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5/28/2015

การอบรมหลกสตรพนฐาน รนท 1/2558

วนท 18 – 22 พฤษภาคม 2558

สมาคมผใหความรโรคเบาหวาน

พญ. ชอแกว คงการคา

งานตอมไรทอ กลมงานกมารเวชศาสตร

สถาบนสขภาพเดกแหงชาตมหาราชน

Symptoms & signs

Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence 2011

*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing

FPG ≥ 126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.*

2-h plasma glucose ≥ 200mg/dL (11.1mmol/L) during an OGTT. The test should be performed as described by the WHO, using a glucose load

containing the equivalent of75 g anhydrous glucose dissolved in water.*

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L).

A1C ≥ 6.5%. The test should be performed in a laboratory using a method that is NGSP

certified and standardized to the DCCT assay.*

Diabetes Care 2015;38(Suppl. 1):S8–S16 | DOI: 10.2337/dc15-S005

Diabetes can be classified into 4 clinical categories:

Type 1 diabetes due to β-cell destruction, usually leading to absolute insulin deficiency

Type 2 diabetes due to a progressive insulin secretory defect on the background of insulin resistance

Other specific types of diabetes due to other causes

e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced (such as in the treatment of HIV/ AIDS or after organ transplantation)

Gestational diabetes mellitus

Diabetes Care Volume 37, Supplement 1, January 2014

T1D T2D MODY Neonatal Diabetes

Age of onset All (> 6mo, 5-7yr, puberty)

Adult (Puberty)

Adult/(all)

Neonatal (< 6 mo)

Onset Sudden Gradual/ variable

Ketosis at onset

Common (DKA ~ 50%)

1/3 (DKA ~ 5%)

- Common (sepsis like)

Genetic Polygenic/ FHx 5% (HLA DR3/4-DQ2/8)

Polygenic/ FHx 75% Single gene Single gene

Insulin Low or absent Resistant and deficiency

Deficiency Deficiency

Pancreatic antibodies

Yes (ICA, IA2, GAD65, IAA)

No (GAD may+)

No No

Obesity Uncommon/ pop. frequency

Strong No/variable No

Insulin dependent

Yes – for life Episodic/ later May need later Yes/ some Rx OHD

Insulin resistant

No Yes No -

• 10% of all diabetes • Over 15 million in the world • 50% of new onset T1D present in children • 3/4 of all cases of T1D are diagnosed < 18 years of age • More than 79,000 children developed type 1 diabetes in

2013 • 24% of T1D children lives in Europe • Incidence: Finland 34.9, US 19, China 0.6, Thai 0.6 per

100,000 (2011)

http://www.idf.org/diabetesatlas/5e/diabetes-in-the-young

Diabetes Care 2015;38(Suppl. 1):S70–S76 http://www.idf.org/diabetesatlas/update-2014

J Med Assoc Thai. 2011 Dec;94(12):1447-50

New Cases of T1D are Growing at a Faster Rate

Ann NY Acad Sci. 2008 December; 1150:1-13 http://jdrf.org/research/prevent/

At A Glance 2011

Total child population (0-14 years. billions) 1.9

Type 1 diabetes in children (0-14 years)

Number of children with type 1 diabetes (thousands) 490.1

Number of newly-diagnosed children per year (thousands) 77.8

Annual increase in incidence (%) 3.0

http://www.idf.org/diabetesatlas/5e/diabetes-in-the-young

T1D in the young

Diabetes in Thai children and adolescent

In 2003, Thailand has 9,419 children and adolescents (< 18 yr) with

diabetes and T1D ~ 78%

Age at onset ≤ 18 yr 2.66%

T1DM 78%

T2DM 18.4%

Other types 3.6%

Thailand Diabetes Registry Project. J Med Assoc Thai. 2006;89:S10-6

T2D increasing

http://www.who.int/nmh/publications/ncd_report_chapter1.pdf?ua=1

WHO 2015, reports of type 2 diabetes in children – previously rare – have increased worldwide Childhood obesity increasing

http://www.who.int/mediacentre/factsheets/fs312/en/

• Know your diabetic kids • Care of children and adolescent with

diabetes – Goal – T1D management – Insulin therapy – T2D management

• Prevention

Children vs Adult Diabetes

• T1D > T2D, T2D increase • Effect to brain development • Ability to provide diabetes self-care • Need supervision • Ability to cope with diabetes

