Pediatric medicine

1. SPECIAL SITUATIONS IN
CHILDREN WITH TYPE 1
DIABETES MELLITUS
Mohammad elsayed gharbia

2. INTRODUCTION
 Type 1 diabetes mellitus, one of the most
common chronic diseases in childhood, is caused
by insulin deficiency resulting from the destruction
of insulin-producing pancreatic beta cells.
 In children and adolescents with type 1 diabetes,
there are circumstances, such as :
 acute illnesses, .
 The school or daycare setting
represents challenges in the management of the
insulin- dependent child.

3. SICK-DAY MANAGEMENT
 In diabetic children with type 1 diabetes, acute
illness complicates diabetes management
because of its varying effects upon insulin
requirements.
 Increased insulin requirements :
are due to an increase in counter-regulatory
hormones released in response to stress.
These hormones, which include epinephrine
and cortisol, raise peripheral insulin resistance,
thereby increasing insulin requirements.
• Increased insulin resistance may persist for a
few days after recovery from the acute illness.

4. SICK-DAY MANAGEMENT
 Decreased insulin requirements are due to
reduced oral intake of carbohydrates because
of decreased appetite, nausea, or vomiting.
Thus, a child with type 1 diabetes during an acute
illness can develop:
 Hypoglycemia
 Significant hyperglycemia
 Diabetic ketoacidosis (DKA) due to inadequate
insulin supplementation
 Ketosis, independent of hyperglycemia

5. aim
 Sick-day management is directed towards
prevention of the above complications and
should not be left solely in the hands of the
child or adolescent.
 Parental involvement is imperative to avoid
these diabetic complications.
 Telephone management with the diabetes care
team is helpful in the care of these patients.

6. Management
 Management includes the following :
 Increased frequency of blood glucose monitoring (eg,
every two to three hours; this may be increased to
every one to two hours if necessary).
 Checking for urinary ketones with each void,
regardless of blood glucose concentration( Ketone
formation can occur without hyperglycemia, especially
if oral intake is poor).
 Home testing of blood for beta-hydroxybutyrate may
permit earlier detection of ketosis than use of urinary
strips (which measure acetone and acetoacetate).
 Blood testing for beta-hydroxybutyrate is particularly
useful for early detection of ketoacidosis in children.

7. hyperglycaemia
 Additional doses of rapid- or very-rapid-acting
insulin for elevated blood glucose or urine
ketones (if blood glucose is not low) .
 administering insulin at a dose of 0.05 to 0.1
units/kg (5 to 10 percent of the total daily
dose), given every two to four hours as
needed based upon blood glucose.
 administering insulin at a dose of 0.1 unit/kg
for moderate to large urinary ketones.

8. hypoglycaemia
 to avoid hypoglycemia : if the child is unable to ingest the required amount
of carbohydrates and blood glucose concentration is not high.
Management is dependent on the insulin regimen used by the patient.
 In children treated conventionally with a fixed schedule that includes
intermediate acting-insulin (NPH), the daily dose(s) of the intermediate-
acting insulin can be reduced by 30 to 50 percent.
 For children on intensive therapy that includes a basal dose (eg, insulin
glargine or insulin pump), the basal dose can be continued at the usual rate
or slightly decreased by 10 to 20 percent.
 In these children, insulin should not be discontinued as this may lead to
DKA, because insulin requirements, although decreased, are not
completely eliminated.
 With either regimen, increased blood glucose can be treated with rapid or
very-rapid-acting insulin .

9. Ketonuria
 Ketonuria with hypoglycemia is not uncommon if oral intake
has been deficient.
These patients should be treated with an increased intake of
carbohydrate-containing fluids and insulin as necessary.
 sugar-containing liquids and/or glucagon in very low doses
(0.1-0.2 mg subcutaneously every hour for up to two hours)
should be given to patients who are unable to eat and have
hypoglycemia.
 However, if vomiting persists or home therapy cannot correct
hypoglycemia, especially if ketosis is present, the patient
should be evaluated and treated at an appropriate medical
facility.
(These patients may require intravenous fluids and additional
insulin).

