Diabetes in Young Diabetes in Young ChildrenChildren

The Lollipop BrigadeThe Lollipop Brigade

Francine R. Kaufman, M.D.Francine R. Kaufman, M.D.

Professor of PediatricsProfessor of Pediatrics

The Keck School of Medicine of USCThe Keck School of Medicine of USC

Head, Center for Diabetes and EndocrinologyHead, Center for Diabetes and Endocrinology

Childrens Hospital Los AngelesChildrens Hospital Los Angeles

What Will Be Discussed What Will Be Discussed

What are the Targets for Young What are the Targets for Young Children?Children?

What are the Diabetes Regimens?What are the Diabetes Regimens?

Is There a Greater Risk of Is There a Greater Risk of Hypoglycemia?Hypoglycemia?

What are the Developmental Issues ?What are the Developmental Issues ?

Question

What are the glycemic targets for young children?

Glycemic TargetsGlycemic TargetsGlucose values are plasma Glucose values are plasma

(mg/mL)(mg/mL)AgeAge Pre-Meal Pre-Meal

BGBGHS/Night HS/Night

BGBGHbA1cHbA1c

Toddler Toddler

(0-5 yrs)(0-5 yrs)100-180100-180 110-200110-200 ≥≥7.5 & 7.5 &

≤8.5%≤8.5%

School-School-ageage

(6-11 yrs)(6-11 yrs)

90-18090-180 100-180100-180 <8%<8%

AdolescenAdolescentt

(12-19 (12-19 yrs)yrs)

90-13090-130 90-15090-150 <7.5%<7.5%

Diabetes Care 28:186-212, 2005

But What are the Goals?But What are the Goals? To give your child a loving, supportive To give your child a loving, supportive

environment where each day is taken at a environment where each day is taken at a time (not each blood sugar)time (not each blood sugar)

Where your child can grow and thrive, Where your child can grow and thrive, learn and explore learn and explore

Where blood sugars are corrected, not Where blood sugars are corrected, not interrogatedinterrogated

Where the family is in balance – like a Where the family is in balance – like a mobilemobile

And where the long haul is what is And where the long haul is what is importantimportant

Question

Can Intensive Management Be Done Safely in

Young Children?

CHLA Type 1 DMCHLA Type 1 DMYearYear199199

5519919966

19919977

19919988

19919999

20020000

20020011

20020022

20020033

20020044

20020055

NN 35735741441446846874774788788799199110710722

12812855

13713755

16616644

16316355

MeaMeanA1nA1

cc

8.48.4 8.68.6 8.58.5 8.28.2 8.38.3 8.58.5 8.58.5 8.28.2 8.38.3 8.28.2 8.08.077

% % <7<7

1818 2020

% 7-% 7-7.997.99

4646 3737 4444 5151 4747 4242 4242 5050 4848 2929 3434

% %

8-108-103737 4545 4242 3838 4040 4444 4444 3939 4040 4242 3535

% % >10>10

1717 1818 1414 1111 1313 1414 1414 1111 1212 1111 1111

HbA1c Statistics for CHLA 2003 HbA1c Statistics for CHLA 2003 Type 1: Diabetes > 1 year, Type 1: Diabetes > 1 year,

followed > 1 yearfollowed > 1 yearEnrolled in Long-term study – Enrolled in Long-term study –

total n 1375total n 1375nn Average ± SDAverage ± SD

All patientsAll patients 13751375 8.2 ± 1.68.2 ± 1.6

MalesMales 673673 8.2 ± 1.68.2 ± 1.6

FemalesFemales 702702 8.2 ± 1.68.2 ± 1.6

< 5 < 5 6161 7.8 ± 1.37.8 ± 1.3

5-10 5-10 450450 7.9 ± 1.3 7.9 ± 1.3

11-16 11-16 579579 8.4 ± 1.88.4 ± 1.8

17-1917-19

>20>20157157

1271278.3 ± 1.58.3 ± 1.5

7.4 7.4 ++ 1.3 1.3

Evaluation of Young Evaluation of Young Children at CHLAChildren at CHLA

Kaufman, et al, Pediatr Diabetes, 3:179-183, 2002.

