Diabetes Treatments

Unless children with diabetes are diagnosed. promptly and treated The term diabetes mellitus refers to sev- eral related disorders, all associated with …

CCUR IE I B E R T R O D G E R S S C H O O L S O O N T S N U 2N G E D U C A T I O N C O U R S E

Diabetes in Children
4 H r s 1695

COURSE

ABSTRACT

This course is designed to provide registered nurses, licensed practical nurses, nursing assistants, social workers, mental health counselors, and other healthcare professionals, particularly those who work in pediatrics or endocrinology, with a thorough knowledge of pediatric diabetes–its diagnosis and its treatment as related to the biopsychosocial and developmental needs of the pediatric diabetes client and family members The content includes pediatric age characteristics and needs; the six types of diabetes; the variations of this chronic disease among adults, children, and adolescents; the diagnosis, signs and symptoms, and staging of diabetes; thorough coverage of type 1 and type 2 diabetes in terms of risk factors, onset, self-care, pharmacological interventions such as insulin and oral hypoglycemic agents, exercise, and diet as well as blood glucose monitoring; hypoglycemia and hyperglycemia; and the emotional, developmental, and psychological needs associated with this chronic disease

Kathleen L Miller,
ARNP, PhD

Bert
Rodgers Schools of Continuing Education is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Centers ANCC Commission on Accreditation Bert Rodgers Schools is also approved by the Florida Board of Nursing, Provider FBN 2783, by the Florida Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling, Provider BAP570Exp 3/2005, and by the California Board of Registered Nursing, Provider CEP 12763

Learning Objectives
1 Differentiate among the six types of diabetes in terms of etiology, incidence, and populations at risk 2 Compare and contrast the features of several types of diabetes among adults and children 3 Describe the signs and symptoms, diagnosis, and staging of diabetes among children 4 Detail type 1 and type 2 diabetes in terms of risk factors, pattern of onset, signs and symptoms, self-care, treatment, and monitoring 5 Detail and compare the etiology, symptoms, treatment, and major features of hyperglycemia and hypoglycemia in children 6 Generate a pediatric plan of care that provides for the emotional, developmental, and psychological needs associated with this chronic
disease

INTRODUCTION
Diabetes is typically perceived as a disorder of older adults; however, diabetes occurs in 1 out of 600 children under 18 years of age, and the incidence appears to be increasing1 Unless children with diabetes are diagnosed promptly and treated appropriately, they are at serious risk for acute and long-term complications

The term diabetes mellitus refers to several related disorders, all associated with alterations in glucose utilization Diabetes mellitus is a complex metabolic disorder that is exemplified by a relative imbalance between insulin production and body metabolic needs There is either a deficiency of insulin production or an impaired sensitivity to the amount of insulin produced Although
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Kathleen Miller received her BSN from West Virginia University and her MSN and PhD in Nursing from the University of Florida She has over thirty years of experience in nursing, primarily in pediatrics She is currently employed as a full time pediatric nurse practitioner and assistant professor in the University of South Florida College of Medicine, Department of Pediatrics, Division of Diabetes and Endocrinology She functions as the clinical
coordinator of the pediatric program for the USF Diabetes Center She has presented

2004 Bert Rodgers Schools of Continuing Education

w w w b e r t r o d g e r s c o m

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Bert Rodgers Schools Continuing Education Course

in numerous local, state, national, and international conferences and has a variety of publications and professional memberships

disordered glucose metabolism and utilization is the most well-recognized characteristic of diabetes, other metabolic problems may be present, including alterations in amino acid, protein, and lipid metabolism2 Insulin is a hormone produced by the beta cells of the pancreas This hormone supports the metabolism of carbohydrates, fats, and proteins Insulin is necessary to: promote the entry of glucose into fat and muscle cells; prevent the mobilization of fats from fat cells; and promote the storage of glucose in the liver and muscles as glycogen The chemical composition and molecular structure of insulin allow it to fit into receptor sites on the cell membrane By a poorly defined mechanism, insulin then facilitates entry of metabolites into the cell and stimulates enzymatic systems to metabolize glucose for energy
production3

TYPES OF DIABETES
Various forms of diabetes have been classified by the National Diabetes Data Group of the National Institutes of Health Table 1 illustrates the current and previous terminology associated with various types of diabetes Individuals with type 1, or insulindependent diabetes mellitus are deficient in insulin production due to beta cell dysfunction These persons are dependent on exogenous insulin for life to prevent ketosis, or the metabolism of fat to produce energy This type is most common in the pediatric population but can occur at any age Individuals with type 2, or noninsulindependent diabetes are those previously designated as having adult-onset diabetes In children, this condition is often referred to as MODY, or maturity onset diabetes of youth; however, MODY is really a subtype of diabetes associated with a specific single gene defect Type 2 diabetes involves a genetic predilection to insulin resistance combined with beta cell dysfunction that consists of the loss of the first-phase response of insulin to glucose levels4 Individuals with type 2 diabetes may have reduced, normal, or increased levels of insulin production and are thought to have a
defect at the cellular receptor level that interferes with the proper utilization of glucose in the face of hyper-

Studypoint
About 17 million people in the United States, which is about 62 of the population, have diabetes Additionally, it is estimated that 111 million people have been diagnosed with the disease, and an astounding 59 million people, about one third of all diabetics, remain unaware of the fact that they are affected with this life threatening disease

glycemia Persons with type 2 diabetes may respond well to certain oral antihyperglycemic agents or may require exogenous insulin, in combination with oral agents, for optimal glycemic control Atypical diabetes mellitus ADM is an autosomal-dominant disease seen primarily in African American children It may demonstrate the clinical characteristics of both type 1 and type 2 diabetes It has been referred to as type 11/2 With the confusion surrounding diagnosis, it is difficult to estimate the number of individuals with this condition Islet cell antibodies ICAs are usually absent The presence of ICAs is an indicator that an autoimmune process is destroying the beta cells that produce insulin, such as occurs in type 1
diabetes; therefore, ADM is not a direct result of autoimmune beta cell destruction A family history that is positive for early-onset diabetes in three or more generations is indicative of ADM Females of childbearing age with gestational diabetes are those who develop glucose intolerance during pregnancy They typically are not diabetic prior to the onset of pregnancy, and, in most cases, the diabetic state ends with delivery Secondary diabetes is a type of diabetes associated with pancreatic disease, hormonal changes, adverse effects of drugs, trauma to the pancreas, or other anomalies Children with cystic fibrosis, individuals who undergo chemotherapeutic treatment of cancer, and victims of trauma are among the populations of individuals affected with this type of diabetes An additional subclass, impaired glucose tolerance IGT, affects individuals whose plasma glucose levels are abnormal but not sufficiently beyond the normal range for them to be diagnosed as diabetic

INCIDENCE
About 17 million people in the United States, which is about 62 of the population, have diabetes Additionally, it is estimated that 111 million people have been diagnosed with the disease, and an
astounding 59 million people, about one third of all diabetics, remain unaware of the fact that they are affected with this life threatening disease5 This approximation includes an increasing number of children under 18 years of age Many children go undiagnosed until they become acutely ill or an elevated

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blood glucose level is found on a routine or sports physical examination The incidence of diabetes increases with age in children as well as in the general population6 Type 1 diabetes represents 5 to 10 of all diagnosed cases of diabetes; however, past statistics indicated that approximately 95 of children with diagnosed diabetes had type 1 Type 2 diabetes accounted for over 90 of the total number of diagnosed cases In the past, fewer than 5 of children had type 2, but the ratio is rapidly changing as more children are diagnosed with type 2 and atypical diabetes Results of studies have demonstrated that type 2 diabetes accounted for 2 to 4 of all cases of diabetes in children prior to 1992 By 1994, the incidence had increased to 16 of all new cases of diabetes in children Recent data indicate that as many as 20 to 30 of newly diagnosed children with
diabetes may have type 27 Gestational diabetes occurs in 2 to 5 of all pregnancies Typically, gestational diabetes develops or is identified during pregnancy and resolves following the birth of the baby; however, 40 of those women will go on to develop diabetes within 10 to 20 years The increasing incidence of teen pregnancies puts young females of childbearing age at greater risk for diabetes in the future8 Approximately 1 to 2 of all cases of diabetes are related to pancreatic insult, genetic disorders, surgery, medications, toxins, malnutrition, infections, or other causes In recent years, a shift to these types of diabetes has occurred in children as those with disorders such as cystic fibrosis and cancer are living longer and are demonstrating an increased incidence of hyperglycemia9 The prevalence of type 1 and type 2 diabetes varies among populations Racial differences in insulin sensitivity are evident in childhood There is some suggestion that type 1 diabetes occurs less frequently in those populations in which the incidence of type 2 diabetes is increasing, such as Native Americans, Hispanics, African Americans, and Polynesians African American children 7 to 11 years of
age have significantly higher insulin levels than age-matched Caucasian children10

