childhood diabetes practical reference manual a practical reference manual treatment of children and...
TRANSCRIPT
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
A practical reference manual
Treatment of children and adolescents with
diabetes
Dr. Birthe S Olsen, Consultant PaediatricianDr. Henrik Mortensen, Chief Physician, Senior Paediatric
Endocrinologist
Department of Paediatrics, Glostrup University Hospital, Copenhagen, Denmark
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Childhood diabetes
• 90% Type 1 diabetes
• Absolute or relative insulin deficiency
• Auto-immune process
• Pancreatic beta-cell destruction
Defin
itio
n
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Aetiology
• Genetic susceptibility:• HLADR3, HLADR4: risk increased
• HLADR2 : risk reduced
• Environmental factors:• viral factors
• nutritional factors
Defin
itio
n
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Epidemiology
• Most common endocrine disease in childhood
• Highest incidence in Finland and Sardinia
• Highest incidence in males
• Highest incidence at 10–12 years and 5–7 years
• Increasing incidence in very young children (0–4 years)
• Seasonality
• More common in families where father has diabetes
Defin
itio
n
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Pre-diabetes phase
• Gradual destruction of beta-cells
• Development of auto-antibodies:• ICA
• IAA
• GADA
Defin
itio
n
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Prevention• Primary intervention:
• aim: reducing the prevalence of a given condition in susceptible individuals
Example: cow's milk exclusion in infancy
• Secondary intervention:• aim: early detection of a given disease and stopping or
slowing further progression Example: ENDIT study
• Tertiary intervention:• aim: preventing complications associated with a disease
Example: improvement in glycaemic control, screening for complications
Defin
itio
n
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Management – primary goals
• To ensure that insulin is available for all children
• To ensure that the child gradually takes over the responsibility for the disease (self-care)
• To ensure optimum glycaemic control
• To ensure freedom from diabetic complications
• To ensure normal growth and development
Th
e n
ew
ly d
iag
nose
d c
hild
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Early diagnosis
• Symptoms and signs:• polydipsia
• polyuria
• night-time incontinence
• loss of weight
• irritability
• abdominal pain
• visual disturbances
• frequent infections
Th
e n
ew
ly d
iag
nose
d c
hild
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Early diagnosis
• Diagnosis:• fasting blood-glucose concentration > 7.7 mmol/l• random blood-glucose concentration > 11 mmol/l• glucosuria• ketonuria• ketoacidosis
• Differential diagnosis:• inflamed appendix• pneumonia• urinary tract infection
Th
e n
ew
ly d
iag
nose
d c
hild
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
The multi-disciplinary team• The cornerstone in childhood
diabetes management:• a paediatric endocrinologist
• a specialised nurse
• a specialised dietician
• a chiropodist
• a specialised social worker
• a childhood psychologist
• close collaboration with other relevant departments
Th
e t
eam
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
The multi-disciplinary team
• The team should…• have common attitudes and philosophy
• meet regularly for discussion and education
• develop written material dealing with daily-life and emergency issues
• encourage research into childhood diabetes
• attend in-service training
Th
e t
eam
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetes education 1
• Initial ‘survival’ education:• the causes of diabetes
• insulin management
• injection technique
• blood glucose measurements
• acceptable blood glucose values
• advice about hypo- and hyperglycaemic episodes
• dietary advice
Dia
bete
s ed
uca
tion
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Over the next months and years a more comprehensive education programme, adjusted to the age and maturity of the child:
Diabetes education 2
• aetiology and pathology
• injection devices and methods
• blood-glucose monitoring
• diet
• insulin adjustments
• hypoglycaemia
• insulin-treatment
• hyperglycaemia
• sick-day management
• sport
• alcohol
• drug abuse
• travelling
• gynaecological issues
• complications
Dia
bete
s ed
uca
tion
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetes education 3
• The knowledge and skills of the child should be regularly assessed
• Re-education should be performed accordingly
Dia
bete
s ed
uca
tion
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment
• At diagnosis
• Remission phase
• Long-term
Init
ial tr
eatm
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Non-ketotic child
• Insulin:• subcutaneous
• multiple dose rapid-acting insulin before meals, or
• combination of rapid- and intermediate-acting insulin twice daily
• insulin requirements may exceed 1.5–2 IU/kg/24 hours
• Potassium:• < 12 years 750 mg KCl for 3–4 days
• > 12 years 1500 mg KCl for 3–4 days
Init
ial tr
eatm
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Non-ketoacidotic child• hospital stay as short as possible• in paediatric setting• frequent visits to out-patient clinic• 24-hour hot-line service• home and institution visits
• Always managed at hospital in case of:• ketoacidosis• severe dehydration• very young age• infection• psychosocial problems• language and cultural difficulties
