PEDS Diabetes - nursece4less.com · Web viewPEDIATRIC DIABETES. Jassin M. Jouria, MD. Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author

PEDIATRIC DIABETES

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical

clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all

USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational

institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter

Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering

various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an

academic textbook on Human Anatomy & Physiology.

ABSTRACT

Type 1 diabetes mellitus, previously known as juvenile diabetes, is a chronic and progressive metabolic disorder. The onset of pediatric type 1 diabetes mellitus can occur at any pre-pubertal age. School nurses, teachers or other personnel trained to perform diabetes care, as part of the interdisciplinary pediatric diabetes healthcare team (DHC), support glycemic monitoring, insulin administration and carbohydrate counting of meals, as well as educating the patient about their disease, its management and treatment. All health professionals, part of the interdisciplinary pediatric diabetes healthcare team, provide continuous support as patients grow independent and become more capable of self-management of the disease.

Continuing Nursing Education Course Director & Planners

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William A. Cook, PhD,Director; Douglas Lawrence, MA, Webmaster;

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement

NurseCe4Less.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Credit Designation

This educational activity is credited for 8.5 hours. Pharmacology content is 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in all Continuing Nursing Education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.

Statement of Need

Knowledge of diabetes research and medical management is important to safe care for the pediatric diabetic patient. Educating health teams and patients, as well as their caregivers, about medical management and lifestyle choices is integral to diabetic health and wellness.

Course Purpose

To provide nurses and associates knowledge of the main and less common forms of diabetes to support patients and families during treatment.

Learning Objectives

1. List current hypotheses for the cause of Type I DM.


2. Identify the types of neuropathy caused by pediatric diabetes.3. Describe the role of beta cells in the pancreas.4. Explain the relationship between Type I DM and autoimmune disorders.5. Explain types of insulin, usage and various ways to administer insulin.6. Describe the role of exercise in the management of pediatric diabetes.7. Describe how diabetic ketoacidosis should be managed with children.8. Explain how schools/day care centers can contribute child diabetes care.9. Explain how carbohydrates impact pediatric diabetic management.10. Identify the importance of medical identification.

Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates

Course Author & Director Disclosures

Jassin M. Jouria, MD; William S. Cook, PhD; Douglas Lawrence, MA; Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.

Start Date: 7/14/2014 Termination Date: 7/14/2017

Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course

1) What is the high blood glucose correction factor for a type 1 diabetic patient weighing 160 lbs?

a. 50 mg/dL


b. 45 mg/dLc. 60 mg/dLd. 65 mg/dL

2) Which type of diabetic neuropathy affects the heart, blood vessels and digestive system?

a. Focal neuropathyb. Peripheral neuropathyc. Autonomic neuropathyd. Proximal neuropathy

3) Which type of insulin has a natural cloudy appearance?a. Rapid acting insulinb. Regular insulinc. Intermediate acting insulind. Long acting insulin

4) Which of the following is intermediate acting insulin?a. NPHb. Glarginec. Aspartd. Lantus

5) What is the bolus insulin dose to cover a patient’s plans to consume 60 grams of carbohydrate for lunch. The patient’s Insulin: CHO ratio is 1:10.

a. 10Ub. 8Uc. 5Ud. 6U

6) Insulin absorption is fastest and most predictable injected in the:a. Upper outer armb. Abdomenc. Anterior lateral thighd. Buttocks


7) All of the following administration strategies minimize pain at the injection site of insulin EXCEPT:

a. Injecting insulin at warm temperatureb. Eliminating air bubbles in the syringe before injectionc. Keeping the muscles at the site of injection relaxed, when

injectingd. Penetrating the skin quickly

8) Which of the following strategies does not help pediatric patients overcome their fear of needles and injection?

a. Using a pillow for trial injectionsb. Using a covered safety needle to conceal the needlec. Allowing the syringe to rest on their skin before injectiond. Injecting insulin without looking at the injection site

9) The following is NOT a standard insulin self-administration route: a. Subcutaneous injection with insulin pensb. Subcutaneous injection with insulin prefilled syringesc. Intramuscular injection with insulin pensd. Subcutaneous infusion using CSII devices

10) Which of the following blood glucose test results is diagnostic for type 1 diabetes mellitus?

a. Random whole-blood glucose concentration > 200 mg/dL b. Fasting whole-blood glucose concentration > 120 mg/dL c. An HB1AC value of more than 6.5%d. All of the above

Introduction

Pediatric diabetes can be a scary and life-changing diagnosis. However, with proper management, patients with pediatric diabetes can live long, full lives. Patients with pediatric diabetes—and their parents and caregivers—will take their cues from health care professionals when it comes to managing diabetes. Having an in-depth knowledge of the pathophysiology and


management techniques of diabetes will allow health clinicians to provide reassuring knowledge and treatment options to their patients. Knowledge and information are powerful tools for every member of the healthcare management team to provide optimal care and a high quality of life for the patient.

Type 1 diabetes mellitus, previously known as juvenile diabetes, is a chronic and progressive metabolic disorder wherein the body is unable to produce insulin to meet its energy needs. The condition is a result of autoimmune destruction of the beta cells in the pancreas. As its former name suggests, the disease has an early onset, usually before 18 years of age. Once diagnosed, an individual will require lifelong insulin treatment and monitoring for complications.

Type 1 diabetes mellitus is also known as insulin-dependent diabetes mellitus (IDDM) because the pancreas is completely unable to produce insulin, as opposed to type 2 diabetes mellitus, which is where the pancreas produces insufficient amounts of insulin to sustain the energy requirements of the body.

According to the CDC, type 1 diabetes is caused by mechanisms much different from those that cause type 2 diabetes mellitus. Despite prolific research into the origins of the disease, the exact etiology of both types of diabetes remains unclear. Nevertheless, studies in the recent years have primarily pointed out its onset as following exposure to environmental stimuli such as a virus and certain dietary factors in genetically predisposed individuals. However, because of the very early onset of the disease in pediatric populations, the role of genetic factors is also a very important consideration.

The onset of pediatric type 1 diabetes mellitus can occur at any pre-pubertal age, however, the peak incidence usually increases with age until mid-


puberty and then declines. This means that the majority of these patients are school-age children whose care and wellbeing is entrusted to the school and day care personnel for the majority of their day. In this case, it is the school nurses, teachers or other personnel trained to perform diabetes care, as part of the interdisciplinary pediatric diabetes healthcare (DHC) team, who are responsible for them especially when it comes to glycemic monitoring, insulin administration and carbohydrate counting of meals. They are also partly responsible for educating the patient about their disease, its management and treatment.

It is important for all health professionals, not just nurses, who are part of the interdisciplinary pediatric diabetes healthcare (DHC) team to be able to provide continuous counseling as patients grow older, and lean toward independent and self-management of the disease. The course is intended to enhance and reinforce the knowledge of health professionals on type 1 diabetes mellitus in pediatric patients, especially with regards to their diagnosis, management, treatment and overall long-term health education.

Pathophysiology

Type 1 diabetes mellitus is a result of the autoimmune destruction of the beta cells of the pancreas.

Hypotheses

Current studies have several hypotheses on the etiologic origins of the disease, pathologic mechanisms and presentation, and progression to microvascular comorbidities. The pathophysiologic mechanisms at play


primarily involve both genetic and environmental factors, and are discussed in detail below.

Genetic Factors

The genetic component of this form of diabetes is complex and involves multiple genes but there is also high risk among siblings, especially monozygotic twins.1 A study by Tseck, et al. found dizygotic twins to possess a 5-6 percent concordance rate for type 1 diabetes mellitus2 while monozygotic twins are half more likely to have similar diagnosis upon reaching 40 years old.3

Children of parents with type 1 diabetes mellitus are also at greater risk for the same disease themselves. However, the risk differs depending on which of the parents has the disease. Those with mothers who have diabetes possess the relatively small risk of 2-3 percent to develop the disease themselves, as compared to those with fathers who have diabetes, which increases their risk of developing it to 5-6 percent. However, if both parents have diabetes, the risk for a child to also develop diabetes increases to about 30 percent. Additionally, the risk is relatively greater if the onset of the parent(s) disease happened prior to the age of 11 years old, and relatively lesser if the onset happened at a later age.The genetic component of diabetes is also apparent in the important difference seen in its frequency of occurrence among various ethnic groups. Type 1 diabetes mellitus is very common in individuals with European ancestry, with those from northern Europe significantly more affected compared to those from the Mediterranean region.4 It is most uncommon among people of East Asian descent.5

Studies on genome-wide association found several loci linked with diabetes, although there were not enough causal relations found. The regions most commonly linked to other autoimmune diseases, the major histocompatibility


complex (MHC), is also where various susceptibility loci for diabetes, specifically, class II human leukocyte antigen (HLA) DR and DQ haplotypes (the detected amino acids involved in the disease process), are found.6,7,8

A list of DR-DQ haplotypes linked to greater risk for diabetes type I is found below, in hierarchical order:6

DRB1*0301 - DQA1*0501 - DQB1*0201 (odds ratio [OR] 3.64) DRB1*0405 - DQA1*0301 - DQB1*0302 (OR 11.37) DRB1*0401 - DQA1*0301 - DQB*0302 (OR 8.39) DRB1*0402 - DQA1*0301 - DQB1*0302 (OR 3.63) DRB1*0404 - DQA1*0301 - DQB1*0302 (OR 1.59) DRB1*0801 - DQB1*0401 - DQB1*0402 (OR 1.25)

Approximately 90-95 percent of young children diagnosed with the disease are carriers of the HLA-DR3 DQB1*0201, HLA-DR4 DQB1*0302, or both. Children who carry haplotypes DR3 and DR4 heterozygotes are the most susceptible. As mentioned previously, the individuals who carry the aforementioned haplotypes and therefore, at most risk, are primarily of European descent. There is not enough study data on other ethnic populations.

An important gene that plays a role in the pathophysiology of type 1 diabetes mellitus is the insulin gene (INS). It encodes for the pre-proinsulin peptide, which is close to a variable number of tandem repeats (VNTR) polymorphism at chromosome 11p15.5.9 Various VNTR alleles can promote both resistance and susceptibility to type 1 diabetes mellitus via their action on insulin gene (INS) transcription in the thymus gland.

Environmental factors

Environmental triggers may also contribute to the development of type 1 diabetes mellitus. These triggers include viruses such as enterovirus,12


mumps, rubella, and coxsackievirus B4, toxic drugs and chemicals, cytotoxins, and exposure to cow’s milk during infancy.13

It is important to remember that a combination of factors may be at play, instead of just one. A study by Lempainen, et al. found that evidence of an enterovirus infection as early as 1 year of age was tied to the appearance of type 1 diabetes mellitus–related autoimmunity among children exposed to cow's milk before the age of 3 years old. This finding strongly suggests a relationship between the two factors. In addition, the finding also offers a possible explanation for the conflicting findings obtained in studies that only studied these factors individually.14

The finding of one meta-analysis points to a weak but important linear elevation in the risk of pediatric type 1 diabetes mellitus associated with increasing maternal age.15 However, there is insufficient evidence to support any substantial increase in type 1 diabetes mellitus risk in children after preeclampsia complications during pregnancy.16 A study by Simpson, et al. based in Denver, Colorado, followed children at increased risk of diabetes since 1993 and did not find any link between vitamin D intake nor 25-hydroxyvitamin D levels during childhood to be linked with autoimmune destruction of the islets of Langerhans nor progression to type 1 diabetes mellitus.17 Another risk factor for the development of type 1 diabetes mellitus may be upper respiratory infection during the first year of life. A data analyzed 148 children who were carriers of genetic markers of the disease and found that upper respiratory infections in the first year of life were linked to greater risk for type 1 diabetes mellitus.18,19

There are toxic substances that have been studied in terms of the effects on the pancreas. RH-787, a rat poison, and Streptozotocin, an FDA-approved drug for the treatment of metastatic cancer of the pancreatic islet cells, are


known to exert selective damage to the islet cells and cause type 1 diabetes mellitus. Additionally, studies have found that nitrosamines, which are carcinogenic chemicals found in many processed foods such as smoked meat and certain water supplies, can also cause type 1 diabetes mellitus in animal models. However, there are currently no studies that found explicit pathologic association between these chemicals and humans. Over the years, there has also been a hypothesis involving the linear increase in the incidence of type 1 diabetes mellitus with corresponding increase in the distance from the equator. It may be that a decreased exposure to ultraviolet (UV) light and subsequently, lower vitamin D levels may be the missing link, which is the explanation for this hypothesis.27

Other Factors

Other factors considered to play a role in the development of type 1 diabetes mellitus include:28

Congenital absence of the pancreas or islet cells, Pancreatectomy, Pancreatic damage such as chronic pancreatitis, hemochromatosis and

cystic fibrosis, Wolfram syndrome (diabetes insipidus, diabetes mellitus, optic

atrophy, deafness (DIDMOAD), and Chromosomal disorders such as Down syndrome, Turner syndrome,

Klinefelter syndrome.

Disease Mechanisms

In the pancreas, approximately 1,000 beta cells are found in a circular formation called islets of Langerhans. The beta cells secrete the hormone insulin, which is responsible for regulating carbohydrate and fat metabolism in the body. The hormone is responsible for the movement of glucose from the blood and into the cells of the liver, skeletal muscles, and fat tissue.29


Lack of insulin results in the build up of glucose in the blood, a condition called hyperglycemia.

The islets of Langerhans are found all over the pancreas and compose 1-2% of its mass. The autoimmune-mediated attack on the beta cells interferes with insulin production within the organ, thus, also interrupting the regulatory functions associated with the hormone.29

The beta cells are initially attacked by the activated cytotoxic T-lymphocytes (CTLs), which target specific islets and destroy them. When CTLs are activated, cytokines are released, which in turn, trigger the production and movement of activated macrophages and autoantibodies towards the site of inflammation. It is the combined inflammatory activities of the autoantibodies, macrophages and CTLs, which are responsible for the overall destruction of pancreatic tissue and produce the succeeding pathologic conditions.29

It is important to note that the autoimmune destruction of the pancreatic tissue has significant physiological consequences. The damaged beta cells impair an individual's ability to respond to alternating blood glucose levels due to the absence or lack of insulin. As mentioned above, insulin is the hormone that regulates carbohydrate, fat, and protein metabolism. Normally, these molecules are readily absorbable by the cells and insulin facilitates their cellular uptake and synthesis into glycogen, triglycerides and proteins, respectively.29 Specifically, insulin regulates carbohydrate (glucose) metabolism, based on glucose levels and cellular needs.29 The role of insulin is further outlined below:

Insulin allows for the passive diffusion of glucose into cells by opening the glucose transport proteins (GLUT 1-5);


Insulin stimulates glycogenesis, or the conversion of glucose to glycogen, for cellular storage in the cells;

Insulin prevents glycogenolysis, or the conversion of glycogen to glucose in favor of cellular glycogen storage and reduction of glucose output by the liver; and, glucose inhibits gluconeogenesis, or the metabolism of glucose from amino acids, by decreasing amino acid levels available to the liver and inhibiting hepatic glucogeneic enzymes.

Insulin also promotes protein synthesis, thereby enhancing the activity of cellular mechanisms. The result is the increased consumption of glucose and reduction of blood glucose levels. It is important to note that insulin is the only hormone which downregulates blood glucose, and thus, it is not uncommon for individuals with type 1 diabetes mellitus to experience acute periods of hyperglycemia. Despite the high levels of glucose in the blood, these individuals are starved for energy because the cells are unable to utilize the blood glucose without insulin.29

Disease Presentation

As mentioned previously, type 1 diabetes mellitus is the result of infiltration and destruction of insulin-secreting beta cells of the islets of Langerhans in the pancreas by lymphocytes. As beta-cell mass diminishes, insulin secretion also decreases until it diminishes completely to the point where blood glucose levels cannot be set back to normal levels without the administration of exogenous insulin.