Retrospective analysis of dataRetrospective analysis of data 147 children < 8 years of age147 children < 8 years of age 2 year data from July 99 – July 20012 year data from July 99 – July 2001

Study Question : Is HbA1c < 8.0 Study Question : Is HbA1c < 8.0 associated with more severe or associated with more severe or assymptomatic hypoglycemia?assymptomatic hypoglycemia?

<8.0<8.0 >>8.08.0 PP

AgeAge 5.775.77 5.675.67 0.70.7

DurationDuration 2.562.56 2.882.88 0.20.2

HbA1cHbA1c 7.07.0++.76.76 8.78.7++.7.744

<0.001<0.001

RegimenRegimen 2.92.9 3.03.0 0.290.29

U/kgU/kg 0.570.57 0.620.62 0.150.15

nn 8989 5858

HypoglyceHypoglycemiamia

5.65.6 3.43.4 NSNS

DKADKA 1.11.1 3.43.4 NSNS

CompetencCompetencyy

4.04.0 3.63.6 0.0190.019

% within% within 40.340.3 29.229.2 <0.0001<0.0001

% above% above 37.137.1 51.751.7 <0.0001<0.0001

% below% below 22.722.7 19.119.1 0.230.23

Question

What are the principles of management?

Diabetes Management Diabetes Management PrinciplesPrinciples

An effective insulin regimenAn effective insulin regimen Monitoring of glucoseMonitoring of glucose As flexible with food and activity as As flexible with food and activity as

possiblepossible Must remember Must remember

Young children need routine and rulesYoung children need routine and rules Young children need to develop autonomyYoung children need to develop autonomy Young children need to explore and experienceYoung children need to explore and experience Young children need to begin to make decisionsYoung children need to begin to make decisions

Insulin managementInsulin management

Fixed dose regimens: Fixed dose regimens: requires scheduled meals and snacks and requires scheduled meals and snacks and

is not flexible enough for most young is not flexible enough for most young childrenchildren

Basal: bolus regimens:Basal: bolus regimens: MDIMDI

useful only if child is willing to take frequent useful only if child is willing to take frequent injectionsinjections

Insulin pumps Insulin pumps child must be willing to wear the pumpchild must be willing to wear the pump

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

8:0012:008:00

Time

Glargineor

Detemir

Pla

sma

insu

lin

Basal/Bolus Treatment Basal/Bolus Treatment Program with Rapid-acting and Program with Rapid-acting and

Long-acting AnalogsLong-acting Analogs

Lispro Lispro LisproGlulysene Glulysine Glulysine

Aspart Aspart Aspart

Type 1 Diabetes: Serum Insulin Concentrations Type 1 Diabetes: Serum Insulin Concentrations Following Subcutaneous Injection of Insulin LisproFollowing Subcutaneous Injection of Insulin Lispro or or

Human RegularHuman Regular

Time (minutes)

Serum Insulin Conc. (ng/mL)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Insulin Lispro (n=10)Human Regular (n=10)

0.2 mU/min/kg insulin infusion

-60 0Meal

60 120 180 240 300 360 420 480

Heinemann et al. Diabetic Medicine,13:625-629, 1996

Injection

Mean + SE

Effectiveness of Effectiveness of Postprandial Humalog in Postprandial Humalog in

Toddlers Toddlers Rutledge, Chase, Klingensmith et al Pediatrics 100:968,97Rutledge, Chase, Klingensmith et al Pediatrics 100:968,97

Determine if postprandial rapid-Determine if postprandial rapid-acting insulin effectiveacting insulin effective

Subjects < 5 years oldSubjects < 5 years old Results: 2-hour glucose excursions Results: 2-hour glucose excursions

lower with postprandial Humalog lower with postprandial Humalog compared to preprandial regularcompared to preprandial regular

Similar to preprandial HumalogSimilar to preprandial Humalog

00

1

2

3

4

5

6

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

NPH

Glargine

Placebo

0.4 U/kg

Hours

Glu

cose

Infu

sio

n R

ates

(mg

/kg

/min

)

Linkeschowa R, et al. Diabetes.1999;48(Suppl 1):A97.