• ISPAD Clinical Practice Consensus Guidelines 2014 • Global IDF/ISPAD Guideline for diabetes in childhood

and adolescence 2011 • Standards of Medical Care in Diabetes – 2015 • Type 1 Diabetes Through the Life Span: A Position

Statement of the American Diabetes Association (2014)

• Care of Children and Adolescents With Type 1 Diabetes (2005)

• Management of Newly Diagnosed Type 2 Diabetes

Mellitus (T2DM) in Children and Adolescents (2013) • Management of Type 2 Diabetes Mellitus in Children

and Adolescents (2013)

The unique aspects of care and management of children and

adolescents with T1D

• Changes in insulin sensitivity related to sexual maturity and physical growth

• Ability to provide self-care • Supervision in child care and school • The unique neurological vulnerability to

hypoglycemia, possibly hyperglycemia and diabetic ketoacidosis

Diabetes Care 2015;38(Suppl. 1):S70–S76

Management of T2D in children and adolescence

• The rapid emergence of childhood T2DM

• Need aggressive treatment - early life complications and decreased life expectancy – Integrating lifestyle modifications (ie, diet and exercise) in

concert with medication (insulin or metformin, first-line treatment)

– frequent HbA1C and BG monitoring are recommended

• Specialist referral and co-management with primary care clinician

• Family-centered diabetes care • Prevent childhood obesity

Pediatrics 2013;131;364;

Pediatrics 2013;131;e648;

Major developmental issues and their effect on diabetes in

children & adolescents

5/28/2015

Major developmental issues and their effect on diabetes in children & adolescents

Developmental stage (approximate ages)

Normal developmental tasks

Type 1 diabetes management

priorities

Family issues in type 1 diabetes

management

Infancy (0–12 months)

• Developing a trusting relationship/ “bonding” with primary caregiver(s)

• Preventing and treating hypoglycemia • Avoiding extreme fluctuations in blood glucose levels

•Coping with stress • Sharing the “burden of care” to avoid parent burnout

Toddler (13–36 months)

• Developing a sense of mastery and autonomy

• Preventing and treating hypoglycemia • Avoiding extreme fluctuations in blood glucose levels due to irregular food intake

• Establishing a schedule • Managing the “picky eater” • Setting limits and coping with toddler’s lack of cooperation with regimen • Sharing the burden of care

5/28/2015 DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005 Diabetes Care 2014;37:2034–2054

Infants and toddlers

• Total dependence on parents and other care providers for injections/management of pumps, food and monitoring and the requirement of a trusting attachment between infant and caregivers

• Mothers may feel increased stress, diminished bonding, and depressive feelings but this applies to many chronic diseases

• Unpredictable erratic eating and activity levels

Pediatric Diabetes 2014: 15(Suppl. 20): 77–85


• Difficulties in distinguishing normal infant behavior from diabetes-related mood swings, e.g., due to hypoglycemia

• Injections, catheter insertion, and BG checks seen as pain inflicted by caregivers



• Hypoglycemia is more common (see chapter on hypoglycemia). Long standing hyperglycemia may be even more harmful. Education on prevention, recognition, risk, and management are therefore a priority

• Care in nursery and kindergarten





priorities


management

Preschooler and early elementary school age (3–7 years)

• Developing initiative in activities and confidence in self

• Preventing and treating hypoglycemia • Unpredictable appetite and activity • Positive reinforcement for cooperation with regimen • Trusting other caregivers with diabetes management

• Reassuring child that diabetes is no one’s fault • Educating other caregivers about diabetes management






priorities


management

Older elementary school-age (8–11 years)

• Developing skills in athletic, cognitive, artistic, social areas • Consolidating self-esteem with respect to the peer group

• Making diabetes regimen flexible to allow for participation in school/peer activities • Child learning short- and long term benefits of optimal control

• Maintaining parental involvement in insulin and blood glucose monitoring tasks while allowing for independent self-care for “special occasions” • Continue to educate school and other caregivers



School age children

• Adjusting to the change from home to school, developing self-esteem, and peer relationships

• Learning to help with and developing skills in injections, pump use, and monitoring

• Progressive recognition and awareness of hypoglycemic symptoms

• Increasing understanding and self-management


• Adapting diabetes to school programs, school meals, exercise, and sport

• Including monitoring of BG levels, injections, giving boluses in the school setting

• Advising parents on the gradual development of the child’s independence with progressive stepwise hand-over of appropriate

School age children





priorities


management

Early adolescence (12–15 years)

• Managing body changes • Developing a strong sense of self-identity

• Managing increased insulin requirements during puberty • Diabetes management and blood glucose control become more difficult • Weight and body image concerns

