Diabetes in Children and Adolescents

Sharon Schwarz, MSN, RN, CDETammy Cawthorn, MSN, RN10/2009Pediatric EndocrinologyMedical University of South Carolina

Target Audience and ObjectivesThe target audience is the RN caring for the child with

diabetes1. The RN will names diabetes educational needs for

all patients with diabetes.2. The RN will identify correct documentation of care of

children with diabetes.3. The RN will discuss management of hyperglycemia,

hypoglycemia, diet, medication, sick days and exercise management in the patient with diabetes.

4. The RN will differentiate between type 1 and type 2 diabetes.

DIABETES IN CHILDREN/ADOLESCENCE

Occurrence: Approximately 90% of children with diabetes have type 1 diabetes, but the percentage of type 2 is increasing.

Rate of Type1 Diabetes 13.8-16.9 per 100,000 for Caucasian American children & 3.3-11.8 per 100,000 African American children.

DIABETES IN CHILDREN/ADOLESCENCE

Approximately 100,000 Children & Adolescents <19 Yrs. Have Diabetes.

About 1 in 400 children have diabetes Development Incidence Type I Increases

With Age And Peaks During Puberty. Occurs More Frequently During Winter Months.

Type 1 Diabetes

Usually results from autoimmune destruction of islet cells

Process has been occurring for a while before symptoms are seen

Results in the PERMANENT loss of ability to produce insulin

Type 2 Diabetes Is the result of insulin resistance The pancreas makes insulin, but the body

cannot use it correctly Can sometimes go into remission with diet

control, exercise and weight loss Is usually treated with a combination of

insulin and oral medication when newly diagnosed

Medication Associated Occurs when medications interfere

with glucose balance by increasing glucose production and/or decreasing insulin production

Steroids, antirejection medications and some chemotherapies

May be treated with diet management or insulin, depending on severity

CF Related

Occurs with damage over time to the pancreas which interferes with insulin production and release

Managed with insulin

Long Term Consequences

Over time, uncontrolled hyperglycemia damages small nerves and blood vessels and can lead to: Blindness Kidney Failure Peripheral Vascular and Nerve Damage

Signs and Symptoms

HYPERGLYCEMIA – glucose is unable to move from the blood into the cells

GLUCOSURIA – Kidney can’t reabsorb all the glucose, so it spills into the urine

DEHYDRATION – Water is pulled into the urine, along with the glucose and other electrolytes

Signs and Symptoms

KETOACIDOSIS – breakdown of fat as a fuel source results in formation of ketone bodies which are very acidic and lower the pH

LOW BICARBONATE – Buffers are used up in an attempt to regulate pH

NAUSEA/ABDOMINAL PAIN

Treatment

At diagnosis, Type 1 and Type 2 are treated with insulin. Insulin doses are based on the weight of the child, and are adjusted to the child’s sensitivity to insulin

Tests to differentiate the type of diabetes are not complete until after the child is discharged.

Treatment

Insulin doses require frequent adjustment as the child grows, enters puberty, goes through illness, or changes lifestyles. Family communication with the endocrine team is essential to the child’s health.

GOALS FOR DIABETES MANAGEMENT IN CHILDREN

Normal growth & development

Optimal glycemic control

Minimal acute or chronic complications

Positive psychosocial adjustment

GOALS FOR DIABETES MANAGEMENT IN CHILDREN

TARGET BLOOD GLUCOSE AND HEMOGLOBIN A1C

AGE BEFORE MEALS

BEDTIME HgbA1C

0 – 6 Years

100 -180 110 – 200 7.5 - 8.5

6 – 12 90 – 180 100 – 180 < 8

13 – 19 90 – 130 90 – 150 < 7.5

INSULIN TYPES/DOSING IN CHILDREN

DOSAGE: most children require 1 unit of insulin per kg/body weight if they are in puberty. Range 0.5-1.5u/kg/day. Overweight children may require the higher dosages.

During honeymoon may need as little as 0.3u/kg/day.

INSULIN TYPES/DOSING IN CHILDREN

70% of children /adolescents with type 1 diabetes enter a transient partial remission phase (honeymoon). During this the time insulin dose may need to be reduced and family will need to call the diabetes team.

Duration of honeymoon can last 2wks to 2 years.

