Diabetes in ChildrenBlaire Adams, APRN, FNP-BCJCPS Health Services, Area 6

(502)485-3387

What is Diabetes?

Diabetes Mellitus Type 1 › (Juvenile)

Diabetes Mellitus Type 2› Used to be later onset, but now developing

younger related to rise of obesity

JDRF Video

Diabetes Mellitus Type 1

DM Type 1 Type 1 diabetes is usually diagnosed in

children and young adults, and was previously known as juvenile diabetes. Only 5% of people with diabetes have this form of the disease.

In Type 1 diabetes, the body does not produce insulin.› a hormone that is needed to convert sugar and

other food into energy needed for daily life. www.diabetes.org/living-with-diabetes.

Diabetes Mellitus Type 2

DM Type 2 Type 2 diabetes is the most common form

of diabetes. If you have Type 2 diabetes your body

does not use insulin properly. This is called insulin resistance. At first, your pancreas makes extra insulin to make up for it. But, over time, it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels.

Diabetes Symptoms Common symptoms of diabetes:

› Urinating often› Feeling very thirsty› Feeling very hungry - even though you are eating› Extreme fatigue› Blurry vision› Cuts/bruises that are slow to heal› Weight loss - even though you are eating more

(Type 1)› Tingling, pain, or numbness in the hands/feet (Type

2) - See more at:

http://www.diabetes.org/diabetes-basics/symptoms/#sthash.LgxPa60k.dpuf

Early Detection EARLY DETECTION and treatment of

diabetes can decrease the risk of developing the harmful complications of diabetes: › damage to the eyes, heart, blood vessels,

nervous system, teeth and gums, feet and skin, or kidneys

Studies show that keeping blood glucose, blood pressure and LDL cholesterol levels close to normal ranges can help prevent or delay these problems.

Diagnosis of Diabetes There are several ways to diagnose

diabetes.› Each way usually needs to be repeated on a

second visit to diagnose diabetes A1C

› Hemoglobin A1C FPG

› Fasting Plasma Glucose OGTT

› Oral Glucose Tolerance testing Random Plasma Glucose test

A1C The A1C test measures your average

blood glucose for the past 2 to 3 months. The advantages of being diagnosed this way are that you don't have to be fasting or drink anything.

Diabetes is diagnosed at an A1C of greater than or equal to 6.5%

RESULT A1C

Normal Less than 5.7%

Prediabetes 5.7%-6.4%

Diabetes 6.5% or greater

http://www.diabetes.org/diabetes-basics

Fasting Plasma Glucose FPG This test checks your fasting blood glucose

levels.› Fasting means not having anything to eat or drink

(except water) for at least 8 hours before the test. It usually done first thing in the morning, before breakfast.

Diabetes is diagnosed at fasting blood glucose of greater than or equal to 126 mg

RESULT FPG

Normal Less than 100mg/dl

Prediabetes 100-125mg/dl

Diabetes 126mg/dl or greaterhttp://www.diabetes.org/diabetes-basics

Oral Glucose Tolerance Test OGTT The OGTT is a two-hour test that checks

your blood glucose levels before and 2 hours after you drink a special sweet drink. It tells the doctor how your body processes glucose.

Diabetes is diagnosed at 2 hour blood glucose of greater than or equal to 200 mg/dl

RESULT OGTT

Normal Less than 140 mg/dl

Prediabetes 140-199 mg/dl

Diabetes 200 mg/dl or greaterhttp://www.diabetes.org/diabetes-basics/

Prediabetes Happens before people develop Type 2 diabetes

› Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people.

› Blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes

Doctors sometimes refer to prediabetes as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on what test was used when it was detected. › This condition puts you at a higher risk for

developing Type 2 diabetes and cardiovascular disease.

http://www.diabetes.org/diabetes-basics

Prevention

You will NOT develop Type 2 diabetes automatically if you have prediabetes. › For some people with prediabetes, early treatment can

actually return blood glucose levels to the normal range. Research shows that you can lower your risk for

Type 2 diabetes by 58% by: › Losing 7% of your body weight (or 15 pounds if you

weigh 200 pounds) › Exercising moderately (such as brisk walking) 30 minutes

a day, five days a week › Don't worry if you can't get to your ideal body weight.