Insulin Glargine - Insulin Glargine - Pharmacokinetics by Glucose Pharmacokinetics by Glucose

ClampClamp

21 Brunner et al. Exp Clin Endocrinol Diabetes. 2000;108.

Insulin Detemir – Insulin Detemir – Pharmacokinetics by Glucose Pharmacokinetics by Glucose

ClampClamp

Elapsed Time (min)

0.0

0.5

1.0

1.5

2.0

100 100 300 500 700 900 1100 1300 1500

Detemir High

Detemir Low

Placebo

Glu

cose

Infu

sio

n R

ate

(mg

/kg

/min

)

GHb, FBG, and Nocturnal GHb, FBG, and Nocturnal Hypoglycemia Hypoglycemia

in Children With T1DMin Children With T1DM(Plus Regular Insulin) (Plus Regular Insulin) (N=349)

-2

0

2

4

6

8

GHb FBG NocturnalHypoglycemia*

Cha

nge

in G

HB

(%

) an

d F

BG

(m

mol

/L)

-6

6

18

% o

f P

atie

nts

Glargine NPH

p<0.05

*Nocturnal hypoglycemia with FBG <36 mg/dL, month 2 to study end

Schoenle et al. EASD 1999; Abst 883. Study 3003

4:004:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch DinnerDinner

8:008:0012:0012:008:008:00

TimeTime

Basal infusion

Bolus Bolus Bolus

Pla

sma

insu

lin

Pla

sma

insu

lin

Variable Basal Rate: Variable Basal Rate: CSII ProgramCSII Program

A1c by Treatment type A1c by Treatment type at CHLA:at CHLA:

YearYear 20002000 20012001 20022002 20032003 20042004 20052005

3 3 InjectioInjectio

nsns

8.5 8.5

± 1.5± 1.58.4 8.4

± 1.5± 1.5

Basal- Basal- BolusBolus

9.2 9.2

± 1.7± 1.78.8 8.8

± 1.5± 1.58.4 8.4

± 1.5± 1.58.4 8.4

± 1.4± 1.48.2 8.2

± 1.4± 1.4

CSIICSII 8.1 8.1

± 1.2± 1.28.1 8.1

± 1.2± 1.27.9 7.9

± 1.2± 1.27.9 7.9

± 1.1± 1.17.8 7.8

± 1.0± 1.07.6 7.6

± 1.2± 1.2

Outcomes of Pump TherapyOutcomes of Pump Therapy Kaufman, et al, Diabetes Metabolism and Reviews,2000 Kaufman, et al, Diabetes Metabolism and Reviews,2000

6 month data 130 subjects6 month data 130 subjectsPREPRE POSTPOST P P

valuevalue

HbA1c HbA1c %%

8.4 8.4 ++ 1.81.8

7.8 7.8 ++ 1.21.2

0.010.01

BMIBMI 22.8 22.8 ++ 44

23.2 23.2 ++ 55

NSNS

Hypo-Hypo-glycemiaglycemia events/pt/yevents/pt/y

0.060.06 0.030.03 0.050.05

DKADKAevents/pt/yevents/pt/y

0.150.15 0.090.09 0.050.05

Results of Insulin Pump Results of Insulin Pump Therapy Therapy

In Young ChildrenIn Young ChildrenKaufman, et al, Diabetes Spectrum, 2001Kaufman, et al, Diabetes Spectrum, 2001Pre Pre PostPost P P

ValueValue

HbA1cHbA1c 8.58.5++1.1.88

7.47.4++1.1.11

0.010.01

Mean Mean BGBG

157157++ 6464

92 92 ++ 3131

0.030.03

Hypo-Hypo-glycemiglycemiaa

0.180.18 0.090.09 NDND

Quality of Quality of LifeLife

Family Family CohesionCohesion

82 82 ++ 6 6 90 90 ++ 5 5 0.0090.009

A Randomized Controlled Trial of Insulin A Randomized Controlled Trial of Insulin Pump Therapy in Young Children With Type Pump Therapy in Young Children With Type