The destruction of 80-90% of the beta cells is followed by the development of hyperglycemia, which may be pronounced enough to precipitate the diagnosis of diabetes. In order to overturn this catabolic condition, prevent


ketosis, and set lipid and protein metabolism back to normal, patients are given exogenous insulin, usually in the form of injections.

Signs and symptoms

The signs and symptoms of type 1 diabetes mellitus in children are:1. Polydipsia2. Polyphagia3. Glycosuria4. Weight loss5. Unexplained fatigue6. Greater frequency of infections7. Symptoms of ketoacidosis

Each of these symptoms is discussed in detail below.

Polydipsia and polyuria

Polydipsia simply means increased thirst. In the case of children with type 1 diabetes mellitus, they may experience an insatiable thirst brought on by frequent urination, or polyuria.

The significant osmotic diuresis that ensues can cause dehydration if not treated. This is especially inconvenient for both parents and children because it leads to frequent urination during the night (nocturnal enuresis), leading to interrupted sleep.

Polyuria and nocturnal enuresis in children should make parents aware that there is something wrong, particularly if the child was previously continent. In infants, these symptoms are easier to overlook due to their naturally high fluid intake and diaper use.


Polyphagia

Polyphagia means excessive hunger. In type 1 diabetes mellitus, the inadequate glucose received by the cells produces the hunger trigger in the brain.

Glycosuria

Glycosuria refers to an abnormal condition wherein glucose is found in the urine. The kidneys normally reabsorb glucose, but in the case of diabetes mellitus, the excess glucose in the blood (hyperglycemia) and damaged renal arteries can compromise the reabsorptive capacity of the kidneys. Weight loss

Weight loss is also seen among children with type 1 diabetes mellitus. Deregulated gluconeogenesis is caused by insulin insufficiency, which also leads to uncontrolled metabolism of protein and fat in the body. They usually exhibit dramatic weight loss despite normal appetite and healthy eating habits.

In infants, weight loss is apparent in the child’s failure to thrive and wasting. These can occur prior to the onset of obvious hyperglycemia.

Unexplained fatigue

Unexplained fatigue is also another symptom of type 1 diabetes mellitus. This symptom may already be present prior to the onset of other symptoms such as hyperglycemia. Because of its non-specific nature and a wide explanation for its causes, this is often overlooked and only recognized retrospectively.

Symptoms of ketoacidosis

The symptoms of ketoacidosis are:


Severe dehydration Fruity breath (Kussmaul respiration) Abdominal pain Vomiting Drowsiness and coma

Other symptoms

Other symptoms of diabetes mellitus are associated with hyperglycemia. High blood glucose levels lead to decreased immune resistance, rendering diabetic children more susceptible to a variety of recurrent infections, such as urinary tract infections, skin infections, and respiratory tract infections. Candidiasis may also develop, especially in the groin and in flexural areas.

Hyperglycemia

Hyperglycemia will be discussed at greater length later on in the study; it simply means elevated blood glucose levels. It is a result of insulin deficiency, which in turn causes deregulated gluconeogenesis. It causes the body to improperly use and store circulating glucose.

As mentioned previously, hyperglycemia also affects the kidneys. High blood glucose levels render the kidneys incapable of reabsorbing the excess glucose load, causing glycosuria, polyuria, polyphagia, and dehydration. Greater fat and protein metabolism leads to ketone production and weight loss. A child with type 1 diabetes mellitus, who does not have insulin to regulate the blood glucose levels, wastes away, drastically loses weight and, if untreated, can lead to death from diabetic ketoacidosis.

Hypoglycemia

Insulin inhibits glucogenesis and glycogenolysis. It stimulates cellular glucose uptake. In non-diabetic children, insulin production by the pancreatic islet


cells is suppressed when blood glucose levels decrease to less than 83 mg/dL. Whereas, children with type 1 diabetes mellitus do not have insulin and, therefore, the mechanism is not regulated. Hypoglycemia can result from administration of insulin in children who have not consumed adequate amounts of carbohydrates, leading to the dangerous progressive fall of blood glucose levels.

Glucose is the fuel for all cellular activities. All organs depend on it, including the brain. When glucose levels fall below 65 mg/dL, counter-regulatory hormones such as glucagon, cortisol, and epinephrine are released, resulting in the symptoms of hypoglycemia. These symptoms include shaking, sweatiness, confusion, behavioral changes, and, changes in consciousness levels. If blood glucose levels fall below 30-40 mg/dL, coma ensues. The level of glucose at which symptoms develop and appear depends on the individual, including comorbidities, severity, frequency of hypoglycemic episodes, the rate of fall of hypoglycemia, and overall glycemic control.

Etiology, Progression and Comorbidities

Autoimmunity

Based on current research data, autoimmunity is considered the primary factor in the pathophysiology of type 1 diabetes mellitus. Individuals who are carriers of the genetic haplotypes are especially susceptible to developing the disease following a bout of viral infections that trigger the production of antibodies against a viral protein, which in turn stimulate an autoimmune response against antigenically alike beta cell components.

About 85% of type 1 diabetes mellitus patients possess circulating islet cell antibodies, with the majority of them also possessing detectable anti-insulin antibodies prior to the start of insulin therapy. Among the most commonly


found islet cell antibodies are those targeting the enzyme found within the beta cells of the pancreas called glutamic acid decarboxylase (GAD).The occurrence of type 1 diabetes mellitus is also considerably greater in patients with other autoimmune diseases, such as Hashimoto thyroiditis, Graves disease, and Addison’s disease. A study by Pilia, et al. found greater amounts of islet cell antibodies (IA2) and anti-GAD antibodies in patients with autoimmune thyroiditis.20 Findings from another study by Philippe, et al. using CT scans, glucagon stimulation test results, and fecal elastase-1 measurements21 noted that reduced pancreatic volume occurred in both individuals with type 1 and type 2 diabetes mellitus. These findings explain the link between exocrine dysfunction and diabetes mellitus.

Neuropathy

Diabetic neuropathy is a major complication of poorly controlled diabetes mellitus. It is caused by the degeneration of axons and segmental demyelination. There are multiple pathologic factors at play, such as the buildup of sorbitol in the peripheral sensory nerves from persistent hyperglycemia. Motor neuropathy and cranial mononeuropathy are the culmination of vascular disease in blood vessels supplying nerves.30

There are four types of diabetic neuropathies, and they are classified according to the organs they affect. These types of neuropathies are outlined in the following table and further explained in the section below.

Type of neuropathy Organs affectedPeripheral neuropathy Toes, feet, legs, hands, armsAutonomic neuropathy Heart and blood vessels, digestive system, urinary

tract, sex organs, sweat glands, eyes, lungsProximal neuropathy Thighs, hips, buttocks, legs

Focal neuropathy Eyes, facial muscles, ears, pelvis and lower back, chest, abdomen, thighs, legs, feet


Peripheral neuropathy

Peripheral neuropathy is also known as distal symmetric neuropathy. The damage is to the peripheral nerves of the arms and legs. Diabetic individuals who present with peripheral neuropathy usually indicate their feet and legs being affected first before their hands and arms. Acquired peripheral neuropathy can also occur in diabetic children.

The symptoms of peripheral neuropathy are often aggravated at night and include the following:30

Numbness Heat and pain insensitivity Paresthesia Sharp cramps Greater sensitivity to touch Loss of balance and coordination

Peripheral neuropathy can also lead to muscle weakness and loss of reflexes, particularly at the ankles. The combined muscle weakness and loss of reflexes leads to changes in gait and causes the affected patient to walk differently.

The muscle and loss of reflex changes described above lead to foot deformities such as hammertoes and the collapse of the mid-foot. Because of the insensitivity to pain and pressure, many patients may not notice the sores and blisters that have developed on their foot. This is especially a cause for concern because untreated open wounds can become infected.

Diabetics have compromised circulation and immune systems, making them susceptible to acquiring infections to the internal structures such as the bone


and blood. If left untreated, a wound that began as a small sore can become large enough to require amputation. However, when these wounds are given prompt medical attention they usually heal in time.30 Autonomic neuropathy

In autonomic neuropathy the damage is to the nerves, which primarily control the cardiovascular system. These include the nerves of the heart and blood vessels that regulate blood pressure and blood glucose levels. It also damages other internal organs, causing impaired and abnormal digestion, respiratory function, urination, sexual response, and vision. Additionally, the homeostatic mechanism that regulates blood glucose levels is affected. The result is the absence of warning symptoms of hypoglycemia.30

The warning symptoms of hypoglycemia include palpitations, shakiness, and sweating. However, in people with autonomic neuropathy, these symptoms may not occur at all, making hypoglycemia unrecognizable and overlooked medically. It is important to remember that conditions other than neuropathy can also cause unrecognizable hypoglycemia.30

Proximal neuropathy

Proximal neuropathy is also known as diabetic amyotrophy. This type occurs more frequently among older diabetics, and those with type 2 form of the disease. One of its most notable symptoms includes a one-sided pain that begins in the thighs, hips, buttocks, or legs.30

Damage to the nerves on the legs causes weakness and inability to switch from a sitting to a standing position without aid. Treatment is usually needed for the weakness and pain. Recovery time differs individually, based on the type of nerve damage.30

Focal neuropathy


Unlike other types of diabetic neuropathy, the onset of focal neuropathy is sudden. As outlined previously in the table, it affects the nerves of the eyes, face, pelvis, ears, and legs.30 Symptoms of focal neuropathy include the following:30

inability to focus the eye double vision pain behind one eye Bell's palsy severe pain in the lumbar or pelvic region pain in the front of a thigh pain in the chest, stomach, or side pain on the outside of the shin or inside of the foot chest or abdominal pain

Focal neuropathy can be painful and unpredictable. Its prevalence is high among older diabetic patients. On the other hand, the pain and neuropathic symptoms improve on their own over a period of weeks or months, and do not lead to long-term damage.30

Diabetics are also more prone to developing nerve entrapment syndromes. The most common of these is carpal tunnel syndrome, which causes symptoms such as numbness, hand tingling, and muscle weakness or pain. A nerve entrapment affecting the lower legs can cause pain on the outer shin or the inner foot.30

Angiopathy

A study by Barchetta, et al. using nailfold video capillaroscopy found a greater occurrence of capillary changes in patients with diabetes, especially


those with comorbid retinopathy. This finding reaffirms the involvement of microvessels in both types 1 and type 2 diabetes mellitus.22 Microvascular disease leads to multiple complications in people with diabetes. For instance, hyaline arteriosclerosis, a condition characterized by thickening of small arterioles and capillaries, is a very common finding and responsible for ischemic changes in the retina, brain, kidneys, and peripheral nerves. Atherosclerosis of the major kidney arteries and their intrarenal branches leads to chronic nephron ischemia, which is an important part of multiple renal lesions in diabetes.

An important predictor of the development of coronary artery calcification in individuals with type 1 diabetes mellitus is vitamin D deficiency.23 A study by Joergensen, et al. found that vitamin D deficiency in type 1 diabetes mellitus is a predictor of mortality but not development of microvascular complications.24

Nephropathy

Another microvascular complication resulting from diabetes mellitus is the characteristic wall thickening of small arterioles and capillaries of the kidneys, which in turn can very well lead to diabetic nephropathy. Diabetic nephropathy is characterized by proteinuria, glomerular hyalinization, and chronic renal failure. Aggravated expression of cytokines (i.e., tumor growth factor (TGF) beta-1) is a component of the pathophysiology of glomerulosclerosis, which starts early in the course of diabetic nephropathy.

Genetic polymorphisms also exert an influence on the development of diabetic nephropathy. Single-nucleotide polymorphisms play a role in the development for diabetic nephropathy in various individuals with type 1 diabetes mellitus.25


Double diabetes

In certain regions where rates of type 2 diabetes mellitus and obesity are high, individuals with type 1 diabetes mellitus may share genetic and environmental factors that cause them to exhibit features of type 2 diabetes mellitus such as reduced insulin sensitivity. This condition is termed double diabetes.

A study by Epstein, et al. of 207 patients with type 1 diabetes mellitus using estimated glucose disposal rate (eGDR) to evaluate insulin resistance found that the mean eGDR was significantly lower (meaning, insulin resistance was higher) in black patients (5.66 mg/kg/min) compared to Hispanic patients (6.70 mg/kg/min) and white patients (7.20 mg/kg/min). Additionally, low eGDR was associated with a marked increase in the risk of vascular complications of diabetes such as cardiovascular disease, chronic kidney disease, and diabetic retinopathy.26

Heart and blood vessels

Damage to the nerves of the heart and blood vessels impairs the body's regulatory control of blood pressure and heart rate. Diabetic children with autonomic damage to the cardiovascular system are prone to feeling light-headed and faint when standing up after long periods of sitting. This is because of the sudden drop of blood pressure after a change in body position. Additionally, damage to the cardiac nerves can also result in a constantly elevated heart rate despite the change in body functions and physical activity.30

Digestive system


Damage to the nerves of the digestive system often leads to constipation. Other effects include slow gastric emptying, a condition called gastroparesis. Severe gastroparesis can lead to constant nausea and vomiting, bloating, and loss of appetite. Additionally, the abnormal digestion of food leads to fluctuating blood glucose levels.30

Another digestive organ that can sustain neural damage is the esophagus, which leads to symptoms such as swallowing difficulties. If left untreated, these problems can combine together and result in massive weight loss.30

Urinary and reproductive systems

Nerve damage also affects sexual function and urination. Autonomic neuropathy causes incomplete bladder emptying, thus, allowing for the growth of bacteria in the urinary system. This predisposes diabetic individuals to recurring urinary tract infections.30 Additionally, autonomic neuropathy affecting the bladder causes urinary incontinence, which may be embarrassing for school-age children.30

Sweat glands

Damage to the nerves that control sweating can result in impaired regulation of body temperature. Children with autonomic neuropathy affecting the sweat glands can exhibit symptoms such as profuse sweating at night or during meals.30

Eyes

Autonomic neuropathy can affect the nerves of the pupils. The result is decreased sensitivity to changes in light. A good example is when a diabetic individual is unable to see properly in a well-lit room or have difficulty driving at night.30


Diagnosis

The diagnosis of type 1 diabetes mellitus in the pediatric and adolescent population is usually straightforward and requires little to no specialized testing. They usually present with a several-week history of polyuria, polydipsia, polyphagia (the 3 P’s symptoms of diabetes), and weight loss, with hyperglycemia, glycosuria, ketonemia, and ketonuria.

When evaluating children for type 1 diabetes mellitus, it is important for clinicians and other health professionals to consider in the differential diagnosis the following conditions:28

Maturity Onset Diabetes of the Young (MODY) Steroid treatment Type 2 diabetes mellitus Diabetes insipidus Transient hyperglycemia with illness and other stress High-output renal failure Psychogenic polydipsia Münchhausen syndrome

Children with Maturity Onset Diabetes of the Young (MODY) may exhibit symptoms of type 1 diabetes mellitus. The following notes may help clinicians and health professionals recognize MODY:28

Long-standing family history of diabetes, usually two or more generations, with the age of diagnosis falling with each successive generation;

Chronic low insulin requirements, especially with good glycemic control; and

Onset of diabetes at birth or within the first year of life.

Genetic testing is expensive and can be substituted by testing for islet autoantibodies in patients suspected of having maturity-onset diabetes of


the young. The presence of these antibodies is the same in patients with MODY as in the non-diabetic groups. A positive test for positive islet autoantibodies eliminates MODY as a possible diagnosis.40

Differential Diagnosis from Type 2 Diabetes Mellitus

The 2011 American Association of Clinical Endocrinologists (AACE) guidelines recommend that clinicians and other healthcare practitioners entrusted with the care of pediatric diabetics do the following in order to differentiate between type 1 and type 2 diabetes mellitus:38

1. Measure insulin levels,2. Measure C-peptide levels and immune markers such as glutamic acid

decarboxylase [GAD] autoantibodies, and3. Obtain detailed family history.

An oral glucose tolerance test (OGTT) is not needed in the diagnosis of type 1 diabetes mellitus. However, the significant increase of type 2 diabetes mellitus merits the evaluation of insulin secretion in the pediatric population.