Losing even 10 to 15 pounds can make a huge difference.

Treatment of Diabetes

Type 1:› Insulin regimen

Different types with different onsets means different dosing and regimens

May get insulin twice a day, or multiple times, depending on their control

Treatment of Diabetes Type 2 Different regimens for different people.

› Most people with Type 2 diabetes are treated with pills, but may need one injection per day.

› Some may need a single injection inserting liquid medication or nutrients into the body with a syringe.

› Sometimes diabetes pills stop working, and people with Type 2 diabetes will start with two injections per day of two different types of insulin. (They may progress to three or four injections of insulin per day.)

See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-routines.html#sthash.R7F7bpP4.dpuf

Insulin For Type 1 and Type 2 Multiple types of Insulin

› Short, intermediate, and long acting Depends on onset, peak, and duration

› Single dose Syringe vs. Insulin Pin

› Pump

Insulin Insulin Pins

› The insulin dose is dialed on the pen, and the insulin is injected through a needle, much like using a syringe.

› Cartridges and pre-filled insulin pens only contain one type of insulin.

Insulin Pump› Small computerized devices that deliver insulin in two ways:

In a steady measured and continuous dose (the "basal" insulin) As a surge ("bolus”: an extra amount of insulin taken to cover an

expected rise in blood glucose, often related to a meal or snack.) dose, at your direction, around mealtime.

› Size of a deck of cards that can be worn on a belt or kept in a pocket. › Many people prefer this continuous system of insulin delivery over

injections. See more at:

http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication

Glucose Monitoring Main tool you have to check your diabetes

control. This test tells you your blood glucose level at any one time. › Keeping a log of your results is vital.

Your doctor may recommend blood sugar testing three or more times a day if you have Type 1 diabetes. › Testing may be before and after certain meals,

before and after exercise, before bed, and occasionally during the night. You may also need to check your blood sugar level more often if you are ill, change your daily routine or begin a new medication.

http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html#sthash.wOSwY5GJ.dpuf

Hypoglycemia-low blood glucose

Hunger Anxiety Paleness

Blurry Vision Irritable

Behavior Changes Crying

Confusion Dazed Appearance

Seizures Unconsciousness/coma

Hyperglycemia-high blood glucose Headache

Stomach pains Weight Loss

Irritable Flushed Face

Sleepiness/Fatigue Dry Mouth

Nausea Confusion

Labored breathing Profound weakness

Unconscious

Effects of Exercise on Blood Sugar Levels

Exercise makes insulin work more effectively because it takes less insulin to balance the carbohydrates consumed.› May result in lower blood sugar levels

In physical education classes, activities and intensity levels vary daily. › Children with diabetes should be more aware of how they

are feeling. Physical education teachers should monitor the student more closely before and during the activity.

A child may also be more active during recess and field trips. Older children with diabetes who participate in a sport need to plan for this additional activity. They may reduce insulin intake or eat extra food before the activity begins.› These changes must be indicated through the authorized

Primary Care Provider (PCP) form.

Effects of Illness, Stress, and Growth on Blood Sugar Levels

Illness and stress, on the other hand, often cause blood sugar levels to rise

A child who doesn’t feel well may have trouble performing in class. › May have difficulty concentrating, for example.

Early adolescence is an especially difficult time: the body grows and HORMONES change everything.› May have more issues with blood sugar at this

time and require more help emotionally and physically.

Psychological/Social Effects

Diagnosis effects children differently based on development

Social Exclusion Denial > Depression > Diabetes

Distress > Diabetes Burnout Aggression Eating Disorders Family Distress

What a Child needs:

Adjustment

Adjustment to diagnosis› 6-9 months for the CHILD› 9-12 months for PARENTS

Stressors such as divorce, violence and abuse negatively effect adjustment

http://spectrum.diabetesjournals.org/content/16/1/7.full

School-Age

Feeling different from peers› Desire to be “Normal”

Good and Bad (“good” or “bad” blood sugars)

Fear of safety when returning to school/separating from parent/caregiver

Need support from school staff› Encourage parents to meet with

teacher/trained personnel/ nurse

Adolescents

Denial› Feel fine

Ignore Vulnerability› Live in here-and-now, feel invulnerable to

long-term complications Only 1/5 adolescents report that they fully

comply with diabetes management› Adopt risky behavior while they perceive

they are able

Social Exclusion

Some children are excluded from sleepovers, birthday parties and camps because of fears from other parents and adults.

