Diabetes Education and Guidance to

the child and family

Tracy Lau, NC(DM), HKEC 26/4/2016

Childhood diabetes (I)

• Childhood Diabetes include ages up until 18 years old age

(United Nations)

• 0.02% (approximately 440,000) developed Diabetes at child population of the world

• 70,000 new cases diagnosed each year

(IDF, 2007)

• International Society for Pediatric and Adolescent Diabetes (ISPAD) & International Diabetes Federation(IDF)developed the guidelines for health care professionals

Type I Diabetes (T1DM)

• Presentation can vary from non-emergency polyuria, polydipsia, enuresis, weight loss and abdominal pain to severe shock, dehydration and Diabetic Ketoacidosis(DKA)

• Some children have a rapid onset of symptoms and present within days in DKA

• A long slow onset over several months, then develop to catastrophic onset to their diabetes and present within a few days in DKA

Type 2 Diabetes(T2DM) (I)

• In Hong Kong, 37% of young onset Diabetes is T2DM

• Presentation is slow, often obese, strong family history of T2DM

• For overweight/obese children >13 years of age with a clinical picture of T1DM, some of whom may have T2DM

• C-peptide measurements for confirmation of T1/T2 DM and requiring insulin therapy

• Immune markers (anti-GAD, ICA, IA-2) showed negative

Type 2 Diabetes (II)

• Commonly associated with insulin resistance, hyperlipidemia, hypertension, acanthosis nigricans, ovarian hyperandrogenism, Non Alcohol Fatty Liver Disease (NAFLD)

• Insulin therapy may be required for initial metabolic stabilization even in the absence of ketoacidosis

• Lifestyle changes in diet and exercise are essential to increase insulin sensitivity

• Pharmacologic treatment:

- Metformin is the initial drug, can improve HbA1c

1-2%

- Insulin therapy: bedtime insulin, e.g.. Glargine can promote

glycaemia control

Classification of Childhood diabetes

The core aspects of Diabetes Care

• Replacement of insulin by giving insulin injections

• A good healthy diet, with a regular intake of food

containing carbohydrate

• Monitoring of blood glucose levels at home

• A healthy amount of exercise

• Regular review by the diabetes team

Critical pathway (I)

• Critical pathway for acute of newly diagnosed insulin dependence diabetes mellitus

• 1st week: stabilization of metabolic index at hospital

• 2nd week: receiving Diabetes Education, preparation of

discharge & resume normal life

• After discharged: ambulatory care to achieve the best

possible glycemic control

( Dr E Kwan, QMH, 1998)

Critical pathway (II)

The Paediatric Diabetes Team: • Diabetes doctor • Diabetes educator/nurse • Dietitian • Clinical Psychologist • Social worker • Hospital staffs responsible the diabetes child & family can follow the life-style of their educated choice, based on the three elements of Empowerment: • Knowledge • Behavioral skills • Self-responsibility

Family – centered care

The institute for Family-Centered Care (2003) in USA described 8 cores concepts about the relationship between health care providers, children and families: • Respect • Support • Strengths • Flexibility • Choice • Collaboration • Information • Empowerment

Empowerment

• Empowerment requires an individual to take care of one’s self and make choices about care from among the options

• Patient empowerment is a process of helping people to assert control over factors that their health

• Patient empowerment begins with information and education and includes seeking out information about one’s own illness or condition, and actively participating in treatment decisions

Diabetes Education (I)

Initial assessment for parents/ caretaker, child and whole family

• educational level

• eating habit, usual meal time

• Lifestyle pattern

• school time table

• Psychological aspect: family member relationship,

emotional stability, coping mechanism,

behavior, needle phobia………

Treatment Mortality of Diabetes Care

• (Medical Nutrition Therapy) : Diet

• Exercise Therapy

• Pharmacological Therapy :Oral Anti-diabetic Agents & Insulin

• Diabetes Self Management Education (DSME)

Medical Nutrition Therapy

• Goal: to assist in the normalization and maintenance of glycaemia, lipid profiles and blood pressure which supply for the growth of the kid.