C-peptide is a product of the conversion of pro-insulin to insulin. An insulin or C-peptide level below 5 µU/mL is suggestive of type 1 diabetes mellitus. A fasting C-peptide level more than 1 ng/dL in a patient with diabetes for more than one year suggests type 2 diabetes mellitus, except if the glucose level is elevated and insulin or C-peptide level is temporarily low. These patients are more likely to recover insulin production once normal glucose is restored.32

Non-diagnostic tests

There are a variety of laboratory tests carried out to diagnose or confirm the diagnosis of type 1 diabetes mellitus, all of which are based on the health of the child. For most children, only urine testing for glucose and blood glucose


measurement is required for a diagnosis of the disease. Other conditions associated with diabetes require several tests at diagnosis.

Urinalysis

Urinalysis is a standard test requiring a sample of urine from patients. One of the findings indicative of diabetes mellitus is the presence of glucose and ketone bodies in the urine sample. A positive urine glucose test is indicative but not diagnostic for type 1 diabetes mellitus. This test must be followed by a blood glucose test to confirm elevated blood glucose levels.28

A urine sample of ambulatory patients should be tested for the presence of ketone bodies at the time of diagnosis.28 The presence of ketone bodies in the urine, ketonuria, confirms the occurrence of lipolysis and gluconeogenesis, which are metabolic processes that normally only happen during cellular starvation. In fact, the combined presence of ketonuria, hyperglycemia and glycosuria are strong indications of insulin deficiency and potential diabetic ketoacidosis.28

It should be noted that the presence of ketone bodies in the urine is not reliable for either the diagnosis or monitoring of diabetic ketoacidosis (DKA), although its measurement is useful in screening a hyperglycemic patient for ketonemia.28 The plasma acetone level or the beta-hydroxybutyrate level is a better indicator of diabetic ketoacidosis, along with plasma bicarbonate measurements.28

Urinary albumin

Children with type 1 diabetes mellitus should be regularly monitored for the development of diabetic comorbidities such as nephropathy. Starting at 12


years old, a urinalysis testing for a slightly elevated albumin excretion rate (AER), a condition known as microalbuminuria, should be conducted yearly. Microalbuminuria is an indicator of risk for diabetic nephropathy. In fact, it is the first indication of nephropathy.

Early identification of microalbuminuria provides opportunities for early resolution and prevention of renal failure. Microalbuminuria is characterized by glomerular hyperfiltration, and by abnormal functioning of glomerular basement membrane and glomeruli.28

Fructosamine test

Fructosamine is the product of a chemical reaction between glucose and plasma protein. Fructosamine levels, although not diagnostic, can also test for glucose levels. They reflect glucose control in the previous 1-3 weeks. Therefore, this test method may show changes in glycemic control before HbA1c testing can be done. In addition, it is also helpful in cases of intensive treatment and in short-term clinical trials.32

White blood count

A white blood cell (WBC) count and blood and urine cultures are performed to rule out infection.

Antibody testing

Since type 1 diabetes mellitus has strong etiologic autoimmune origins, antibody testing for the presence of islet cell antibodies, insulin antibodies, glutamate decarboxylase (GAD) antibodies, thyroid antibodies, and antigliadin antibodies should be considered.28


Islet cell antibodies

Screening for islet antibodies in low-risk children with no symptoms is not recommended.36 However, children at high risk such as those who have first-degree relatives with diabetes may be good candidates for annual screening for the presence of anti-islet antibodies before reaching the age of ten, along with an additional screening during adolescence.37

Islet cell antibodies are non-specific disease markers of autoimmune diseases affecting the pancreas. Their presence at diagnosis may indicate but are not needed to diagnose type 1 diabetes mellitus. They have been found in approximately 5% of children without type 1 diabetes mellitus.28

Other antibody markers of type 1 diabetes mellitus include:28 Insulin antibodies Glutamate decarboxylase (GAD) antibodies

Thyroid antibodies

The presence of thyroid antibodies may indicate a risk of developing thyroid disease. On the other hand, it is not uncommon for children with type 1 diabetes mellitus to also have an undiagnosed thyroid condition such as hypothyroidism. This is because hypothyroidism, in its initial stages, has few easily recognizable clinical signs in children. The diagnosis of this disease is important because if left untreated, it may interfere with diabetes management.28

Generally, children with hypothyroidism have lower insulin requirements compared to those who do not have the disease. They also experience more episodes of hypoglycemia. On the other hand, children with hyperthyroidism have greater insulin requirements and are more prone to hyperglycemic episodes. This is why it is very important for clinicians and health


professionals to be wary of this comorbidity when starting insulin therapy since insulin requirements can easily fluctuate.28 Thyroid function tests should be conducted regularly, usually every 2-5 years if thyroid antibodies are present.28

Antigliadin antibodies

The presence of antigliadin antibodies is suggestive of celiac disease. If positive, a jejunal biopsy must be conducted to confirm or refute the diagnosis. Once celiac disease is confirmed, the diabetic patient must start on a gluten-free diet for life. The disease can be identified in about 4% to 9% of children with type 1 diabetes mellitus, although more than half of them do not have outward symptoms (asymptomatic).28 Children with type 1 diabetes are at greater risk of developing classic celiac disease within the first 10 years of diabetic life.

Recent studies suggest that a gluten-free diet improves intestinal and extra-intestinal symptoms of celiac disease. The same studies suggest that it may even prevent its sequelae.28 Lipid profile

Children with type 1 diabetes usually have abnormal lipid profiles because of increased triglycerides (hypertriglyceridemia) in the circulation released due to gluconeogenesis. Hyperlipidemia is common with poor metabolic control but can quickly be restored to normal when metabolic control improves.

Blood glucose monitoring tests


Random and fasting blood glucose is covered here. Aside from the signs and symptoms of temporary stress-induced hyperglycemia, a random whole-blood glucose concentration exceeding 200 mg/dL is diagnostic for diabetes. A fasting whole-blood glucose concentration more than 120 mg/dL is also diagnostic for diabetes. On the other hand, if the signs and symptoms of hyperglycemia are not present, the clinician must confirm the results of these tests on a different day. It is very common for children with diabetes to be detected because of hyperglycemic symptoms accompanied by blood glucose levels of at least 250 mg/dL.28

Children with type 1 diabetes need to monitor their blood glucose levels several times a day using capillary blood samples, reagent sticks, and blood glucose meters. A finger-stick glucose test is usually recommended in the emergency department for almost all patients with confirmed diabetes mellitus. All finger-stick capillary glucose levels require serum or plasma tests to confirm the diagnosis. All other lab studies must either be chosen or foregone depending on the individual clinical situation. Intravenous glucose testing may also be considered to detect subclinical diabetes early.28

It is important to note that individually measured glucose levels can vary significantly from estimated glucose averages measured using hemoglobin A1c (HbA1c) tests.31 It is therefore, important to proceed with caution especially if the measurements were taken to estimate rather than accurately measure glucose concentration. The difference between the two measurements has a potential influence on clinical decisions regarding treatment and management.

Glycosylated hemoglobin


Glycosylated hemoglobin derivatives, such as HbA1a, HbA1b, and HbA1c, are products of non-enzymatic reaction between glucose and hemoglobin. There is a strong correlation between the average blood glucose levels taken over a period of 8 to 10 weeks and the proportion of glycosylated hemoglobin in the blood. For the diagnosis of type 1 diabetes mellitus, the percentage of HbA1c is the most common product measured. In fact, the measurement of HbA1c levels is the best method for monitoring medium to long-term blood glucose levels.28

HbA1c is formed when the beta chain of hemoglobin is irreversibly glycosylated by plasma glucose. Its rate of formation increases with rising plasma glucose levels. HbA1c levels provide an approximation of plasma glucose levels of the preceding 1-3 months. The reference range for non-diabetics is 6% in most laboratories. Glycosylated hemoglobin levels can help predict the development and progression of microvascular complications associated with diabetes mellitus.28

The American Diabetes Association (ADA) guidelines recommend the measurement of HbA1c at least once every 6 months in diabetics who meet their treatment goals and exhibit stable glycemic control. On the other hand, the ADA recommends HbA1c testing every 3 months for diabetics whose insulin therapy was altered or unable to meet glycemic targets.33

HbA1c testing has not always been widely recognized and used as today in the diagnosis of diabetes mellitus. This drawback is attributed to the lack of international standardization and insensitivity for the identification of milder forms of glucose intolerance. However, this all changed in 2009 when a panel consisting of members of the ADA, the European Association for the Study of Diabetes, and the International Diabetes Association reached


consensus and recommended HbA1c testing for the diagnosis of both types 1 and 2 diabetes mellitus.34 The committee specifically recommended the test for patients with suspected type 1 diabetes mellitus who do not exhibit the classic symptoms of the disease such as polyuria, polydipsia, polyphagia, unexplained weight loss, and do not have a random glucose level of 200 mg/dL.

The ADA panel recommended that HbA1c levels ≥6.5% to be indicative of diabetes. These results should be accompanied by diagnostic confirmation through repeat testing if clinical symptoms are absent. However, glucose testing remains the diagnostic choice for pregnant women and in cases where HbA1c testing is unavailable.34 The panel mentioned the following advantages of HbA1c testing over glucose measurement:34

It provides long-term glucose monitoring It presents less biologic variability It does not have fasting or timed sample requirements It is currently the standard used in making disease management

decisions

The results of the Diabetes Control and Complications Trial (DCCT) discovered that patients with HbA1c levels of approximately 7% possessed the best prognosis when it comes to long-term diabetic complications. Currently, many clinicians aim for HbA1c levels between 7-9%, which is the target range. Levels <7% are associated with greater risk for severe hypoglycemia while levels >9% put diabetics at greater risk for long-term complications of the disease. The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends a pediatric target level of 7.5% or less.28

Normal HbA1c levels vary slightly depending on the laboratory method used, however; children without type 1 diabetes mellitus usually have levels


between the low to normal range. At diagnosis, these levels are usually well above the upper limit of the reference range. Their HbA1c levels should be checked every 3 months.28 Clinicians must remember that there are various methods of measuring HbA1c levels, and the differences between these assays can be significant and unpredictable.

Oral glucose tolerance test (OGTT)

OGTT is not needed in the diagnosis of type 1 diabetes mellitus, although it can help in the differential diagnosis. It helps exclude the diagnosis of diabetes when hyperglycemia or glycosuria is identified without the usual causes such as recent illness, steroid therapy or when the patient also exhibits renal glucosuria.28

This OGTT is done by first obtaining a fasting blood sugar level followed by the administration of an oral glucose load according to the ages specified below:28

2 g/kg for pediatric patients < 3 years old

1.75 g/kg for pediatric patients between 3-10 years old

75 g for pediatric patients >10 years old

Next, the blood glucose concentration is checked after 2 hours. A fasting whole-blood glucose level more than 120 mg/dL or a 2-hour value more than 200 mg/dL is indicative of diabetes. However, it is important to note that mild elevations may not always indicate diabetes, especially when the patient exhibits no symptoms and have not tested positive for diabetes-related antibodies.28


A modified OGTT may be used to single out cases of MODY, if in addition to blood glucose levels, insulin or c-peptide levels are measured at fasting, 30 minutes, and 2 hours. Children with type 1 diabetes mellitus produce very negligible, if at all, amounts of insulin, while those with MODY or type 2 diabetes mellitus can produce variable and substantial insulin in the presence of hyperglycemia.28

The criteria for the diagnosis of type 1 diabetes mellitus are outlined in the table below. Any child who fits into any of the three criteria has type 1 diabetes mellitus.

Casual plasma glucose Fasting plasma glucose Oral glucose tolerance test

≥ 200 mg/dL accompanied by classic symptoms such as polydipsia, polyuria, and unexplained weight loss

≥ 126 mg/dL ≥ 200 mg/dL

Diabetes Management

Initial careAfter the diagnosis, initial diabetic care can begin. It generally depends on several factors such as:

Age of the child, The ability to provide outpatient education, The clinical severity of the child at presentation, and The geographic proximity of the patient to a tertiary care center.


Ideally, children who are newly diagnosed with type 1 diabetes should be initially evaluated by a diabetes healthcare team whose members are qualified to provide advice and counseling on the latest in pediatric management of type 1 diabetes mellitus. The team ideally should consist of the following members:

Pediatrician with training on diabetes care Pediatric endocrinologist Nurse educator Dietitian/nutritionist, and Mental health professional

Other health professionals may also be included in the team, including the following:48

Psychologist Social worker Exercise specialist

Regardless of the sources of care available, all healthcare professionals involved in the care of children with diabetes should have a good grasp of the developmental stages of childhood and adolescence and how each one impacts diabetes management differently. A study by Kaufman, et al. found that both short and long term outcomes are enhanced with regular outpatient review with a specialized diabetes team.48 The involvement and coordination among these team members during the first weeks of diagnosis is crucial to the prognosis of the patient. It is usually during this time that the family members learn about diabetes management.49,50


The diabetes healthcare team is useful in helping newly diagnosed children start their glycemic control program. The start can be overwhelming both to the team and to the patients and the family. Since self-management is one of the major goals of the team, they may want to impart the following useful tips to these patients.

Start slowly: For example, the nurse educator may first teach the patient how to check the blood glucose level several times each day. Once the patient has adapted to the routine, the nurse educator might want to teach the patient how to self-administer multiple daily injections next. Once the patient has learned this, the exercise specialist might incorporate a new exercise program and help the nutritionist make the necessary changes in the diet to accommodate the program’s energy requirements.

Be honest and open to changes: The school psychologist or nurse might want to encourage newly diagnosed patients to be honest and open to the upcoming major changes in their lifestyle.

Set realistic goals: The team needs to assure patients that blood glucose levels will not always be on target levels every time. With enough practice and experience, patients can develop the skill at choosing correct insulin doses for various situations.

Children diagnosed with type 1 diabetes mellitus require a lifetime therapy with insulin. The following are also required to manage the disease successfully:


Glycemic monitoring Lifestyle changes Diet Monitoring for the development of diabetic complications

All of these elements are discussed in detail in the succeeding pages.It is important for all healthcare professionals involved in the management of type 1 diabetes mellitus to create effective strategies that help these pediatric patients and their parents achieve glycemic control targets through a combination of proper lifestyle and diet changes, patient education and frequent glucose monitoring. A well-organized healthcare team can offer the patient education and support in an outpatient setting. Some of the immediate requirements following a confirmed diabetes diagnosis are the education and training of the patient and family on:

Blood glucose level (glycemic) monitoring, Insulin therapy, and Recognition and treatment of hypoglycemic symptoms.

Hypoglycemia becomes harder to recognize over time, and severe hypoglycemic episodes can happen spontaneously. It is therefore important to reiterate the warning signs and symptoms of hypoglycemia to children (and parents) who maintain low blood sugar levels and who already have a history of frequent hypoglycemic episodes. Inappropriate or inadequate treatment of hypoglycemia can result in serious consequences.

As mentioned previously, microvascular complications such as retinopathy and nephropathy are common among diabetics. Therefore, frequent monitoring for their development should be a regular part of the management plan.

Glycemic Monitoring


A tight glycemic control decreases both the onset and development of diabetes-related complications in adults and adolescents with type 1 diabetes.40,41 Solid attempts to reach the recommended glycemic goals should be made (see table below).

Age (in years)

HbA1c

(%)Fasting plasma glucose

Two-hour post-prandial

plasma glucoseConsiderations

<6 <8.0 6.0–10.0 - Exercise caution to prevent hypoglycemia due to potential association between severe hypoglycemia and later cognitive impairment. Consider target of <8.5% if excessive hypoglycemia occurs.

6-12 ≤7.5 4.0–10.0 - Targets should gradually increase as the child's age increases. Consider target of <8.0% if excessive hypoglycemia occurs.

13-18 ≤7.0 4.0–7.0 5.0–10.0 Suitable for majority of adolescents.