TABLE 1: CLASSIFICATION OF DIABETES MELLITUS
CURRENT TERMINOLOGY PREVIOUS TERMINOLOGY

Type 1, insulin-dependent

Juvenile-onset, insulinsensitive, labile, ketosisprone, brittle Maturity-onset, insulinresistant, nonketotic, ketosis-resistant None Gestational, diabetes of pregnancy None Chemical, latent, borderline, asymptomatic, prediabetes

Type 2, noninsulin-dependent

Type 11/2, atypical Gestational Secondary Impaired glucose tolerance

Source: Table prepared by the author

COMPARISON OF TYPES OF DIABETES IN CHILDREN
Understanding the differences between the various types of diabetes is critical for diag-

nosis and treatment Table 2 illustrates the differences between the two most prevalent types of diabetes in adults and children The heterogeneity of diabetes has been demonstrated through family, twin, hormonal, immunologic, and genetic studies Family studies indicate that type 1 and type 2 diabetes segregate in an unrelated fashion Studies involving twins show that fewer than 50 of monozygotic twins are both likely to develop type 1 diabetes, whereas 100 of monzygotic twins show concordance
for type 2 diabetes Hormonal studies demonstrate a deficiency of insulin production in type 1 diabetes and a resistance to the action of insulin in type 2 diabetes Immunologic studies show that a predominance of individuals with type 1 diabetes have islet cell antibodies, while those with type 2 diabetes are ICA negative The presence of ICAs indicates a potential for the destruction of insulin-producing beta cells by a poorly understood autoimmune process Genetic studies reveal an association between specific alleles in type 1 but not in type 2 It is now possible to diagnose different types of diabetes more specifically than in the past, despite the fact that they share signs and symptoms Evidence indicates that an interplay between genetic, environmental, and

Studypoint
Understanding the differences between the various types of diabetes is critical for diagnosis and treatment

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TABLE 2: COMPARISON OF TYPE 1 AND TYPE 2 DIABETES IN CHILDREN AND ADULTS
FEATURES Age at onset of all diagnosed persons Seasonal trend Family history Appearance of symptoms Weight at onset Insulin levels Insulin resistance Insulin therapy Beta cells
Ketoacidosis ICA antibodies Acanthosis TYPE 1 Usually under 40 yrs of age 10 adults; 95 children Fall and winter Uncommon Usually acute Weight loss; usually thin Decreased Occasional Always Decreased Frequent Usually positive Absent TYPE 2 Usually over 40 years of age 90 adults; 5 children None Common Slow, insidious Obese High, normal, low Often Optional Variable Rare Negative Present

Source: Table prepared by the author

other biological mechanisms must occur to produce the disease This is evidenced by the marked incidence of auto-antibodies in genetically predisposed but nondiabetic firstdegree relatives of persons with diabetes11 Table 3 illustrates a comparison of factors in the various types of diabetes in children and adolescents Studypoint
Despite warning signs, diabetes in children often goes unrecognized

DIAGNOSIS
Despite warning signs, diabetes in children often goes unrecognized Children in normal circumstances experience occasional episodes of excessive fluid intake, followed by increased urination, nocturia, and enuresis The coexistence of abdominal pain with elevated blood sugar in the child with diabetes is extremely common and remains a leading cause of confusion
in making the diagnosis Pediatricians often pursue possible causes for the abdominal pain such as psychogenic factors and miss the primary diagnosis of diabetes Children also demonstrate episodes of increased appetite during growth spurts, with a perceived slimming down as the

child grows taller In the obese child, weight loss is often praised by the parents, and the situation persists Therefore, parents are often unaware of the existence of the metabolic imbalance until the child visits a clinic or doctor for a routine checkup or becomes acutely ill The symptomatology of diabetes is even more evident in children than in adults, so it is surprising that children are often misdiagnosed or undiagnosed In many instances, a child is thought to have a urinary tract infection because of polyuria, polydipsia, and nocturia and/or enuresis, or gastroenteritis if the child is vomiting The child may be mildly or acutely ill, depending on the extent of beta cell destruction and the degree of progression of the condition Lack of recognition of the situation often results in excessive parental guilt, particularly if the child becomes acutely ill As in the adult population, more cases of
diabetes are being diagnosed since the American Diabetes Association lowered the level of serum glucose that constitutes a diagnostic criterion in June 1997 Table 4 summarizes the diagnostic criteria for diabetes

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TABLE 3: COMPARISON OF TYPES OF DIABETES IN CHILDREN AND ADOLESCENTS
CHARACTERISTIC Age Onset Insulin level Insulin sensitivity Insulin dependence Genetics Race/ethnicity TYPE 1 Throughout childhood Acute, severe Very low Normal Permanent Polygenic All TYPE 2 Pubertal Mild to severe; often insidious Variable Decreased No Polygenic African American, Hispanic, Asian, Native American 1020 ADM Pubertal Acute, severe Moderately low Normal Variable Autosomal dominant African American MODY Pubertal Mild, insidious Variable Normal No Autosomal dominant Caucasian

Frequency of all diabetes in youth Associations: Obesity Acanthosis Autoimmunity

80

510

Rare

No No Yes

Strong Yes No

Variable No No

No No No

Source: A L Rosenbloom, J R Joe, R S Young, and W E Winter, Emerging Epidemic of Type 2 Diabetes in Youth, Diabetes Care, 22:345351 1999

Differential Diagnosis
Findings on physical examination depend on the duration and severity of the dysfunction
The onset of diabetes may be insidious and may occur in several stages The progression through the stages may be gradual or rapid and may go unrecognized during the earlier stages Stage 1 A finding of elevated blood glucose may be present on a routine physical examination Hyperglycemia may be present in either the fasting or the postprandial state The child may be otherwise asymptomatic Acanthosis, a thickening and hyperpigmentation of the skin, may be present in children with type 2 diabetes in response to elevated glucose levels The presence of acanthosis often results in childrens being referred to dermatology Determination of underlying factors such as islet cell destruction by antibodies, trauma, infection, chemicals, or insulin resistance will direct further treatment Stage 2 As the blood glucose level exceeds the renal threshold, glycosuria, polyuria, polydipsia, and enuresis develop At this point, a child may be misdiagnosed as simply having a transient urinary tract infection Because of individual variation in the

renal threshold for glucose reabsorption, glycosuria alone is not diagnostic for diabetes If diminished glucose utilization has been present for many weeks or
months, weight loss or a decline in weight gain may be present The child may demonstrate fatigue or diminished exercise tolerance There may be blurred vision, headache, stomachache, polyphagia, or anorexia and nausea Children with blurred vision and headaches are frequently taken for eye exams; those with GI symptoms are often thought to have a flu Obese girls with irregular menses or amenorrhea and hirsutism are most likely to be diagnosed with

TABLE 4: DIAGNOSIS OF DIABETES
Fasting blood sugar Random blood sugar GTT
Source: Table prepared by the author

125 mg/dl on two separate occasions 200 mg/dl signs and symptoms 2 2 hr PP level 200 mg/dl 2

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Bert Rodgers Schools Continuing Education Course

polycystic ovarian syndrome as well as diabetes, which is usually not diagnosed except by an endocrinologist Stage 3 If fats have been metabolized for energy production, ketones may be present in varying amounts Depending on the severity of insulin deficiency in type 1 diabetes, laboratory findings of reduced plasma bicarbonate, reduced blood pH, increased anion gap, and hyperlipidemia may be present If glucose metabolism has been severely impaired, dehydration, respiratory
compensation for metabolic acidosis, and an altered level of consciousness may be present This constellation of symptoms is known as diabetic ketoacidosis DKA In type 2 diabetes, laboratory findings of increased insulin and C-peptide levels may be identified Treatment plans are typically determined by further laboratory findings, including ICA results Children with type 2 diabetes may be initially treated for type 1 diabetes until all laboratory results are back and a more definitive picture emerges The diagnosis of atypical diabetes mellitus, or type 11/2, often emerges over time Studypoint
Type 1, or insulindependent diabetes mellitus IDDM, is the most common form of diabetes in children

viduals with type 1 diabetes usually have islet cell antibodies as a result of the autoimmune process Research indicates that ICAs are present in more than 85 of persons with type 1 diabetes and may be present for more than ten years prior to the actual onset of symptoms and diagnosis Although the onset of type 1 appears to be acute, the disease may actually occur progressively and silently over several years as beta cells are destroyed It is not until 80 to 90 of the beta cells have been
destroyed that the signs and symptoms of diabetes become evident Children with type 1 typically present with the three Ps polyuria, polydipsia, and polyphagia, weight loss, lethargy, ketosis, hyperglycemia, and glycosuria They may also experience blurred vision, headache, nausea, and vomiting