1 Diabetes 1 Diabetes Larry A. Fox, et al Larry A. Fox, et al Diabetes CareDiabetes Care 28:1277-1281, 2005 28:1277-1281, 2005

26 children randomly assigned to 26 children randomly assigned to current therapy or CSII forcurrent therapy or CSII for 6 months, 6 months, age 46.3 ± 3.2 monthsage 46.3 ± 3.2 months

RESULTSRESULTS—— Mean HbAMean HbA1c1c and BG did not change and BG did not change Frequency of severe hypoglycemia, Frequency of severe hypoglycemia,

ketoacidosis,ketoacidosis, or hospitalization was or hospitalization was similar between groupssimilar between groups

Subjects on CSII had more fasting and Subjects on CSII had more fasting and predinner mild/moderatepredinner mild/moderate hypoglycemia hypoglycemia

All subjects continued CSII after study All subjects continued CSII after study completioncompletion

CSII in Young ChildrenCSII in Young ChildrenCONCLUSIONSCONCLUSIONS

CSII is safe and well tolerated in young CSII is safe and well tolerated in young childrenchildren with diabetes and may have with diabetes and may have positive effects on QOLpositive effects on QOL

CSII didCSII did not improve diabetes control not improve diabetes control when compared with injectionswhen compared with injections

The benefits and realisticThe benefits and realistic expectations expectations of CSII should be thoroughly examined of CSII should be thoroughly examined before startingbefore starting this therapy in very this therapy in very young childrenyoung children

CGMS TracingCGMS Tracing

Use of CGMS to Use of CGMS to Improve Improve

Clinical CareClinical Care47 Patients

18 boys, 29 girls

Age 11.8 ± 4.6 years

Duration 5.5 ± 3.5 years

A1c start 8.61 + 1.51

A1c end 8.36 + 1.28

p=0.01Kaufman, et al: Diabetes Care 24:2030, 2001.

6

7

8

9

10

11

12

13

Baseline 3 months postSensor

Hb

A1

C (

%)

Mean Data for All Pts by Mean Data for All Pts by SensorSensor

0

50

100

150

200

250

300

350

Ist Sensor 3rd Sensor 5th Sensor 7th Sensor

# of readingsmean glucose levelSD mean glucose

Result Summary: Result Summary: Treatment ChangesTreatment Changes

4%9%

30%

15%

42%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Increase BasalRate

DecreaseBasal Rate

Increase inCHO Dose

Increase inCorrection

Dose

Other

Percent of Total Changes

Basal (57%) Bolus (43%)

Result Summary: Result Summary: Glucose ChangesGlucose Changes

HbA1c reduced from 8.1 to 7.8% after only 30 daysHbA1c reduced from 8.1 to 7.8% after only 30 days Average glucose decreased from 167 to 156 mg/dlAverage glucose decreased from 167 to 156 mg/dl

a

Subject #1 #2 #3 #4 #5 #6 #7 #8 #9 #10

A1c Start 7 6.9 9.4 7.5 7 8.3 9.3 8.8 8.2 8.3

A1c End 7.3 6.7 8.7 7.3 6.7 7.7 9.4 7.7 8.2 8.2

Daily GlucoseSensor 1-2(First Week)

194± 55

143± 34

187± 23

154± 14

153± 23

175± 24

183± 21

138± 21

171± 31

174± 46

Daily GlucoseSensor 6-7(Last Week)

182± 26

120± 21

172± 22

163± 38

145± 38

138± 28

167± 24

123± 25

177± 20

169± 31

Name: Telephone: FAX: E-Mail:

Base Dose/Basal Rates: CHO Ratio: Sensitivity:

Other Medications: [ ] Symlin [ ] Metformin Average Glucose: Daily Insulin Totals:

DateAM Sugar

Lo OK Hi DoseMid AM Sugar

Lo OK Hi DoseLunch Sugar

Lo OK Hi DoseAfter noon Sugar

Lo OK Hi DoseDinner Sugar

Lo OK Hi DoseEve Sugar

Lo OK Hi DoseNight Sugar

Lo OK Hi DoseOver night Sugar

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Total

1 2 3 4 5 6 7 8

Fixed Regimen: Evaluate Rapid Insulin if High/Low Trends at Time 2,3,6,7Evaluate NPH I Insulin if High/Low Trends at Time 1,4,5,8

Basal Bolus Injections: Evaluate Rapid Insulin if High/Low Trends at Time 2,3,4,5,6,7Evaluate Long-Acting Insulin if High/Low Trends at Time 8,1

Basal Bolus Pump: Evaluate Bolus if High/Low Trends at Time 2,4,6Evaluate Basal if High/Low Trends at Time 1,3,5,7,8 (Not related to food)

Use Glycemic Target to Determine if Blood Glucose Trend is High, OK or Low

Question

Why About the Risk of Hypoglycemia

From Intensive Regimens?

Intensive Management Intensive Management and Hypoglycemiaand HypoglycemiaHbA1c AssociationHbA1c Association

Is There Greater Risk of Is There Greater Risk of Hypoglycemia at Lower HbA1c Hypoglycemia at Lower HbA1c

Levels?Levels?

Or withOr with

Intensive Regimens?Intensive Regimens?

Lack of Association Lack of Association Between Between

HbA1c and HbA1c and HypoglycemiaHypoglycemiaCox – Cox – no association in 78 pts no association in 78 pts with mean level of 10.25%with mean level of 10.25%

Bhatia, Wolfsdorf – Bhatia, Wolfsdorf – incidence of 0.12/pt/yr in incidence of 0.12/pt/yr in 196 pts with HbA1 11.4% 196 pts with HbA1 11.4% (nl 5.4-7.4)(nl 5.4-7.4)

Daneman -Daneman - 16% of 311 pts with HbA1 16% of 311 pts with HbA1 of 8.7%of 8.7%

Nordfelt, Ludvigsson –Nordfelt, Ludvigsson – 146 pts intensive therapy, 146 pts intensive therapy, no increase in severe no increase in severe hypoglycemiahypoglycemia

Levine-Levine- highest HbA1c tertile,highest HbA1c tertile,36/pt/yr36/pt/yr

Kaufman et al Endocrinologist 9:342,99Kaufman et al Endocrinologist 9:342,99

Analysis of data to Analysis of data to determinedetermine

bedtime BG level bedtime BG level 167 nights167 nights

Analyze the number of Analyze the number of glucose values glucose values <<40 and 40 and << 50 50 mg/dl through the nightmg/dl through the night

Kaufman FR, et al, J Pediatr. 141:625-630, 2002.

ResultsResults

45 nights (27%) – at least one 45 nights (27%) – at least one reading reading << 40 mg/dl 40 mg/dl

59 nights (35%) – at least one 59 nights (35%) – at least one reading reading < < 50 mg/dl50 mg/dl

For nights For nights << 100 at HS – 86.4 100 at HS – 86.4 minutes minutes

No relation to A1c or regimenNo relation to A1c or regimen

Kaufman FR, et al, J Pediatr. 141:625-630, 2002.

Adverse Events in Adverse Events in Intensively Treated Intensively Treated

Children and Adolescents Children and Adolescents with Type 1with Type 1

Nordfeldt, Ludvigsson Acta Pediatr 88:1184,99Nordfeldt, Ludvigsson Acta Pediatr 88:1184,99 139 Subjects, ages 1-18 yrs on MDI139 Subjects, ages 1-18 yrs on MDI Mean HbA1c 6.9%Mean HbA1c 6.9% Severe Hypoglycemia - 0.17 events/pt/yrSevere Hypoglycemia - 0.17 events/pt/yr

Decreased from 1-2 injectionsDecreased from 1-2 injections Correlated with previous severe Correlated with previous severe

hypoglycemia r=.38,p<0.0001hypoglycemia r=.38,p<0.0001 DKA rate 0.015 events/pt/yrDKA rate 0.015 events/pt/yr