Not every child with diabetes can safely attain these goals. This is why prudent clinical judgment is needed to establish which children can realistically and safely achieve these goals. The treatment goals and strategies need to be specific to each child, giving special consideration to those with risk factors such as young age and previous severe episodes of hypoglycemia. In fact, a study by Gaudieri, et al. found that an onset of diabetes before the age of 7 years old is linked to poorer cognitive function.42

Episodes of severe hypoglycemia and chronic hyperglycemia are also associated with poorer cognitive function and performance.43,44,45,46


Tight glycemic control refers to safely attaining a blood glucose level that is as close to the normal level as possible (non-diabetic blood glucose level). This means the following should be obtained:

Pre-prandial blood glucose levels between 70-130 mg/dl, Post-prandial blood glucose levels <180 mg/dl, and Glycosylated hemoglobin (A1C) level <7%.

The target value for glycosylated hemoglobin will vary based on the laboratory method used. In actuality, it is very difficult and impractical to sustain near-normal blood glucose levels consistently. The ultimate goal is to reach blood glucose levels that help prevent the development of complications.

Researchers at the Diabetes Control and Complications Trial (DCCT) found several positive benefits of tight glycemic control. Over a period of several years, they followed 1,441 patients with type 1 diabetes and noted their glycemic control patterns and overall health status. Fifty percent of them continued standard diabetes treatment while the other half were on a tight glycemic control program. Those on a tight glycemic control program sustained lower blood glucose levels over long periods than those on standard treatment. The results of the study showed that those on tight glycemic control program developed fewer complications, namely:47

Only one-quarter developed retinopathy, Only half developed nephropathy, Only one-third developed neuropathy, and


Far fewer people who already had early forms of these three complications got worse.

More than preventing complications, children who keep tight glycemic control can reap early benefits, such as:47

Better self-esteem and greater energy, Option to engage in various physical activities, and Variable meal timings.

However, the DCCT study also reported two primary drawbacks with tight glycemic control:47

Hypoglycemia, and Weight gain.

As the patient attempts to keep a tight control on glucose, there is less room to work with. As such, any changes to modify blood glucose levels can keep the patient either hypoglycemic or hyperglycemic for too long.

Hypoglycemia

Children who tightly control their blood glucose levels are three times more prone to develop hypoglycemia. If a the child misses a meal, or the meal is delayed slightly, blood glucose levels can be pushed very easily in the wrong direction, leading to hypoglycemia. Its important these patients be advised to:47

Be alert to the symptoms of hypoglycemia to be able to immediately begin self-treatment with insulin.

Check blood glucose levels before driving. Consult members of the diabetes healthcare team if hypoglycemic

episodes become more frequent than they used to. Ease up on individual goals or revert back to standard therapy for a

while.


Weight gain

Children who tightly control their blood glucose levels also tend to gain more weight easily compared to those on standard insulin treatment. One of the most important ways to avoid this is by creating meal and exercise plans that best suit their lifestyle with the dietitian and exercise specialist.47

Insulin Therapy

Insulin therapy is a mainstay in the management of type 1 diabetes mellitus. Insulin was first made available in 1925 in the form of animal insulin. The first analogs were extracted from beef (bovine insulin) and pork (porcine insulin). It wasn’t until the early 1980s that technology enabled pharmaceutical companies to produce synthetic human insulin. Currently, synthetic human insulin has largely been replaced by insulin analogs in the U.S.52

Insulin classification and characteristics

Insulin is classified by the onset, peak and duration of its action in the body following administration. Insulin analogs are a synthetic version of the human insulin and mimic their effects on the body. Insulin analogs were developed because human insulin has limitations when given subcutaneously. High concentrations of human insulin contained in a vial or cartridge clump together. This solid mass results in the slow and erratic absorption of insulin from the subcutaneous tissue. Ultimately, it alters the dose-dependent duration of action of insulin.52


On the other hand, insulin analogs exhibit greater stability and predictable absorption and duration of action. The rapid acting insulin analogs, as their names suggest, have faster onset of action followed by a peak effect, and consequently a drop. The long acting insulin analogs have longer onset of action but provide an even and sustained insulin supply throughout the day.52

Characteristics of Insulin

As mentioned previously, insulin is largely classified by differences in onset, peak and duration of action. Other defining characteristics include:52

Concentration (insulin analogs in the U.S. have a standardized concentration of 100 units per ml or U100), and

Route of delivery (subcutaneous or IV administration).

Insulin is usually injected into the fatty tissue just under the skin, subcutaneous tissue.

Types of insulin

Based on the characteristics above, insulin is classified into four main groups:52

Rapid acting insulin Regular insulin Intermediate acting insulin Long acting insulin


The onset and duration of actions and peak effects of each type are outlined in the table below.

Type of insulin analog Onset of action

Duration of action

Peak effect

Appearance

Rapid acting insulin 5-15 mins 4-6 hours 1-2 hours ClearRegular insulin 30 mins –

60 mins6-8 hours 2-4 hours Clear

Intermediate acting insulin

60-120 mins >12 hours 4-6 hours Cloudy

Long acting insulin 90-120 mins 12-24 hours - Clear

Rapid acting insulin

Rapid acting insulin includes rapid acting insulin analogs such as insulin Aspart, insulin Lyspro, and insulin Glulisine. It has the following characteristics:52

Rapid absorption from the subcutaneous tissues into the bloodstream, and

Administered usually to control blood glucose levels during meals and snacks and correct hyperglycemic episodes.

All doses, both large and small, exhibit similar onset of action and the time to peak effect. However, the duration of action is dose-dependent which means higher doses may last longer and lower doses generally have shorter duration of action. For example, a few units (U) may last 4 hours or less, while U25 or U30 may last 5 to 6 hours. As a general rule, rapid acting insulin analogs exhibit duration of action lasting up to 4 hours. Because rapid acting insulin analogs enter the bloodstream within minutes of administration, it is important to inject them only within 5 to 10 minutes prior to meals.52


Rapid acting insulin analogs are the insulin of choice for bolus insulin replacement. Generally, they are used in insulin pumps, also called continuous subcutaneous insulin infusion (CSII) devices.52

Regular insulin

Regular insulin has an onset of action of 30 to 60 minutes, peak effect in 2 to 4 hours, and duration of action of 6 to 8 hours. Similar to the rapid acting insulin analogs, the duration of regular insulin is dose-dependent. This means that the larger the dose, the more rapid is the onset of action. This also means a longer time to reach peak effect, and its duration.52

Intermediate acting insulin

NPH is intermediate acting insulin. It has the following characteristics:52

Slower absorption compared to rapid acting analogs,

Longer duration of action, and Administered to control the blood glucose levels overnight, during

fasting and between meals.

NPH has an onset of action of 1 to 2 hours, a peak effect of 4 to 6 hours, and duration of action of more than 12 hours. This type of insulin when given in very small doses will exhibit early peak effect and shorter duration of action, while higher doses will exhibit longer time to peak effect and longer duration of action.52

Pre-mixed insulin is a pre-mixed NPH combined with either regular insulin or a rapid acting insulin analog. Its onset and duration of action, as well as peak


effect are a combination of the short and intermediate acting insulin analogs.52

Long acting insulin

Long acting insulin analogs include insulin Glargine and insulin Detemir. They have the following characteristics:52

Slowest absorption rate among all insulin types

Very minimal peak effect Constant plateau effect throughout the

day Administered to control blood glucose

levels overnight, during fasting and between meals

Long acting insulin analogs have an onset of insulin effect in 90 to 120 minutes. Their effect plateaus over the next few hours and followed by a steady duration of action that lasts 12 to 24 hours for insulin detemir and 24 hours for insulin glargine.52 It is important to remember that long-acting insulin analogs should not be mixed in the same syringe with other insulin analogs since doing so can alter the effects of the two insulin analogs in the body once administered.52

Just like the earlier versions of the human insulin, insulin glargine forms clusters when injected subcutaneously. The formation of the clusters is part of its drug delivery design. In fact, it is the cluster formation that gives insulin glargine its long duration of action. The individual insulin units are designed to gradually detach from the cluster, allowing for the slow release and gradual absorption of insulin into the blood stream.52

Principles of insulin therapy


Insulin therapy is based on two basic principles:51 1. Basal insulin replacement2. Bolus insulin replacement

The basal replacement insulin or basal insulin represents about half of the body’s daily insulin requirements. Its goals include:51

Nocturnal control of blood glucose levels, Control of blood glucose levels between meals by preserving the fat in

fat tissue and preventing gluconeogenesis in the liver, and Provide a low and steady supply of insulin.

Basal replacement insulin (basal insulin) may consist of either:51 Long acting insulin injected once or twice daily such as insulin glargine,

insulin detemir and NPH, or Rapid acting insulin continuously infused under the skin, if using an

insulin pump.

Bolus insulin replacement

Bolus insulin replacement or bolus insulin is used when a rapid surge of insulin at mealtimes is required. It represents about 10% to 20% of the daily insulin requirements per meal, or about half of the body’s daily insulin requirements.51 There are two kinds of bolus insulin:51

1. Mealtime bolus insulin, which covers the carbohydrate in the meal or snack.

2. High blood glucose correction bolus insulin, which gives extra insulin to return the blood sugar back to the target level following hyperglycemic episodes.

Bolus insulin is usually administered using rapid-acting insulin analogs such as insulin Aspart, insulin Lyspro, and insulin Glulisine or Regular insulin.51


Route of insulin administration

Insulin may be given via multiple injections throughout the day or continuous subcutaneous insulin infusion (CSII), otherwise known as insulin pump. Simply put, insulin is administered in two ways:53

1. Injection (using insulin vials and syringes, insulin pens)2. Infusion (via insulin pump or CSII devices)

The type of insulin therapy chosen depends on many factors, such as:53

Age of the pediatric patient Duration of diabetes Family lifestyle Socioeconomic factors Family, patient, and physician preferences

Insulin therapy may be given intensively via continuous subcutaneous insulin infusion (CSII) or conventionally (multiple daily injections). An intensive therapy with CSII involves the administration of low level of insulin at all times and extra insulin prior to meals. Generally, this type of dosing technique seeks to mimic the body’s natural pattern of insulin release from the pancreas.53 Multiple injections generally involve injecting insulin doses at different times of the day.Multiple daily injections

Multiple daily injections of insulin are the most common insulin delivery method. The most frequently used injection device is an insulin syringe. These are disposable, made of plastic, presently available in three sizes, and hold up to U30, U50 or U100 of insulin. The needles are up to 31 gauge with lengths varying from 3/16th of an inch for infants, to ½ inch or more for adults. The insulin is usually injected into the subcutaneous tissue. There are rare instances when insulin may be injected into a muscle. This is not the


standard practice and should only occur under medical supervision in a hospital or medical care setting.53

An alternative to the insulin syringe is the insulin pen. It has a replaceable cartridge, which contains the insulin, a replaceable needle, a dial for the selection of insulin dose, and a mechanical release mechanism.53 Insulin pens are available both as disposable devices and re-useable devices, with disposable insulin cartridges. These devices are especially very convenient for active individuals requiring multiple daily multiple injections, as well as those who have visual and dexterity difficulties.53

Continuous subcutaneous insulin infusion (CSII) devices are also popularly called insulin pumps. To date, they represent the most sophisticated type of insulin drug-delivery system. These are relatively small, computerized devices, which may be programmed to deliver insulin at specific times throughout the day. They are durable and capable of lasting for years. However, its components, such as the insulin supply, may need to be replaced regularly.53 The basic components of CSII devices are listed, and further described below:53

Pump Infusion set Cannula

The pump

The insulin pumps are small, approximately the size of a pager. They are attached to the cartridge containing the insulin, the pumping mechanism, battery, computer chip and screen. They are worn outside of the body, either attached to a belt or holster. Some are carried in the pocket.53

Infusion set and cannula

The infusion set serves as the connection between the cartridge and the administration site (skin). It allows insulin to flow from the pump into the


subcutaneous tissue via a cannula. A strong adhesive keeps it affixed to the skin. The cannula passes through the skin and into the subcutaneous layer where it delivers the drug.53 The cannula is the tube that allows the insulin to flow from the pump and into the infusion set.53

Honeymoon period

The honeymoon period is characterized by stable glycemic control and low insulin requirements (<0.5 units/kg/day). It usually occurs over a period of up to two years following diagnosis.54 The end of the honeymoon period can sometimes mark the beginning of more intensive management to sustain the fulfillment of glycemic goals. Currently, there are two methods of intensive diabetes management, namely:54

Basal-bolus regimens which consist of long-acting basal insulin analogues and rapid-acting bolus insulin analogues, and

CSII or insulin pump therapy.

Some studies including those by Robertson et al. and Chase et al. found that basal-bolus therapy improved glycemic control more than conventional twice-daily NPH and rapid-acting bolus analog therapy.55,56 CSII is a safe and effective therapy, which can be started at any age.57 Contrary to the studies by Robertson, et al. and Chase, et al., a Cochrane review found that CSII slightly improved metabolic control over basal-bolus therapy.58

Some studies of CSII in school-age children have found a significant decrease in HbA1c with decreased hypoglycemia 1-2 years following the start of therapy when compared to pre-therapy levels.59 When used with a continuous glucose sensor, CSII therapy leads to enhanced control compared to basal-bolus therapy alone.60 The majority of pediatric studies of the long-acting basal insulin analogs, detemir and glargine, have shown enhanced fasting blood glucose levels and fewer occurrences of nocturnal hypoglycemia with a reduction in HbA1c.55,61,62,63


On the other hand, two large population-based observational studies by de Beaufort, et al. and Rosenbauer, et al. have not shown improved HbA1c in patients on basal-bolus or CSII therapies when compared to those on NPH and rapid-acting bolus analogs.64,65 The conflicting evidence of efficacy merits tailored and individualized insulin therapies to reach HbA1c goals, reduce hypoglycemic episodes and to optimize quality of life.

Non-Insulin Therapy

Non-insulin based therapy is also available for children with type 1 diabetes mellitus. The standard medication used is pramlintide, an injectable available either in pen form or vial. It is not taken singly; instead, it is taken as an adjunct to insulin therapy, to help control blood glucose levels during meals. It acts by lowering the glucagon levels during a meal, slowing down gastric emptying and curbing the appetite.66

The drug resembles the hormone amylin, which is normally released with insulin from the beta cells of the pancreas. Patients with type 1 diabetes also do not secrete amylin, in addition to insulin, due to the autoimmune destruction of pancreatic beta cells.66

Pramlintide dosing

The drug is started on a low dose and titrated upward (usually every three days) once the patient tolerates it. Its initial dose is 15 micrograms or 2.5 units on the insulin syringe pre-prandially. If after 3 days the patient can tolerate the drug, the dose is titrated to 30 micrograms or 5 units on the insulin syringe pre-prandially. The dose may be further increased every three days as tolerated to a maximum dose of 60 micrograms. The meals taken after this drug must contain at least 30 grams of carbohydrate.66


The following notes must be taught to the pediatric patient once pramlintide is introduced into the diabetic management plan:66

Decrease pre-prandial insulin dose by half or more to prevent hypoglycemic episodes,

If using an insulin pump, extending the meal bolus to 90 or 120 minutes may prevent early post-prandial hypoglycemia and late post-prandial hyperglycemia due to delayed gastric emptying rate,

Administer both pramlintide and insulin at about the same time, but at different injection sites, and

Do not mix pramlintide with insulin in the same syringe.

The most common side effects of pramlintide are:66 Nausea Vomiting Headache Hypoglycemia

Diet

Dietary changes and management is crucial to the successful management of type 1 diabetes mellitus in children. In the past, before the discovery of insulin, children with diabetes were managed by diets with severe restrictions in carbohydrate and energy intake. These extreme dietary methods of diabetic management resulted in a long tradition of restricted carbohydrate intake and unbalanced diets.


Currently, dietary management of diabetes focuses on a well-balanced diet consisting of high carbohydrate and fiber contents and low fat content. The following represents the recent dietary consensus recommendations:67

Carbohydrates – Source of 50-55% of daily energy; no more than 10% from sucrose or other refined carbohydrates,

Fat – Source of 30-35% of daily energy, and Protein – Source of 10-15% of daily energy.