Diabetic Ketoacidosis
When a deficiency of insulin occurs, glucose is unable to enter the cell and become available for energy production The glucose level in the blood rises This condition is called hyperglycemia Elevated serum glucose triggers an osmotic gradient that moves fluid into the intravascular space When the glucose concentration in the blood exceeds the renal threshold usually around 160180 milligrams per deciliter, glucose spills into the urine and produces glycosuria, the abnormal presence of glucose in the urine Polyuria, or excessive urine production, occurs as the kidney eliminates an abnormal amount of water along with the glucose Fluid losses result in polydipsia, or excessive thirst, as the body attempts to replace the water Fluid losses also result in the loss of essential body chemicals, especially potassium In the face of a cellular glucose deficiency resulting from a
deficiency of insulin production, the body utilizes fats and proteins for energy production This process produces the same drives that are seen in starvation The hunger mechanism is triggered, but excessive intake, or polyphagia, does not correct the problem Glucose levels in the blood are further increased as glucose is unable to enter the cells The body then resorts to alternative sources of fuel, such as fat Fat metabolism results in the conversion of fats to fatty acids and glycerol, which are then converted by the liver into ketone bodies as an alternative source of energy The presence of excessive ketones, or ketosis,

TYPE 1 DIABETES MELLITUS
Type 1, or insulin-dependent diabetes mellitus IDDM, is the most common form of diabetes in children The risk of developing type 1 diabetes is higher than that of developing virtually any other severe chronic disease associated with childhood Type 1 diabetes may be present at birth or may occur at any age throughout the life span This type of diabetes seems to have a peak onset at around 10 to 12 years of age in girls and at 12 to 14 years of age in boys The exact cause of diabetes is unknown; however, type 1, or IDDM, is thought to be
an autoimmune disease that occurs when an individual with a genetic predisposition to diabetes is exposed to a precipitating event, such as a viral infection The body reacts to the viral insult in an autoimmune fashion that causes the body to destroy its own tissue, in this case, the beta cells of the pancreas that produce insulin This viral etiology also helps to explain the seasonal variation in the onset of IDDM The seasonal variation is not as evident in children under five years of age; however, the marked increase of onset during winter months suggests a relationship to infectious disease, either in etiology or onset Indi-

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readily produces large quantities of hydrogen ions, causing a fall in plasma pH, or ketoacidosis Buffer systems, such as bicarbonate, combine loosely with hydrogen ions to form carbonic acid The carbonic acid dissociates into water and carbon dioxide Respiratory efforts to eliminate excess CO2 result in what are referred to as Kussmaul respirations, or labored breathing Unless proper therapy is initiated, the individual will eventually exhaust all compensatory mechanisms and death will result Diabetic ketoacidosis DKA is the
strongest contributor to the mortality rate of children with diabetes Type 1 diabetes should be strongly suspected in three groups of children: 1 children with glycosuria, polyuria, and a history of weight loss or failure to gain weight despite a voracious appetite; 2 children with transient or persistent glycosuria, with or without ketones; and 3 children who demonstrate metabolic acidosis, with or without stupor or coma DKA is determined by the presence of hyperglycemia usually 300 milligrams per deciliter, ketones, acidosis pH 73, and bicarbonate 15 milligrams per deciliter12

Insulin preparations In the past, insulin was derived from beef or pork sources; however, a human insulin is currently available It is produced by gene-splicing techniques or recombinant DNA in sources such as E coli The newer human insulin is less allergenic than beef or pork insulins, but it is somewhat more expensive A variety of insulin types are available and are dispensed in the United States in the 100-units-per-milliliter dosage strength A comparison of insulin types is presented in Table 5 As is evident, types of insulin vary in rapidity of onset and duration of action Blood glucose levels are
lowest when insulin has its peak effect It is important that snacks and meals be planned with this concept in mind Most children need parental supervision or assistance with insulin injection even when they are able to demonstrate proficiency with the task Children may accidentally or intentionally administer incorrect amounts or types of insulin Dosage There is no standard insulin protocol In the initial stabilization period and during diabetic ketoacidosis, insulin is administered intravenously to provide for tighter dose titration and serum glucose level regulation IV insulin is initially administered at a dosage of 01 units per kilogram of body weight per hour After stabilization, insulin may be given at one unit per kilogram per day for older children Children who are less than four years of age may receive one-half unit per kilogram per day Most children can be controlled with twice-daily injections of insulin In children over six years of age, the dosage is evenly divided into morning and evening doses; in many cases, younger children may receive two-thirds of their total daily dose in the morning and the remainder in the evening Insulin protocols vary according to physician
preferences and each childs individual situation The precise dose of insulin cannot be predicted, as insulin requirements do not remain constant but change continuously as the child grows and daily situations change When the initial diagnosis of diabetes is made, insulin requirements may be greater than one unit per kilogram of body weight per day However, the younger the child, the more sensitive he or she may be to the effects of exogenous insulin The insulin doses, therefore, have to be adjusted accordingly

Pharmacologic Treatment of Type 1 Diabetes: Insulin
For children with type 1 diabetes, the definitive treatment is insulin, because they are deficient in insulin production Prior to the discovery of insulin in 1921, diabetes was a fatal disease Now, however, the development and administration of exogenous insulin has successfully compensated for this previously fatal insulin deficiency In individuals with IDDM, exogenous insulin is a lifelong requirement A diversity of treatment plans must be available to meet the unique needs of each individual child Insulin needs are affected by and have to be modified according to dietary intake, physical activity, emotions, infections,
and physical growth Patterns of insulin requirement may be determined by frequent monitoring of serum glucose levels; insulin adjustments may be tailored to prevent hyper- and hypoglycemia The tighter the glucose control, the less at risk the child is for long-term complications, but the child is at a higher risk for acute complications, such as hypoglycemia, when unplanned or unexpected variations in diet, exercise, emotions, or state of health occur

Studypoint
A diversity of treatment plans must be available to meet the unique needs of each individual child Insulin needs are affected by and have to be modified according to dietary intake, physical activity, emotions, infections, and physical growth

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Bert Rodgers Schools Continuing Education Course

TABLE 5: COMPARISON OF INSULIN TYPES
TYPE Rapid Acting Humalog Short Acting Regular Intermediate Acting NPH Lente Long Acting Ultralente SOURCE COLOR ONSET PEAK DURATION

Human Human, beef, pork Human, beef, pork Human, pork Human, pork

Clear Clear Cloudy Cloudy Cloudy

515 minutes 30 minutes1 hour 12 hours 125 hours 46 hours

1 hour 24 hours 412 hours 615 hours 830 hours

24 hours 612 hours 618 hours 22 hours 36 hours

Source:
Table prepared by the author

Soon after initial diagnosis, stabilization, and initiation of insulin therapy, the beta cells resume increased insulin production and the need for exogenous insulin diminishes This phenomenon may be documented by increased plasma C-peptide levels This honeymoon period is of variable duration, from a few weeks to more than a year Following cessation of the honeymoon, insulin requirements are determined primarily by body weight Adjustments of insulin may also be necessary to accommodate hormonal changes during puberty and other periods of increased growth, to conform to patterns of blood glucose levels, and to compensate for the effects of psychological and stress factors Insulin needs are greatest during the period of adolescence Not only is this a time of increased growth, but the hormones of puberty reduce the effect of insulin, making the child insulin resistant It is not unusual for an adolescent to require as much as two or more units per kilogram Attempts are made to provide the majority of insulin to compensate for, or cover, food intake during the day, with a lesser dose at night when the child is fasting Alterations in the dose or the timing
of administration may be made during periods of increased physical activity, such as during football season Episodes of increased food intake, such as those that occur during some holidays, are often accommodated with increases in fastacting insulin Occasionally, additional insulin is needed during periods of illness, when metabolic needs are altered

Timing of insulin administration Insulin is typically given before breakfast and before the evening meal A variety of combinations of insulin types may be used according to physician preference Typical combinations include a rapid-acting and an intermediateacting insulin given as a single injection Alterations in the schedule can be made to adjust for patterns of hypo- or hyperglycemia For example, small children may receive the evening dose of intermediateacting insulin before bedtime to reduce the risk of nocturnal hypoglycemia Morning blood sugar levels are influenced primarily by the evening dose of intermediate-acting insulin on the preceding day, while bedtime blood sugars are mainly controlled by the dinner dose of fast-acting insulin Afternoon blood sugar levels are influenced primarily by the morning dose of
intermediate-acting insulin, while lunchtime blood sugars are dependent primarily on the action of fastacting insulin Therefore, alterations can be tailored to each childs unique blood glucose patterns The typical recommendation is to administer insulin at least 30 minutes before meals to allow sufficient time for absorption and to prevent a postprandial rise in blood sugar, which could occur if the meal were eaten immediately after injection However, this recommendation may be impractical in children who are unwilling to wait to eat, who are extremely active, who do not work this recommendation into their hectic schedules, or who have blood sugars at lower levels Children under these conditions may