Comparison of Insulin

INSULIN ONSET OF ACTION

PEAK EFFECT

DURATION

Novolog/

Humalog

5-15 minutes

1-2 hours 4-6 hours

NPH 1-2 hours 4-8 hours 10-20 hours

(avg 12 )

Glargine

(Lantus)

1-2 hours Flat 24 hours

INSULIN TYPES/DOSING IN CHILDREN

Dosage Breakdown NPH / Novolog or Humalog or Regular

2/3 of insulin is given in am and 1/3 in pm. This is further broken down to am: 2/3NPH & 1/3 Novolog. PM: 1/2 Novolog at dinner & 1/2NPH at bedtime.

Must have set meal times and fixed carbohydrate amounts.

Very rigid regimen and must be very structured family

INSULIN DOSAGES IN CHILDREN

Lantus insulin 24 hour basal insulin. Given once a day,

but never mixed in syringe with any other insulin.

Dose based on weight or previous total daily insulin dose (TDD). Dose is approximately 40-50% of TDD.

Lantus regimen continued

Novolog or Humalog insulin is used to cover meals/snacks. Diabetes team will prescribe and explain carbohydrate counting and ratio.

Should not have snacks that are not covered by Novolog/Humalog unless Lantus is given HS and then only 10 gram carb snack is needed.

INSULIN TYPES/DOSING IN CHILDREN

CORRECTION INSULIN : (Novolog or Humalog )

Given before meals and as ordered by Doctor.

Usually give 3% TDD > 200, 5% > 250, and 10% > 300. May decrease dose in ½ from 9pm-6am. Refer to MUSC diabetes orders.

INSULIN TYPES/DOSING IN CHILDREN

Type of insulin used based upon: eating patterns and age of child family patterns is individualized to meet all of above

INSULIN TYPES/DOSING IN CHILDREN

SITES:

Rotate sites . Young children will usually prefer arms, legs, & buttocks.

Insulin is absorbed quickest from abdomen, then arms, then legs, and slowest from hips.

Assess sites for hypertrophy or thickening before giving injections.

Abdomen and hips are used for insulin pump sites.

Diluted Insulin

When children require a very small amount of insulin, it must be diluted to make it easier to draw up and/or adjust the dose. Humalog insulin can be diluted. Only certain pharmacies can dilute insulin. Check with your diabetes team.

For most cases, insulin is diluted in a 1:10 ratio. So that 1 unit of insulin = 10 lines on the insulin syringe or 1 line = 0.1 units of insulin, or 1/10th of one unit.

Insulin Pumps Tips Any blood glucose > 240 on pump-

Check urine ketones If no ketones, give bolus via pump

and re-check in 1 – 2 hours. If positive ketones- DO NOT use

pump! Give a subcutaneous injection of Novolog/Humalog based on sensitivity factor and have the family change the pump site.

Insulin Storage Unopened vials of insulin

and unopened pen cartridges should be refrigerated

Insulin in use does not need to be refrigerated

Discard insulin vials and pen cartridges in use after one month

Dietary Teaching

A dietary consult must be ordered on All newly diagnosed diabetics All diabetics with an HgA1C > 9 All poorly controlled diabetics (admitted with

hypoglycemia, DKA, HHNK) Nurses do NOT need a physician order to call

for a dietary consult

Hyperglycemia

Causes: Too much food Not enough insulin

Stress

Illness/Injury

Injection Site

Symptoms: increased hunger, thirst and urination, “fruity odor” to breath, nausea, lethargy, blurred vision, decreased LOC

Hyperglycemia

Treated with insulin using a correction scale

Check ketones if FSBG is greater that 240. Moderate to Large ketones indicate ketoacidosis

Hypoglycemia Possible causes

-not enough food

-exercise without snack

-too much insulin

-stress

-injection site

-nausea and vomiting

Hypoglycemia Symptoms:

-mild: sweating, trembling, difficulty concentrating, lightheadedness

-severe: inability to self-treat due to mental confusion, lethargy, unconsciousness

Sugar is the main source of fuel for the brain. Young children may not recognize symptoms of shakiness, fast heart rate, and may go quickly to symptoms of drowsiness, behavior change, confusion, double vision, loss of consciousness, and/or seizure.

Hypoglycemia Prevention

Tell patient/family to call for low blood glucose reading patterns.

Tell patient/family to check blood glucose before bed. If blood glucose is less than 100 (children 6 and older) or 110 (under six), add approximately 10 grams of complex carb with protein/fat to the bedtime snack. Recheck blood glucose at 2 am.

