evidence based nursing management of diabetes mellitus in children

Management of pediatrics diabetes

05/01/23 BY:Aklilu Endalamaw 1

By: Aklilu Endalamaw (Department of pediatrics and child health nursing)

Objective

To manage pediatrics diabetes mellitus To prevent and manage its complication


Out line• Case history• DDX• Epidemiology• Types• Pathophysiology• Diagnosis modality• Evidence based nursing intervention• Complication• Summary• References



8 year old Belachew is brought to UoGRH by his mum with a 2 week history of increased thirst, increased urination & being very tired. Over the last 2 days he has been very thirsty, breathing fast & vomiting.Case histo

ry

List DDX

Weight 26kg , Alert co-operative afebrile,Blood gas-pH =7.16, pHCO3- = 12meq/LRBG= 210mg/dlUrine ketones 4+,

What is the diagnosis?

• Newly diagnosed type 1 diabetes mellitus with diabetic ketoacidosis.


What are the Differential Diagnosis?Disease/Disorder Description (Typical)

Diabetes Insipidus Polydipsia and may also cause excessive voiding of dilute urine and mild to moderate nocturia. Fatigue and signs of dehydration occur in severe cases

Diabetes Mellitus Polydipsia is a classic finding with this disorder with a consequence of the hyperosmolar state. include polyuria, polyphagia, nocturia, weakness, fatigue, and weight loss. Signs of dehydration may occur.

pheochromocytoma, neuroblastoma, and Prader-Willi syndrome.

Rare cases =>polydipsia

medullary cystic disease, polycystic renal disease, and distal renal tubular acidosis

Rare cases=>Polyuria


Professional Guide to Signs and Symptoms, 5th Edition

Diabetes Mellitus• The term diabetes was probably coined by Apollonius of

Memphis around 250 BC. It was in 1675 that Thomas Willis added the word “'mellitus'” to the word diabetes (Mandal A,2012).

• Greek word diabetes meaning siphon - to pass through and the Latin word mellitus meaning honeyed or sweet.

• It was known in the 17th century as the “pissing evil” (Mandal A,2012).

• Metabolic disease characterized by hyperglycemia. (Nelson,20th edition).


Statistics of Dm


Cont…In Africa & Ethiopia• Africa is the region with the lower prevalence

of diabetes (4.9%) (WHO,2013).• The prevalence of DM in Ethiopia stands at

3.32 % (IDF 2012 report). • DM prevalence of as high as 8% has been

reported in 2013 on HIV/AIDS patients taking HAART, in Ethiopia.(Sachithanan than V et al, 2013)


Types of Diabetes in Children


sugar

or lack of useful insulin

insulin produced tissues resistant to insulinby pancreas & pancreas unable to

produce enough insulin

type 1(90%) type 2(Nelson,20th edition).

• Specific types of diabetes due to other causes,

e.g., monogenic diabetes syndromes, diseases

of the exocrine pancreas, and drug- or

chemical-induced diabetes.


(ADA,2016)

The onset DM type I occurs predominantly in childhood, with median age of 7 to 15 yrs, but it may present at any age.


(Nelson,20th edition).

Unlike type 1, type 2 diabetes is


(Nelson,20th edition

Pathophysiology of DM


Insulin

Decrease in glucose uptake from blood

MUSCLE LIVER

Gluconeogenesis

Intra-cell glucose Rise in blood for metabolism glucose

Counter regulatory hormones Osmotic diuresisLipolysis Ketones Vomiting

Dehydration

What are the abnormal results & what do they signify?

• 3-Polyuria• Weight loss• Lethargy• weaknessThese symptoms may be present for days to

weeks.• Vaginitis in teenage may occur.• Skin infections less common.


Diagnosis of DM


• Symptoms of diabetes mellitus plus random or casual plasma glucose ≥200 mg/dL or

• Fasting (at least 8 hr) plasma glucose ≥126 mg/dL or

2 hr plasma glucose during the OGTT ≥200 mg/dL.

Results should be confirmed by repeat testing

if in absence of unequivocal hyperglycemia.

(Nelson, 20th edition)

Complications of DM (acute)

• Diabetic ketoacidosis• Nonketotic hyperosmolar coma• Hypoglycemia, • Somogyi phenomenon• Dawn phenomenon• Brittle Diabetes


Complications of DM (long-term)• Diabetic retinopathy• Diabetic nephropathy• Angiophathy of lower

extremities• Diabetic neuropathy

(peripheral, central, autonomic)• Hairopathy• Skin pathology (, lipodystrophy,

paronychia, lipoid necrobiosis05/01/23 BY:Aklilu Endalamaw 18

Diabetic ketoacidosis

Biochemical criteria for the diagnosis of DKA ( up to date 2.21):•Hyperglycemia: a blood glucose of >200 mg/dL AND•Metabolic acidosis: venous pH <7.3 and/or a plasma bicarbonate <15 meq/L.•Accompanied by disturbances in fluid and electrolyte balance.


Cont…Findings in DKA:•Air hunger•Kussmaul’s respiration•Acetone on the breath•Mentation change•Vomiting & dehydration•Elevated blood urea nitrogen and hematocrit but not elevated urine specific gravity=> used as a measure of hypovolemia in patients with DKA.


Evidence based nursing interventionModerate and severe DKA1.Fluid and electrolyte deficits and repletion:•Start with isotonic fluids: reduce the risk for cerebral edema.Initial volume expansion: RL Or NS•Start with 10 mL/kg over one hour. Still volume compromise 10 ml/kg for next an hour. Generally do not give more than 20 mL/kg in total boluses unless the patient's cardiovascular status is compromised.05/01/23 BY:Aklilu Endalamaw 21

Cont…Subsequent fluid administration•It should initially consist of isotonic saline (normal saline or lactated Ringers) for approximately four to six hours.•The rate over the first 24 hours should not exceed 1.5 to 2 times the usual rate of administration of maintenance fluid.•For most patients, 40 mEq/L of potassium salts should be added.