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be more at risk for omission of the insulin dose or for hypoglycemia if insulin is given and then eating is delayed Therefore, insulin may be administered just prior to eating Although the majority of children can be successfully managed on two injections of insulin per day, many practitioners prefer intensified insulin therapy, in which multiple injections are given throughout the day In this type of administration, one injection of long-acting insulin is
given with multiple injections of fast-acting insulin throughout the day This method is thought to more closely simulate the basal secretion of endogenous insulin with periodic peaks of insulin in response to elevations in blood glucose with meals The Diabetes Control and Complications Trial 1993 showed that this type of more intensive treatment regimen provides tighter glucose control A multiple daily injection regimen is particularly suitable for a child whose diabetes is difficult to manage and who experiences wide daily variations in blood sugar levels Methods of insulin administration Although insulin is traditionally administered subcutaneously by injection, insulin may also be given through an insulin pump, administered by means of an air-jet needleless injector, or inhaled through a device similar to the inhaler with a spacer that a patient with asthma uses With the insulin pump or inhaled insulin, adjustments must be made more frequently, generally three or more times per day Usually, these variable adjusted doses occur with ingestion of food to prevent postprandial increases in blood sugar The insulin pump, of which there are several types, is a portable device that
delivers a small amount of fast-acting insulin every few minutes, similar to the naturally occurring basal and bolus doses of a normal pancreas before meals or with episodes of hyperglycemia When inhaled insulin is prescribed for the patient, a single dose of long-acting insulin is typically given by subcutaneous injection and is accompanied by doses of inhaled insulin throughout the day, usually before meals This method provides for tighter control of blood sugar values with a single injection Other methods of insulin administration are in the process of development In the normal pancreas, insulin is released at a steady basal rate with periodic bursts of insulin secretion in response to elevations in serum glucose levels Conse-

quently, serum insulin levels rise and fall in concert with glucose levels Regardless of the type of insulin used or the method of administration, this natural pattern cannot be precisely duplicated; the child receiving exogenous insulin is at constant risk for hyper- or hypoglycemia

Diet
The child or adolescent with diabetes has essentially the same nutritional needs as any other child of the same age, with the exception of a generally reduced need for
concentrated sugars, and concentrated sugars are not prohibited but may be merely reduced In a very active child, the need for sugar may actually be increased to prevent hypoglycemia Children with diabetes have little need for special foods such as diabetic or sugar-free products, or food supplements Unlike the child who releases endogenous insulin in response to elevations in blood glucose, the child with diabetes has a relatively unpredictable insulin response, dependent upon the type of insulin, time and site of administration, peak effect, duration, and absorption Consequently, there is not always a match between food and insulin effects In type 1 diabetes, a relative balance of food consumption, insulin, and physical activity influences fluctuations in serum blood glucose levels The types of foods consumed determine the times at which the blood sugar rises: for example, simple sugars raise the blood sugar quickly, while fats are more slowly metabolized and elevate the blood sugar hours after eating rather than having an initial effect When an individual has lost the ability to self-regulate the secretion of insulin in response to varying stimuli of glucose or amino acids, it
is essential to maintain the level of glucose as constantly as possible to avoid wide fluctuations between hypo- and hyperglycemia However, when the focus of the child and family is on the types and amounts of foods consumed, anxiety and family dysfunction occur The most critical aspects of diet are timing, regularity of intake, quality, and quantity of the foods consumed There are numerous dietary approaches to the regulation of blood glucose, including measured diets, unmeasured diets, calorie counting, exchange systems, and carbohydrate counting Despite everyones best efforts, though,

Studypoint
The child or adolescent with diabetes has essentially the same nutritional needs as any other child of the same age, with the exception of a generally reduced need for concentrated sugars

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Bert Rodgers Schools Continuing Education Course

no one approach has accomplished the desired effects Despite the difficulties, several nutritional principles can minimize problems with diabetes control: The diet should contain sufficient calories to balance daily expenditures for physical activity The distribution of calories should be calculated to meet the activity patterns of the child Extra
food should be provided for increased activity This can be a good time to allow the concentrated sugars that children often crave Cookies and candy may be used to prevent or treat hypoglycemia during times of intense physical exercise Nutritional needs for optimal growth and development should be met Weight and height should be tracked approximately every three months to ascertain that growth is appropriate and that the growth trajectories are normal and consistent Children must gain weight to grow; therefore, it should be noted that a decline in weight is usually mirrored by a decline in the slope of the height trajectory three to six months later Growth trajectories typically plateau at 16 to 17 years of age and can level out earlier in girls The diet should include a balance of all the essential nutritional components: carbohydrates, fats, proteins, vitamins, minerals, and water The total number of calories and nutritional components should be consistent from day to day The child may need snacks between meals to prevent interim hypoglycemia The midmorning snack is usually the first to be eliminated as the child grows older A bedtime snack is important for the prevention of
nocturnal hypoglycemia A common recommendation is to offer 45 to 60 grams of carbohydrate for meals, with 15 to 30 grams of carbohydrate for snacks However, this can vary among children, and it can vary in an individual child according to changes in his or her daily routine If possible, meals and snacks should be designed to correspond to the estimated peak action of the insulin administered Meals and snacks should be consumed at consistent times of the day The child should be offered a wide variety of foods

The child should be involved in the selection of his or her own diet Parental guidance should be offered in a nonjudgmental way Children should feel free to tell their parents if they deviate from the diet plan by omitting a meal or snack or if they consume concentrated sugars This will facilitate the adjustment of insulin and activity to avoid problems The diet should not become a focus of child and parental anxiety and concern During adolescence, resistance to the effects of insulin may increase The release of growth hormones and the hormones of puberty also contribute to natural elevations in blood sugar In addition, adolescents are typically emotional and subject to
exogenous stress; these emotional fluctuations may result in variations in blood sugar During this period, it is not unusual for parents to accuse a child of cheating and eating highcarbohydrate foods, since blood glucose values are unpredictably high However, diet and exercise play important roles in the management of the condition and in the achievement of optimal metabolic control A variety of dietary strategies have been utilized, including measured diets, caloric restrictions, exchange systems, carbohydrate counting, and unmeasured diets As a general rule, the less restrictive the diet, the more likely the child is to accept and follow it The most successful dietary management plan is one that the child and family can understand, accept, and use

Exercise
Exercise is highly recommended in diabetes as it lowers blood glucose and reduces the need for exogenous insulin Exercise tends to increase tissue sensitivity to the effects of insulin, even in the resting state; therefore, insulin requirements may be reduced The exercising muscles increase blood flow and increase the circulation, absorption, and utilization of insulin as well Exercise should be included as part of the plan
of daily activities and should be planned around the childs interests, developmental needs, age-specific characteristics, and capabilities Hypoglycemia can be prevented by adding or increasing a snack prior to or during exercise The timing and dosage of insulin can be adjusted to accommodate periods of intense activity

Studypoint
Exercise is highly recommended in diabetes as it lowers blood glucose and reduces the need for exogenous insulin

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Since childrens physical activities are largely unpredictable in time of occurrence, duration, and intensity, frequent monitoring of blood glucose levels can assist in the prevention and prompt treatment of low blood sugar Children with diabetes are never prohibited from exercising unless other health problems exist or unless the child has ketones in the urine Children with exceptionally poor diabetes control are particularly at risk for hyperglycemia; exercise in these children may stimulate ketone production as the body attempts to meet its increased metabolic needs Ketones contribute to abdominal discomfort, nausea, and possibly vomiting When this occurs, nutritional and metabolic imbalances are increased
Therefore, the child with demonstrated hyperglycemia and ketonuria should be discouraged from exercising until improvement is achieved The child should be encouraged to be involved in keeping his or her diabetes under control so that he or she may fully participate in physical activity The beneficial effect of exercise on metabolic control can be demonstrated by the decline in hemoglobin A1c levels when physical activity is increased

TYPE 2 DIABETES IN CHILDREN
Type 2, or noninsulin-dependent, diabetes is becoming more prevalent in children and at younger ages The pathophysiology of type 2 diabetes in children is similar to that in adults: insulin resistance and an inability of the body, despite elevated insulin levels, to maintain euglycemia blood sugar levels within the normal range Both genetic and environmental influences are thought to be involved For example, it has been found that a majority of individuals with type 2 diabetes have a positive family history for the same disorder Children with a family history of type 2 diabetes may manifest evidence of insulin resistance early in life13 Insulin resistance is a condition in which body tissues dont use insulin effectively to
reduce hyperglycemia Gradually, it takes more and more insulin to achieve the same effect on blood sugar levels Data suggest that a genetic predisposition to insulin resistance is highest in minority children A genetic predisposition, in combination with environmental factors, can result in an increased incidence of type 2 diabetes during physiologic and pathologic

states, such as puberty and obesity, that are typically associated with insulin resistance Additional hypotheses for the increased incidence of type 2 diabetes include changes in lifestyle that promote high-calorie, highcarbohydrate food intake combined with a more sedentary way of life These factors tend to promote obesity The dramatic increase in type 2 diabetes in children parallels the incidence of obesity In the obese individual, the pancreas must work very hard to provide enough insulin to meet the bodys metabolic demands As body size increases, insulin demands accelerate However, in type 2 diabetes, the body is unable to reduce blood glucose levels effectively Even though insulin levels may be extremely elevated, a relative insulin deficiency persists since endogenous insulin cannot be effectively utilized
Initially, the pancreas may secrete ever increasing amounts of insulin to compensate for hyperglycemia; however, eventually it fails to keep up as the beta cells become exhausted Individuals with type 2 diabetes may have elevated, normal, or deficient insulin production In addition, the level of C-peptide, a precursor of insulin formation, is frequently elevated as well Islet cell antibodies are usually negative in these individuals Children with type 2 diabetes present at different ages, but usually not before eight years of age Most of those diagnosed with type 2 are teens It appears that the growth hormones and sex steroids associated with puberty are associated with insulin resistance; thus, it is not surprising that the peak age at presentation of type 2 diabetes in children coincides with midpuberty When a child with a genetic predisposition for insulin resistance is affected by environmental risk factors, the additional insulin resistance during puberty may tip the balance from a state of compensated hyperinsulinism to inadequate insulin secretion and a glucose intolerance that persists Children with type 2 diabetes usually present with obesity, although weight loss may
occur as well In addition, these children have elevated blood glucose levels, glycosuria with or without ketosis, blurred vision, headache, and nocturia In many children, particularly in those with more highly pigmented skin, acanthosis nigricans, a thickening and hyperpigmentation of skin, may be evident Polyuria may be absent or mild Many children have no symptoms whatsoever Although this type of diabetes