• Renegotiating parents and teen’s roles in diabetes management to be acceptable to both • Learning coping skills to enhance ability to self-manage • Preventing and interventing with diabetes-related family conflict • Monitoring for signs of depression, earing disorders, risky behaviors






priorities


management

Later adolescence (16–19 years)

• Establishing a sense of identity after high school (decision about location, social issues, work, education)

• Begin discussion of transition to a new diabetes team • Integrating diabetes into new lifestyle

• Supporting the transition to independence • Learning coping skills to enhance ability to self-manage • Preventing and intervening with diabetes-related family conflict • Monitoring for signs of depression, eating disorders, risky behaviors



• Accepting the critical role of continued parental involvement and yet promoting independent, responsible self-management appropriate to the level of maturity and understanding

• Understanding that knowledge about diabetes in adolescents is predictive of better self-care and (metabolic) control but the association is modest

• Discussing emotional and peer group conflicts

• Discussion weight control and preventing disordered eating

Adolescents


• Teaching problem-solving strategies for dealing with dietary indiscretions, illness, hypoglycemia, blood glucose fluctuation due to puberty, sports, smoking, alcohol, drugs, and sexual health

• Negotiating targets, goals and priorities and ensuring that the tasks taken on by the adolescent are understood, accepted, and achievable

• Understanding that omission of insulin is not uncommon. The opportunity should be grasped for non-judgmental discussion about this

• Developing strategies

Adolescents



diabetes – Goal – T1D management – Insulin therapy – T2D

• Stop childhood obesity

การดแลรกษาเบาหวานในเดกและวยรน

Kid

Family Care Giver

School Friends

Care Team

สงทควรร

• มความร เขาใจ เกยวกบเบาหวานในเดกและวยรนอยางแทจรง

• ความเฉพาะของแตละบคคล เขาใจการเปลยนแปลง ชวต

– รจก เขาใจ ตวเดก วย พฒนาการ พนอารมณ

– รจก เขาใจ ผดแล และครอบครว

– รจกโรงเรยน สงคม สงแวดลอม

• รจกตนเอง เรยนรอยางตอเนอง



• Prevention

เปาหมายของการดแลรกษาเบาหวาน

5/28/2015

“Healthy and Happy” ลกมสขภาพแขงแรง เจรญเตบโต ตามศกยภาพทควรเปน

อยางมความสข ครอบครวมความสข

T1D • An HbA1c goal of

<7.5% is recommended across all pediatric age-groups

T2D • The goal of initial

treatment should be HbA1c < 6.5% (ISPAD2014), < 7% (AAP2013, ADA2015

Pediatric Diabetes 2014: 15(Suppl. 20): 102–114 Diabetes Care 2015;38(Suppl. 1):S70–S76


And each child should have their targets individually determined with the goal of achieving a value as close to normal as possible while avoiding severe hypoglycemia as well as frequent mild to moderate hypoglycemia

Pediatrics 2013;131;e648

ISPAD 2014: T1D Target indicators of glycemic control


ADA 2015: T1D glycemic control


T2D glycemic goal


Diabetes Care Volume 37, Supplement 1, January 2014

Patient and family education and support

Intensive diabetes management

5/28/2015

DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005

Diabetes Care 36:2009–2014, 2013 Pediatrics 113:e47– e50, 2004 Pediatrics 112:914–922, 2003

Message to T1D children and family

• สมดลนาตาล

• กลโคสสาคญกบรางกาย

• การใชอนซลนเลยนแบบรางกาย

• อาหารสขภาพสาหรบทกคน

• ออกกาลงกายเปนประจา

• ลกจะเตบโตแขงแรง

• เจบปวยได ตองดแล

• เดกตองการการดแลเอาใจใส

• สรางวนย

• ชวตตองวางแผน

• วางใจ เราเหนอยได พก ไปตอ

• ทมชวยเหลอ

5/28/2015

Message to T2D children and family

• ตบออนกาลงทางานหนกมาก

เราตองชวยรางกายของเรา

• การรกษาชวยชะลอการเสยของ

หลอดเลอด

• ปรบเปลยนพฤตกรรม

ตงเปาหมายระยะสน ทเปนไปได

• ประเมนตวเองทกวน

• มวนย

• ครอบครว Role model จด

สงแวดลอม กจกรรม

• เนนใหกาลงใจ เสรมแรงบวก

ชมเชย ไมเปนไรพยายามใหม

ลดการดวา

• โตแลว เชอวาทาได

• อยากเหนมสขภาพแขงแรง อายยน

• เปาหมายในชวต 5/28/2015 Pediatrics 2013;131;364



• Prevention

Type 1 Diabetes

Children with T1D have characteristics and needs

• Differences between various ages • Developmental stage • The consequences of hypoglycemia • Risks for diabetic complications • The targets of education

DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005 5/28/2015

• Every child should be evaluated and provided up to date pediatric-specific education and support by a qualified diabetes team

• Ideally, diabetes care team consists of a pediatric

endocrinologist, a nurse educator, a dietitian, and a mental health professional

• Immediately provide after the initial diagnosis

• Inpatient or outpatient setting

DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005

5/28/2015

Newly diagnosed T1D children: Initial Care and Education


• Essential provides: – Diabetes self-management education(DSME) &

support (DSMS) – Medical nutrition therapy (MNT) – Psychosocial support

• And regularly there after by individuals experienced with the educational, nutritional, behavioral, and emotional needs of the growing child and family



• The balance between adult supervision and self-care should be defined at the first interaction and reevaluated at each clinic visit

• This relationship will evolve as the child reaches physical, psychological, and emotional maturity


• Education components: – Patient and family, all caregivers simultaneously – Intensive diabetes care management – Education program – Necessary basic management, “Survival Skills” – Personalization to accommodate individual needs – Skillful educator team, pediatric-specific, type 1

diabetes

DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005 5/28/2015


Content of Education Program

Pediatric Diabetes 2014: 15 (Suppl. 20): 77–85

Essential in developing and implementing an optimal diabetes regimen

• Attention to family dynamics • Developmental stages • Physiological differences related to sexual maturity


การรกษาสมดลนาตาลในรางกาย

อนซลน อาหาร

กจกรรม จตใจ เจบปวย

ในคนทไมเปนเบาหวาน

เมอเรากนอาหาร ตบออนจะหลงอนซลนปรมาณมาก

ระหวางมออาหาร ตบออนจะหลงอนซลนปรมาณนอย

กนอาหารมอใหญ กนอาหาร

อนซลน

หลงมออาหาร

อนซลน

ระหวางมออาหาร

เวลา

ระดบ

อนซล

นในเ

ลอด



• Prevention

Type of insulin

Insulin type Brand name Lab. Onset of

action(hr) Peak (hr)

Duration of action (hr)

Human insulins Regular insulin NPH

Humulin R Novolin R Actrapid Humulin N Novolin N Insulatard

Lilly Novo-Nordisk Lilly Novo-Nordisk

0.5

1-2

2.5-5

4-14

5-8

10->24

Rapid-acting analogues Lispro insulin Aspart insulin Insulin gluisine

Humalog Novolog Novorapid Apidra

Lilly Novo-Nordisk Aventis

<0.5 <0.25

<0.25

0.5-1.5 40-50

55

<6 3-5

<6

Long-acting analogues Glargine Determir

Lantus Levemir

Aventis Novo-Nordisk

1-2

No true peak

24

Insulin regimen

1. Conventional

2. Modified conventional

Intensified insulin therapy

การรกษาเบาหวานชนดท 1 ดวยการใชอนซลนแบบเขมงวด คอ การให

อนซลนเลยนแบบการหลงอนซลนจากตบออน

หลกการ Basal-bolus

ม 2 แบบ

• Multiple daily injection • Insulin pump/ Continuous Subcutaneous Insulin

Infusion (CSII)

3. Basal-bolus: multiple daily injection (MDI)

• อนซลนทใช ไดแก rapid acting insulin และ long acting insulin

• โดยฉดอนซลน อยางนอย 4 ครงตอวน คอ long acting insulin เปนอนซลนพนฐาน (basal insulin) ฉดวนละ 1-2 ครงตามเวลาทกาหนด และใช rapid acting insulin เปนอนซลนสาหรบอาหาร (prandial insulin) โดยคานวณตามปรมาณคารโบไฮเดรตทจะกนในมอนนๆ (insulin to carbohydrate ratio) ไดแก กอนอาหารเชา กอนอาหารกลางวน กอนอาหารเยน และกอนอาหารวาง และเมอพบวาระดบนาตาลเกนเปาหมายสามารถให/เพมขนาดอนซลนตามระดบนาตาลทวดได (insulin sensitivity หรอ correction factor)

