Children with Diabetes

Learning ObjectivesIdentify T1DM & T2DM in youth

Implement management strategies specific to a younger population

Apply screening and interventions for comorbidities and complications

Facilitate the transition from pediatric to adult diabetes care

Scope of Problem: IndonesiaNumber of children diagnosed with diabetes has increased more than 400% in last 3 years Estimate: 3/1000 children are diabetic

Jakarta Globe. Nov 8, 2012. http://www.thejakartaglobe.com/news/indonesias-reported-diabetes-cases-spike/554909

Clinical Characteristics of T1DM and T2DM in Children and AdolescentsIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Clinical Characteristics of T1DM and T2DM in Children and AdolescentsIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

PolyuriaPolydipsiaBlurring of visionWeight lossGlycosuriaKetonuriaVary from non-emergency to severe dehydration, shock and ketoacidosis

Presenting SymptomsIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Identification of KetoacidosisSevere dehydrationFrequent vomiting, abdominal painContinuing polyuria despite dehydrationWeight lossFlushed cheeksAcetone on breathHyperventilationDisordered senses (disorientation or semicomatose)Decreased peripheral circulation with rapid pulseHypotension and shock with peripheral cyanosisIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Ketoacidosis: ManagementImmediate assessment to confirm diagnosis: History, clinical signs, biochemical features and investigations

As needed: Resuscitation, IV therapy, insulin

Critical observations: Regular and frequent measurementsEvaluation of progress

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

T1DM and The Honeymoon PeriodPeriod of partial remission of the diseaseChilds pancreas produces some insulinDecreased demand for injected insulin (

Managing T1DM in Children

Goals of CareGain glycemic control

Minimize acute complications

Prevent/delay chronic complications

Achieve normal psychosocial development

Tamborlane WV, et al. In: Therapy for Diabetes Mellitus and Related Disorders. ADA. 5th ed; 2009.IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

BG and A1C Goals for T1DM by AgeADA. Standards of Medical Care in Diabetes-2012. Diabetes Care 35(suppl 1).

Insulin Therapy for T1DMAnalog-based basal-bolus regimensContinuous subcutaneous infusion of insulinMultiple daily insulin injections NPH-based regimensMay play a role for newly-diagnosed patients in honeymoon periodCorrect insulin dose: Achieves the best attainable glycemic control without hypoglycemic events, leading to healthy growth and developmentTamborlane WV, et al. In: Therapy for Diabetes Mellitus and Related Disorders. ADA. 5th ed; 2009.IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Managing T2DM in Children

Goals of CareIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DMManagement strategy will depend on the level of symptomsIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DM: SymptomaticIf target BG achievedIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DM: Asymptomatic If not reaching BG targetsIf not reaching BG targetsIf not reaching BG targetsMonthly reviews of progress including 3 monthly A1CsIDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Overweight Children and Adolescents in IndonesiaOver 3 years, the obesity prevalence increased in all childrens age groups, with the largest increase in the 15-18 year old female group

RISKESDAS 2010

Disease Management Strategies: T1DM & T2DM

Medical Nutrition TherapyChallenges: Nutritional requirements vs. food preferencesFitting in with friends Body image concerns Eating disorders Parties, special events, overnight trips

Recommendations: Collaborate with pediatric dietitian; adapt advice to cultural and family traditions as well as the childs needs

Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Exercise for Youth with DiabetesT1DM: Adjust snacks and insulin to level of physical activity

T2DM: Encourage physical activity to counteract sedentary lifestyleLimit screen time (computer, video games, etc.)Participate in group activitiesInclude family

Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Self-ManagementFamily involvement is important

Self-monitoring: Essential toolUsually 4-6 times/dayUsed to assess glycemic control and reduce the risks of acute crises and long-term complications

Encourage adolescents to assume increasing responsibility for diabetes management with parental involvement and support

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

Monitoring Sick DaysProvide patients with written guidance and counsel on management of diabetes when sick, and when to seek advice