Total Daily Energy Intake:

Nutrient % of Daily Caloric Intake

Carbohydrate > 50%

Fat < 35%

Protein

10-15%

Meal planning for DM: protein, fiber

Carbohydrate > 50% of daily calorie intake 1g of starch = 4 Kcal

Protein 10-15% of daily calorie intake (normal renal function) > 1g protein/kg(BW)/day (Diabetic Nephropathy)

Fat Avoid saturated fat & trans fat Fiber Soluble fiber can improve glycemic control, cardio-protective &

reduce total cholesterol & LDL (strong recommendation by Academy of Nutrition and Dietetics, 2008) Maximize fiber intake

Benefits of Regular Exercise

EXERCISE

weight loss in T2DM &

Enhance insulin sensitivity

Improve glycaemic control

Reduce the need for insulin or OHA

Improve blood pressure

Lower bad cholesterol(LDL)

& triglycerides

Raise good cholesterol

(HDL) Lower

stress level

Planning of Exercise (F I T T)

Frequency: for increase cardiovascular fitness & body fat loss (>3X/wk) Intensity : start from low intensity 1. Calculation of max. Heart Rate: Max HR = 220-age - Low Intensity: 50-60 % of Max HR - Moderate Intensity:60-75 % of Max HR - High Intensity: 75-85% of Max HR 2. Talk Test :observe for client’s breathing pattern during exercise: - Low intensity: breathing and talking comfortably - Moderate intensity: Increased RR, Talking OK - High intensity: Increased RR, Talking difficultly

Specific considerations for T1DM

Avoid hypoglycemia :

• Avoiding exercise during peak insulin action

• Using non-exercising sites for insulin injections

• If sing MDI, reduce pre-exercise insulin dosages by 20-50% or more if needed

• For using insulin pump Diabetes, reduce basal rate or bolus before exercise

• Monitor Self Monitoring Blood Glucose(SMBG)

• Take extra CHO, prevention of hypoglycemia:

• 15g CHO before exercise, 15g after 30 mins intervals

Specific considerations for T2DM

• Hypoglycemia less common

• Extra CHO usually needed

• In patients on insulin or sulphonylurea, may need reduction in medications

• Frequent SMBG monitoring

Diabetes Education (II)

Skill • Insulin injection technique

• Self monitoring of blood glucose

Special care • Sport & exercise

• Management/ prevention of hypoglycemia, injection of Glucagon

• Sick day management

• Diabetes at home & at school

• Discharge advice

• Membership of diabetes association & support services

• Emergency contacts, 24 hours telephone hotline

• Arrange screening for complication

Diabetes Education (III)

Counseling

before education to let the Diabetes family accept the disease

To start education with :

• Explain how the diagnosis was made and reasons for symptoms

• Simple explanation of uncertain cause/ possible cause of diabetes (no blame on parents)

• For T1DM, the need for immediate insulin and how it will work

• For T2DM, understand the importance of modification to the healthy dietary habit

• What is glucose-normal blood glucose target

• Practical skills- injection, blood/urine-glucose/ketone monitoring

• Basic dietetic advice

Holistic approach towards Diabetes

Understanding

Education & Care Acceptance

Holistic approach towards Diabetes

Psychological impact for diabetes children &

their family

Infants and preschool children(I)

Parents:

Guilt, fear, frustration,

overprotect

Kid:

fear, cry

Attention :

- metabolic, psychosocial

- developmental status

Management objective:

- parent’s acceptance

- return to normal life

- prevent severe hypoglycemia or convulsion

Infants and preschool children(II)

Education:

Creative & innovative

Teaching tools

Learning through “play”

Parent’s group

support

Learning

surviving skill

School children (I)

School children (II)

School

life

Vigorous

Exercise

hypoglycaemia

Ego,

Self- esteem development,

Enforced maturity

Peer influence,

Feeling of being

different

from their peer

Management objective:

• School personnel acceptance

• Adjust daily life VS school activities

• Normal health development of ego & self-esteem

• Gradually develop child’s independence & responsibilities, learning skills in injections and monitoring

School children (III)

Adolescents(I)

• Dream to be adult

• Bored with routine, high priority to fulfill their psychological need

• Towards independence & self care

• Strong peer influence & peer group pressure

• Shame and fear to let people know they have diabetes

• Embarrassed to SMBG, eat when needed,& treating

hypoglycemia

• Strong concern with weight-related issue,

particularly teenaged girls

Management objective: • According to the maturity & understanding, to promote independence • Empowerment & re-education • Respect, non-judgmental discussion • Encourage decision making • Adjust treatment regimen • Developing strategies to manage transition to adult service • Advice on issues such as alcohol, smoking, exercise, conception