Current dietary management aims to strike a balance between the food intake with insulin dose and activity. Ultimately, it should help achieve a blood glucose concentration that is as close as possible to reference ranges, and prevent extreme episodes of hyperglycemia and hypoglycemia.67

Children who are on fast-acting insulin, either via injection or pump, at mealtimes need to be especially educated about how to estimate the carbohydrate content of food. It allows these children to precisely match their carbohydrate intake with their insulin dose. Additionally, they should also receive sufficient complex carbohydrates such as cereals prior to bedtime to prevent nocturnal hypoglycemia, especially those who are receiving twice-daily injections of mixed insulin.

The nutritionist or dietitian needs to create an individual diet plan for children that meet their specific needs and circumstances. In addition, these plans need to be reviewed regularly and adjusted according to the child's growth and lifestyle changes.

Diets low on carbohydrate content are regaining popularity as a management option for diabetes. This is based on the long-standing logic of lower carbohydrate intake amounting to lower insulin requirement. However, there are no past or existing trials that substantiate this management rationale, and such diets are not presently recommended.


Children with type 1 diabetes mellitus do not need to have their physical activities restricted. In fact, on the contrary, exercise has shown tangible benefits for such patients. Current guidelines have improved a lot over the years, allowing these children to compete at the highest levels in sports.68 In addition, most type 1 diabetic children are educated enough to know how to adjust their insulin dosage and diet according to the levels of physical activities they engage in.

As mentioned previously, it is vital for both patients and parents or caregivers to be able to identify and treat the symptoms of hypoglycemia. Hypoglycemia most often occurs after prolonged periods of physical activities involving the legs, such as walking, running or cycling. However, it is also important for patients and caregivers to remember that this may not occur immediately. In fact, it can occur several hours following exercise and even cause changes to insulin requirements the following day. This is why a large snack prior to bedtime is recommended in such cases.

Artificial sweeteners

In the U.S., there are five artificial sweeteners approved by the U.S. Food and Drug Administration (FDA):

acesulfame potassium (also called acesulfame K) aspartame saccharin sucralose neotame

These sweeteners are used in beverages, foods, and pharmaceutical and oral hygiene products. They are also available as tabletop sweeteners and granular forms for cooking and baking purposes. Other names for artificial sweeteners include:


Low-calorie sweeteners Sugar substitutes Non-nutritive sweeteners

Artificial sweeteners are largely preferred over regular sugar because of their non-carbohydrate content by diabetics and diet watchers. As such, they can also be called sugar replacements. Additionally, their sweetening power is at least 100 times more than regular sugar, so only a small amount is needed to provide the necessary sweetness. The body does not metabolize artificial sweeteners, with the exception of aspartame, and they are excreted unchanged.

Nutritionists and other members of the diabetes healthcare team need to reiterate to children with diabetes and their parents that there are many foods and beverages containing artificial sweeteners that still contain calories and carbohydrates from other ingredients. Therefore, caution must be exercised when consuming foods labeled as "sugar-free," "low in sugar" or "no sugar added" since they are not necessarily carbohydrate-free or contain lower carbohydrate content. In these cases, it is always best to check the nutrition facts panel, especially for foods that carry these claims.

Physical activity

A sedentary lifestyle is a silent killer, especially among patients who already have existing risks, such as, familial history of metabolic disorders, cardiovascular disease and renal disease. Physical activities, especially those of moderate intensity, improve the overall health of diabetics. However, before beginning a program of moderate intensive physical activity,


diabetics should be thoroughly evaluated for health conditions that put them at greater risk for adverse events associated with some types of exercise.

Examples of moderate intensity activities include aerobic and resistance exercises, all of which provide great health benefits for diabetic patients. The table below outlines several examples of aerobic exercises that children with type 1 diabetes mellitus can engage in inside and outside school.

Definition Recommended frequency

Intensity Examples

Rhythmic, repeated and continuous movements of the same muscle groups

10 minutes at a time

Moderate Biking, brisk walking, continuous swimming, dancing, raking leaves, water aerobics

Generally, euglycemic individuals become more sensitive to insulin during and several hours after moderate exercise. In patients with type 1 diabetes mellitus, there is very little, if at all, endogenous secretion and physiological regulation of insulin in the body. This is why if the insulin regimen and carbohydrate intake is not adjusted, hypoglycemia can occur.

Long Term Monitoring and Complications

Once a patient is on daily insulin therapy, the diabetes healthcare team needs to conduct a structured examination and review at least once a year to evaluate for possible complications. This review and examination should include:28

Growth evaluation Injection site exam


Examination of the peripheral extremities including the hands, feet, and peripheral pulses for signs of limited joint mobility, peripheral neuropathy, and vascular disease

Assessment for signs of associated autoimmune disease Blood pressure

Children older than 11 years old may need further examination that includes: Retinal screening Urine examination for microalbuminuria

Diabetic ketoacidosis

Approximately a little more than one fourth of children who are newly diagnosed with type 1 diabetes develop diabetic ketoacidosis and need hospitalization.87 The remaining 70% do not develop this complication unless facilities for long term outpatient care and self-management education are unavailable.

Diabetic ketoacidosis (DKA) is an acute, fatal consequence of poorly controlled type 1 diabetes mellitus. Patients who develop this complication require immediate medical attention. It is a complex metabolic abnormality characterized by hyperglycemia, ketoacidosis, and ketonuria. Additionally, children with considerable symptoms of dehydration, persistent vomiting, metabolic derangement, or serious illness also require inpatient care and intravenous rehydration therapy.

Diabetic ketoacidosis is a fairly common complication among children with new-onset diabetes.69 It is the leading cause of morbidity and mortality in diabetic children.70 However, with early recognition and initiation of insulin treatment, it can be prevented in these children. In fact, public awareness programs of the early signs of diabetes have resulted in considerable reduction of incidence of diabetic ketoacidosis among these children.71


On the other hand, children with established diabetes may also experience diabetic ketoacidosis due to failure to regularly administer insulin on time or poor sick-day management. The risk of developing the acute complication is greater among the following children:72-74

Those with poor metabolic control, Those with history of diabetic ketoacidosis, Peripubertal and adolescent girls, Children administered with insulin through pumps or long-acting basal

insulin analogues, Children with comorbid mental disorders, and Children with family difficulties.

The incidence of diabetic ketoacidosis in children with established type 1 diabetes mellitus may be reduced with the following interventions:

Adequate patient education, Behavioural changes, Family and peer support,75,76 and Greater access to 24/7 telephone counseling services for parents of

children with diabetes.77,78

Management of diabetic ketoacidosis

The majority of cases of diabetic ketoacidosis in pediatric patients can be treated without significant complications. However, some may be complicated by cerebral edema,79 which can lead to significant morbidity and mortality.80 On the other hand, cerebral edema is rare among adult diabetics.72,80 Its etiologic roots remain unclear; however, many factors are associated with greater risk of its development, such as:

Young age Presence of new-onset diabetes


High initial serum urea Low initial pCO2

Rapid infusion of hypotonic fluids Intravenous bolus of insulin Early intravenous insulin infusion Failure of elevation of serum sodium during fluid and insulin therapy Greater use of bicarbonate.

A bolus of insulin before fluid infusion should not be given because it does not provide rapid resolution of acidosis82,83 and can actually lead to cerebral edema.84 In fact, a study conducted recently found that the early administration of insulin (within the first hour of fluid replacement) can actually increase the risk for cerebral edema.81 Additionally, clinicians and other members of the healthcare diabetes team should exercise caution in young children with diabetic ketoacidosis, new-onset diabetes, and more severe form of acidosis and extracellular fluid volume depletion since they can all contribute to the risk of cerebral edema.85 Ultimately, the management of diabetic ketoacidosis should be done based on published protocols.86

Diabetes Education

Diabetes education should be targeted towards the pediatric patient, and their parents or guardian and family. Additionally, school-age children with diabetes need the support of school and day care personnel, including teachers, school nurses, school guidance counselors, and school administrators.

Patient and Family Education

The ultimate goal of educating patients and families is to foster confidence in diabetes self-management and self-monitoring. Research data in the recent years have shown that these children can benefit greatly from patient and


family education and support. Specifically, they translate to decreased hospital admissions, ER visits, and total healthcare costs.88,89 The educational program should be tailored to the individual needs of the patient and family, as well their culture. Because of the seemingly overwhelming attention and care given to the patient following the initial diagnosis by their family, siblings may feel neglected; an issue that should also be addressed by the family.

Because diabetes education for children and families is intense and complex, it needs nurse educators to be armed with a set of special skills including:

Good communication Empathy Sensitivity Humor In-depth knowledge of childhood diabetes

It is essential that the information given be in the context of pediatric diabetes. The ideal educational information should address challenges and concerns facing the family as a whole. More importantly, it should address survival skills for the patient. It is crucial for substantial educational materials to be handed out to the family immediately following the initial diagnosis.

When educating children with newly diagnosed type 1 diabetes mellitus, the nurse educator must impart information in a way that is sensitive to the age and stage of development of the child. For example, a diabetic preschooler is not matured enough to handle such information and its parents and primary caregiver most likely receive it. For adolescents on the other hand, education is most likely directed primarily towards them, with parents being part of the management team.


Insulin Therapy Education

As much as possible, insulin should be self-administered by the patient. In pediatric patients, the right age to start on self-administration depends on three primary factors:

1. The individual developmental level,2. The family circumstances, and3. The social circumstances.

However, self-administration must not be delayed beyond adolescence. Patients who have visual impairments are best given access to mechanical aids to ensure accuracy of their visual readings. If these aids are inadequate, relatives and family members can help by pre-filling the syringes so that patients need only to self-inject them. The same strategy may be employed in diabetics who have borderline dexterity or lack arithmetic skills. In any case, a relative or family member should be trained on how to administer insulin in case of emergency.

Generally, diabetic children are prescribed with an insulin dose schedule by their clinicians; however, they are still required to calculate certain insulin doses on their own. The insulin dose schedule offers a formula that allows patients to calculate accurately their bolus insulin requirements at every meal, or for correcting of high blood glucose levels. Only carbohydrates (protein and fats are not included) are taken into account because when metabolized in the liver, they are converted into glucose, the primary energy source of cells. The methods for calculating various insulin requirements are:

1. Bolus insulin dose, 2. High blood glucose level correction dose, 3. Total mealtime (prandial) dose, and4. Total daily requirements

All these insulin requirements need to be taught to pediatric patients and their parents and caregivers as part of diabetes management.


Calculating bolus insulin dose (bolus insulin for carbohydrate coverage)

The bolus dose for carbohydrate coverage is calculated as insulin to carbohydrate (CHO) ratio. It is a constant formula wherein each patient has his or her own.93 See the formula below.

Insulin: CHOThe ratio symbolizes the amount (in grams) of carbohydrates covered by 1 unit of insulin.Usually, 1U (one unit) of rapid acting insulin covers an estimated 12-15 grams of carbohydrates. The bolus dose for hyperglycemia attenuation is defined as the amount (in units) of rapid acting insulin needed to restore euglycemia.93 Usually, blood glucose levels drop by 50 mg/dL for every 1U of insulin administered. The reduction in blood glucose levels can vary between 15-100 mg/dl or more, depending on many factors. See the examples below:

For example: To calculate the carbohydrate coverage at a meal, follow the following steps in sequential order:93

Firstly, find the total amount of CHO in the meal (usually found on the nutrition label of the food), and

Finally, divide the insulin dose by the amount of total CHO (in grams).

For example: a patient plans to consume 80 grams of carbohydrate for lunch and the patient’s Insulin: CHO ratio is 1:10. To get the bolus insulin dose for carbohydrate coverage, follow the calculations below:

CHO insulin dose = Total CHO in the meal ÷ CHO covered by 1U of insulin CHO insulin dose = 80 g / 10 g = 8U of rapid acting insulin

Therefore, the patient needs 8U of rapid acting insulin to cover the planned consumption of 60 g of carbohydrates.


Calculating high blood glucose correction dose (attenuation of hyperglycemia)

The high blood glucose correction dose is calculated by finding the difference between actual blood glucose level and target blood glucose level; and, dividing this number by the correction factor.93 See the formula below.

High blood glucose correction dose = (Actual blood glucose level - Target blood glucose level) ÷ Correction factor:

The actual blood glucose level (obtained through blood tests / blood glucose monitors)

The target blood glucose level (obtained from and determined by the clinician based on individual patient factors)

Correction factor is a constant i.e. it is derived from the general assumption that every 1U of insulin is capable of lowering blood glucose levels by 50 mg/dL.

For example, a patient has a pre-prandial blood glucose reading of 90 mg/dL and an actual blood glucose reading of 240 mg/dL. To get the high blood glucose correction dose, follow the calculations below:

High blood glucose correction dose = (Actual blood glucose level - Target blood glucose level) ÷ Correction factor.

High blood glucose correction dose = (240 - 90 mg/dl) / 50 = 3U

Therefore, the patient needs 3U of rapid acting insulin to correct the hyperglycemia and bring down the blood glucose level to the target of 90 mg/dl.

Total mealtime (pre-prandial) dose


The total prandial dose of insulin can be obtained by adding the bolus insulin dose to the high blood glucose correction insulin dose.93 See the formula below.

Total pre-prandial dose = CHO insulin dose + High blood glucose correction dose

For example, a patient has a carbohydrate coverage dose of 8U of rapid acting insulin and a high blood sugar correction dose of 2U of rapid acting insulin for lunch. To get the total pre-prandial dose, follow the calculations below:

Total pre-prandial dose = 8U + 2U = 10UTherefore, the total insulin dose for lunch is 10 units of rapid acting insulin.

Estimating total daily insulin requirements

The following examples show a general method for calculating basal and bolus insulin doses, and estimated total daily insulin requirement when patients need full insulin replacement. Keep in mind that the following examples are not set in stone. The insulin may be too much if the patient is newly diagnosed or too little if the patient is very resistant to its action.93

The initial calculation of the basal and bolus insulin doses requires the estimation of the patient’s total daily insulin dose requirement.

The general formula for calculating the total daily insulin requirement is:Total daily insulin requirement (in units of insulin) = Weight (in lbs) ÷ 4

For example, the total daily insulin requirement of a 16-year-old type 1 diabetic weighing 120 lbs is calculated below.


Total daily insulin requirement = 120 lbs ÷ 4 = 30U of insulin/day

Alternatively, this can also be measured using body weight in kilograms using the following formula:

Total daily insulin requirement (in units of insulin) = 0.55 X Weight (in kg)

For example, the total daily insulin requirement of a 13-year-old type 1 diabetic weighing 55 kg is calculated below:

Total daily insulin requirement = 0.55 x 55 kg = 30U of insulin/day

Now that the total daily insulin requirement has been established, the carbohydrate coverage dose (insulin to carbohydrate ratio) and high blood sugar correction dose (correction factor) can be calculated.93

Basal Insulin Dose

As mentioned previously, the basal insulin dose is about 50% of the total daily insulin requirement. For example, a patient weighing 120 lbs would be having a total daily insulin requirement of 30U. See the calculations below.

First, the total daily insulin requirement is calculated:Total daily insulin requirement = 120 lbs ÷ 4 = 30 units (30U).

Second, since the basal insulin dose is about 50% of the total daily insulin requirement:

Basal insulin dose = 30U x 50% = 15U This dose may be of either long acting insulin such as glargine or detemir or rapid acting insulin if the patient is on insulin pump.


Carbohydrate coverage ratio

The carbohydrate coverage ratio is 500 divided by the total daily insulin requirement. It is calculated using the Rule of 500.93

For example, a type 1 diabetic patient weighing 120 lbs will have a 1U: 17 g CHO coverage ratio. See the calculation below.

Total daily insulin requirement = 120 lbs ÷ 4 = 30UCarbohydrate coverage ratio = 500 ÷ 30U = 1U insulin: 17 g CHO

This calculation of the carbohydrate coverage ratio is based on the assumption that the patient has a constant response to insulin throughout the day. In reality, the insulin to carbohydrate ratio may vary during the day.