Hypoglycemia Treatment Check blood glucose for

any symptoms of hypoglycemia. Blood glucose < 70 give 15 grams of fast acting sugar (3 glucose tabs, glucose gel, or 4 ounces of juice) and recheck blood glucose in 15 minutes. Repeat as needed until over 70.

Hypoglycemia Treatment Glucagon: Used for unconscious hypoglycemia in

patients without an IV

Glucagon is a hormone secreted by the pancreatic alpha cells that works to bring blood glucose up. When injected, it stimulates the body to release glucose immediately.

dosage: 1 mg IM for adults and children >20kg

0.5 mg IM for children under 20kg

Hypoglycemia Treatment

Unconscious hypoglycemia in hospitalized child with an IV should be treated with D25 (Diluted from D50)

See orders for dose.

Documentation Documentation is VITAL in diabetes management

Blood glucose Time of treatment for hypoglycemia Treatment of hypoglycemia Reason for hypoglycemia Time of retest Doses of insulin Ketones Carbohydrates consumed

Hemoglobin A1C

HgA1C is a measurement that allows an assessment of AVERAGE blood glucose levels over the last few months.

This should be done on every admitted diabetic patient who have no documented HgbA1C within the past 60 days.

Diabetic Admission History The nursing diabetic admission history allows: - Assessment of the patient/family understanding of their plan of care - Identification of problems in home management - Current insulin doses/regimen

The Diabetic Admission History MUST be done for every patient with diabetes, EVERY admission, regardless of the reason for Admission. All blanks must be filled in.

Exercise and Diabetes

As a general rule, for 30 minutes of exercise, you need to add 5 grams of complex carbohydrate before exercise if your blood glucose is under 100 (i.e. 2 saltines or ½ cup milk).

For 1 hour of exercise add 10 grams of complex carb before exercise if your blood glucose is under 100 ( i.e. 4 saltines). If exercise is going to be prolonged for more than 1 hour, add solid protein to the carbohydrate (i.e. peanut butter or cheese on saltines).

Sick Day Rules for Type 1 Diabetes

It is important to have a sick day plan.

Do not skip long acting insulin--ever.

Check blood glucoses every 2 hours

Check urine for ketones with every 2 hours, regardless of blood glucose.

Sick Day Rules Parents are taught to never skip long acting insulin when

sick. They will follow sick day diet and monitor more frequently. Will give short acting insulin if eating or for hyperglycemia.

During colds, sore throats, fever with high blood glucose not accompanied by Nausea/vomiting they may need to give entire insulin dose and may still need to cover hyperglycemia with additional insulin.

Sick Day Rules for Type 1 Diabetes

For nausea and vomiting that last more than 4- 6 hours, or for moderate to large ketones, call the diabetes team.

Sick Day Rules for Type 2 Diabetes If have type 2 diabetes and on insulin, follow

insulin and sick day diet guidelines for type 1 diabetes. If on 70/30 insulin, call diabetes team for dose adjustment.

If the patient is on Glucophage, Glucotrol, or Precose, oral diabetes medications arte not taken if nausea or vomiting is present.

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Sick Day Rules for Type 2 Diabetes

If blood glucose is running low will also need to drink at least 10-15 grams carbohydrate in the form of sugar containing fluids every hour .

This is best tolerated in 1-ounce amounts every 10-15 minutes. Good choices are Gatorade, ginger-ale, coke, Jell-O and regular popsicles.

Diabetic Teaching The Pediatric Diabetic Patient/Family

Interdisciplinary Education Flowsheet needs to be completed for EVERY diabetic patient on EVERY admission.

Newly diagnosed diabetics need in-depth teaching.

Known diabetics need a review of all survival skills with focus on problems identified.

Survival Skills Medication Management Nutrition Management Exercise Signs/Symptoms/Treatment of

Hypoglycemia Signs/Symptoms/Treatment of

Hyperglycemia Sick Day Guideline Discharge Information Emergency Contact Information

Closing Tips To Keep On Target

Monitoring: Because children with diabetes are still growing, their insulin doses require frequent adjustments.

Monitoring blood glucose at least 4 times per day is important to identify trends requiring insulin dose, diet and/or exercise regimen changes. Without frequent monitoring, there is more risk of developing dangerously high or low blood glucoses.

Closing Tips To Keep On Target

Eye exams are necessary for children with type 1 diabetes after 5 years and then yearly. Eye exams for children with type 2 diabetes should be conducted after achieving glucoses in a desired range for several months and then every 1-3 years.

Lipids, Thyroid levels, and Urine for Micoalbumin are assessed annually.