Studypoint
Children with a family history of type 2 diabetes may manifest evidence of insulin resistance early in life

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Bert Rodgers Schools Continuing Education Course

tends to be nonketotic, children may initially demonstrate some degree of ketosis: up to 33 have ketonuria at diagnosis, and 5 to 25 of patients who are subsequently classified as type 2 have ketoacidosis at presentation This mixed pattern of symptomatology has caused some clinicians to designate these individuals as type 11/2 diabetics14 In adolescent females, menstrual irregularities, hirsutism, and virilization development of male secondary sex characteristics may occur This condition is known as polycystic ovarian syndrome Data about hyperandrogenism and type 2 diabetes are limited in the pediatric
population The symptoms of this syndrome tend to decrease with improved glycemic control

levels under control However, few guidelines for dosages and treatment schedules exist for children, as little information is available Despite these limitations, the longterm benefits of pharmacologic agents encourage their use The following categories of medications are currently available for use in type 2 diabetes in adults: Sulfonylureas eg, glipizide [Glucotrol] These agents, which have been in use for over 50 years, stimulate the secretion of insulin from the beta cells of the pancreas Side effects include hypoglycemia, weight gain, and progressive decline in beta cell function Meglitinides eg, repaglinide [Prandin] These agents also stimulate beta cell secretion of insulin; however, they are very shortacting and are usually taken prior to meals to provide a burst of insulin to prevent postprandial hyperglycemia Biguanides eg, metformin [Glucophage] These agents seem to inhibit glucose release from the liver by blocking gluconeogenesis and glycogenolysis Side effects include weight loss but also gastrointestinal symptoms of nausea, diarrhea, and other GI problems This medication has
been the most widely used in the pediatric population Alpha-glucosidase inhibitors eg, acarbose [Precose] These agents slow the absorption of glucose from the intestine, thereby blunting the rise in glucose Side effects may include gastrointestinal symptoms Thiazoladinediones eg, rosiglitazone, pioglitazone [Avandia, Actos] These drugs enhance glucose transport into target cells, especially muscle and adipose tissue Combination drugs glipizide/metformin [GlucoVance] Combination drugs combine the actions of two agents, glipizide and metformin, into a single pill, thereby enhancing efficacy and compliance These drugs are untested in the pediatric population Insulin Insulin has typically been used in individuals who are unresponsive to other therapeutic agents; however, current recommendations include starting insulin therapy early in the pharmacologic process, not as a last resort This recommendation has little popularity with children and

Treatment of Type 2 Diabetes
Children with type 2 diabetes are treated much like adults with the same diagnosis The primary treatment approach is an alteration in lifestyle, including both dietary modification and an increase in physical
exercise It is possible to ameliorate the condition with these two modalities alone However, children and adolescents can be more resistant to changing existing habits than adults With pediatric patients, implementing such changes can be especially challenging and may require the involvement of family and peers Attitudes toward food and physical activity are often deeply ingrained and culturally influenced A multidisciplinary approach can be effectively used, particularly if the individual is motivated to gain control over the condition Frequent positive reinforcement can be a valuable technique In the event that the child or adolescent is unable or unwilling to modify his or her lifestyle, pharmacologic intervention may become necessary

Studypoint
The primary treatment approach for type 2 diabetes is an alteration in lifestyle, including both dietary modification and an increase in physical exercise

Pharmacologic Treatment of Type 2 Diabetes
At present, few pharmacologic alternatives exist for the management of type 2 diabetes in children This is in contrast to the vast armamentarium of drugs available for treatment of type 2 diabetes in adults The discrepancy exists because few
antihyperglycemic agents have been approved by the Federal Drug Administration FDA for use in children As is the case with adults, children with type 2 diabetes may ultimately require treatment with medications to keep their blood sugar

Diabetes in Children

13

families who would prefer to avoid using injections if possible

The nutritional principles for type 2 diabetes that should be incorporated into the educational and management plan include the following: The diet should be nutritionally adequate for the age, activity level, and condition of the child The diet should include all food groups with smaller amounts of concentrated sugars, fats, and carbohydrates The diet should promote optimal physical development without obesity The diet should be culturally acceptable with regard to ethnic group and religious preference The diet should also take into account the childs individual preferences and should be based on the familys usual eating practices Acceptable substitutes for peer groupendorsed foods, such as pizza, chips, and fast-food dining, should be explored and incorporated into the dietary plan whenever possible Patterns of caloric intake should be proportionate to
blood glucose patterns throughout the day There is wide variation among individuals in their release of glucose in response to various foods Amounts of food and diet composition must take this fact into consideration The relative availability of glucose in the postprandial state makes interpretation of blood glucose levels difficult Although it is generally advisable for children to monitor their blood glucose levels in the preprandial state, determination of blood sugar levels two hours after eating can provide valuable information to guide management

Diet
As with other types of diabetes, diet is a primary concern in the management of type 2 diabetes In many instances, regulation of dietary intake alone can alter the progression of the condition and can control blood glucose levels Curbing or reducing obesity can be a valuable contribution to the prevention as well as the treatment of type 2 diabetes Aggressive educational efforts should be directed at modifying the eating habits of both children and their parents Parents may serve as negative role models if their dietary habits are poor Patient and family education about diet should take into consideration the cultural mores,
attitudes, and health beliefs of the child and family Often, a reduction in caloric intake or an alteration in the proportions of the components of the diet plan can result in weight loss and a reduction in glucose levels For example, reducing the consumption of carbohydrates alone can make a significant difference Just changing from regular soda to diet soda may help A nutritional consultation to design an individual treatment plan should be provided In many children and adolescents with type 2 diabetes, cholesterol and triglyceride levels are also elevated Nutritional counseling regarding a low-cholesterol diet may be indicated The pregnant teenager with diabetes has additional nutritional and pharmacologic challenges and concerns In gestational diabetes, elevated maternal glucose is transmitted through the placenta to the fetus, stimulating the release of fetal insulin High insulin levels contribute to the storage of extra glucose as fat, and fetal macrosomia, or large body size, results Fetal growth and development have implications for a safe, natural delivery In addition, oral hyperglycemic agents are prohibited during pregnancy These agents may have a possible teratogenic
effect on the fetus and result in congenital anomalies In secondary diabetes, such as that related to cystic fibrosis CF, diet can be a double-edged sword Children with CF need extra calories for weight gain and physical growth; however, those extra calories may contribute to hyperglycemia

Studypoint
In many children and adolescents with type 2 diabetes, cholesterol and triglyceride levels are also elevated Nutritional counseling regarding a low-cholesterol diet may be indicated

Exercise
Lack of physical exercise is strongly associated with the development of obesity and the development of type 2 diabetes Exercise or physical activity is essential in the control of type 2 diabetes Recommendations include: at least 30 minutes of physical exercise daily; limitation of sedentary activities, such as television viewing and computer use; participation in sports and other organized physical activities; and

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a regular program of exercise that has been developed around the childs interests and abilities Specific recommendations for exercise should be individualized to meet the unique needs of the particular child, family, and
social situation Safety issues also need to be considered; for example, outdoor activities may not be possible if the child lives in a socially unsafe environment Initially, it may be difficult for the obese child to exercise, particularly in front of peers Encouraging the child to walk rather than ride, to dance to music in the privacy of the bedroom or house, and to exercise for frequent, brief periods can have an advantageous effect For the child, exercising in the company of family or perhaps a peer can provide social support and encouragement Organized activities are especially beneficial in this regard As the child loses weight, physical activity should become easier

BLOOD GLUCOSE MONITORING
Home blood glucose monitoring has contributed greatly to improved diabetic control Children are able to use a small device to check their blood sugar levels within seconds wherever they are They can then use their knowledge of their blood sugar levels to make decisions regarding dietary intake, insulin dosages, and exercise Even young children can develop the capacity to perform this task and to initiate appropriate treatment Newer technologies allow for testing blood sugar levels in a
wide variety of sites Noninvasive methods are being developed and should be available soon Children usually tolerate this activity well with encouragement and support It is recommended that children with diabetes check their blood glucose levels at least three times a day: in the morning before breakfast, before the evening meal, and at bedtime In addition, checking it before lunch and during times of vigorous activity can be helpful in making adjustments in food and insulin In general, the higher the number of insulin injections patients take per day, the more frequently they should check their blood sugar levels Frequent monitoring is advisable with intensified, multiple-dose therapy and with insulin pumps15