Do not stop insulin; dose may need to be adjusted

More frequent monitoring of blood or urine ketonesChilds BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Screening and Management of Diabetes Comorbidities and Complications in Youth

ScreeningAnnual screening for microalbuminuria, with a random spot urine sample for albumin-to-creatinine (ACR) ratio

ManagementACE inhibitor

ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S40.IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.Recommendations: Nephropathy (T1DM)

Recommendations: Hypertension (T1DM)ScreeningBP should be monitored at every visit

Management:Diet & exercise interventionsIf target BP not reached within 3-6 months: ACE inhibitors

Target:

ScreeningIf family history: Fasting lipid soon after glucose control establishedOtherwise: At puberty (10 years)

ManagementOptimize glucose control, MNT, lifestyle changes> Age 10: Add statin if,LDL cholesterol >160 mg/dL (4.1 mmol/L) orLDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more CVD risk factors

Recommendations: Dyslipidemia (T1DM)Target: LDL cholesterol

Screening Ophthalmologic examination10 years of age; has had diabetes for 3-5 years Routine follow-up as recommended by eye care professionalRecommendations: Retinopathy (T1DM)ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

ScreeningMeasure tissue transglutaminase or antiendomysial antibodies, with documentation of normal total serum IgA levels, soon after diagnosisRepeat testing in children with symptoms or failure to thrive

ManagementPositive antibodies: Refer to a gastroenterologist Confirmed celiac disease: Consult with a dietitian to implement gluten-free dietRecommendations: Celiac Disease (T1DM)ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

ScreeningThyroid peroxidase, thyroglobulin antibodies at diagnosis; TSH after metabolic control established If normal, recheck every 1-2 years; or if patient develops symptoms of thyroid dysfunction, thyromegaly, or an abnormal growth rateRecommendations: Hypothyroidism (T1DM)ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

Recommendations: Screening for Complications T2DMHypertension: Routine BP checksDyslipidemia: Screen at diagnosisRetinopathy: Annual eye examNephropathy: Annual screening for microalbuminuriaADA. Therapy for diabetes mellitus and related disorders. 5th Edition. 2009.

How Good is Diabetes Control in Indonesian Youth?

T1DM Self-Management in IndonesiaResults of qualitative in-depth interviews:T1DM associated with fear, shame, sadness Participants sought alternative medicine Difficulty complying with self-management (especially diet) Suggest a buddy to help with self-management

(n=4 adolescents with T1DM)

Maylani AN, Wahyu YK. Int J Res Stud Psychol 2012;1(2):81-95.

Glycemic Control in Indonesian YouthStudy: 7 pediatric diabetes centers (n=69):T1DM mean HbA1C=10.5%85%/95% met ADA/EUDPG cut-off for inadequate controlT2DM mean HbA1C = 8.7%All patients had HbA1C >8%

Study: Pediatric endocrinology centre (n=24):8.2% had good metabolic controlMajority showed a low frequency of self-management

Batubara JRL, et al. Paediatr Indones 2002;42(11-12):280-6.Batubara JRL, et al. Paediatr Indones 2001;41:256-9.

Diabetes Complications & Self-Monitoring in Indonesian Youth Complications:5 out of 64 patients had recent hypoglycemia (8% in last 3 months)11 out of 64 patients had chronic complications:6 cases of neuropathy (9%)2 cases of retinopathy (3%)3 cases of microalbuminuria (5%)Self-monitoring 59% of patients did blood glucose self-monitoring8% of patients did urine glucose self-monitoring

Batubara JRL, et al. Paediatr Indones 2002;42(11-12):280-6.36

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Can Education Improve Outcomes? Indonesian DataStructured 6-month educational program:Improved patients and parents knowledge significantly but HbA1C at 3 months and 6 months did not improve

Two-day intensive diabetic camp:Improvement in glycemic control at 3 months follow-upEndyarni B, et al. Paediatr Indones 2006;46(11-12):260-5.Soenggoro EP, et al. Paediatr Indones 2011; 51:294-7.

