be sure you have a copy of and understand yourdiabetes team’s sick day protocol. Check your supply and the expiration date of ketonestrips regularly. Use blood ketone strips for assessing ketones on sickdays if possible. Discuss when use of “mini-glucagon” injections might beuse with your diabetes team.27
  28. 28. Evolving understanding of what diabetes isand how it impacts identity28
  29. 29. Evolving understanding of what diabetes isand how it impacts identity Infant/toddler: 0-36 months Developing understanding of words and routines Reflects caretakers’ emotions and expressions Begins to recognized difference between self and others,but does not make any meaning of distinction. Usually incorporates diabetes management tasks into dailyroutine after initial objections.29
  30. 30. Evolving understanding of what diabetes isand how it impacts identity Preschool: (3-5 years) Magical thinking Explores ways of gaining attention including physicalcomplaint Begins to experience feelings of guilt – diabetes aspunishment or somehow caused by thoughts30
  31. 31. Evolving understanding of what diabetes isand how it impacts identity School age: (6-8 years) Continued magical thinking Beginning awareness of own appearance and abilities vs.peers Understanding of contagion may generalize to non-contagious conditions View of self based on approval/disapproval of importantothers May begin to avoid peer who is perceived as different31
  32. 32.  School age (8-10 years) Diminished magical thinking Identity defined in comparison to others Increased awareness of peers’ academic and athleticabilities Adheres to rigid group norms – abled child may abandonfriend perceived as disabled Increased responsibility for health habits May use health issue to avoid new challenges.32Evolving understanding of what diabetes isand how it impacts identity
  33. 33. Need for Age-Appropriate DevelopmentalExperiences33
  34. 34. Need for Age Appropriate DevelopmentalExperiences Play groups Preschool Kindergarten and elementary school Physical activity Diabetes camps34