Init
ial tr
eatm
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
The remission phase
• Duration from weeks to months
• Shorter in young children
• Blood glucose values between 4–8 mmol/l
• Decreasing insulin requirements < 0.5 IU/kg/24 hours
• One daily insulin injection is often sufficient
• Insulin injections should not be abandoned
Part
ial re
mis
sion
ph
ase
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Long-term management
• Twice daily or multiple insulin injections
• Regular blood glucose measurements
• At least 4 visits to out-patient clinic every year
• Instant HbA1c measurements at every visit
• Height and weight measurements at every visit
• Physical examination with pubertal staging every year
• Regular screening for diabetes related complications
Part
ial re
mis
sion
ph
ase
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin
• All children with Type 1 diabetes must have insulin
• Consequences of long-term insulin omission:• growth retardation
• delayed puberty
• poor metabolic control
• microvascular complications
• short life expectancy
• poor quality of life
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Onset of
action
(h or min)
30 min.
1–2 h
0.5–1 h
0.5–1 h
0.5–1 h
0.5–1 h
0.5–1 h
10–20 min.
Peak
action
(h)
1–3
4–12
2–8
5–10
5–9
1–3
1–3
1–3
Maximal
duration
(h)
6–8
18–24
18–24
18–24
18–24
18–24
18–24
3–5
Insulin types and duration of action
Insulin
preparation
• Short-acting
• Intermediate-acting
• Premixed insulin 10/90
• Premixed insulin 20/80
• Premixed insulin 30/70
• Premixed insulin 40/60
• Premixed insulin 50/50
• Rapid-acting insulin analogue
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Short-acting insulin
• Clear solution
• Indications for use:• daily management of diabetes,
alone or in combination with intermediate-acting insulin
• hyperglycaemia
• sick-day management
• intravenous therapy
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Intermediate-acting insulin
• Cloudy solution (should be thoroughly mixed before use)
• Indications for use:• daily management of diabetes,
alone or in combination with short-acting insulin
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Pre-mixed insulin
• Cloudy solution (should be thoroughly mixed before use)
• Indications for use:• daily management of diabetes,
alone or in combination with short-acting insulin
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Rapid-acting insulin (Insulin Aspart)
0 5 10 150 5 10 150 5 10 150 5 10 15
• Clinical benefits• improved metabolic control compared with
human soluble insulin
• fewer hypoglycaemic episodes
• no post-prandial hypoglycaemia
• rapid onset of action
• short duration of action
• better quality of life and improved convenience
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Rapid-acting insulin (Insulin Aspart)
• Patient targeting:• newly diagnosed children and adolescents
with diabetes
• children and adolescents currently on basal/bolus regimens
•children and adolecents with poorly controlled diabetes on twice daily therapies
Insu
lin
0 5 10 150 5 10 150 5 10 150 5 10 15
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Storage of insulin
• Stable at room temperature for weeks
• Should not be exposed to temperatures > 25ºC or under freezing point
• Unused vials and cartridges should be stored in the refrigerator
• Should never be exposed to sunlight
• Should never be frozen
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Injection sites
• Short acting insulin:• injected subcutaneously into the abdomen at a 45°
angle
• Intermediate-acting and pre-mixed insulins:• injected subcutaneously in the front of the thighs or
into the buttocks at a 45° angle
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin absorption
• Factors influencing insulin absorption:• injection site
• injection depth
• insulin type
• insulin dose
• physical exercise
• skin temperature
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin requirements
• Remission period• < 0.5 IU/kg/24 hours
• Pre-pubertal period• 0.6–1.0 IU/kg/24 hours
• Pubertal period• 1.0–2.0 IU/kg/24 hours
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin regimens• Insulin regimens should be:
• adjusted to age, maturity and motivation
• as simple as possible
• Children for multiple injection therapy should:• be selected carefully
• understand the relationship between insulin, food and physical exercise
• be motivated and have family support
• be willing to measure blood glucose several times each day
• be willing to inject insulin at school
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin regimens
• Most widely used insulin regimens:• twice-daily injections, mixture short and
intermediate, before breakfast and the evening meal
• three daily injections, mixture short and intermediate before breakfast, short-acting before the evening meal and intermediate-acting before bed
• short-acting insulin before main meals, intermediate before bed
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin distribution
• Twice daily injection regimen:• 2/3 of daily dose before breakfast,
• 1/3 before supper
• both 2/3 intermediate-acting and 1/3 short-acting insulin
• Three-times daily injection regimen:• 40–50% before breakfast (2/3 intermediate- and 1/3 short-
acting)
• 10–15% short-acting before supper
• 40% intermediate-acting before bed.
