Dr. Kannan, PG, Pediatrics, MGMCRI, Pudhucherry

1. DAY CARE MANAGEMENT OF
DIABETES IN CHILDREN
Dr. C. Kannan
Department of pediatrics
MGMCRI

2. 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%

3. DIAGNOSIS
• Symptoms as mentioned above
• 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%)

4. 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

5. 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

6. 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

7. MONITORING
Interpretation of SMBG

8. 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

9. MONITORING
Education for school teachers/school workers
• All teachers who are teaching him and 1 or 2 school workers
• Clearly explained 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

10. 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 privacy area for
• Finger test
• Insulin administration
• Special attention during
• Field trips
• Extra curricular activities
• Sports events

11. MONITORING
Rationale behind monitoring
• Accuracy of glycaemic control
• Prevent both acute and chronic complications of diabetes
• Effects on cognitive function

12. 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

13. INSULIN
Rapid Acting Insulins
• Lispro
• Aspart
Short acting
• Insulin Glulisine
• Regular Insulin
Intermediate acting
• NPH- Neutral Protamine
• Hagedorn
• Pre mixed Insulins
Long Acting
• Glargine
• Detemir

15. INSULIN

16. 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

17. 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.

18. INSULIN PUMP THERAPY

19. AUTOMATED CLOSED LOOP SYSTEM

20. 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

21. 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

22. 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

23. 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

24. 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 mg

25. 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

26. SOMOGYI PHENOMENON
• Rebound hyperglycemia from an exaggerated counter
regulatory response

27. SICK DAY PATHOPHYSIOLOGY
• Infections disrupt the glucose control
• Hyperglycemia osmotic diuresis dehydration
• DKA ketosis-emesis dehydration
Anorexia
Hypoglycemia

28. 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

29. SICK DAY MANAGEMENT
If ketones (-)
• 5-10% of total daily insulin (or) 0.5-1U/kg
• Short acting every 2-4 hours based on blood glucose levels
If ketones (+)
• 10- 20% of total insulin (or) 0.1 U/kg of insulin
• Every 1 hour.

30. NUTRITIONAL GUIDELINES
Age 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

31. 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

32. NUTRITIONAL GUIDELINES
• Carbohydrate Vary (depends upon fibre content)
• Fibre >20g/day
• Protein 12-20
• Fat <30
• Saturated <10
• Polyunsaturated 6-8
• Monounsaturated Remainder of fat allowance
• Cholesterol 300 mg
• Sodium 3-4 g

33. 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

34. SCREENING FOR COMPLICATIONS