High blood glucose correction factor

The high blood glucose correction factor is calculated using the following formula and the Rule of 1800:93

High blood glucose correction factor = 1800 ÷ Total daily insulin requirement For example, a type 1 diabetic patient weighing 120 lbs will have a correction factor of 60 mg/dL. See the calculations below:

Total daily insulin requirement = 120 lbs ÷ 4 = 30U

High blood glucose correction factor = 1800 ÷ 30U = 60 mg/dL

Therefore, 1U of insulin is capable of reducing the blood glucose level by 60 mg/dl.

Keep in mind that these calculations are only examples. Patients need to have their specific insulin doses calculated individually by their clinician or other members of the diabetes healthcare team.93


Switching Between Different Types of Insulin

Switching between different types of insulin must always be done in consultation with a clinician and necessitates close medical supervision and monitoring of blood glucose levels. However, if medical supervision is not available under emergency conditions, the following recommendations may be considered.94

Regular insulin and rapid acting insulin:One brand of regular insulin such as Humulin R may be substituted for another brand such as Novolin R, and vice versa. Alternatively, one brand of rapid-acting insulin such as Humalog may be substituted for another brand such as Novolog and vice versa. The substitution should be made on a unit per unit basis during emergency situations.94

Regular insulin needs to be injected about 30 minutes before the start of each meal. On the other hand, rapid acting insulin has faster onset of action and must only be injected 15 minutes or less before the start of each meal to prevent hypoglycemic episodes.94

Intermediate and long acting insulin:One brand of intermediate acting insulin analog such as Humulin N may be substituted for another intermediate acting insulin analog such as Novolin N on a unit per unit basis during emergency situations. Similarly, these intermediate insulin analogs may also be substituted for long acting insulin products such as Lantus and Levemir on a total unit per day basis, or vice versa during emergency situations.94

It is important to remember that when switching from a once daily dose of long acting insulin to an intermediate acting insulin, the dose of the former must be cut in half and given as twice-daily injections of the latter; one in the morning with breakfast and one in the evening with dinner to avoid


hypoglycemic episodes.94 When switching from intermediate acting insulin to once daily long acting insulin, the total amount of intermediate acting insulin units for one day must be added together and given as a single long acting insulin dose once daily. During this transition period, close monitoring of blood glucose and adjustment in insulin dose is required.94

Insulin mixes

Similar to switching between types of insulin, switching to different insulin mixes must also be done in consultation with a clinician and needs medical supervision and close monitoring of blood glucose levels.94 Insulin mixes contain a specified ratio of intermediate to short/rapid acting insulin. The first number represents the amount of intermediate insulin and the second number represents the quantity of short/rapid acting insulin delivered per dose administered. For example, one dose of 70/30 insulin mix contains 70% intermediate acting insulin and 30% short/rapid acting insulin.94 Switching between insulin mixes

There are two options to consider in patients using pre-mixed insulin.94 Firstly, in emergency situations, on a unit per unit basis, one insulin mix can replace another. Insulin mixes containing rapid acting insulin such as Humalog Mix and Novolog Mix) must be injected approximately within 15 minutes of the start of the meal compared to insulin mixes containing regular insulin such as Humulin 70/30.94

Secondly, in case an insulin mix is unavailable there is a short process below that may be followed by patients:94

Substitute intermediate acting insulin of the mix with an intermediate acting or a long acting insulin on a unit-per-unit basis.i) Substituting with an intermediate acting insulin: Allow 70% of total

units for each dose


ii) Substituting with a long acting insulin: Get the total insulin units given in one day and add them; and, give 70% as one daily dose

If regular or rapid acting insulin are also available, administer them pre-prandially in doses equal to roughly 30% of the total dose of pre-mixed insulin and in combination with the intermediate or long acting insulin also taken pre-prandially.

It must be noted that longer and shorter acting insulin should be injected separately unless directed otherwise by the clinician.94 CSII devices

Using different insulin in CSII is discussed here. Patients using CSII devices can substitute rapid acting insulin such as Humalog, Novolog, and Apidra for another on a unit per unit basis in emergency situations. To ensure an adequate dose, they should check the instructions for use of the CSII device they are using to see if the insulin they plan to use is compatible with their device.94

Switching from CSII device to multiple daily shots of injectable insulin is another consideration. Patients using CSII devices who need to switch to multiple daily shots of injectable insulin can substitute intermediate or long acting insulin for the total basal requirement infused over 24 hours on a unit per unit basis in emergency situations. For example, a patient using a CSII device with a basal rate of 1 unit per hour has a total 24-hour basal dose of 24 units or 24U.

If intermediate insulin or long acting insulin is available, the 24U should be given as two injections of 12U, once in the morning and once in the evening.94


Alternatively, if regular or rapid acting insulin is also available, patients can administer them with each meal. They should substitute their mealtime bolus dose on a unit per unit basis to an injected dose. For example, those using a bolus dose of 5U on their CSII devices to cover every breakfast meal should inject 5U of regular or rapid acting insulin instead.94

Insulin storage, handling and effectiveness

The following information should be relayed to the patient and the family regarding insulin storage, handling and effectiveness as soon as diabetic management is discussed. The type of insulin given to patients in an emergency may differ from the usual type of insulin used. It is always best to check and/or ask about the specific insulin given at all times.94

When it comes to storage, the product labels from all three American insulin manufacturers recommend insulin to be stored in a refrigerator at approximately 2°C to 8°C. When unopened and stored in this manner, the insulin retains its potency until the expiration date on the package.94 Insulin in vials or cartridges either opened or unopened may be stored outside a refrigerator at a temperature between 15°C-30°C for up to 28 days and still retain its potency. However, insulin that has been altered for dilution or by removal from the manufacturer’s original vial must be disposed of within two weeks.94

It must be noted that insulin loses its effectiveness when exposed to extreme temperatures. The general rule is that the longer the time of exposure to extreme temperatures, the less effective the insulin becomes. Consequently, control of blood glucose levels is affected, which may result in hyperglycemic episodes. Under emergency conditions, patients might still need to use insulin which have been stored over 30°C.94


Lastly, patients must ensure that their insulin supply is kept as cool as possible, but must take care not to freeze them. Insulin that has been frozen must never be used, even when defrosted. Alternatively, it must also be kept away from direct heat and out of direct sunlight.94

It is important for new stock of insulin to be separately stored or properly labeled to distinguish it from old stock, which has been exposed to extreme conditions. The old stock should be discarded to prevent mix-ups and their accidental use.94 Insulin contained in the infusion set of CSII devices needs to be disposed of after 2 days. Alternatively, insulin contained in the infusion set of CSII devices and exposed to temperatures greater than 37°C must also be disposed.94 Under non-emergency circumstances, caution must also be used before insulin administration. Each insulin bottle or pre-filled syringe should be visually inspected before each use for changes such as clumping, frosting, precipitation, or changes in clarity or color, all of which indicate a loss in potency. Normally, the inspection should reveal rapid, short acting insulin products, and glargine to be clear and all other types of insulin to be consistently cloudy.

In times of unexplained increase in blood glucose, patients must consider loss of insulin potency as a possible cause. Alternatively, in times when the potency of an insulin vial is in question, it should be replaced with another of the same type.94

Insulin administration

When it comes to insulin administration, two of the most important things to teach children with type 1 diabetes mellitus are:1. Where to inject the insulin (choosing injection sites), and 2. How to self-inject it (self-administration).


Selection of injection sites

In order to understand the rationale behind injection site rotations and administration timings, one must know how insulin is absorbed and the administration techniques that enable its optimal absorption. Optimal absorption of insulin is partly based on injection into the subcutaneous tissue. Latest study findings suggest that shorter needle length found usually in 4 to 5 mm insulin pen needles enter subcutaneous tissue with the least risk of injection into the muscle tissue and leakage, even in obese patients. Other studies have shown no difference in glycemic control between 4 mm, 5 mm and 8 mm needles.95 Other factors that influence the rate of absorption of insulin are its type and site of injection. Rapid acting insulin analogs and regular insulin are more rapidly absorbed compared to intermediate and long acting insulin analogs. Insulin is absorbed the fastest and most predictably when injected in the abdomen (except for the 2-inch radius around the navel).

Other sites of injection are listed below, in decreasing order of absorption rate:95

Upper outer arm Anterior lateral thigh Anterior lateral buttocks

Intramuscular injection is not recommended for routine injections.95 Patients who are new to self-administration of insulin should be advised to practice injection site rotation. This means using different sites per injection so as to avoid lipohypertrophy or lipoatrophy. Rotating within one injection


site is recommended. One example is rotating injections systematically within the abdomen instead of switching to different sites (i.e., buttocks and arms) per injection. This is because doing so can reduce the daily variability in absorption rates.95 Non-insulin related factors that affect the rate of insulin absorption into the subcutaneous tissue include:95

Exercise Presence of lipohypertrophy High temperature at the injection site Re-suspension of cloudy insulin

Exercise stimulates the circulation, thereby also increasing the rate of absorption from injection sites. This is why the physical activity level of patients is also an important consideration. On the other hand, areas of lipohypertrophy exhibit slower insulin absorption rates due to a compromised circulation at the injection site.95

High temperature at the site of injection enables faster absorption, which is why patients should avoid injecting insulin immediately before or after taking a hot bath or being in a sauna.

Re-suspension of cloudy insulin should be done to prevent erratic absorption of injected insulin. Additionally, re-suspension also allows for maintenance of appropriate concentration of the remaining insulin in the vial or pen. Package inserts usually remind patients to re-suspend their insulin products either by rolling the vial or pen in the palms or tipping it several times. In fact, tipping or rolling the insulin vial or pen 15 to 20 times is what is considered “adequate re-suspension”.95

Self-administration


Outlined below is the step-by-step process of insulin self-administration:96 1. Verify the insulin label to prevent the accidental injection of the wrong

type of insulin.

2. Make sure that the injection site and the hands are clean.

3. Roll or tip gently the insulin pen or vial to re-suspend insulin preparations. This must be done for all types of insulin except for rapid and short acting insulin, and insulin glargine.

4. Draw up an amount of air equal to the dose of insulin required and inject into the vial to avoid creating a vacuum. For mixed dose insulin preparation, it is important to put sufficient air into both bottles before drawing up. When mixing rapid or short acting insulin with intermediate or long acting insulin, draw up the latter into the syringe first.

5. Inspect the syringe for the presence of air bubbles. If present, flick the upright syringe using the forefinger to allow the bubbles to escape. Air bubbles are not considered dangerous but can lower the dose of the injected insulin. In insulin pens, air bubbles can reduce the rate of insulin flow into the tissues. To prevent the presence of air bubbles, the needle of an insulin pen must not be left between injections and primed with 2 units of insulin before injection.

6. Inject the needle into the subcutaneous tissue. To ensure proper delivery of the dose, patients usually need to do either of the following:

Lightly grasp a fold of skin, release the pinch, then inject at a 90° angle

Use short needles Pinch the skin and inject at a 45° angle to avoid intramuscular

injection, especially when injecting into the thighs


7. Embed the needle within the skin for 5 seconds after complete depression of the plunger to make sure that the insulin dose is delivered completely.

After administration care

Outlined below are recommendations on how to deal with after-administration care.

1. An injection that is especially painful, bloody or result in the sighting of clear fluid after needle withdrawal requires the application of pressure for 5–8 seconds (without rubbing) by the patient. Additionally, frequent blood glucose monitoring is also required when this happens.

2. Frequent blood glucose monitoring, usually within a few hours of the injection should follow any suspected significant incomplete administration of insulin.

3. The presence of bruising, soreness, welts, redness, or pain occur at the injection site necessitates the review of the patient’s injection technique by a clinician or other members of the diabetes healthcare team. To avoid or at least minimize painful injections, patients may do the following: Inject insulin at room temperature Eliminate air bubbles in the syringe before injection Wait until topical alcohol evaporates completely before injection Keep muscles at the site of injection relaxed when injecting Penetrate the skin quickly Maintain the same needle direction during insertion or withdrawal Avoid reusing needles

Syringes


When patients opt for daily multiple insulin injections, they need to learn how to use them properly, including how to read the markings of insulin units. Depending on the manufacturer and size of the syringe, the way the way units are indicated can vary. Insulin syringes are available as 0.3-, 0.5-, 1-, and 2-ml capacities.96

The needle lengths also vary. Before switching to another length, the blood glucose should be monitored first to evaluate its effect on insulin absorption. In the U.S., state laws regulate the purchase of syringes, which is why patients are advised to know the availability of their syringes when they travel.96

Under the current OSHA standards, several medical devices including syringes used for insulin administration have undergone design overhaul to reduce the risk of needle sticks and other sharps injuries. The new design includes features that reduce injury such as engineered sharps injury protection (ESIP). The new feature may hinder effective insulin self-administration training. Therefore, it is important that patients be assessed individually to help diabetes educators and other members of the diabetes healthcare team ensure that they know how to use these devices effectively during self-administration.96 Because of the high risk of contamination and contagious blood-borne diseases, such as HIV and hepatitis infections, syringes must never be shared with another person for any reason.96

Proper disposal

The greatest risk pose by needles comes from their improper handling such as:96

Recapping Bending Breaking


The above actions increase the risk of needle stick injury and must be strongly discouraged.

Disposal of insulin syringes and pens, needles, and lancets should be done according to local regulations. In some places, there are special needle disposal programs that prevent sharps, such as insulin needles, from joining the primary waste disposal stream. Alternatively, if such programs are not in place, used insulin needles should be put into puncture-resistant containers and local trash authorities contacted for their proper disposal. These containers must be properly labeled and separated from those to be recycled.96

Needle reuse

There are several reasons for discouraging needle reuse, one of the most important of which is to maintain sterility. Manufacturers of insulin syringes and pen needles recommend that they only be used once and then safely disposed. This is to avoid contamination and ensure that all needles injected are sterile. However, some would argue that most insulin preparations, if not all, contain bacteriostatic additives that prevent bacterial growth. Regardless of this, the reuse of syringes and needles put patients at greater risk of infection especially those with poor personal hygiene, acute concurrent illness, open wounds on the hands, or compromised immune system.96

Another reason for discouraging needle reuse is the greater risk of lipohypertrophy, particularly with 30 and 31 gauge needles. The needle tips of these needles can bend from its normal position even with first use,


putting their users in danger of tissue lacerations or needles breaking off within the skin.96

Although needle reuse is discouraged, some patients find the practice practical. Those who do are advised to discard needles that are obviously dull or deformed or have come into contact with surfaces other than skin. If planning to reuse needles, they must be recapped after each use to prevent further contamination. Additionally, those who reuse needles need to inspect injection sites for redness, swelling, and other signs of inflammation. Before reuse is considered, patients need to do the following:96

Consult their clinician before starting this practice.

Be evaluated and determined capable of safely recapping a used syringe. This means that the patient should possess adequate vision, manual dexterity, and no obvious tremor.

Obtain proper instruction on how to recap used syringes safely. A safe recapping technique involves supporting the syringe with one hand and replacing the cap with a straight motion of the thumb and forefinger. Replacing the cap by guiding both the needle and cap to meet in midair must be prohibited, since it often results in needle-stick injuries.

