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Diabetes Management In Early Childhood

Chasing a Moving Target

Deborah Holtorf, MPH, MSN, NP

March 9, 2013

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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.

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Type 1 Diabetes in Young ChildrenEpidemiological Trends

SEARCH for Diabetes in Youth StudyJAMA 2007;297:2716-2724

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Type 1 Diabetes in Young ChildrenEpidemiological Trends

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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.

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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.

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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

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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

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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”.

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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.

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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

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Unpredictable Activity PatternsTools

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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

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Susceptibility to Communicable Illness

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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.

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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.

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Evolving understanding of what diabetes is and how it impacts identity

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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.

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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

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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

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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

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Need for Age-Appropriate Developmental Experiences

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Need for Age Appropriate Developmental Experiences

Play groups

Preschool

Kindergarten and elementary school

Physical activity

Diabetes camps