10. MEDICAL PROCEDURES
 In patients with diabetes who require medical, dental, and
surgical procedures, glycemic management can be
complicated by factors that affect insulin requirements, such
as :
 a period of medically mandated fasting (NPO),
 anesthesia,
 stress.
Withholding oral intake will decrease insulin requirements,
while stress may increase insulin needs because of increased
peripheral insulin resistance.
 If the procedure requires a period of fasting, it is preferable to
have the patient scheduled as the first case to minimize the
duration of fasting.
 Insulin management is dependent on the insulin regimen
used by the patient.

11. Intensive regimen
 In children using an intensive insulin regimen
with a basal insulin (eg, insulin glargine or
insulin pump), the normal basal rate should be
maintained.
 During and after the procedure, rapid- or very-
rapid-acting insulin can be used to cover
additional insulin needs as determined by
blood glucose concentrations .
 Intravenous dextrose should be administered if
blood glucose decreases.

12. conventional regimen
 In children using a conventional insulin regimen with an
intermediate acting-insulin (eg, NPH), :
 patients should receive 2/3 of their normal( NPH )dose and
no very-rapid or rapid-acting insulin before the procedure.
 During and after the procedure, very-rapid or rapid-acting
insulin can be used to cover additional insulin needs as
determined by blood glucose concentrations .
 During long procedures, switching from the usual
conventional regimen to infusions of intravenous insulin
administrated at a rate of 0.02 to 0.03 units/kg per hour and 5
percent dextrose with electrolytes has been used successfully
to maintain glycemic control .
 Ongoing blood glucose monitoring permits adjustment of the
insulin infusion rate to avoid hypo- or hyperglycemia.

13. TRAVEL
 In children who travel large distances and cross multiple time
zones, an intensive insulin basal/bolus regimen (eg, insulin
glargine with lispro/aspart or the insulin pump) simplifies care.
 The long-acting insulin (eg, insulin glargine) that provides the
basal insulin dose should continue to be administered at the
time that the child would have received this injection in his/her
home time zone.
 If the child is advancing time zones by more than two hours
for an extended time period, the family can adjust the time of
insulin glargine injections by an hour a day to a time that is
more appropriate for the new time zone.
 Very-rapid and rapid-acting insulin should continue to be
administered before meals and snacks.

14.  Management is more complicated in children
on conventional regimens.
 The child can receive additional doses of
very-rapid and rapid-acting insulin if the last
dose of NPH insulin does not cover the child's
insulin requirements before the next scheduled
administered NPH dose.

15.  During air travel, insulin supplies should be
transported as carry-on luggage.
 Insulin should be protected (but not frozen) in
a cooler during long trips where heat exposure
is likely.
 The newer insulins are particularly heat
sensitive.

16. SCHOOL AND DAYCARE
 Children can spend up to 8 to 10 hours a day at school or extended
daycare.
 The overall goals for children in these settings are to
1. maintain excellent glycemic control,
2.minimize interruptions of their daily learning,
3.prevent complications, and
4.prevent or eliminate any stigmatization related to their disease.
 Children must be allowed to check blood glucose levels,
 give insulin injections under the supervision of a knowledgeable
adult,
 be treated for hypoglycemia in close proximity to the school
classroom

17.  In one study of 58 children and their parents,
better glycemic control was demonstrated in
children who had greater flexibility in
performing diabetes care at school and
 who attended schools where school personnel
received diabetes training .

18.  A school staff member, preferably a school nurse
if available, needs to be identified and
appropriately trained.
 The adult supervisor is responsible for successful
implementation of daily care including :
 insulin administration,
 timing
 content of meals,
 physical education classes, and
 any additional sport activities.

19.  Teachers need to be able to identify and treat
hypoglycemia.
 Oral rapidly absorbed simple carbohydrates
should be available in the classroom setting.
 A glucagon emergency kit should be kept at
the school.

20. Thank you