The target range for blood sugar levels varies according to physician expectations and the type of diabetes For example, a range of 80180 milligrams per deciliter is generally acceptable for children with type 1 diabetes Individuals with type 2 diabetes are advised to keep their blood sugar levels below 140 milligrams per deciliter at two hours after meals Premeal glucose levels should ideally be within a normal range of 80120 milligrams per deciliter for all types of
diabetes Children using pump therapy should expect their two-hour postprandial blood sugars to be within normal range as well The Diabetes Control and Complications Trial in 1993 indicated that keeping blood sugar levels below 180 milligrams per deciliter greatly reduced the risk of complications including retinopathy, nephropathy, and neuropathy Patients and family members should also be educated about hypoglycemia, its symptoms, and how to treat the condition appropriately The type of meter provided to the child should be consistent with the childs abilities and needs For example, meter strips that require a minimal amount of blood or that are easy to apply a blood sample to are ideal for infants and toddlers Children and adolescents who are interested in data management would benefit from a meter that retains large amounts of data and can be downloaded onto a computer to generate printouts of patterns Education about the use and care of the meter is important so that children can use it appropriately

HEMOGLOBIN A1C
Hemoglobin A1c is a measurement of the average serum blood glucose values over a three-month period As red blood cells circulate in the bloodstream, glucose
molecules become attached to the hemoglobin A molecules and remain there for the duration of the cells lifetime Red blood cells break down after approximately 90 to 120 days, and the amount of glycosylated hemoglobin can be measured This measurement is valuable in assessing glycemic control, detecting incorrect testing or falsified results, monitoring the effectiveness of treatment changes, and determining nonadherence to the treatment plan The A1c is the gold standard of diabetic glycemic control and is used to determine insulin adjustments and alterations in management In the nondiabetic

Studypoint
It is recommended that children with diabetes check their blood glucose levels at least three times a day: in the morning before breakfast, before the evening meal, and at bedtime

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15

individual, the A1c is 4 to 6 In the patient with diabetes, a level of 6 to 8 is considered acceptable, while levels above that represent poor metabolic control Determination of the hemoglobin A1c level is instrumental in making alterations in the treatment plan

ACUTE COMPLICATIONS OF DIABETES IN CHILDREN Hypoglycemia
Hypoglycemia is usually defined as a blood sugar level below 60
milligrams per deciliter It is often referred to as insulin shock or insulin reaction Etiology Any time an individual is treated with insulin, oral antihyperglycemic agents, or other medications that have the effect of lowering the blood sugar, he or she is at risk for hypoglycemia Low blood sugar can occur when the body gets too much insulin, when snacks or meals are missed or delayed, when insufficient food is eaten relative to the amount of medication or physical activity, and when illness interferes with the absorption of sugar As blood sugar levels fall, the autonomic nervous system senses the decline and releases adrenaline, a stress hormone that elevates the blood sugar This occurs to ensure that the brain has an adequate supply of glucose, the major substrate for brain function If the situation is not treated promptly, the liver releases stored glucose to sustain blood sugar levels If the situation remains untreated, the individual becomes unconscious and may have seizure activity A significant result of seizure activity is an elevation in blood sugar Signs and symptoms Low blood sugar symptoms may vary in different people Signs and symptoms may include a change in
personality, shakiness, tremors, dizziness, faintness, slurred speech, muscle cramping, hunger, nervousness, stomachache, blurred vision, headache, fatigue, weakness, pallor, confusion, loss of ability to concentrate, irritability, sweaty or clammy skin, tingling of the mouth or tongue, drowsiness, loss of consciousness, and seizures Infants generally become irritable and jittery and may feed poorly Treatment When signs or symptoms occur, it is best to check the blood sugar to ascertain that hypoglycemia is truly present

With a rapid decline in blood sugar from a higher level to a lower level, signs and symptoms of hypoglycemia may occur in the presence of hyperglycemia If the blood sugar is elevated, no treatment is indicated as the signs and symptoms will spontaneously resolve without intervention If the blood sugar is low, a source of fast-acting sugar should be administered In infants, this may be glucose water or formula Give older children items such as 4 to 6 ounces of juice, three glucose tablets, hard candy, or regular soda Foods containing fat or protein should be avoided as they slow absorption and do not elevate blood sugar as rapidly as necessary If the child is
unable or unwilling to eat or drink, a tube of glucose gel or cake frosting can be instilled into the cheek pouch where it will be absorbed through the mucous membrane to raise the blood sugar Immediate treatment should be followed in 10 to 15 minutes by a snack containing carbohydrate, fat, and protein to prevent a further decline in blood sugar In the event that the child becomes unconscious, glucagon may be administered by injection Glucagon is a hormone naturally produced by the pancreas that rapidly elevates the blood sugar During seizure activity, the primary concern is to protect the airway and to protect the individual from injury Glucagon should also be given in the event of seizure Food and liquids should not be administered to an unconscious or seizing person Optimally, the medical management plan for the childs diabetes should be designed to prevent or minimize the occurrence of hypoglycemia

HYPERGLYCEMIA
Hyperglycemia, or blood sugar that is elevated above the normal range, may result from an imbalance of insulin, food, and exercise Etiology Causative factors of high blood sugar include insufficient insulin, excess food or food high in concentrated sugar, a reduction
in physical activity, infection or illness, and the effects of hormones The onset is usually gradual but can be rapid following the ingestion of concentrated sugar In the child with type 1 diabetes, levels over 180 milligrams per deciliter may be considered hyperglycemia; in the child with type 2 diabetes, high blood sugars are those over

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Bert Rodgers Schools Continuing Education Course

TABLE 6: COMPARISON OF THE MANIFESTATIONS OF HYPOGLYCEMIA AND HYPERGLYCEMIA
CHARACTERISTIC Onset Mood Mental status Somatic feelings Skin Mucous membranes Respiration Pulse Breath odor Neurologic signs Ominous signs Blood values: Glucose Ketones Osmolarity pH Hematocrit HCO3 Urine: Output Sugar Acetone Source: Table prepared by the author HYPOGLYCEMIA Rapid minutes Labile, irritable,nervous, weepy, combative Difficulty in concentrating, speaking, and focusing, lack of coordination Shakiness, hunger, headache, dizziness Pallor, sweating Normal Shallow Tachycardia Normal Tremors, hyperreflexia, dilated pupils, seizure Shock, loss of consciousness 6070 mg/dl Negative Normal Normal Normal Normal Normal Negative Negative HYPERGLYCEMIA Gradual Lethargic Dulled sensorium, confusion Thirst, weakness,
nausea, vomiting, abdominal pain Flushing, dehydration Dry, crusty Deep, rapid Kussmaul Less rapid, weak Fruity, acetone Paresthesia Acidosis, coma 200 mg/dl Positive High Low 725 High 15 meq/L Polyuria High High

140 milligrams per deciliter in the postprandial state Signs and symptoms Symptoms may vary among different individuals; however, they may include increased hunger and thirst; frequent urination; dry mouth; warm, dry, or flushed skin; fatigue, drowsiness, or diminished energy; headache; abdominal pain; blurred vision; and nocturia or enuresis Treatment The primary treatment of transient high blood sugar levels in persons with type 1 diabetes is the provision of additional insulin When blood sugar is elevated without an identifiable cause, the urine should be checked for the presence of ketones Ketones can contribute to abdominal pain, nausea, and vomiting The presence of ketones indicates a significant deficiency of insulin relative to the bodys

Studypoint
The manner in which children accept and deal with their diabetes depends in large measure on how their parents accept and deal with the diagnosis

metabolic demands In the absence of ketones, exercise may reduce an
elevated blood glucose level by using up excess sugar In individuals with any type of diabetes, the ingestion of large amounts of sugar-free fluids can assist in eliminating excess glucose from the body through the kidneys In the face of high glucose levels, food intake may be restricted or a reduction in carbohydrate intake may be recommended A comparison of hypoglycemia and hyperglycemia is presented in Table 6

EMOTIONAL ASPECTS
The manner in which children accept and deal with their diabetes depends in large measure on how their parents accept and deal with the diagnosis Those parents who are extremely overprotective may prohibit

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their childs development of autonomy in self-care of the condition and often prohibit them from experiencing many of the independent activities typical for their childs age, such as sleepovers, sports, and field trips These children may rebel against parental restraints as well as treatment demands and may not do well in managing the condition Parents who appear unconcerned or are in denial of the diagnosis give their child the message that compliance with the medical management plan and optimal metabolic control are
unimportant Children of these parents also do poorly in managing the condition and may develop long-term complications by not taking proper care of themselves Parents who normalize the condition into the family lifestyle and accommodate the demands of diabetes management within the normal context of the childs schedule provide the best scenario Children in these situations tend to do the best in terms of their emotional and physiologic adjustment to a complex and demanding condition

a wide array of emotions while dealing with the demands of the condition Behaviors related to denial, fear, anger, guilt, feelings of social isolation, and depression may occur Many of these feelings are related to the frustrations of not achieving good control; nonetheless, optimal metabolic control must be facilitated through a comprehensive collaborative plan of care, based on current needs, in order to avoid acute and chronic complications The plan should be adjusted as the childs and familys situation changes