• Multiple injection regimen:• 30–40 % (intermediate) before bed
• the rest (short-acting) before main meals
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin adjustments
Twice-daily injection regimen:
• Blood glucose high: Dose of insulin to increase• Before breakfast or overnight Evening intermediate-acting• Before lunch Morning short-acting • Before dinner Morning intermediate-acting • Before bed Evening short-acting
• Blood glucose low: Dose of insulin to decrease• Before breakfast or overnight Evening intermediate- acting• Before lunch Morning short-acting • Before dinner Morning intermediate-acting • Before bed Evening short-acting
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin adjustments
Three-times daily injection regimen:
• Blood glucose high: Dose of insulin to increase• Before breakfast or overnight Evening intermediate-
acting • Before lunch Morning short-acting• Before dinner Morning intermediate-acting• Before bed Evening short-acting
• Blood glucose low: Dose of insulin to decrease• Before breakfast or overnight Evening intermediate-
acting • Before lunch Morning short-acting• Before dinner Morning intermediate-acting• Before bed Evening short-acting
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Insulin adjustments
Basal-bolus (multiple injection) regimen:
• Blood glucose high: Dose of insulin to increase• Before breakfast or overnight Evening intermediate-acting• Before lunch Morning short-acting• Before dinner Lunch time short-acting• Before bed Evening short-acting
• Blood glucose low: Dose of insulin to decrease• Before breakfast or overnight Evening intermediate-acting• Before lunch Morning short-acting• Before dinner Lunch time short-acting• Before bed Evening short-acting
Insu
lin
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diet
• Nutritional advice should take into consideration:• individual requirements• local customs• family dietary habits
• General recommendations:• eat a broad variety of food• eat plenty of bread, cereals, vegetables and fruit• eat only small amounts of sugar• in young children fat intake should not be restricted• older children and adolescents should eat a low fat
diet• choose food with small amounts of salt• encourage breast-feeding at least until six
months of age
Die
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diet: principles• Number of meals:
• 3 main meals• 3 snacks• adapted to age, physical activity and insulin
regimen
• Energy intake:• 1000 calories (4180 Kj) + 100 calories/year of
age• 50–55% of energy from carbohydrates • 30% of energy from fat• 15–20% of energy from protein
Die
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Carbohydrates
• Glycaemic index (GI):• carbohydrate ranking system
• based on post-prandial blood glucose response
• low GI = slow, sustained blood glucose response (e.g. rice, pasta)
• high GI = rapid and high blood-glucose response (e.g. white bread, candy/sweets, cornflakes, honey, sugar)
Die
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Carbohydrates
• Carbohydrate exchange system:• based on the carbohydrate content and not
the weight of the food
• makes it easy to exchange carbohydrate containing food elements (e.g. 15 g carbohydrates in candy for 15 g carbohydrates in fruit)
• one exchange usually contains 10–15 g carbohydrate
Die
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Effects of exercise
• Increases insulin sensitivity
• Improves the physical state
• Reduces the risk of cardiac diseases
• Reduces the risk of hypertension
• Does not improve metabolic control
• Increases the risk of hypoglycaemia
Exerc
ise
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Food adjustments
Type of activity
Blood glucose
(mmol/L)
Carbohydrate intake
Before exercise
Before Duringexercise
After
Mild exercise (walking, slow speed cycling)
below 7 0-15g from 2nd hour
10-15 g/h
if necessary 10 g
above 7 nothing
Moderate exercise
(tennis, jogging, golf, cycling)
below 7 25-50 g 15-25 g/h 50 g within the first hour
7-10 10-15 g 15-25 g/h
10-15 nothing from 2nd hour
15-25 g/h
carb rich meal after 2
hrs
Strenuous exercise (football,
basketball, running,
swimming, aerobics)
below 7 50 g 25-50 g/h 50 g within the 1st hour
7-10 25-50 g 25-50 g/h carb rich meal after 2
hrs10-15 10-15 g from 2nd hour
25-50 g/h
Exerc
ise
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Guidelines
• Measure blood glucose before, during and after physical exercise
• Increased risk of hypoglycaemia 12–40 hours after strenuous physical exercise
• Reduce short-acting insulin accordingly