Syringes for reuse may be stored at room temperature. Attempting to clean the used needle with alcohol is not advisable since it may remove its silicon coating that makes skin punctures less painful. Refrigerating the syringe has not been proven to be either beneficial or risky for users of reused syringes.96

Pre-filled syringes


Diabetic patients who are also visually or physically impaired or eat out in restaurants often can benefit from the use of prefilled syringes. These syringes are stable up to one month when stored in a vertical position in a refrigerator. The vertical position storage prevents the suspended insulin particles from clogging the needle.96

Alternative to syringes

Insulin may be administered using jet injectors instead of the traditional syringes. Jet injectors deliver insulin as a fine stream into the subcutaneous tissue. These jet injectors are advantageous for patients who are unable to administer insulin by using syringes due to needle phobias. Another advantage is it allows short acting insulin to be absorbed more rapidly.96

On the other hand, these also offer two disadvantages. For one, they are more expensive than regular syringes, especially their initial cost. Second, they may traumatize the skin. Thus, they are neither the first device of choice nor a preferred option for routine insulin administration in diabetic patients.96 There are also pen-like devices and insulin-containing cartridges available for subcutaneous delivery of insulin through a needle. These devices may be preferable in diabetic patients who are also neurologically impaired and require multiple daily injection regimens. These devices have been found to enhance accuracy of insulin administration and adherence.96 Insulin pens containing low doses of the drug are also available. An example is a type of pen that delivers insulin in half-unit increments.96

Continuing Education

Patients and parents should continually receive education and support, even years after the initial diagnosis. Continuing education and support is needed as the patient passes through different developmental stages and takes on


more responsibilities of self-management. A member of the diabetes healthcare team should assess their knowledge and survival skills regularly.

Research has shown that educational interventions need to be continuous with regular telephone contact in order to be effective. Once in place and ongoing, they can improve HbA1c and reduce hospitalization visits for acute diabetes complications.88,89,90,91,92 Additionally, microvascular and macrovascular complications must be monitored regularly. Effective strategies that prevent and screen their risk factors must be put in place. Counseling should reiterate the significance of maintaining blood glucose level targets, lipid, and blood pressure therapy and smoking cessation.

Barriers to Insulin Therapy

There are many different barriers faced by all involved in the treatment and management of type 1 diabetes mellitus in children. These barriers do not only hinder patients from starting insulin therapy but they also discourage them, and sometimes prevent them from adhering to guidelines and tools set by the diabetes healthcare team.95 It is imperative that barriers to the treatment of diabetes be identified as soon as possible so that they can be addressed accordingly. In fact, the identification of these barriers is the first critical step toward successful long-term diabetes self-management. This step usually takes place by careful patient assessment, which includes asking open-ended and non-judgmental questions. By doing so, members of the diabetes health care team can help patients deal with their concerns and adopt effective problem solving techniques.95 Listed in the table below are the most common barriers to insulin therapy faced by patients, providers, and the health care system.95

Patient barriers Provider barriers System barriersPsychological resistance Patient resistance Overwhelming workload

Myth-based fear of insulin Non-adherence by patients Access to education


Fear of hypoglycemia Belief of improved glucose level status

Limited training in injection techniques

Weight gain concerns Adverse effect concerns Underutilization of resourcesFear of needles and pain Time constraints Reimbursement issuesSelf-blame Lack of resources Poor follow-up systemLoss of control Lack of organizational

structure for guideline adherence

Poor team cooperation

Social stigma Poor chronic care modelPoor self-efficacy

Lifestyle

InconvenienceTravel issues

Financial

Reimbursement issues

Physical/mental

Cognitive impairmentVisual/dexterity/hearing issuesLearning difficulties

Barriers faced by patients

It is not uncommon or unheard of for patients to resist insulin therapy due to myths and misconceptions. One example is the belief that the need to administer insulin several times a day on a daily basis is a reflection of personal failure.95

Members of the diabetes healthcare team can eradicate this self-blame by explaining that the etiologic roots of type 1 diabetes mellitus are still unknown and appear to be a combination of genetic and environmental factors. They may further reassure patients that type 1 diabetes mellitus is not acquired through personal contact and is not contagious.95


There are also other patient concerns regarding insulin therapy that is rooted on anxiety and personal phobias about pain and needles. Others continue to resist therapy and cite it to be complicated and inconvenient. In this case, members of the diabetes healthcare team can demonstrate how insulin pens work. Unlike syringes and insulin vials, insulin pens are found to be easier to use, more discreet, and less painful.

Other strategies that help patients overcome their fear of needles and injections are by:95

Using a pillow for trial injections, Using a covered safety needle to conceal the needle, and Desensitizing patients. This practice involves placing the needle on the

patient’s skin and allowing it to remain there momentarily before penetrating the skin.

Patients who are concerned about weight gain and hypoglycemia should be taught how the long-term health benefits of insulin therapy far outweigh these issues. The topic of hypoglycemia should be addressed early in the education process. In this process, patients must be taught how to recognize the symptoms, treat with insulin, and avoid hypoglycemia. Additionally, patients must be taught the strategies of effective meal planning.

Patients are usually started on a low dose that is gradually titrated to the optimal level. In this process, patients may be further reassured by explaining that hypoglycemia is in fact rare among patients who are on insulin therapy. On the other hand, weight gain as an adverse effect of insulin therapy is due to calories being retained, rather than excreted as


glucosuria. The weight gain may be attributed to improved glycemic control, fluid retention, and higher food intake to prevent hypoglycemia. One strategy of preventing weight gain is using insulin analogs instead of human insulin products.95

Another barrier to insulin therapy is insurance non-coverage for insulin pens. Nevertheless, this should not be used as an excuse to forego insulin therapy altogether. In fact, pharmacoeconomic data show favorable cost benefits of using insulin pens compared to the insulin vials and syringes. The benefits stem from enhanced therapy adherence and decreased hospitalization. In addition, some insurance plans offer to cover insulin pens with only one co-payment, resulting in obtaining more insulin supply with each copayment made compared to buying a vial. Lastly, pens are more economical. They reduce the unnecessary disposal of insulin compared to those stored in vials, which require disposal within 28 days after opening regardless of its usage. This is especially true for patients with only lower insulin requirements.95

Financial barriers also affect patients with visual impairments because Medicare at present does not reimburse non-visual insulin drawing devices. These patients may also be hindered by the lack of accessible insulin-related information and clinicians who may opt not to teach insulin injection without such materials. It is therefore imperative for members of the diabetes healthcare team to find ways to make such materials accessible to these patients.95

Patients with learning difficulties and disabilities such as low literacy and numeracy skills may find themselves unable to be fully independent and restricted in their efforts to learn self-monitoring of glucose levels and self-management with insulin. They may be unable to fully comprehend written information and measure accurate doses. To overcome this barrier, members of the diabetes healthcare team may turn to enhanced instructional design


for print materials and availability of the information in audio and video formats.95

Barriers faced by providers

Members of the healthcare team are trained to overcome patient resistance and help them eliminate the barriers they face in starting and adhering to insulin therapy. However, they also face barriers themselves, often because of their perceptions of patient-derived barriers such as concerns about weight gain, adherence to therapy, and desire to prolong non-insulin therapy.95

Barriers faced by the U.S. healthcare system

The U.S. healthcare system also experiences limitations and drawbacks that hinder insulin therapy. The Diabetes-Attitudes-Wishes-Needs (DAWN) study reported that both clinicians and nurses agree that greater participation by nurses is required in diabetes management. The committee even highlighted the poor insulin therapy education among nurses and primary care physicians as an important hindrance. To overcome this, three strategies recommended be put in place include:95

1. Greater training in injection techniques of insulin for nurses, 2. Greater titration protocols available for non-medical staff, and 3. Greater support for primary care physicians to help them identify and

use available resources.

Time constraints also delay insulin therapy initiation.

Self-Management Education

As mentioned previously, patients with type 1 diabetes mellitus must be taught how to control their own blood glucose levels through self-


administration and self-monitoring education. Learning these two strategies is very crucial in patients who experience daily variability in blood glucose levels.95

However, before patients start independent insulin treatment and blood glucose monitoring, the diabetes educator (i.e., nurse, clinician, and pharmacist) must teach them how to go about these tasks safely and effectively. Outlined below are teaching techniques and recommendations that they may use. Most of these have been mentioned in the previous topics but due to their importance, are reiterated here.95

1. Evaluate patients thoroughly prior to the start of insulin therapy to check for possible barriers such as impaired cognitive capacity, health literacy, phobias, lack of number skills, or other problems, which can interfere with safe insulin self-administration. During this assessment, patients should be encouraged to discuss their therapy-related concerns. Once therapy has started, they should be checked regularly through phone calls and follow-up visits.

2. Once the patient has started the therapy, treatment adherence needs to be assessed and its importance reiterated. The assessment should identify changing barriers, adherence problems, and errors that can result from poor recollection of previous instructions or other reasons. Additionally, the injection practice should be observed, and re-education and re-iteration of instruction provided whenever required.

3. Patients need to be advised and reminded on the importance of site rotation within the chosen body area. They should be instructed on how to inspect injection sites for signs of lipohypertrophy.

4. When teaching patients on the safe injection techniques, inappropriate language must be avoided. Examples include vague and discomforting


terms such as “spearing”. Patients should also be advised not to delay injecting as it may only lead to more discomfort.

5. Advice patients on the elements of dose preparation including insulin inspection, following manufacturer instructions regarding re-suspension of cloudy insulin products, and prevention of air bubbles in the syringes.

6. Reiterate the importance of following the guidelines of the American Diabetes Association for mixing different insulin preparations.

7. Teach innovative techniques that prevent confusion over different insulin preparations. One example is storing different insulin in separate locations or applying colored dots, rubber bands, or different colored insulin vial sleeves to vials.

8. Patients need to refrigerate unused vials and recap needles meant to reuse. They must also remove the needle from the syringe especially in very cold climates.

Physical activity education

Members of the diabetes healthcare team must help devise an individualized meal and activity plan that is realistic and can be followed by the patient on conventional insulin regimens.97 For example, they may consider adding bedtime snacks to avoid nocturnal hypoglycemia in those taking NPH as basal insulin or those at greater risk of developing severe hypoglycemia, especially when bedtime blood glucose levels are below 7.0 mmol/L.98,99

Patients with type 1 diabetes mellitus are more prone to feel the acute effects of exercise because of their lack of endogenous insulin supply. This is why they must be made aware of how blood glucose levels increase and


decrease, both during and after physical activities. Low to moderate intensity exercise decreases blood glucose levels both during and after it, enhancing the risk of hypoglycemia. However, this can be avoided by changing the diet, insulin regimen, and the type and timing of exercise.

On the other hand, high intensity exercise results in blood glucose level elevation during and immediately after the activity. Self-management of blood glucose levels before, during and several hours after exercise is important in identifying the response to exercise and directing the proper management of exercise and other physical activities. If ketosis is present, patients must avoid exercise since metabolic deterioration can very well occur.100 Exercise-induced hypoglycemia can be prevented through the use of insulin detemir as the basal insulin.101

Overcoming fear of hypoglycemia

Many patients with type 1 diabetes mellitus, especially those newly diagnosed, fear the exercise-induced hypoglycemia. This fear serves as a barrier to engaging in exercises that have long-term health benefits to their overall health. The duty of each member of the diabetes healthcare team is to advice these patients on strategies that help reduce their risk of hypoglycemia when exercising. These strategies include:102,103,104,108

Consumption of extra carbohydrates for exercise Restriction of pre-prandial bolus insulin doses Changing basal insulin for those using CSII Performing maximal intensity exercises intermittently, or at the end or

beginning of the session Performing resistance exercises immediately before aerobic exercises

These strategies can be used singly or in combination.105,106


Performing maximal-intensity exercises intermittently or at the end or beginning of sessions is ideal because it lowers the risk of hypoglycemia due to temporarily decreased glucose disposal.107 Another important advice to give patients with type 1 diabetes mellitus regarding exercises is to avoid performing them, if possible, late during the day or in the evenings. Exercises performed during these times are associated with greater risk of overnight hypoglycemia.102 If exercises are to be performed during these times, patients can decrease the risk by:109

Lowering their bedtime intermediate or long acting insulin dose, or

Decreasing their overnight basal insulin infusion rate by about 20 percent from bedtime to 3 AM for those using CSII devices

Hyperglycemia can also occur following vigorous (moderately intense) physical activity. Unusually higher glucose output in the liver combined with moderately intense activity resulting from beta and alpha-adrenergic stimulation can lead to hyperglycemia during and right after exercise, succeeded by hypoglycemia within one to six hours after. If this happens, patients may be treated with a small bolus of short acting insulin analog or, in CSII users, temporarily increase the basal insulin infusion until the normal blood glucose level has been restored.

Seasonal sports activities

Children and adolescents, especially those who go to school do not always have the same all-year round schedule of activities to participate in. The seasonal changes in sports activities they engage in throughout the year necessitate regular dose adjustments and monitoring. In the beginning, they may require regular blood glucose monitoring in order to determine the best method of adjusting their insulin and carbohydrate requirements to the type


of sports activity. As mentioned previously, it is ideal to perform blood glucose monitoring before and after the activity, and every hour throughout all periods of extended vigorous activity.

Parents need to inform the school personnel and sports coaches of the diabetic status of their children and the hypoglycemia risk associated with exercise, its symptoms, and how to treat it using emergency glucose sources such as electrolyte sports drinks, glucose tablets and juice. For example, 15 g of carbohydrate may be taken by the patient, in the form of emergency sugar sources, if blood glucose levels are less than 100 mg/dl during the activity period.

Lowering the dose of insulin for a planned exercise, instead of increasing calorie intake, is an important consideration in weight management for diabetic children. However, it may not be the most ideal in very young children who engage in sporadic physical activities. With meticulous and adequate planning, all diabetic children can safely engage in sports and other physical activities.

Weight issues

It is not unusual for diabetic children to be either overweight or obese. Consequently, they must especially be encouraged to participate in physical activities and exercise programs. In fact, attaining the normal body weight is an important element of diabetes management plan. Studies in the recent years have found that pediatric populations who spend a great deal of sedentary time watching TV or playing computer games are more prone to obesity and overweight.

In conclusion, members of the diabetes healthcare team must recommend the following:123


The CDC and American Academy of Sports Medicine recommendations for a minimum of 30–60 minutes of moderate physical activity everyday

Blood glucose monitoring prior to physical activities accompanied by recommended consumption of 15 g of carbohydrate to achieve blood glucose levels lower than the target range. This amount needs to be lower in younger children. Vigorous and prolonged physical activities expected to last longer than 30 minutes may require an additional 15 g of carbohydrate.

Hourly blood glucose monitoring during periods of vigorous and prolonged activities.

Post-activity blood glucose monitoring after activities to help establish carbohydrate consumption and future insulin dose adjustment for frequent sports activities

At the start of a new sports season, frequent blood glucose monitoring throughout the 12 hours following the activity should be done to guide insulin dose adjustments.

Discourage sedentary activity in diabetic children, especially those who are either obese or overweight.

Providing Motivation

Members of the diabetes healthcare team are in the best position to motivate their patients. They can help patients realize the significance of physical activities by:110

Explaining how exercise habits are a crucial element of diabetes management and therapy, and


Helping find support in the community that can help them get started.

Members of the diabetes healthcare team should also encourage patients to:111

Set specific and realistic physical activity objectives, Be ready to face barriers to these goals including weather and

constrained time, Create approaches to conquer these barriers, and Record daily physical activities.

The last advice is to help patients keep track of their physical activity and to guide them in improving self-efficacy and self-confidence.112 According to a study in 2008 by R.C. Plotnikoff, self-efficacy is a very strong cognitive predictor of both aerobic and resistance exercise participation among diabetics.113 Other studies reported that organized physical activity counseling by a clinician,114 trained healthcare staff115,116 encourages physical activity, enhances glycemic control,115 decreases insulin requirements,116 and results in modest but constant weight loss.117

Another important motivational factor to starting and sustaining physical activities is the presence of social support such as a gym partner, especially among diabetic females.118 Children and adolescents may be motivated to engage in regular physical activities by enrolling them in organized courses using social media, text messaging, pedometers, and coaches.119,120,121

Medical Identification

Medical identification devices such as tags and bracelets are important for anyone who has a special health condition including type 1 diabetes mellitus. In case of emergency such as


diabetic ketoacidosis, these devices help identify these patients and guide responders to the appropriate course of action. For example, type 1 diabetes mellitus patients who require intravenous fluids might develop rapid hyperglycemia when given fluids with glucose, which could worsen their condition.