Education About the Condition
The child and the family require education about the condition immediately following the diagnosis Even if the child and the family have been dealing with
diabetes in another family member, each situation is unique Initially, the educational plan should be formulated based on what the family already knows Misinformation may have been given, or the familys understanding may be lacking or inaccurate Also, anxiety may interfere with learning; therefore, identifying and addressing major concerns before presenting additional information may help Learning to manage the condition occurs over time and with experience The child and family should be educated in survival skills first: administration of medication, blood glucose monitoring, and recognition and treatment of hypo- and hyperglycemia may be all the family can handle at first Diet, exercise, sick-day management, and other components of the treatment plan can be taught at a later time

DEVELOPMENTAL LEVEL
Consideration of the childs developmental level is important from the time of diagnosis The childs developmental level and its implications for self-care should be continually reassessed Simply because the child is chronologically advanced does not mean that the child is emotionally or developmentally able to manage this complex condition independently However, the childs
developmental level may determine to a large degree the childs response to the condition and the level of his or her participation in its care Some children may accept responsibility for components of their care at younger or older ages than other children

Studypoint
The childs developmental level and its implications for self-care should be continually reassessed

Risk of Complications
Children with diabetes live moment to moment with the risk of complications, either acute or chronic At any time, hypoglycemic episodes can occur and affect their ability to function With prolonged poor metabolic control and persistent hyperglycemia, individuals are at risk for a wide variety of complications affecting the renal, cardiovascular, and nervous systems as well as visual problems and alterations in somatic growth and sexual function It is cognitively difficult for children to comprehend the ramifications and risks associated with longterm complications Developmentally, children feel invulnerable and live in the present moment without much consideration of the future Seeing a person who is blind or who

Living with a Chronic Condition
A chronic condition is defined as one that interferes
with or changes daily functioning for more than three months in a year Like all chronic illnesses, diabetes has a profound effect on the entire family, not just the affected child Incorporating the demands of the condition into the family lifestyle can be exhausting Family coping mechanisms should be assessed and supported by the entire multidisciplinary team The child with diabetes, as well as the family, may experience

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Bert Rodgers Schools Continuing Education Course

TABLE 7: CHILD DEVELOPMENT AND PARTICIPATION IN SELF-CARE
AGE 45 years FOOD Knows and dislikes INSULIN Knows where injections should be given Can pinch up skin Can wipe off area Can begin to assist with injections by inserting needle and pushing plunger May perform own injections with adult supervision TESTING Can collect urine for ketone testing Can turn on meter and wipe finger Can perform blood test with finger prick Can record results PSYCHOLOGICAL Identifies good and bad These terms should be avoided

67 years

Can begin to tell carbohydrate content of foods Able to make food choices and set limits Can select foods according to criteria and blood sugar values Knows whether foods fit diet plan Can help plan
meals and snacks

Needs many reminders and parental supervision

810 years

Can perform blood sugar test Can keep records Can perform urine test for ketones Can identify patterns in blood sugar levels Needs help in responding to urine ketones Can use test results to adjust insulin

Needs reminders and adult supervision of tasks Understands only immediate effects, not long-term effects

1113 years

Can measure and inject insulin

May be rebellious against conditions Concerned with being different

14 years

Can prepare some meals and snacks

Can mix and administer multiple insulins

Knows consequences of poor control Independence and self-image important Continued rebellion Preparing for the future

Source: Table prepared by the author

has had an amputation because of diabetes may be frightening, but it does not necessarily produce a change in behavior Additionally, constant reminders and scolding about the possibility of chronic problems may have the negative effect of causing children to give up on the idea of good control Studypoint
Children living with diabetes must learn to integrate the demands of the condition into their individual and everchanging lifestyles and
routines

poor self-esteem frequently have difficulty controlling the condition Table 7 provides reference for child development and appropriate participation in self-care

Self-concept
Many issues of self-concept arise from the need to fit in, or not be different from peers Fearing rejection, a child may attempt to hide the fact that he or she has diabetes In some instances, denial may lead to a deliberate rejection of components of selfmanagement, which may result in poor diabetes control Other issues that may interfere with successful management, particularly in adolescent girls, are weight awareness and body image Teens often use insulin adjustment to control weight gain Feelings of depression associated with the constant demands of managing the condi-

Self-empowerment
Children living with diabetes must learn to integrate the demands of the condition into their individual and ever-changing lifestyles and routines Children may be assisted along this continuum of care through careful assessment and encouragement of their individual capabilities Providing opportunities to develop self-care skills will promote selfconfidence Ultimately, a childs positive selfconcept will assist in
the achievement of control over the situation Children with

Diabetes in Children

19

tion may contribute to poor self-image and further reduce the childs motivation and ability to deal with the diabetes In many instances, counseling may be recommended to assist the child and family in dealing with the diagnosis, prognosis, treatment demands, and emotional issues At the very least, participation in support groups or camps for children with diabetes may help In instances in which the child demonstrates recurrent episodes of diabetic ketoacidosis, a psychiatric evaluation may assist in understanding the dynamics of the situation that are contributing to the poor metabolic control It is not unusual for children or adolescents to use their diabetes as an attentiongetting mechanism Being hospitalized with DKA is likely to garner the desired attention Children and adolescents often do not recognize the risks and consequences of poor metabolic control A childs ability to successfully control his or her diabetes over time indicates a successful outcome

Glossary
Acanthosis: A thickening and hyperpigmentation of the skin that may be present in children with type 2 diabetes in response to
elevated glucose levels The presence of acanthosis often results in children being referred to dermatology Atypical diabetes mellitus ADM type 11/2: An autosomal-dominant disease seen primarily in African American children It may demonstrate clinical characteristics of both type 1 and type 2 diabetes Diabetes mellitus: Several related disorders, all associated with alterations in glucose utilization It is a complex metabolic disorder that is exemplified by a relative imbalance between insulin production and body metabolic needs Diabetic ketoacidosis DKA: May occur if the metabolism has been severely impaired It causes dehydration, respiratory compensation for metabolic acidosis, and altered levels of consciousness Gestational diabetes: Affects females of childbearing age who develop glucose intolerance during pregnancy Typically, they do not have diabetes prior to the onset of pregnancy, and, in most cases, the diabetic state ends with delivery Glucagon: A hormone naturally produced by the pancreas that rapidly elevates the blood sugar Glycosuria: The abnormal presence of glucose in the urine Hyperglycemia: Occurs when a deficiency of insulin prevents glucose from entering the
cells Hypoglycemia: A blood sugar level below 60 milligrams per deciliter It is often referred to as insulin shock or insulin reaction Impaired glucose tolerance IGT: A subclass of diabetes that affects individuals whose plasma glucose levels are abnormal but not sufficiently beyond the normal range for them to be diagnosed as diabetic Insulin-dependent diabetes mellitus type 1: Affects individuals who are deficient in insulin production because of beta cell dysfunction

CONCLUSION
It is important to remember that the management of any given type of diabetes in children is different in some respects from the management of the same type of diabetes in adults These differences are related to the fact that children are physically growing and have cyclic release of numerous hormones; they have dramatic alterations in appetite and food preferences throughout the day; they have rapid fluctuations in levels of physical activity; and they have less stable and predictable daily routines Therefore, recommendations for the control of diabetes in adults may not work equally well in children, particularly in children of younger ages Parents feel particularly frustrated and confused when
confronted with wellmeaning advice from adults with diabetes They need reassurance that the treatment protocol should be individualized to the particular child and situation

NOTES
1 Long Island Jewish Medical Center Schneiders Childrens Hospital, Pediatric Endocrinology and Metabolism: The Program for Childhood Diabetes/ Pediatric Diabetes Diabetes: The Nature and Importance of the Problem

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Bert Rodgers Schools Continuing Education Course

Glossary continued
Intensified insulin therapy: A therapy in which multiple injections of insulin are given throughout the day instead of two per day Ketoacidosis: A fall in plasma pH caused by excessive ketones that produce large quantities of hydrogen ions Ketosis: The presence of excessive ketones that readily produce large quantities of hydrogen ions, causing a fall in plasma pH Kussmaul respirations: Also known as labored breathing, it refers to respiratory efforts to eliminate CO2 Maturity onset diabetes of youth MODY: While often used to refer to type 2 diabetes in children, it is actually a subtype of diabetes associated with specific single gene defects Noninsulin-dependent diabetes type 2: Involves a genetic predilection to insulin
resistance combined with dysfunctioning beta cells that have lost their first-phase response of insulin to glucose levels Polycystic ovarian syndrome PCOS: A condition in which menstrual irregularities, hirsutism, and virilization may occur in adolescent females Polydipsia: Excessive thirst that occurs as the body attempts to replace water losses Polyphagia: Eating to the point of gluttony Polyuria: Excessive urine production Secondary diabetes: A type of diabetes associated with pancreatic disease, hormonal changes, adverse effects of drugs, trauma to the pancreas, or other anomalies