• Blood glucose before bedtime should be > 10–12 mmol/l
Exerc
ise
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Definition and causes
• Blood glucose < 3 mmol/l• Mild (Grade 1): recognised and treated orally by the
patient• Moderate (Grade 2): treated orally, with help from
someone else• Severe (Grade 3): unconscious or having fits – nothing
by mouth
• Causes:• strenuous exercise• missed meals• injection errors
Hyp
og
lyca
em
ia
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Symptoms
• Neurogenic:• sweating
• hunger
• tremor
• pallor
• restlessness
• Neuroglycopenic:• weakness
• headache
• change in behaviour
• tiredness
• visual and speech disturbances
• vertigo
• lethargy
• confusion
• fits and unconsciousness
Hyp
og
lyca
em
ia
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment
Mild hypoglycaemia (Grade 1):
• 10–20 g glucose tablets, juice or sweet drinks
• 1–2 slices of bread
Moderate hypoglycaemia (Grade 2):
• 10–20 g glucose tablets
• 1–2 slices of bread
Severe hypoglycaemia(Grade 3):
• Outside hospital:• children < 10 years: 0.5 mg
glucagon i.m.
• children > 10 years: 1.0 mg glucagon i.m.
• In hospital:• bolus glucose (20%) 1 ml/kg
over 3 min followed by
• glucose (10%), 0.2 ml/kg/min
Hyp
og
lyca
em
ia
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Definition and aetiology• Severity degree:
• Mild ketoacidosis bicarbonate> 16 and < 22 mmol/l
• Moderate ketoacidosis bicarbonate > 10 and< 16 mmol/l
• Severe ketoacidosis bicarbonate < 10 mmol/l
• Characterised by:• absolute insulin deficiency• increased level of counter regulatory hormones
• Aetiology:• newly diagnosed• infections• insulin omission
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Symptoms and signs
• Dehydration
• Vomiting
• Loss of weight
• Kussmaul respirations
• Acetone smell
• Impaired sensorium
• Shock
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diagnosis
• Clinical appearance
• Hyperglycaemia
• Ketonuria
• Ketonaemia
• Plasma bicarbonate < 22 mmol/lD
iab
eti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment: fluid
• Due to the risk for overhydration:• fluid volume in the first 24 hours should not exceed 4 l/m2
• rehydration over 24–36 hours
• Initiate treatment with isotonic 0.9 % saline:• 1st hour: 20 ml/kg body weight (previous)
• 2nd hour: 10 ml/kg body weight
• 3rd hour onwards: 5 ml/kg body weight
• When blood glucose levels are below 12 mmol/l:• 5–10 % glucose solution
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment: insulin
• Low-dose insulin regimen:• short-acting insulin
• intravenously
• bolus or continuous infusion
• 0.1 IU/kg/hour
• Ideal blood-glucose reduction:• maximal 4–5 mmol/l
• Until acidosis is corrected:• adjust insulin and fluid to blood glucose level between
5–15 mmol/l
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment: potassium
• DKA is always accompanied by severe potassium deficiency
• Treatment:• initially add 20 mmol KCl to 500 ml fluid• adjust potassium replacements to plasma potassium level:
plasma potassium potassium chloride (mmol/l) (mmol/kg/h)
< 3 0.53–4 0.4 4–5 0.3 5–6 0.2> 6 nothing
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment• Sodium:
• measured level low due to dilution• only correction if values are below 120 mmol/l• if values are above 160 mmol/l (hypernatriaemic state)• rehydrate over 48–72 hours
• Bicarbonate:• only in very sick children with severe ketoacidosis (pH <
7.0)• recommended dose 1–2 mmol/kg• ½ of the dose over 30 minutes and ½ over 1–2 hours
• Hazards of bicarbonate treatment:• precipitation of hypokalaemia• paradoxical exacerbation of CNS acidosis• cerebral oedema
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Cerebral oedema• Aetiology:
• rapid fluid correction• hyperglycaemia• bicarbonate treatment
• Treatment:• fluid restriction• hyperventilation• mannitol infusion 1–2 g/kg over 20–30 minutes
• Prognosis:• very poor
Dia
beti
c keto
aci
dosi
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Sick-day management
• Basis for sick-day management at home:• insulin should never be omitted• frequent blood glucose measurements• frequent urine testing for ketone bodies• close contact with the diabetes team
• Situations where admittance to hospital is indicated:
• persistant vomiting• increasing ketone bodies in the urine• increasingly sick child• abdominal pain• non-compliance and psycho-social problems• language and cultural difficulties• very young age (< 2 years)
Sic
k-d
ay m
an
ag
em
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Sick-day management