The bottom line is that the emergency treatment of patients with diabetes follows a different approach.122 The companies listed below manufacture medical identification devices such as bracelets, necklaces, charms, and stickers:122

American Medical ID Diabetes Identification Program (The necklace is free) Fifty-50 Pharmacy (50 percent of the proceeds go to diabetes

research) Life Tag Medic Alert Medicool: Medical Identification products Miss Brooke's Online Store TAH Handcrafted Jewelry

Managing diabetes at school

There are several federal laws which protect children with diabetes, including the:123

1. Section 504 of the Rehabilitation Act of 1973 2. Individuals with Disabilities Education Act of 19913. Americans with Disabilities Act

These laws consider type 1 diabetes mellitus to be a disability and prohibit schools and day care centers from discriminating against children with this condition. They also require schools that receive federal funding or any


facility considered open to the public to provide reasonable accommodations to the special needs of these children. Reasonable accommodations must be offered within the usual school setting with as little disruption as possible to the routine of both the school and the children. Additionally, they should allow them full participation in all school activities.123

However, even these federal laws are not enough to protect children with type 1 diabetes mellitus from discrimination in the school and day care settings. For example, certain day care centers may reject admission applications of these children, and if accepted, they may not be provided the support necessary to monitor their blood glucose levels and may be forbidden from eating snacks.123 To overcome these obstacles, the American Diabetes Association has general guidelines for the safe and fair treatment of children with diabetes in the school and day care setting.

Schools and day care settings

Adequate diabetes care should extend to the school and day care setting to ensure the safety of children with the disease, their long-term well being, and optimal academic performance. These children require the same management protocols as other type 1 diabetics, except that they require the cooperation of school personnel, such as nurses, teachers, and coaches to successfully manage their disease in these environments. To achieve glycemic control, diabetic children must monitor their blood glucose frequently, create and follow a meal plan, and receive multiple injections of insulin daily.123

School and day care personnel have important roles to play in facilitating the appropriate care of children with diabetes. This is why they must have an


understanding of type 1 diabetes mellitus and be trained in its daily management and treatment in case of emergencies.

Diabetes Health Care Plan (DHCP)

Collaboration and cooperation are crucial to helping students with type 1 diabetes mellitus cope with their school life and disease. According to the American Diabetes Association, a custom-made Diabetes Health Care Plan (DHCP) should be developed together by the parents/guardians, the diabetes healthcare team, and the school or day care provider.

A DHCP is an individualized written plan developed by the school nurse in collaboration with the student’s personal diabetes health care team and the family to implement the student’s Diabetes Medical Management Plan. According to the American Diabetes Association, each of these parties has inherent responsibilities, which are outlined below.123

Parents or guardians

Parents and guardians need to provide the school with the following:123 All materials and equipment necessary for diabetes care tasks,

including blood glucose testing, insulin administration (if needed), and urine or blood ketone testing. The parent/guardian is responsible for the maintenance of the blood glucose testing equipment (i.e., cleaning and performing controlled testing per the manufacturer’s instructions) and must provide materials necessary to ensure proper disposal of materials. A separate logbook should be kept at school with the diabetes supplies for the staff or student to record test results; blood glucose values should be transmitted to the parent/guardian for review as often as requested.


Supplies to treat hypoglycemia, including a source of glucose and a glucagon emergency kit, if indicated in the Diabetes Health Care Plan.

Information about diabetes and the performance of diabetes-related tasks.

Emergency phone numbers for the parent/guardian and the diabetes care team so that the school can contact these individuals with diabetes-related questions and/or during emergencies.

Information about the student’s meal/snack schedule is important. The parent should work with the school to coordinate this schedule with that of the other students as closely as possible. For young children, instructions should be given for when food is provided during school parties and other activities.

The information listed below needs to be offered by the school or day care providers.123

Training to all adults who provide education/care for the student on the symptoms and treatment of hypoglycemia and hyperglycemia and other emergency procedures. An adult and back-up adult(s) trained to:

perform fingerstick blood glucose monitoring and record the results;

take appropriate actions for blood glucose levels outside of the target ranges as indicated in the student’s Diabetes Health Care Plan; and

test the urine or blood for ketones, when necessary, and respond to the results of this test.

Immediate accessibility to the treatment of hypoglycemia by a knowledgeable adult. The student should remain supervised until


appropriate treatment has been administered, and the treatment should be available as close to where the student is as possible.

If indicated by the child’s developmental capabilities and the Diabetes Health Care Plan, an adult and back-up adult(s) trained in insulin administration.

An adult and back-up adult(s) trained to administer glucagon, in

accordance with the student’s Diabetes Health Care Plan.

A location in the school to provide privacy during testing and insulin administration, if desired by the student and family, or permission for the student to check his or her blood glucose level and to take appropriate action to treat hypoglycemia in the classroom or anywhere the student is in conjunction with a school activity, if indicated in the student’s Diabetes Health Care Plan.

An adult and back-up adult(s) responsible for the student who will know the schedule of the student’s meals and snacks and work with the parent/guardian to coordinate this schedule with that of the other students as closely as possible. This individual also will notify the parent/guardian in advance of any expected changes in the school schedule that affect the student’s meal times or exercise routine. Young children should be reminded of snack times.

Permission for the student to see school medical personnel upon request.

Permission for the student to eat a snack anywhere, including the classroom or the school bus, if necessary to prevent or treat hypoglycemia.


Permission to miss school without consequences for required medical appointments to monitor the student’s diabetes management. This should be an excused absence with a doctor’s note, if required by usual school policy.

Permission for the student to use the restroom and have access to fluids (i.e., water) as necessary.

An appropriate location for insulin and/or glucagon storage, if necessary.

Additionally, the American Diabetes Association has also recommended that the Diabetes Health Care Plan be able to address the specific needs of the diabetic student and provide specific instructions for each of the following:123

Blood glucose monitoring, including the frequency and circumstances requiring testing.

Insulin administration (if necessary), including doses/injection times prescribed for specific blood glucose values and the storage of insulin.

Meals and snacks, including food content, amounts, and timing.

Symptoms and treatment of hypoglycemia (low blood glucose), including the administration of glucagon if recommended by the student’s treating physician.

Symptoms and treatment of hyperglycemia (high blood glucose).

Testing for ketones and appropriate actions to take for abnormal ketone levels, if requested by the student’s health care provider.


There should be sufficient number of school or day care personnel (not necessarily a health professional) trained in executing diabetes care to students with type 1 diabetes mellitus. Specifically, they should know the proper response to abnormally high and low blood glucose levels. Schools and day care centers must also make sure that there is at least one such personnel present to execute diabetes care procedures in a timely manner while these students are in their care, on field trips, and engaging in extracurricular activities or other events they sponsored.123

Expectation for students at various developmental stages

The ability of diabetic students to participate in diabetes management and monitoring must be decided upon by the school/day care personnel, the parents/guardians, and the health care team, whenever applicable.123

Preschool and day care:

At this age, they are generally dependent on a guardian or parent to monitor their blood glucose levels and administer insulin. Upon reaching 4 years old, they may be taught to cooperate in such tasks.

Elementary school:

At this age, they are fully expected to cooperate in tasks such as glucose monitoring. Upon reaching age 8 years old, the majority of them are able to do their own finger-stick blood glucose tests under supervision. Upon reaching 10 years old, some, if not all, children are able to administer insulin doses on their own with supervision.

Middle school:


At this age, they should be able to administer insulin with supervision and monitor their blood glucose levels independently under usual circumstances.

High school:

At this age, they should be able to monitor their blood glucose levels under usual circumstances as well as administer insulin without supervision.

Blood glucose monitoring in the classroom

Because hyperglycemia and hypoglycemia can occur at school and lead to serious complications, diabetic students should be permitted to monitor their blood glucose levels and treat hypoglycemic episodes in the classroom or anywhere the student may be in the school during the onset of symptoms. However, some may desire privacy during testing and should also be accommodated accordingly.123

Summary

Type 1 diabetes mellitus is a chronic progressive autoimmune disease wherein the beta cells of the pancreas are destroyed by the body’s own immune cells. The disease is usually diagnosed early in life.The exact etiology of the type 1 diabetes mellitus is unknown, however; studies in recent years strongly suggest that autoimmunity, genetic and environmental factors play crucial roles in its disease origins and pathologic mechanisms. An individual with a known family history of type 1 diabetes mellitus have inherently greater risk of developing the disease at some point before they reach adulthood.


Type 1 diabetes mellitus in children is usually diagnosed with blood tests. Specifically, a casual plasma glucose test result of ≥200 mg/dL, or a fasting plasma glucose (FPG) test result of ≥126 mg/dL, or an oral glucose tolerance test (OGTT) result of ≥200 mg/dL is diagnostic for type 1 diabetes mellitus. This type of diabetes is not uncommon in children. Diabetic children require the same monitoring and insulin protocols as adults, with the added requirement of cooperation and collaboration between school or day care personnel, parents or guardians and members of the diabetes healthcare team.

Children at each developmental stage (i.e., preschool, middle school, high school) have different abilities when it comes to monitoring their own blood glucose levels and self-administration of insulin. Younger children may be counted on to cooperate when a parent, guardian or qualified personnel perform these tasks, while older children and adolescents in high school can do these tasks themselves.

At the core of type 1 diabetes mellitus management is insulin therapy. Insulin may be administered through CSII devices or more traditionally, by multiple daily injections using syringes and vials, insulin pens, and pre-filled syringes. There are different types of insulin; classified according to their onset, duration and peak of action. Rapid acting insulin is usually administered immediately before meals (15 minutes pre-prandial) while long-acting insulin are meant to stabilize blood glucose levels over a long period of time such as during the night to prevent the onset of nocturnal hyperglycemia.

Children with type 1 diabetes mellitus need to learn to match their every carbohydrate intake and physical activity with their insulin dose. This is to ensure that there is enough insulin in the body to handle the carbohydrate load per meal and the energy needed to sustain the activity.


There are several complications associated with long term poorly controlled blood glucose levels such as retinopathy, neuropathy, and nephropathy. In the short term, if blood glucose levels dip too low, a fatal complication can ensue called diabetic ketoacidosis. This is a diabetic emergency that requires immediate medical attention. It is usually treated with fluid replacement therapy given over an appropriate period of time.

Schools and day care facilities are required by law to accommodate and accept children with type 1 diabetes mellitus. As such, they need to be properly equipped with the right materials and information and personnel trained to perform diabetes care.

One of the self-management strategies that children with diabetes can learn is how to recognize the various symptoms of hypoglycemia and how to self-administer their insulin when it occurs. In order to ensure that children are safe wherever they go, they are recommended to wear medical identification devices such as bracelets and necklaces to help emergency responders identify them and their condition in the event of an emergency.

DEFINITION OF TERMS:

Addison’s disease: An autoimmune condition characterized by chronic adrenal insufficiency which can occur as comorbidity among children with type 1 diabetes mellitus.

Blood glucose: The amount of glucose in the blood at a given time.

Celiac disease: An autoimmune disorder characterized by intestinal damage due to gluten. It is a common comorbidity among type 1 diabetes patients.


Euglycemia: A state or condition of normal blood glucose levels.

Glomerulosclerosis: A condition characterized by the hardening of the glomerulus in the kidney due to complications related to diabetic nephropathy.

Gluconeogenesis: A metabolic process occurring in the liver that refers to the synthesis of glucose from molecules that are not carbohydrates, such as amino and fatty acids.

Glycosuria: It refers to the presence of excess glucose excreted into the urine due to untreated diabetes mellitus.

Honeymoon period: The period during insulin therapy following diagnosis which is characterized by good glycemic control and low insulin requirements.

Hyperglycemia: The condition characterized by high levels of circulating glucose in the blood, usually due to poor glycemic control.

Hypoglycemia: The condition characterized by low levels of circulating glucose in the blood, usually following missed meals and rigorous exercise or physical activity.

Ketoacidosis: A metabolic disorder characterized by hyperglycemia, acidosis, and ketonuria due to complete or relative insulin deficiency.

Ketones: Organic compounds produced by the liver during fatty acid metabolism.


Ketonuria: It refers to the presence of high levels of ketone bodies in the urine as a result of cellular breakdown of proteins.

Lipolysis: The breakdown of lipids and hydrolysis of triglycerides into glycerol and free fatty acids.

Lipohypertrophy: It refers to fatty lumps on the surface of the skin caused by accumulation of extra fat due to repetitive subcutaneous injections of insulin.

Microalbuminuria: A condition wherein there is an abnormally high permeability for albumin in the renal glomerulus.

Nephropathy: A renal complication of poorly controlled diabetes mellitus characterized by persistent albuminuria, progressive decline in glomerular filtration rate, and elevated arterial blood pressure.Neuropathy: A complication of poorly controlled diabetes mellitus involving the peripheral nerves characterized by pain, numbness and tingling sensations on the extremities.

Paresthesia: It is a neuropathic symptom characterized by tingling, tickling, prickling, pricking, or burning sensations on the skin.

Retinopathy: An eye complication of poorly controlled diabetes mellitus involving the retinal blood vessels characterized by progressive loss of vision (new-onset blindness).


Please take time to help the NURSECE4LESS.COM course planners evaluate nursing knowledge needs met following completion of this course by completing

the self-assessment Knowledge Questions after reading the article. Correct Answers, page 112.

1) What is the high blood glucose correction factor for a type 1 diabetic patient weighing 160 lbs?

a. 50 mg/dLb. 45 mg/dLc. 60 mg/dLd. 65 mg/dL

2) Which type of diabetic neuropathy affects the heart, blood vessels and digestive system?

a. Focal neuropathyb. Peripheral neuropathyc. Autonomic neuropathyd. Proximal neuropathy

3) Which type of insulin has a natural cloudy appearance?a. Rapid acting insulinb. Regular insulinc. Intermediate acting insulind. Long acting insulin


4) Which of the following is intermediate acting insulin?a. NPHb. Glarginec. Aspartd. Lantus

5) What is the bolus insulin dose to cover a patient’s plan to consume 60 grams of carbohydrate for lunch. The patient’s Insulin: CHO ratio is 1:10.

a. 10Ub. 8Uc. 5Ud. 6U

6) Insulin absorption is fastest and most predictable injected in the:a. Upper outer armb. Abdomenc. Anterior lateral thighd. Buttocks

7) All of the following administration strategies minimize pain at the injection site of insulin EXCEPT:

a. Injecting insulin at warm temperatureb. Eliminating air bubbles in the syringe before injectionc. Keeping the muscles at the site of injection relaxed, when injectingd. Penetrating the skin quickly

8) Which of the following strategies does not help pediatric patients overcome their fear of needles and injection?

a. Using a pillow for trial injectionsb. Using a covered safety needle to conceal the needlec. Allowing the syringe to rest on their skin before injectiond. Injecting insulin without looking at the injection site

9) The following is NOT a standard insulin self-administration route:a. Subcutaneous injection with insulin pens


b. Subcutaneous injection with insulin prefilled syringesc. Intramuscular injection with insulin pensd. Subcutaneous infusion using CSII devices

10) Which of the following blood glucose test results is diagnostic for type 1 diabetes mellitus?

a. A random whole-blood glucose concentration exceeding 200 mg/dL b. A fasting whole-blood glucose concentration more than 120 mg/dL c. An HB1AC value of more than 6.5%d. All of the above

CORRECT ANSWERS:

1. B2. C3. C4. A5. D6. B7. A8. D9. C10. D

Footnotes:

1) Davies, J.L., Kawaguchi, Y., Bennett, S.T., Copeman, J.B., Cordell, H.J., Pritchard. L.E. (1994). A genome-wide search for human type 1 diabetes susceptibility genes. Nature, 371(6493):130-6.


2) Steck, A.K., Barriga, K.J,, Emery, L.M., Fiallo-Scharer, R.V., Gottlieb, P.A., & Rewers, M.J. (2005). Secondary attack rate of type 1 diabetes in Colorado families. Diabetes Care, 28(2):296-300.

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http://care.diabetesjournals.org/content/26/suppl_1/s131.full

http://www.chadkids.org/diabetes/diabetes_medical_identification.html

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PEDS Diabetes - nursece4less.com · Web viewPEDIATRIC DIABETES. Jassin M. Jouria, MD. Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author