3 D L Wong, Nursing Care of Infants and Children, 5th ed St Louis, MO: Mosby, 1995, 17641789 4 G Bernstein, Type 2 Diabetes in Children and Adolescents, Practical Diabetology 19, no 3 2000: 3741 5 American Diabetes Association, Basic Diabetes Information 2003 www diabetesorg/main/application/commercewf;JSESSIONID_WLCS_DEFA ULTPp1UPeQ6pG87wqXNZxvYA2Z MMcENBu1meuZ0LXK1UtWUarl91 YzC-1011287227492283311107280 997775017502?originjspevent linkB 6 American Diabetes Association, Type 2 Diabetes in Children and Adolescents, Diabetes Care 23, no 3 2000: 381389 7 Bernstein, 3741 8 American Diabetes Association,
381389 9 Ibid 10 Bernstein, 3741 11 Ibid 12 Wong, 17641789 13 Bernstein, 3741 14 Ibid 15 MC Riddle and D M Karl, Starting Insulin for Type 2 Diabetes, clinical monograph Postgraduate Institute for Medicine Englewood, CO: Pfizer Corp, 2000

BIBLIOGRAPHY
American Diabetes Association Basic Diabetes Information 2003 www diabetesorg/main/application/commercewf;JSESSIONID_WLCS_DEFA ULTPp1UPeQ6pG87wqXNZxvYA2Z MMcENBu1meuZ0LXK1UtWUarl91 YzC-1011287227492283311107280 997775017502?originjspevent linkB American Diabetes Association Type 2 Diabetes in Children and Adolescents Diabetes Care 23, no 3, 2000: 381389 Bernstein, G Type 2 Diabetes in Children and Adolescents Practical Diabetology 19, no 3, 2000: 3741 Champanier, P Type 2 Diabetes Countdown 21, no 4, 2000: 3638 Gonsalves, M Y Coordinating Care for Patients with Type 2 Diabetes Patient Care for the Nurse Practitioner 3, no 9, 2000: 1536

2003 wwwlijedu/sch/ped_endocrin ology/ped_diabetes_edu_centerhtml 2 R E Greenberg, Diabetes Mellitus, in Primary Pediatric Care, 2nd ed, edited by R A Hoekelman, S B Friedman, N M Nelson, and H M Seidel St Louis, MO: Mosby Year Book, 1992, 12191224

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Greenberg, R E Diabetes
Mellitus In Primary Pediatric Care 2nd ed Edited by R A Hoekelman, S B Friedman, N M Nelson, and H M Seidel St Louis, MO: Mosby Year Book, 1992: 12191224 Libman, I, and S A Arslanian Type II Diabetes Mellitus: No Longer Just Adults Pediatric Annals 28, no 9, 1999: 589593 Long Island Jewish Medical Center Schneiders Childrens Hospital Pediatric Endocrinology and Metabolism: The Program for Childhood Diabetes/ Pediatric Diabetes Diabetes: The Nature and Importance of the Problem 2003 wwwlijedu/sch/ped_endocrin ology/ped_diabetes_edu_centerhtml

Rennert, O M, and G L Francis Update on the Genetics and Pathophysiology of Type I Diabetes Mellitus Pediatric Annals 28, no 9, 1999: 570575 Rickheim, P, J Flader, and K M Carstensen Type 2 Diabetes Basics Minneapolis, MN: International Diabetes Center, 2000 Riddle, M C, and D M Karl Starting Insulin for Type 2 Diabetes Clinical Monograph Postgraduate Institute for Medicine Englewood, CO: Pfizer Corp, 2000 Rosenbloom, A L, J R Joe, R S Young, and W E Winter Emerging Epidemic of Type 2 Diabetes in Youth Diabetes Care 22, 1999: 345351 Wong, D L Nursing Care of Infants and Children 5th ed St Louis, MO: Mosby, 1995

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Continuing Education Course

POST TEST
1 Which type of diabetes seems to be increasing at the fastest rate in children? a type 1 b type 2 c type 11/2 d secondary diabetes 2 Determining which type of diabetes a child has may be difficult because: a the signs and symptoms of each type may be similar b recognition of the signs and symptoms is difficult c no exact lab test exists that can differentiate between them d children are not reliable in reporting the signs and symptoms 3 Initial diagnosis of diabetes is indicated by: a a fasting blood glucose of 140 milligrams per deciliter on two separate occasions b a fasting blood glucose of 125 milligrams per deciliter on two separate occasions c a random blood sugar of 200 milligrams per deciliter without signs and symptoms d a one-hour value of 140 milligrams per deciliter on an IV glucose tolerance test 4 Which outcome indicates that the child has successfully assumed the responsibility for diabetes management? a the childs chronologic age b the childs ability to perform selfadministration of insulin c the ability to control diabetes over time d the childs understanding of the management plan 5 Initially, insulin dosages in children
are determined primarily by: a the childs age b the childs weight c the physicians preferences d how high the blood glucose was during the evening 6 A child of ten years of age could probably be expected to: a be totally responsible for the management of the condition b be able to check the blood sugar and record it accurately c give insulin injections in an independent manner d prepare appropriate meals 7 The recent increase in type 2 diabetes in children is thought to be a response to which of the following? a diets high in fats and carbohydrates, combined with a sedentary lifestyle b a hereditary predilection for this type of diabetes c ungrounded fears about diabetes d better detection and diagnostic methods 8 In a child with diabetes, if the morning fasting blood sugar is consistently elevated, which insulin should be adjusted? a the am fast-acting insulin b the am intermediateacting insulin c the pm fast-acting insulin d the pm intermediateacting insulin 9 In beginning education for the child and family who have just received a diagnosis of diabetes, the educator should first determine: a the age of the affected child b the family history of diabetes c the childs past medical
history d what the child and family already know about diabetes Post Test continues on the next page

Diabetes in Children

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10 The mother of a 14year-old girl complains that her daughters blood sugar values are frequently elevated She accuses the child of cheating on her diet plan The best response would be to: a discuss possible insulin resistance during puberty b agree with the mother that her suspicions are probably true c check the blood glucose yourself to see if it is elevated d lecture the child on the importance of being honest about what she has eaten

11 An African American teenager who is obese and has no acanthosis is most likely to have which type of diabetes? a type 1 b type 2 c type 11/2 d secondary diabetes

12 The child with diabetes who is involved in athletic activities should observe which of the following recommendations? a not to exercise when the insulin is peaking b to give additional insulin before exercise to meet the bodys metabolic demands c to check the blood sugar level one hour after exercising d to have a snack before or during strenuous exercise to prevent hypoglycemia

Transfer your answers to the space provided on the Answer Sheet

ANSWER
SHEET
Student Name: Daytime Phone:

Please write in your name and daytime phone number for each answer sheet you submit

Course : 122 Course Title: Diabetes in Children Course Expiration Date: October 31, 2006 Instructions

Tuition: 1695 Contact Hours: 4
FOR OFFICE USE ONLY

0404DIA

Read the course material Answer the Post Test Questions at the end of the course Transfer your answers to the Post Test Questions section below Remember to fill in the number of hours and minutes it took to read and review the course and take the test Also please include your signature Fill out the Course Evaluation section below, indicating the extent to which you agree or disagree that you achieved each objective Complete the Registration Form and mail or fax it to us with your Answer Sheets

Post Test Questions:
1 a b c d 2 a b c d 3 a b c d 4 a b c d 5 a b c d 6 a b c d 7 a b c d 8 a b c d 9 a b c d 10 a b c d 11 a b c d 12 a b c d
It took ______ hours and ______ minutes to read and review the course and take the test
____________________________ Signature

Course Evaluation:
I achieved the following learning objectives: Differentiate among the six
types of diabetes in terms of etiology, incidence, and populations at risk Compare and contrast the features of several types of diabetes among adults and children Describe the signs and symptoms, diagnosis, and staging of diabetes among children Detail type 1 and type 2 diabetes in terms of risk factors, pattern of onset, signs and symptoms, self-care, treatment, and monitoring 5 Detail and compare the etiology, symptoms, treatment, and major features of hyperglycemia and hypoglycemia in children 6 Generate a pediatric plan of care that provides for the emotional, developmental, and psychological needs associated with this chronic disease The objectives stated above related to the overall goals of the course The teaching/learning method was effective 1 2 3 4
Agree Disagree

Notes:
Certificates of Completion are dated the day our School receives and processes your Answer Sheet, Registration Form, and payment Duplicate Certificates of Completion are available at no charge There is no charge for processing a re-exam

Bert Rodgers Schools of Continuing Education 800 432-0320 wwwbertrodgerscom
PO Box 4708 Sarasota, FL 34230-4708 Fax 941
343-0303

Source:diabetes.com.au