Adolescents(II)

Adolescents to adult (I)

Life-style

modification

Study / Employment

Family / social

support

Financial

Friendship / Love

/ Marriage

Peer

STRESS

Management objective:

• Early detection and management of complications

• Enhance compliance: Empowerment program

• Patient’s group support

Adolescents to adult (II)

School & Diabetes

- Issue to be discussed with school personal:

• Give general Diabetes information/Diabetes education to school, esp. management of hypoglycemia

• Special provisions for privacy for SMBG/insulin injection

• Avoid delay in meals/snacks

• Encouraging full participation in all school social, sporting & academic activities

• Knowing that diabetes does not alter the child’s academic potential

DM Camp (I)

• A program full immersion in the management of diabetes with structured diabetes program

• Duration: 3 days to 3 weeks

• Aim: thro’ social & recreational activities with peers in a non-medical environment to provide an ideal learning opportunity, experience common difficulty and encourage feelings of freedom and independence

• A respite for parents and the rest of family from the routine of diabetes

DM Camp (II)

Role of Volunteer Doctors / DM nurses 1. assigned to one small group of children (around 6-10) as program

facilitator 2. Supervise all the children in the group esp. on medical issues (reference

can be taken from camp protocol in diabetes care): 3. Assist children to record blood glucose level and insulin dosage 4. Detect and manage hypoglycemia or hyperglycemia or ketosis 5. Review & adjust insulin dose with respect to blood glucose level, activity

and food intake before insulin administration 6. Monitor H’stix at night (2-3 am) for delayed hypoglycemia 7. Supervising the injection technique of participants together with DM

nurse

DM Camp (III)

Role of Volunteer Doctors / DM nurses in the DM camp:

8. educate participants on food exchange, food compliance, glycemic index etc. before each meal or when chances arise together with dietitian 9. document clearly of H’stix profile, insulin given, amount of exercise and food taken throughout the camp 10. check and refill the content of hypokits and emergency kits 11. deal with other medical problems / emergencies eg. asthmatic attack 12. provide DM education to participants 13. provide psychological and physical supports to participants 14. ensure safety outdoors activities 15. A brief summary of the events and management is expected for each child after the camp to be given to the corresponding hospitals to facilitate future management.

DM Camp (IV)

Role of Volunteer Dietitian : 1. provide eye portioning for the snacks and meals of the children. 2. help to distribute the snacks/ food for the children. Role of Volunteer Leaders Roles: • Friends of DM children • Assistant of professionals • In-charge team on some activities Responsibility: • Be a good model on DM control for learners of DM children • Be a good assistant to help professionals • Be a reporter to report to professionals or their team leaders when they

encounter any problems

DM Camp (V)

Sharing issues:

Hypo experience

Injection

SMBG

Exercise

School life

DM Camp (VI): Hypo kit

Community Support

Community resources: • Diabetes Hongkong (www.diabetes.hongkong.org) • Diabetes Youth Action Hong Kong • Hospital own diabetes support group

Support with Visit of newly diagnosed patients by another parents with

diabetes child Provide opportunity for them to share experiences and

feelings Prevent social isolation Participate on activities and services related to diabetes

Diabetes Educational Journals (HK)

Educational materials

Guidelines for professionals

• IDF Guideline

• IDF Position

Statement

• HA- Nursing

Standard

Hotline services

• Special consultation e.g. sick day management, missed dosage…etc.

• Assess and discuss the results of self monitoring with patient and care taker

• Review adjustment of the therapeutic regimen (esp. new case)

• Provides chances for reinforcement, misconception clarification and problem solving related to daily diabetes care

• A flexible system which may fit in patient’s daily activities

Diabetes complication screening

For Diabetes children: Girls over 11 years and boys over 12 years who had DM for more than 2 years - Urine for micro-albuminuria - Blood for lipid, HbA1c, CBP, RFT, LFT - Retino-photo - foot examination - Blood pressure - BMI - Puberty progression, menstrual irregularities - Obstructive sleep apnoea