diabetes management in early childhood
DESCRIPTION
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.TRANSCRIPT
1
Diabetes Management In Early Childhood
Chasing a Moving Target
Deborah Holtorf, MPH, MSN, NP
March 9, 2013
2
Type 1 Diabetes in Young ChildrenEpidemiological Trends
Type 1 diabetes has increased in incidence and prevalence during the late 20th and early 21st centuries.
During this time period there has been a shift towards a younger age of onset.
3
Type 1 Diabetes in Young ChildrenEpidemiological Trends
SEARCH for Diabetes in Youth StudyJAMA 2007;297:2716-2724
4
Type 1 Diabetes in Young ChildrenEpidemiological Trends
5
EURODIAB ACE study groupLancet 2000;355:873-876
Age (yrs)Increased
Incidence %
0-4 6.3
5-9 3.1
10-14 2.4
Type 1 DiabetesGoals of Therapy (ADA)
Plasma blood glucose range (mg/dl)
Values by age before meals bedtime A1c
Toddler/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 be reasonable based on
benefit-risk assessment. Goals should be higher than those listed above in children with frequent
hypoglycemia or hypoglycemic unawareness. Postprandial blood glucose should be measured when there is a disparity
between pre-prandial values and A1c levels.
*A lower goal (<7%) is reasonable if it can be achieved without excessive hypoglycemia.
7
Type 1 DiabetesGuidelines of Therapy (ISPAD)
ISPAD (International Society for Pediatric and Adolescent Diabetes) recommends A1C less than 7.5%, with higher goals based on risk factors rather than age of child.
8
Challenges of Caring for Young Children With 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 it impacts identity
Need for age-appropriate developmental experiences
9
Unpredictable Eating PatternsInsulin
Insulin Therapy – Human Insulin/Analogs
Insulin Preparation Onset Peak Duration
Very rapid-acting insulin analogs
Insulin lispro (Humalog) 5-15 min 30-90 min 3-5 h
Insulin aspart (Novolog) 5-15 min 30-90 min 3-5 h
Insulin glulisine (Apidra) 5-15 min 30-90 min` 3-5 h
Rapid-acting insulin
Regular 30-60 min 2-3 h 5-8 h
Intermediate-acting insulin
NPH 2-4 h 4-10 h 10-16 h
Long-acting insulin
Insulin glargine (Lantus) 2-4 h “peakless” 23-25 h
Insulin detimir (Levemir) 2-4 h “peakless” 16-20 h
11
Unpredictable Eating PatternInsulin Plans
Basal/bolus by multiple injections
Insulin pump therapy
Insulin plans that include NPH
Unpredictable Eating PatternInsulin Plans – Insulin Pumps
An insulin pump has the potential to provide:
Insulin delivery that more closely resembles physiologic insulin production.
Flexibility in timing and amount of food eaten, exercise, and sleep patterns.
Short term dosing modifications to address unexpected activity, illness, and travel.
Fewer “shots”.
13
Unpredictable Eating PatternInsulin Plans
Insulin Pumps
A pump is not “smart”. It requires accurate and regular information from the user, including blood glucose data, grams of carbohydrate to be eaten, need for modified bolus patterns, and temporary basal rate adjustments.
A pump uses only rapid-acting insulin to meet all insulin needs. If insulin is not being delivered due to a pump or infusion set failure, ketones will be produced. If this situation is not addressed appropriately, the rise in ketones will lead to ketoacidosis.
14
Unpredictable Activity Patterns
Unpredictable Activity PatternsHypoglycemia
Hypoglycemia is the main risk factor when children are active
Insulin cannot be turned off or limited once it is delivered
Young children are unaware of symptoms of hypoglycemia, and older children miss symptoms when focused on activity
Young children are less likely to experience a blood glucose raising adrenaline response during vigorous activity
Unpredictable Activity PatternsHypoglycemia
Too little carbohydrate to sustain prolonged activity
Too much insulin available or “on board”
Unplanned activity
Swimming and sledding
Unpredictable Activity PatternsHyperglycemia
Too little insulin before during, and/or after exercise
Too much carbohydrate consumed before or during exercise
Unplanned naps
Rainy days
18
Unpredictable Activity PatternsTools
19
Unpredictable Insulin PatternsInsulin Management
Program a temporary basal rate 10-30% less than usual rate, 30-90 minutes before, during, and /or 30-90 minutes after activity
Correct elevated blood glucose to a higher target (180-200 mg/dL) prior to exercise
Modify insulin-to-carbohydrate ratio for meal or snack before exercise
Disconnect insulin pump for a maximum of 1-2 hours, giving 50% of anticipated missed insulin as bolus before disconnection
Consider untethered approach to pump management if activity requires pump to be disconnected for more than 1-2 hours during a 24-hour period
Unpredictable Exercise PatternsCarbohydrate Adjustment
Estimate 5-15 grams of extra carbohydrate for every 30 minutes of vigorous activity depending on body weight and intensity of activity
Add fat and protein to help carbohydrate last longer during activity
Decrease carbohydrate and fat content of meals and snacks on low activity days if child is not underweight
Hypoglycemic Unawareness
Hypoglycemic Unawareness
Increase blood glucose monitoring during and after activity
Increase blood glucose monitoring during episodes of illness
Consider use of continuous glucose monitoring device in consultation with diabetes care providers
Periods of Rapid Growth
Periods of Rapid Growth
Adequate insulin is needed to utilize carbohydrate for growth. Children with diabetes who do not get enough insulin will grow and gain more slowly than would be predicted by their genetics.
Children who have frequent episodes of low blood sugar and/or whose caretakers are unusually frightened by hypoglycemia may gain excess weight
Hormones that accompany rapid growth cause increased insulin resistance
Growth hormone is usually active during periods of deep sleep causing a young child to have different daily patterns of insulin need than an older child has
25
Susceptibility to Communicable Illness
26
Susceptibility to Communicable Illness
Children’s day to day activities bring them into contact with a variety of viral and bacterial illnesses
Even mild viruses such as colds can increase insulin requirements
Gastrointestinal illnesses with vomiting and diarrhea can result in poor absorption of carbohydrate and dehydration causing blood glucose to fall and ketones to rise.
Management of “sick days” requires frequent blood glucose and ketone monitoring, assessment of fluid and carbohydrate intake, and regular contact the child’s diabetes team as needed.
27
Susceptibility to Communicable Illness
Be sure you have a copy of and understand your diabetes team’s sick day protocol.
Check your supply and the expiration date of ketone strips regularly.
Use blood ketone strips for assessing ketones on sick days if possible.
Discuss when use of “mini-glucagon” injections might be use with your diabetes team.
28
Evolving understanding of what diabetes is and how it impacts identity
29
Evolving understanding of what diabetes is and 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 daily routine after initial objections.
30
Evolving understanding of what diabetes is and how it impacts identity
Preschool: (3-5 years) Magical thinking
Explores ways of gaining attention including physical complaint
Begins to experience feelings of guilt – diabetes as punishment or somehow caused by thoughts
31
Evolving understanding of what diabetes is and 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 important others
May begin to avoid peer who is perceived as different
32
School age (8-10 years) Diminished magical thinking
Identity defined in comparison to others
Increased awareness of peers’ academic and athletic abilities
Adheres to rigid group norms – abled child may abandon friend perceived as disabled
Increased responsibility for health habits
May use health issue to avoid new challenges.
Evolving understanding of what diabetes is and how it impacts identity
33
Need for Age-Appropriate Developmental Experiences
34
Need for Age Appropriate Developmental Experiences
Play groups
Preschool
Kindergarten and elementary school
Physical activity
Diabetes camps