Pediatric Type 1 Diabetes MellitusChelsea Stegman and Kelly Davis

Test your Knowledge Type 1 Diabetes Mellitus is a/an _____ disease. a. Thyroid b. Bacterialc. Viral d. Autoimmune

Test your KnowledgeType 1 Diabetes is most commonly diagnosed amongst: A. Overweight adults B. Children and adolescents C. Overweight children and adolescents

Type 1 Diabetes • Most often diagnosed in children, adolescents, or young adults. • Causes of type 1 diabetes are complex and still not completely understood

but type 1 diabetes can not be prevented. • People with type 1 diabetes are thought to have an inherited or genetic

predisposition to developing the disease• The disease process is believed to be stimulated by an environmental

trigger such as a virus, toxin, drug or chemical

Type 1 Diabetes: Etiology • T1DM is characterized by the autoimmune destruction of beta cells. • Patients with type 1 diabetes produce little or no insulin via beta cells due

to this destruction. o Insulin is a hormone produced in the pancreas by beta cells. o Insulin is needed to move blood sugar, glucose, into the cells where it

is stored and later used for energy. o Without using insulin, glucose builds up in the bloodstream instead of

going into the cells. o The body is unable to use this glucose for energy, which leads to the

symptoms of type 1 diabetes.

Symptoms: • Extreme thirst• Frequent urination• Drowsiness• Sugar in urine• Sudden vision changes• Increased appetite• Sudden weight loss• Fruity, sweet, or wine-like odor on breath• Heavy, labored breathing• Stupor and unconsciousness

Diabetic Ketoacidosis • Severe Hyperglycemia • Most commonly found in patients with T1DM• Individuals experiencing DKA experience weight loss due to decreased

blood volume (hypovolemia) and muscle metabolism • Precipitating factors include:

o Lack of blood glucose self monitoring o Severe illness/infection o Increased insulin needs with growth spurtso Inappropriately stored insulin

Diagnostic Measures: • Symptoms of diabetes plus casual plasma glucose concentration greater

than/ equal to 200 mg/dL • Fasting plasma glucose greater than/ equal to 126 mg/dL • 2- hour post-prandial glucose greater than/ equal to 200 mg/dL during an

oral glucose tolerance test (OGTT)

Diagnostic Measures: T1DM• Islet Cell Cytoplasmic Autoantibodies (ICA antibodies) • Glutamic Acid Decarboxylase Autoantibodies (GADA antibodies) • Insulin Autoantibodies (IAA) • If an autoimmune disease is present in the family, their first-degree family

members may be at risk for developing the same or different autoimmune disease.

• Generally, T1DM is a childhood onset disease

Patient: Rachel Roberts • 12 year old female• 7th grade• Height: 5’ 60 in• Weight: 82 lbs 70 kg• BMI: 16.0 kg/m2• IBW: 89 lbs• Upon hospital admittance: acute-onset hyperglycemia • Serum glucose 724 mg/dL• Chief Complaints: Increased thirst, increased urination, slight weight loss• Diagnosis: Type 1 Diabetes Mellitus

Abnormal Lab Values:

Rachel’s Diagnosis● Rachel was diagnosed with T1DM due to:

○ Her symptoms of unexplained weight loss, polyuria, and polydipsia. ○ A serum glucose level of 724 mg/dL upon ER assessment (above

200).○ The presence of B-cell destroying autoantibodies ICA, GADA, and

IAA. ○ Low C-peptide levels, indicative of low insulin secretion. ○ There is a history of autoimmune diseases in her family. Her mother

hyperthyroidism and her sister has Celiac’s disease.

Rachel’s Nutritional Diagnosis ● PES Statement 1: Altered nutrition-related lab values (NC 2.2) related to

Type 1 Diabetes Mellitus as evidenced by a blood glucose concentration of greater than 110 mg/dL.

● PES Statement 2: Unintended weight loss (3.2) related to inadequate insulin due to Type 1 Diabetes as evidenced by a reported weight loss of 8 lbs.

Pharmacological Treatment● A physician prescribes a type of insulin, insulin dosage, and insulin

regimen per individualized case. ● Rachel is prescribed a combination of Apidra prior to meals with glargine

given in the a.m. and p.m. Both are administered via insulin injection● Prescribed discharge dosages: 7 u glargine with Apidra prior to each

snack, which is a 1:15 insulin: carbohydrate ratio.

Justification of Prescription ● Injection is used because oral pills are only used with Type II Diabetes. ● The lower dosage of insulin is due to the temporary “honeymoon” phase.

○ honeymoon phase: relative self-sufficient insulin production after T1DM is clinically diagnosed and insulin treatment is initiated.

● Glargine is given in the a.m. and p.m. for maintenance of the “dawn phenomenon” that Rachel is experiencing.○ dawn phenomenon: consistently high blood glucose levels in the

morning. This is a result of the lack of insulin injections while the individual is sleeping.

Types of Insulin● Glargine

○ Onset of action: 2-4 hours.○ Peak of action: peakless.○ Duration of action: 20-24 hours.

● Apidra○ Onset of action: 5-15 minutes.○ Peak of action: 30-90 minutes.○ Duration of action: 3-5 hours.

Treatment: MNT● Daily kcals: 2400-2500

○ 15-20% of kcals from protein○ 25-35% kcals from fat○ 50-60% kcal from carbohydrates. Insulin should be taken accordingly

to eliminate unsafe postprandial glucose responses.● Insulin Carbohydrate Ratio (ICR)- 1:15

○ Patient and parents are educated on the importance of carbohydrate counting and are given literature on carbohydrate counting.

Treatment: MNT● Rachel’s active lifestyle should also be taken into account [she is a soccer

player]○ Blood glucose levels should be monitored before and after exercise to

recognize hypoglycemic or hyperglycemic conditions.○ She should consume an additional 15 g of carbohydrates for every

hour of moderate physical activity and 30 g for every hour of strenuous activity.

○ She will not have a decrease insulin dosage levels prior to exercise because of the regularity of her exercise regimen.

Prognosis ● T1DM cannot be cured, yet it can be managed.● Prescribed insulin doses will most likely increase based on the transitory

nature of the current “honeymoon” phase. ● Self monitoring of blood glucose should be done at home.

○ Purpose: to identify patterns and the ways in which food, exercise, and other factors affect glycemic control.

○ Method: a drop of blood obtained via a finger prick is applied to a chemically treated reagent strip.

○ This is recommended at least three times daily because hypoglycemia and hyperglycemia are dangerous conditions. Rachel and her family should be cognoscente of symptoms of hypoglycemia: rapid heartbeat, weakness, shakiness, perspiration, and hunger.

Prognosis Continued● Rachel should attend routine follow-up visits with her physician and

dietitian to analyze laboratory values, diet logs, and adherence to glycemic goals.

● Microvascular and macrovascular complications generally occur 15-20 years after the onset of T1DM.

● She is also at risk for nephropathy, retinopathy, and nervous system damage.

● The incidence is reduced through intensive treatment and strict adherence to insulin regimens to prevent hypoglycemia or hyperglycemia.

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