Primary Care Providers: The Child with Diabetes

Leslie K Scott PhD, PCPNP-BC, CDE

University of Kentucky

Lexington, KY

Objectives• Briefly review diabetes as it occurs in children

including typical management strategies• Discuss the role of the primary care provider

in the management of common childhood illnesses as they relate to the child with diabetes

• Apply strategies discussed with case studies

Diabetes in Children• Diabetes is one of the most common chronic

diseases in children and adolescents.• About 215,000 (under 20 years) in U.S.• 15,600 children diagnosed with type 1 diabetes

annually• 3,600 children diagnosed with type 2 diabetes

annually (2000-2005) (<10 years)

• 23% adolescents in U.S. have diabetes or prediabetes (2007-2008)

(NIH/NIDDK 2013)

Making the Diagnosis• Any of the following tests can be used to

diagnose diabetes and prediabetes (Confirm)– Fasting plasma glucose (FPG)– Random plasma glucose (RPG)—With diabetes

symptoms– Oral Glucose Tolerance Test (OGTT)

• 75 Gm load• 1.75 Gm/kg up to 75 Gm

– A1c

Diabetes Prediabetes

• FPG > 126 mg/dl• RPG > 200 mg/dl, with

diabetes symptoms• OGTT >200 mg/dl at 2

hours post-load• A1c > 6.5%• T1DM—

– GAD antibodies

– IA2 antibodies

– Insulin autoantibodies

• FPG 100-125 mg/dl• OGTT 140-199 mg/dl at 2

hours post-load• A1c 5.7-6.4%

Medical Management• T1DM and T2DM with A1c > 8%

– Insulin (.5-.8 units/kg/day); • Basal (Half of TDD)• Bolus

– Insulin to CHO ratio (500/TDD)– Correction (1500-1800/TDD)

• Prediabetes and T2DM with A1c < 8%– Lifestyle modification– Metformin

• 500 mg for 2 weeks, then 1000 mg daily (max 2000 mg)

Insulin Therapy• Basal-Bolus Therapy

Insulin Onset Peak Duration

Lantus

Levemir

NPH

70/30

Regular

Humalog

Novolog

Apidra

Education Basics• Monitoring

– Glucose– Ketones

• Medications• Meals

– CHOs– Nutrition

• Miscellaneous– Hyperglycemia/hypoglycemia (glucagon)– Illness– Travel

Insulin Pump & Sensor Basics• Pumps

– Basal-Bolus Therapy– Rapid insulin analogs used– ARE NOT MAGIC!!!

• Glucose sensors– Require second SQ site– Require calibration– DO NOT REPLACE FINGERSTICK SBGM

Leslie’s Cardinal Rule’s for Pumpers

• NEVER disconnect from pump for more than 1 hour

• NEVER change pump site at bedtime – unless at least 1 glucose check, 1 hour post set change

• When correcting for hyperglycemia, the first correction can be administered via pump. If in 1 hour the glucose has not dropped > 50mg/dl, then correction is re-administered via syringe and insulin, tubing, site changed.

Primary Care

• Well child screenings/immunizations– Periodic screenings– Influenza

• Acute episodic visits– Consider impact of treatment on glycemic

control

• Diabetes/glycemic support

“Sick Day Management”Maintain Adequate Hydration 8 oz. Calorie-free, Caffeine-free fluids per hour.Check Urine KetonesIncrease Blood Glucose MonitoringContinue Medications (Hold Metformin with Severe Illness)

Encourage 100 + grams of CHO Intake throughout the day

Contact Health Care Provider for Assistance

Sick Day Management • Mini-glucagon dose

– Typically raises glucose 50-100 mg/dl in 30 min. (lasts for about an hour)

– Dose• 0-2 years----2 units (using insulin syringe)• 2 years + ---- 1 unit per year of age up to 15 units

(max ‘mini’ dose)– Check glucose every 15-20 minutes. If by 30 minutes the

glucose remains < 80 mg/dl, repeat with doubled original dose.– Repeat dose hourly to keep glucose > 80 mg/dl

Surgery Management

Medication Adjustment Remember Type 1 Diabetes requires basal insulin!!!!

Fluid & Electrolyte Replacement

Frequent Blood Glucose Monitoring

Travel and “Shift-work” with Diabetes

Carry Medicine on your person during Travel.

Be Prepared for Delays—carry Food

Insulin adjustments

Eastbound travel—shorter day

Westbound travel—longer day

Important for Patient to understand

medication action and monitor

Glucose levels frequently.

Troubleshooting for the Primary Care provider

• Recognize DKA!

• Illness– Treatment impact on glycemic control– Consider regimen when making suggestions

• Counseling/support

Case 1• 8 year-old with T1DM for 3 years.

– 10 units Lantus daily; I:C 1:15;CF 1:60>120

• Complaint: 2 day history of stuffy nose and sore throat this morning. No fever.

• Exam: consistent with seasonal allergies

• Treatment: symptomatic treatment

• Suggestions regarding diabetes

Case 2• 6 year-old with T1DM for 2 years.

– Lantus 7 units daily; I:C 1:20; CF 1:50>150

• Complains: Right ear pain

• Exam: consistent with AOM

• Treatment: Amoxicillin 3 tsp. PO, BID

• Suggestions regarding diabetes

Case 3

• 12 year-old girl with T1DM for 4 years– Novolog via insulin pump

• Complaint: irregular periods with hyperglycemia 4 days prior to periods

• Suggestions regarding diabetes

Case 4• 14 year-old with T1DM for 4 years.

• Complaint: trouble breathing. Had ‘cold’ few days ago. Vomiting yesterday (resolved)

• Exam: Deep, rapid respirations. Lungs essentially clear (moderate distress)

• Suggestions regarding diabetes

Case 5

• 9 year old with T1DM for 3 years– Humalog via pump (Basal .5 units per hour)

• During well child visit, pump alarmed ‘low battery, replace now’ while in waiting room. Glancing at pump, you notice child is not wearing pump presently.

• Suggestions regarding diabetes

Case 6

• 6 year old with T1DM for 2 years, asthma.

• Complaint: Wheezing, coughing, and not-sleeping well for past day

• Exam: Consistent with asthma exacerbation

• Treatment: Prednisone burst (5 days)

• Suggestions regarding diabetes

Case 7

Case 8

Case 9

Case 10