MDI effective and safeMDI effective and safe

How Well Are We Doing? How Well Are We Doing? Metabolic Control in Metabolic Control in

Patients with DiabetesPatients with DiabetesThomsett, Shield, Batch, Cotterill J Pediatr & Child Health Thomsett, Shield, Batch, Cotterill J Pediatr & Child Health

35:479,99 Brisbane35:479,99 Brisbane 268 < 19 yrs 268 < 19 yrs mean 11.2 yrsmean 11.2 yrs Duration 4.4 Duration 4.4 0-16 yrs0-16 yrs Mean HbA1c Mean HbA1c 8.68.6++1.4%, range 5.2-14%1.4%, range 5.2-14% Puberty 8.7Puberty 8.7++1.5%, Prepubertal 8.51.5%, Prepubertal 8.5++1.2%1.2% 33% < 8.0%33% < 8.0% HbA1c correlated HbA1c correlated

insulin dose, durationinsulin dose, duration Not correlated Not correlated

severe hypoglycemia, DKA, age, # of injections, severe hypoglycemia, DKA, age, # of injections, # clinic visits# clinic visits

Prediction of Prediction of HypoglycemiaHypoglycemia Good PredictorsGood Predictors

Weighted assessment Weighted assessment of low BG for 2-3 wksof low BG for 2-3 wks

Nighttime BG < 100-Nighttime BG < 100-108 mg/dl108 mg/dl

Age < 5-7 yrsAge < 5-7 yrs > 2 previous episodes> 2 previous episodes Daily dose > 0.85 U/kgDaily dose > 0.85 U/kg Duration > 2 yrsDuration > 2 yrs >> 2 consecutive low 2 consecutive low

BG in 2 wksBG in 2 wks >> 4 BG < 50 mg/dl in 4 BG < 50 mg/dl in

2 wks2 wks

Poor PredictorsPoor Predictors

Glycated Glycated hemoglobin levelhemoglobin level

Number of insulin Number of insulin injections injections

Intensive vs Intensive vs conventional conventional treatmenttreatment

Kaufman et al Endocrinologist 9:342,99

Question

What are the Developmental Issues of

Young Children?

Babies and Babies and ToddlersToddlers

0-30-3  PhysicalPhysical Rapid growthRapid growth Erratic eating and Erratic eating and

sleepingsleeping

CognitiveCognitive Differentiates self Differentiates self Learns language to Learns language to

represent objects/peoplerepresent objects/people

Moral DevelopmentMoral Development Judgments based on Judgments based on

personal preferencepersonal preference

PhysicalPhysical Greater mastery of gross Greater mastery of gross

and fine motor skillsand fine motor skills

CognitiveCognitive Egocentric/Classifies Egocentric/Classifies

objects by a single objects by a single featurefeature

Magical thinking/SimpleMagical thinking/SimpleMoral DevelopmentMoral Development Judgment of good/bad Judgment of good/bad

based on punishment/ based on punishment/ reward reward

PreschoolPreschool4-64-6

Emotional and Sense of Emotional and Sense of SelfSelf

Begins to recognize that Begins to recognize that others' feelings are others' feelings are different from owndifferent from own

Begins to have sense of Begins to have sense of self self

SocialSocial Parallel playParallel play

ResponsibilityResponsibility Total care by parents/ Total care by parents/

caretakerscaretakers

Emotional and Sense of Emotional and Sense of SelfSelf

Sex role differentiationSex role differentiation Likes to helpLikes to help Wants to do things by Wants to do things by

selfself Deference to authorityDeference to authoritySocialSocial Cooperative playCooperative playResponsibilityResponsibility Child begins to have Child begins to have

some responsibility with some responsibility with adult assistanceadult assistance

Babies and Babies and ToddlersToddlers

0-30-3

PreschoolPreschool

4-64-6

SchoolSchool At home/daycare At home/daycare

Beginning to learn Beginning to learn routinesroutines

Adjusting to different Adjusting to different caretakers caretakers

Extra-Curricular Extra-Curricular Activities Activities

BabysittersBabysitters

IncentivesIncentives Immediate and concreteImmediate and concrete

SchoolSchool Entering school /Separation Entering school /Separation

from parentsfrom parents Learning routines, rules Learning routines, rules

outside of homeoutside of home School readiness skillsSchool readiness skills

Extra-Curricular ActivitiesExtra-Curricular Activities School aftercare School aftercare