Check – Count – Shot

เจาะ – นบ – ฉด – กน

5/28/2015

เทคนคงายๆ ชวยลดระดบ HbA1C ใน Type 1 Diabetes

ฉดกอนกน ฉดอนซลนกอนกนอาหารทมคารบ

ไมลมฉด ไมลมฉดอนซลนกอนนอน

รอกอนกน รออนซลนออกฤทธกอนจงเรมกนอาหาร

เชคอยางนอย 4 ครง ตรวจระดบนาตาลตงแต 4 ครงขนไปตอวน

มเพอนคคด คณพอแม/ผใหญ/ผปกครอง/เพอน ชวยเตอน

ความจา ชวยคดคารบและขนาดอนซลนทจะฉด

Modified from Diabetes Care 36:2009–2014, 2013

เดกเบาหวานชนดท 1 ทวนจฉยใหม

ไดเรยนรการดแลเบาหวานดวยตนเองเบองตน Survival with type 1 diabetes

หลกสตรมาตรฐาน โดยทมเบาหวาน ทมความร ประสบการณ เปนมตร

Hospital

ตดตามทางโทรศพท

ท 3 และ 7 วน ทก 1-3 เดอน

เมอมภาวะฉกเฉน

โดยทมเบาหวาน และ case manager

New Onset Type 1 Diabetes Care Model

คลนกเบาหวาน

โดยทมเบาหวาน Continuing educational

บาน

รร.

Other issues

• Exercise • Sick day • School • Travel • Drive • Teen • Employment

• Psychological care • Screening for

Microvascular and macrovascular complications

• Transitional to adult care



• Prevention

Type 2 Diabetes

T2D: Need aggressive treatment

• Prevalence of associated comorbidities and complications early in the course of disease – The majority of T2D will have comorbidities, (such as fatty

liver, sleep apnea, hypertension) at the time of diagnosis – appear to develop microvascular and macrovascular

complications at an accelerated rate


T2D: Management goals

• Lifestyle education: – education on diet and physical activity – intensive lifestyle intervention

• Normalization of glycemia • Weight loss • Reduction in carbohydrate and calorie intake • Increase in exercise capacity • Control of comorbidities (including hypertension,

dyslipidemia, nephropathy, sleep disorders, and hepatic steatosis)


T2D children and adolescents: physical activity

• moderate to vigorous exercise for at least 60 min daily

• Limiting nonacademic screen time < 2 hr per day

• No TV in bedroom


T2D: Education

• Expertise and knowledge with T2D in youth Care Team • Emphasis on behavioral, dietary, and physical activity changes • A culturally sensitive and age-appropriate manner, nearly all

are adolescents • Family-centered diabetes care • Initial uncertainty “type”


T2D:

Behavioral change Dietary management Exercise management Smoking and tobacco use


T2D: Glycemic monitoring

• Self-monitored blood glucose (SMBG) should be – Performed regularly – The frequency of SMBG should be individualized

based on the degree of glycemic control and available resources


T2D: Initial treatment

• Initial pharmacologic treatment of youth with T2D should include metformin and insulin alone or in combination

• Initial treatment is determined by symptoms,

severity of hyperglycemia, and presence or absence of ketosis/ketoacidosis


• Patients with symptoms can deteriorate rapidly irrespective of eventual diabetes type and need urgent assessment and appropriate treatment

• Metabolically stable patients (HbA1c<9 and no symptoms) should be started on metformin monotherapy

• Patients who are not metabolically stable require

insulin

T2D: Initial treatment


Approach to initial and subsequent treatment of youth with type 2 diabetes


T2D: Assessment and management of comorbidities and complications

• Urine ACR • BP • Testing for dyslipidemia • Examine for retinopathy • Evaluation for NAFLD • Screening for menstrual irregularities,

hyperandrogenism, depression, and OSA • Screening for smoking and alcohol use




• Prevention

Thirty minutes of moderate-intensity physical activity on most

days and a healthy diet can drastically reduce the risk of developing type 2 diabetes.

Type 1 diabetes cannot be

prevented.

http://www.who.int/mediacentre/factsheets/fs312/en/

Prevention of childhood obesity

• Early initiation of breastfeeding

within one hour of birth • Exclusive breastfeeding for the first 6

months of life • The introduction of nutritionally-

adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to two years of age or beyond

For infants and young children, WHO recommends:

Prevention of childhood obesity

• Limit energy intake from total fats

and sugars • Increase consumption of fruit and

vegetables, as well as legumes, whole grains and nuts

• Engage in regular physical activity

(60 minutes a day)

School-aged children and adolescents should:

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