Psychosocial Concerns

Emotional DynamicsAdolescent PatientwithDiabetesParentsConfusedConcerned/FearfulGuiltySiblingsJealous of the attentionConcernedResponsibleTeachersConfusedConcernedPeersResponsibleConcernedChilds BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Diabetes EducationNeed multidisciplinary team including family, teachers, and peers

Routine assessment and education:Disease management: Including knowledge, insulin adjustment, problem-solving, treatment adherenceDevelopmental progress in physical, academic, and psychosocial development

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

Diabetes at SchoolTeachers/staff may require education about diabetes

Parents can helpMeet with staffProvide basic education if necessaryProvide training on what to do in an emergencyEnsure that supplies are available

Adapted from Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Adolescent ChallengesPuberty can have a physiological impact on glycemia

Self-image and body issues

Risk-taking behaviours, exposure to smoking and drugs

Protectiveness of parents versus adolescent desire for independence

Recommendations: Use communication skills that are patient-centered, supportive and confidential

Adapted from Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Promoting a Successful Transition from Pediatric to Adult Diabetes Care

Why is the Transition to Adult Care Important?Young adults are vulnerable and at high risk of falling through the cracks

Poor glycemic control

Psychosocial issues

Reproductive health issues

Substance use and abuse

ADA Joint Position Statement. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems. Diabetes Care 2011;34:2477-2485.

Evolving Targets: From Adolescence to AdulthoodADA. Standards of Medical Care in Diabetes. Diabetes Care 2012;35(1):S11-S63.

Long-Term Impact of Glycemic Control: From Adolescence to AdulthoodDiabetes Control and Complications Trial (DCCT):Subset of patients 13-17 years of ageIntensive insulin vs. conventional therapyFollow-up 4-9 years later

DCCT Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Ped 1994;125(2):177-88.vs.

Chart1

57Microalbumin.Microalbumin.

53RetinopathyRetinopathy

70Retin progressionRetin progression

Intensive

Column1

Column2

Decreased risk (%)

Decreased risk of complications with intensive vs conventional therapy

Sheet1

IntensiveColumn1Column2

Microalbumin.57

Retinopathy53

Retin progression70

To update the chart, enter data into this table. The data is automatically saved in the chart.

Sheet1

Summary: Factors Influencing Poor TransitionUndetected and untreated complications

McGill M. Horm Res 2002;57(suppl 1):66-68.

Transition GoalsProvide effective process for transition of care from pediatric to adult centres

Achieve glycemic control to prevent complications and maximize functioning

Provide education, skills training, and transition support ADA Joint Position Statement. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems. Diabetes Care 2011;34:2477-2485.

What This Means for AdolescentsAs adolescents grow up, they must learn toAccept responsibilityMake independent decisionsHave financial independence

They mightBe unwilling (or unable) to see a pediatric diabetes health care teamBe leaving home for school/work Become pregnant and receive care from an adult diabetes health care team

Why Do Some Patients Have Difficulty with the Transition?Fear of leaving the pediatric care team they know

Lack of preparation for transition

Lack of trust in the adult health care system

Transition: Educational Needs

Steps for Successful Transition: Pediatric TeamBegin transition process during adolescence

Work with the patient and family to create a plan

Identify appropriate adult diabetes health care teams for transition

Create transition clinic days

Write a transition plan

Develop a clinical summary document

Weissberg-Benchell J. Transitioning from pediatric to adult care. Diabetes Care 2007;30:2441-2446.

Steps for Successful Transition: Adult TeamInteract with pediatric diabetes team

Consider needs of young adults

Include family members as requested by patient

Obtain/create developmentally-appropriate teaching materials

Weissberg-Benchell J. Transitioning from pediatric to adult care. Diabetes Care 2007;30:2441-2446.