“Diabetes is like being expected to play the piano with one hand while juggling items with another hand, all while balancing with deftness and dexterity on a tight rope.”

http://diabetes.about.com/od/doctorsandspecialists/a/diabetesdenial.htm

www.idf.org/psychological-challenges-living-diabetes

Aggression

Internalized and externalized behavior problems were increased in children with diabetes.› Boys with diabetes became more

aggressive than general peer population. A high level of family conflict acts as a

predictor of behavioral problems.

http://spectrum.diabetesjournals.org/content/16/1/7.full

Depression 15-25% of adolescents with Type 1 DM

diagnosed with depression› (14.3% adolescents w/out chronic disease)

Lower self-efficacy Diabetes distress –negative feelings

directly r/t diabetes (frustration, “bogged down” by routine, isolation)

Leads to “Burnout”-being unable to cope with diabetes› Those with poor coping skills, problem-

solving and self-carehttp://idf.org/psychological-challenegs-children-living-diabetes

Eating Disorders Prevalence of eating disorder in diabetics is

2-6X higher than peers 25% of females with diabetes are

diagnosed with an eating disorder Correlation, not causative effects Both emphasize body states, weight

management, control of food Anorexia, Bulimia, Insulin Abuse

› (20-40% alter insulin doses to control weight) Diabetes can camouflage eating disorder

› “Just practicing dietary control”www.diabetes.org/living-with-diabetes/

Family Distress Often experience stages of grief:

› Anger, denial, bargaining, depression, and resolution/acceptance

Parental conflict› Overprotective vs. Neglectful

Children report that parents “nag them” or chastise them more than siblings.

Close supervision of diabetic child may lead to sibling rivalry and jealousy.

Siblings may fear developing diabetes.http://spectrum.diabetesjournals.org/content/16/1/7.full

Counselors Promote supportive environment Encourage social support Communication Treat the child normally Reduce social exclusion

› Non-food rewards and parties Respond to ineffective coping skills Encourage participation in SELF-

MANAGEMENT› Appropriate for child’s developmental level

A Few Resources

Health Services Just a reminder: Any student with a health condition

must have the proper authorized Primary Care Provider form complete.

Staff must attend Health Services training before they can provide a service or administer medications.

Health Services Nurse Practitioners need to be invited to ALL IEP, ARC, Placement, & 504 meetings for anyone with a health condition.› Especially those that require nursing care

14-15 Nurse PractitionerArea Assignments

Area 1: Angela Hayes› angela.hayes@jefferson.kyschools.us

Area 2: Megan Habich› megan.habich@jefferson.kyschools.us

Area 3: Mary Texas› mary.texas@jefferson.kyschools.us

Area 4: Holly Walker› holly.walker@jefferson.kyschools.us

Area 5: Amanda Burks› amanda.burks@jefferson.kyschools.us

Area 6: Blaire Adams› blaire.adams@jefferson.kyschools.us

Or, please call Health Services at 485-3387

Sources: Diabetes and Eating Disorders. Diabetes Spectrum.

http://sectrum.diabetesjournals.org, vol 15, no 2, April 2002. Eating Disorders. American Diabetes Association.

www.diabetes.org/living-with-diabetes. Eating Disorders and Diabetes: A Dangerous Connection.

www.raderprograms.com/health-concerns/diabetes-eating-disorders.html.

Guthrie, D., Bartsocas, C., Jarosz-Chabot, P., & Konstantinova, M. “Psychological Issues for Children and Adolescents with Diabetes: Overview and Recommendations. http://spectrum.diabetesjournals.org/content/16/1/7.full. Vol 16, no 1, Januray 2003.

Hicks, Jennifer. What’s the Big Deal? Denying a Diagnosis of Diabetes. http://diabetes.about.com. October 23,2007.

Naranjo, Diana and Hood, Korey. “Psycholigical Challenegs for Children Living with Diabetes.” www.idf.org/psychological-challenegs-children-living-diabetes. August 21, 2013.