• Situations with high fever, high blood-glucose and ketonuria:
• most often caused by bacterial infections• seek and treat the infection focus• give frequent subcutaneous injections of short-acting
insulin• continue treatment until ketone bodies have
disappeared• give glucose containing food or drinks to maintain
acceptable blood glucose values• encourage the child to drink plenty of fluids
Sic
k-d
ay m
an
ag
em
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Sick-day management
• Situations with low-grade fever, low blood-glucose and ketonuria
• most often caused by viral infections
• associated with anorexia, vomiting and diarrhoea
• reduce short- and intermediate- acting insulin according to blood glucose values
• give glucose containing food or drinks to maintain acceptable blood glucose values
• encourage the child to drink plenty of fluidsSic
k-d
ay m
an
ag
em
en
t
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Minor surgery (duration < 3h)
• Insulin:• in the morning intermediate-acting insulin, 1/2 to 2/3
of total daily dose• if blood glucose is above 20 mmol/l supply with a small
dose short-acting insulin• in the evening give intermediate-acting insulin, 1/3 of
daily dose
• Fluid:• glucose 5% intravenously, volume according to age
• Blood glucose monitoring:• every 1–2 hours• values between 10–14 mmol/l
Su
rgery
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Major surgery (duration > 3h)
• Insulin and fluid:• infusion solution containing 5% glucose and 20 mmol/l
sodium chloride (maintenance volume)
• 50 IU short-acting insulin in 500 ml 0.9 % saline by separate drip infusion 0.5 ml = 0.05 IU/kg/hour
• Blood glucose monitoring:• every 1–2 hours
• values between 6–14 mmol/l
• if < 5 mmol/l reduce infusion rate
• continue infusion therapy until food intake is re-established
Su
rgery
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Tests• HbA1c:
• average blood glucose over last 4–6 weeks• should be measured and available at every out-patient
clinic visit
• Home blood glucose (HBG) measurement:• ideally before breakfast, lunch, evening meal and bedtime• before, during and after physical exercise• during intercurrent illnesses• if hypo- or hyperglycaemia is suspected• following hypoglycaemia• after changing insulin dose• frequency of HBG should be adjusted to age, insulin
regimen and acceptance of the child
• Urine testing:• ketone testing in case of fever and high blood glucose
Gly
caem
ic c
on
trol
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Goals
• Well-adjusted children/adolescents with normal growth and development
• HbA1c between 7–9%
• Less than 10–20 severe hypoglycaemia episodes and ketoacidosis per 100 patient years
• Post-prandial blood glucose values below 10–12 mmol/l
• Pre-prandial blood glucose values between 4–8 mmol/l
• Glycaemic goals less strict for very young children
• Goals realistic and individualised in puberty
Gly
caem
ic c
on
trol
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Microvascular complications
• Microvascular complications in kidneys, eyes and nerves:• closely related to poor long-term metabolic
control
• occur from puberty
• preceded by subclinical changes
• can be delayed or prevented by good metabolic control
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic nephropathy
• Leading cause of increased morbidity and mortality in Type 1 diabetes
• Preceded by microalbuminuria (albumin excretion rate > 20 µg/min)
• Prevalence in adolescence 5–20%
• Correlated with long-term metabolic control
• Long diabetes duration
• Elevated arterial blood pressure
• Genetic susceptibility
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic nephropathy
Annual screening:• after 5 years’ diabetes duration in pre-pubertal children
• after 2 years’ diabetes duration in adolescents
• Screening method:• albumin excretion rate calculated from night-time urine
collections
• Microalbuminuria treatment:• improved long-term metabolic control
• normalising arterial blood pressure
• smoking discouraged
• ACE-inhibition
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic retinopathy
• Leading cause of visual loss and blindness in working-age population
• Prevalence in adolescence: 10–80%
• Correlated with long-term metabolic control
• Long diabetes duration
• Elevated arterial blood-pressure
• Genetic susceptibility• Background
retinopathy:• not vision threatening
• stable for many years
• Proliferative retinopathy:
• vision-threatening
• new vessels
• retinal retraction
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic retinopathy