Playdates PlaydatesIncentivesIncentives Immediate and can be Immediate and can be

symbolic (stickers, stars, symbolic (stickers, stars, etc)etc)

Babies and Babies and ToddlersToddlers

0-30-3

PreschoolPreschool4-64-6

Management IssuesManagement Issues

  

  

Babies and ToddlersBabies and Toddlers

0-30-3PreschoolPreschool

4-64-6

Medication Medication RegimenRegimen

  

Choosing a regime to Choosing a regime to fit eating patterns fit eating patterns and lifestyleand lifestyle

Getting child to Getting child to accept injections accept injections

Requiring supervision Requiring supervision in all settingsin all settings

Needing insulin Needing insulin coverage at preschoolcoverage at preschool

PumpsPumps Picking the right Picking the right catheter Finding the catheter Finding the right catheter right catheter placement based on placement based on fatfat

Using very small Using very small basalbasal

Choosing a person to Choosing a person to be responsible for be responsible for pumppump

Child wanting to push Child wanting to push buttonsbuttons

TestingTesting Choosing sites for Choosing sites for testing testing Checking overnightChecking overnight

Selecting the right Selecting the right metermeter

Having a small Having a small sample sizesample size

Needing to include Needing to include child in carechild in care

Progressing to do own Progressing to do own checkschecks

Avoiding labeling Avoiding labeling blood glucose "good" blood glucose "good" or "bad”or "bad”

CGMSCGMS Reducing anxiety about Reducing anxiety about overnight hypoglycemiaovernight hypoglycemia

Evaluating basal bolus Evaluating basal bolus balance balance Checking overnight Checking overnight basal rates or long-basal rates or long-acting insulinacting insulin

Hypo/HyperglycemiaHypo/Hyperglycemia Unable to tell caregiver Unable to tell caregiver when high or lowwhen high or low

May not cooperate with May not cooperate with treatmenttreatment

Learning meaning of Learning meaning of high/low BGhigh/low BG

Needing help in Needing help in identifying symptomsidentifying symptoms

Fearing hypoglycemiaFearing hypoglycemia

Insulin Administration Insulin Administration and Adjustmentand Adjustment

  

Using very small doses Using very small doses Needing quarter unitsNeeding quarter units

Requiring diluted Requiring diluted insulininsulin

Minimizing pain and Minimizing pain and fearfear

Having needle phobiaHaving needle phobia

Health & Sick DayHealth & Sick Day Having more frequent Having more frequent vomiting and diarrheavomiting and diarrhea

Becoming dehydrated Becoming dehydrated rapidly rapidly Needing Needing immunizationsimmunizations

Having more outside Having more outside exposures exposures Increasing number Increasing number of sick days of sick days Contracting Contracting childhood illnesses childhood illnesses

NutritionNutrition Breastfeeding Breastfeeding makes measuring makes measuring intake difficult intake difficult Introducing solid Introducing solid foods foods Eating habits Eating habits often erratic often erratic

Using food as Using food as power strugglepower struggle

Grazing eating Grazing eating patternspatterns

Using artificial Using artificial sweeteners may sweeteners may be controversialbe controversial

Needing to Needing to involve child in involve child in meal plan meal plan

Exercise/Exercise/ActivityActivity

Growing very Growing very rapidlyrapidly

Becoming mobileBecoming mobile

Continuously in Continuously in motion motion Energy level is Energy level is highhigh

Case Study 1Case Study 1

Ana is a two-year old recently Ana is a two-year old recently diagnosed diagnosed

Very spirited toddler Very spirited toddler Fights blood glucose testing by Fights blood glucose testing by

screaming, hiding and clenching her screaming, hiding and clenching her fists. fists.

What should this family do with this What should this family do with this challenge?challenge?