SummaryManagement plan:Address psychosocial factors unique to adolescentsDiet and self-monitoring informationEducation directed to patient, family, teachers, and peers

Promote optimal glycemic management and screening for complications to prevent complications or allow for early intervention

Plan for transition from pediatric to adult diabetes care to include:Methods to ensure follow-up and adherence Education on adult topicsPromotion of glycemic controlScreening and prevention of complicationsScreening and management of psychosocial issuesEducation and support for disease self-management

Summary

Case Study: Mr. K.L.18-year-old male with T1DMCurrent regimen: Premixed insulin 25/75 32-0-30Physical examinations: Within normal limitsLaboratory examinations:Hb 13.2 mg/dL; Leu 6,000; Thrombosit 280,000; AST 30 ALT 28; BUN 40; Creatinine 0.6; HbA1C 8.8%He feels glucose control is fine and rarely visits the doctor He often self-adjusts his insulin dose

Case Study: QuestionsWhat issues should be considered with regard to his transition from pediatric to adult care? What strategies can be used to address these issues?

***WDF pres found at:http://www.arrow.org.my/WDF/SS2.9-2DM%20and%20Maternal%20and%20foetal%20healthnew.pdf

*Acanthosis nigricans is a skin disorder in which there is darker, thick, velvety skin in body folds and creases.

**Youth with DKA should be managed in centres experienced in its treatment and where vital signs, neurological status, and laboratory results can be monitored frequently.

*Detailed algorithm available in:IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

****Speakers Notes:The key concepts in setting glycemic goals are the following:Goals should be individualized, and lower goals may be reasonable based on the benefit-risk assessment.Blood glucose goals should be higher than those listed above in children with frequent hypoglycemia or hypoglycemia unawareness.Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels, and to help assess glycemia in those on basal/bolus regimens.

*Tamborlane WV, Sikes KA, Swan K, et al. Type 1 Diabetes in Children. In: Therapy for Diabetes Mellitus and Related Disorders. ADA. 5th ed; 2009.

Speakers Notes:Analog-based basal-bolus regimensContinuous subcutaneous infusion of insulin. Consider in patients with recurrent severe hypoglycemia, wide fluctuations in BG, or suboptimal diabetes control.

******Indonesia Basic Health Survey was conducted by MOH in 33 provinces. First IBHS was conducted in 2007, while IBHS-2 was in 2010.IBHS-1 covered 258,366 households and IBHS-2 covered 69,875 households.IBHS-2007 and IBHS-2010 showed that during 3 years the obesity prevalence in Indonesia was increased in all age groups: by 1.8% in toddlers, 2.5% in children 6-12 years old, and 5.5% in youths 15-18 years old.In adults 18 years the prevalence of obesity was increased by 1.4% (from 10.3% to 11.7%) while obesity among adults also increased from 8.8% to 10.7%.The results of IFLS and IBHS demonstrate that the prevalence of obesity in Indonesia has been increasing since 1993 and is greater in females.

Note BMI classification used:Normal = 18.5-22.9Overweight = 23-24.9Obese >25

**Refer to CORE Medical Nutrition Module for detailed information on Medical Nutrition Therapy.

*Refer to CORE module on Exercise for more detailed information.

****Recommendations:Confirmed, persistently elevated ACR on two additional urine specimens from different days should be treated with an ACE inhibitor, titrated to normalization of albumin excretion if possible.

Note IDF and ADA recommendations differ slightly with respect to when to begin screening:ADA: Once child is 10 years of age and has had diabetes for 5 yearsIDF: Once child is 11 years of age and has had diabetes for 2 years

*Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise aimed at weight control and increased physical activity, if appropriate.If target blood pressure is not reached with 3-6 months of lifestyle intervention, pharmacologic treatment should be initiated.

*People diagnosed with T1DM in childhood have a high risk of early subclinical1-3 and clinical4 CVD.

If there is a family history of hypercholesterolemia (total cholesterol 240 mg/dl) or a cardiovascular event before age 55, or if family history is unknown, then a fasting lipid profile should be performed on children 2 years of age soon after diagnosis (after glucose control has been established).