• Annual screening:• after 5 years’ diabetes duration in pre-pubertal
children• after 2 years’ diabetes duration in adolescents
• Screening method:• ophthalmoscopy• fundus photography• fluorescein angiography
• Retinopathy treatment:• improved long-term metabolic control• normalising arterial blood pressure• laser therapy in case of proliferative retinopathy
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic neuropathy
• Peripheral and autonomic
• Rare in childhood and adolescence
• Preceded by subclinical abnormalities
• Correlated with • poor long-term metabolic control• long diabetes duration• older age• higher Tanner stage• male sex
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Diabetic neuropathy
• Annual screening:• from puberty
• Screening method:• ankle reflexes
• sensation (temperature discrimination)
• non-invasive test of nerve function (biothesiometry)
• Neuropathy treatment:• improved long-term metabolic control
Com
plic
ati
on
s
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Adolescence
• Insulin insensitivity
• Poor metabolic control
• Insulin omission
• Overweight
• Eating disorders
• Psychosocial problems
• Microvascular complications
Ad
ole
scen
ce
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Treatment strategies
• Non-threatening open-minded atmosphere
• Patience
• Respect
• Flexible appointment times
• Opportunity to meet other adolescents with diabetes
• Planned transition to adult setting
• Parental involvement
Ad
ole
scen
ce
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Risk-taking behaviour• Alcohol:
• impairs gluconeogenesis• associated with severe hypoglycaemia
• Advice:• drink in moderation• eat complex carbohydrates while drinking alcohol• if HBG is not measured always eat extra food before
bedtime• make sure that your friends are aware of your
diabetes• always wear your diabetes amulet when going to
parties• measure HBG before going to bed• measure blood glucose (HBG) regularly
Ad
ole
scen
ce
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Risk-taking behaviour
• Smoking:• harmful to the health of all people
• associated with increased risk of microvascular complications
• is expensive
• is addictive
• Drug abuse:• should be considered in connection with
other risk-taking behaviour
Ad
ole
scen
ce
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Gynaecological issues
• Menstruation:• may be irregular due to poor metabolic control• may be accompanied by high blood glucose levels
• Oral contraceptives with low-dose oestrogen:
• safe for most adolescents with diabetes• may be accompanied by insulin resistance• not to be used in cases of arterial hypertension
• Condoms:• safe contraceptive method• protect against sexually transmitted diseases
Ad
ole
scen
ce
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
School
• All children should be attending school
• Academic expectations should be the same
• Teachers and school nurse should be informed about general rules and emergency situations
• Written material about diabetes should be handed out to school staff
• A close communication should exist between home and schoolC
am
ps,
sch
ool an
d t
ravel
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Travelling
• Appointment in the out-patient clinic 4–6 weeks before travel
• Improve metabolic control, if necessary
• Make sure that the family is capable of treating hypo- and hyperglycaemic episodes
• Make sure that the family is informed about sick-day management
• Make sure that travel health insurance is validCam
ps,
sch
ool an
d t
ravel
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Travelling
• Bring:• introduction letter
• sufficient insulin, needles, blood glucose testing material and glucagon
• blood glucose meters and extra batteries
• extra food and drink
• Long flights: • stick to the ‘home-time’ and normal routines
• 6-hourly injections of short-acting insulin
Cam
ps,
sch
ool an
d t
ravel
Ch
ildh
ood
dia
bete
s P
ractic
al R
efe
ren
ce
Man
ual
Psychosocial problems• Psychosocial problems in childhood diabetes:
• imposes major demands on child and family• pre-existing problems may interfere with patients compliance• different psychological problems may emerge in different
age-groups
• Parents:• in shock at diagnosis
• Young children: • needle-phobia and eating problems
• Adolescents:• poor compliance, insulin omission, eating disorders
• The team should:• look for these problems from diagnosis• take care that early counselling is initiated
Psy
choso
cial p
rob
lem
s