Issues by Developmental Issues by Developmental StatusStatus

Challenges of Diabetes Challenges of Diabetes ManagementManagement: : TestingTesting

Factors Contributing to the Factors Contributing to the ChallengeChallenge: :

Normal Growth and Development Normal Growth and Development Family DynamicsFamily Dynamics

Developmental TasksDevelopmental Tasks: : Moral Development Moral Development Emotional Development Emotional Development IncentivesIncentives

SolutionSolution Ana’s judgment about glucose testing based on Ana’s judgment about glucose testing based on

personal preference – she did NOT like fingersticks personal preference – she did NOT like fingersticks Not possible to “convince” Ana she needs to test her Not possible to “convince” Ana she needs to test her

blood blood Parents worked together and developed matter-of-fact Parents worked together and developed matter-of-fact

attitude attitude Committed to routine, no bargaining, stalling, chasingCommitted to routine, no bargaining, stalling, chasing Parents provided immediate and concrete incentives - Parents provided immediate and concrete incentives -

a hug, a “good job”, let her pick finger, read book as a hug, a “good job”, let her pick finger, read book as reward reward

Picked meter capable of alternate site testing, very Picked meter capable of alternate site testing, very small sample and results in five secondssmall sample and results in five seconds

Within a very short time, Ana willingly participated Within a very short time, Ana willingly participated

Case 2Case 2 Terrel, 4-year old, type 1 for ten months and Terrel, 4-year old, type 1 for ten months and

celiac diseaseceliac disease BG testing 8-10 times per day, MDI, on BG testing 8-10 times per day, MDI, on

gluten-free diet with few management gluten-free diet with few management problems at homeproblems at home

Problems occurred in pre-school Problems occurred in pre-school In school, regular episodes of hypoglycemia In school, regular episodes of hypoglycemia

Continuous activity Continuous activity Not as much blood testingNot as much blood testing Skipped snacks related to less supervision Skipped snacks related to less supervision

What does family do?What does family do?  

DEVELOPMENTAL DEVELOPMENTAL ISSUESISSUES

Challenges of Diabetes Challenges of Diabetes ManagementManagement: Testing, : Testing, Hypoglycemia, NutritionHypoglycemia, Nutrition

Factors Contributing to the Factors Contributing to the ChallengeChallenge: Normal Growth and : Normal Growth and Development, SchoolDevelopment, School

Developmental TasksDevelopmental Tasks: :

Physical; Moral Development; Physical; Moral Development; Emotional Development; Emotional Development; Responsibility; IncentivesResponsibility; Incentives

SolutionSolution At age four, Terrel likes to help, wants to do At age four, Terrel likes to help, wants to do

things by himself and adapts well to routinesthings by himself and adapts well to routines He is able to understand the meaning of low He is able to understand the meaning of low

blood glucose and the importance of eating blood glucose and the importance of eating his carbohydrates his carbohydrates

In the school setting, he needs supervision In the school setting, he needs supervision while at the same time he needs to learn to while at the same time he needs to learn to take some responsibility for participating in take some responsibility for participating in testing and eating testing and eating

Incentives he likes - praise, stickers and Incentives he likes - praise, stickers and providing choices providing choices

SolutionSolution Every day before snack and recess Every day before snack and recess

BG test BG test Choose a gluten-free snack provided by motherChoose a gluten-free snack provided by mother

After the snack After the snack Pick a small prize from a treasure chest Pick a small prize from a treasure chest Terrel liked being involved Terrel liked being involved

He was more inclined to eat and checkHe was more inclined to eat and check Getting a prize an extra incentive Getting a prize an extra incentive

In a short time, this routine became the norm In a short time, this routine became the norm and hypoglycemia resolvedand hypoglycemia resolved

ConclusionConclusionUltimate Goals Of Ultimate Goals Of

Diabetes TreatmentDiabetes TreatmentSustained Normal Blood

Glucose Control

Lowest Possible Incidence of

Hypoglycemia

No Long-Term DiabetesComplications

No Acute DiabetesComplications

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Best Quality of Life with Diabetes

For the child and your family