Cont…• After the first four to six hours of treatment,

reduce the sodium concentration to not less

than one-half isotonic.

• The total fluid intake should be no greater

than 3500 mL/m2 for 24 hours.


Cont…2. Insulin — After the initial fluid bolus is complete, an insulin infusion is begun at a rate of 0.1 unit/kg per hour. •A lower dose of 0.05 unit/kg per hour may used initially in younger children.•It can be mixed in one-half isotonic saline and administered in a syringe infusion.•Do not give an initial bolus of insulin.


Cont…• When the serum glucose concentration

decreases to 250 to 300 mg/dL , the intravenous fluid infusion should be changed to 5 percent dextrose in isotonic saline or lactated Ringer's solution.

• If the serum glucose falls below 250 mg/dL before complete resolution of the ketoacidosis, the concentration of dextrose in the intravenous solution should be increased to up to 10 to 12.5 percent.


Cont…

• For patient safety reasons, it is advisable to

keep serum glucose concentrations around

150 to 200 mg/dL for younger children; or

100 to 150 mg/dL in older children, before

switching to subcutaneous insulin.


Cont…• Rapid-acting (eg, lispro, aspart, glulisine) and

short-acting types (eg, regular insulin ) are

typically administered as a pre-meal bolus

(typically 5 to 15 minutes before the meal for

the rapid-acting insulins, and 20 to 30 minutes

before meals for the short-acting type).


Cont…• Intermediate-acting NPH insulin is usually given

two or three times a day, but may be given in a

targeted manner in combination with long-

acting insulin.

• Long-acting insulin preparations (eg,

insulin glargine and insulin detemir ) are given

once or twice a day


Cont…

NB. Insulin glargine cannot be mixed with any

other form of insulin and must be administered

separately.

Correction dose of insulin on average

0.75IU/kg for 100mg/DL increase of blood

glucose level from normal value.


Value of an intensive regimen

1. Conventional regimen: Two-thirds of the total

daily dose is administered before

breakfast (2/3 as NPH and 1/3 as rapid- or short-

acting insulin) and one-third before dinner and

at bedtime (1/3 to 1/2 as rapid- or short-acting

insulin before dinner and 2/3 to 1/2 as NPH at

bedtime). 05/01/23 BY:Aklilu Endalamaw 30

Cont…2.Intensive regimens:

•Delivered either by multiple daily injections, or

by continuous insulin infusion (pump).

•Multiple daily injections : a long-acting insulin

analog (insulin glargine or detemir) with pre-

meal/snack boluses of rapid- or short-acting

insulin[ Hathout EH et.al,2003]05/01/23 BY:Aklilu Endalamaw 31

Cont…

• Insulin Dose: The newly diagnosed child

requires an initial total daily insulin dose of 0.5

to 1.0 units/kg. (upto date, 2.21).


Cont…• Blood glucose monitoring: Frequent

monitoring has been shown to improve glycemic control in children(Ziegler R , et.al,2011).

• Finger sticks — it is recommended testing of blood glucose at least four times a day (ADA, 2011).

• Age-based care is recommended (Silverstein J et.al,2005).


Cont…• Providing age-appropriate psychosocial

support for the patient and the

family=>improved glycemic control and

reduced hospitalization rates (Ellis DA

et.al,2005 RCT).

• Immunization: All vaccine on a standard

schedule should be provided.


Cont…• Parental and caregiver involvement:

important for diabetes management in children & adolescents [ Shorer M, et.al, 2011]

• Information for parent and patients regarding disease process, medication, exercise and nutrition.

• Follow-up visits at least every three months• Screening : at least twice a year.


Summary

• Diabetic ketosis is a form of hypertonic dehydration.

• Start IV fluids before insulin for a child with DKA.


Reference• Nelson 20th edition• Upto date 2.21• Mandal A. History of Diabetes,2012.• American Diabetes Association Diabetes Care. Classification and Diagnosis of

Diabetes, 2016.• Svoren BM, Butler D, Levine BS, et al. Reducing acute adverse outcomes in youths

with type 1 diabetes: a randomized, controlled trial. Pediatrics 2003; 112:914.• Ellis DA, Frey MA, Naar-King S, et al. Use of multisystemic therapy to improve regi

men adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial. Diabetes Care 2005; 28:1604.

• Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care 2005; 28:186

• American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care 2011; 34 Suppl 1:S11


Cont…• Ziegler R, Heidtmann B, Hilgard D, et al. Frequency of SMBG correlates with HbA1c and acute

complications in children and adolescents with type 1 diabetes. Pediatr Diabetes 2011; 12:11.• Hathout EH, Fujishige L, Geach J, et al. Effect of therapy with insulin glargine (lantus) on glycemic control in

toddlers, children, and adolescents with diabetes. Diabetes Technol Ther 2003; 5:801.• Phillip M, Battelino T, Rodriguez H, et al. Use of insulin pump therapy in the pediatric age-group:

consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2007; 30:1653.

• Shorer M, David R, Schoenberg-Taz M, et al. Role of parenting style in achieving metabolic control in adolescents with type 1 diabetes. Diabetes Care 2011; 34:1735.

• Professional Guide to Signs and Symptoms, 5th Edition• Sachithanan than V, Loha E, Gose M. Prevalence of diabetes mellitus, hypertension and lipodystrophy in

HAART receiving HIV patients in Southern Ethiopia. Internat STD Rese &Revi2013;1(1):1-11. • IDF Diabetes Atlas. 5th ed. 2012 updates.



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evidence based nursing management of diabetes mellitus in children

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