*Although retinopathy most commonly occurs after the onset of puberty and after 5-10 years of diabetes duration,1 it has been reported in prepubertal children and with diabetes duration of only 1-2 years.Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, and experience in counseling the pediatric patient and family on the importance of early prevention/intervention.Note: IDF recommends screening begin after 11 years of age and diabetes for 2 years.Recommendations for those with type 1 diabetes and pediatric retinopathy2 are summarized on this slide.The first ophthalmologic examination should be obtained once the child is 10 years of age and has had diabetes for 3-5 years.After the initial examination, annual routine follow-up is generally recommended; less frequent examinations may be acceptable on the advice of an eye care professional.

*Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with T1DM (1-16% of individuals compared with 0.3-1% in the general population).1,2Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition due to malabsorption, other gastrointestinal problems, and unexplained hypoglycemia or erratic blood glucose concentrations.3

Children with T1DM should be screened for celiac disease by measuring tissue transglutaminase or anti-endomysial antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes.Testing should be repeated in children with growth failure, failure to gain weight, weight loss, diarrhea, flatulence, abdominal pain, or signs of malabsorption, or in children with frequent unexplained hypoglycemia or deterioration in glycemic control.

*Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17-30% of patients with type 1 diabetes.1About one quarter of children with type 1 diabetes have thyroid autoantibodies at the time of diagnosis;2 presence of these autoantibodies is predictive of thyroid dysfunction, generally hypothyroidism but also less commonly hyperthyroidism.3Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia4 and with reduced linear growth.5Hyperthyroidism alters glucose metabolism, potentially resulting in deterioration of metabolic control.6

***

Maylani AN, Wahyu YK. Experiencing and managing Type 1 diabetes mellitus for adolescents in Indonesia: An integrated phenomenology and indigenous psychological analysis. International Journal of Research Studies in Psychology 2012;1(2):81-95.

*Batubara JRL and the Diabcare-Indonesia 2001 Study Group. Audit of childhood diabetes control in Indonesia. Paediatrica Indonesiana 2002;42(11-12):280-6.

7 pediatric diabetes centres:4 in Java: Jakarta, Bandung, Semarang, Surabaya2 in Sumatra: Medan, Palembang1 in Sulawesi: Makassar

Mean age of onset for T1DM = 10.6 years (range 1-17)* Centrally measured HbA1C was available in 60 of the type 1 patients

*Batubara JRL and the Diabcare-Indonesia 2001 Study Group. Audit of childhood diabetes control in Indonesia. Paediatrica Indonesiana 2002;42(11-12):280-6.

*Endyarni B, Batubara JRL, Boediman I. Effects of a structured educational intervention on metabolic control of type 1 diabetes mellitus patients. Paediatrica Indonesiana 2006;46(11-12):260-5.

Endyarni et al.Participants: 21 children with T1DM (aged 8-17 years) and their parentsLocation: University of Indonesia Medical School, 2005Educational program: Classroom teaching + small group discussion + role playing

Soenggoro et al.Participants: 28 children aged 7-18 yearsA1C measured before and 3 months after camp

**********Speakers Notes:Initiate discussion with audience using the following questions to adult health care providers:How do these patients usually find you?How long have these patients typically been without care by the time you see them?

***Speakers Notes:Researchers have found that a mutual trust forms among pediatric patients, their families, and their health care providers. Patients and families surveyed said they perceived pediatric staff to be more available for questions and emotional support compared to adult-oriented office teams.Past studies have shown the transition isn't easy, even for the average healthy adult often because of lack of insurance and many drop out of the health care system until they become sick. However, a smooth shift is vital for young adults with chronic illness who cannot afford to experience a lapse in care. Yet these patients often must switch doctors at a time when they too are least likely to be covered by health insurance due to their age and issues related to school attendance and employment.

Reference:Adapted from: Anne Arundel Medical Center. Children with chronic illness need guidance to adult care. For Your Child. Available at http://www.aahs.org/neighbors/news/index.php?id=16302. Accessed January 11, 2008.

**Things to be included in written transition plan:Assessment of patients knowledge and skillsInformation regarding adult-care providersInformation about access to funding/insurance coverage

Consider patients/familys needs and requestsProvide info on adult diabetes care teamsReview insurance issues

******