diabetes%20mellitus%20(pediatric)
DIABETES MELLITUS (PEDIATRIC)
Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.
It can occur at any age and the earlier the onset, the more serious is the long-term damage, dysfunction and failure of various organs due to the chronic hyperglycemia with diabetes mellitus patients having <10 year in life span compared to non-DM patients.
Type 1 DM patients have complete insulin deficiency due to beta-cell destruction. It may be immune-mediated or idiopathic. More commonly occurs in children 7-15 year of age, but may occur at any age.
Type 2 DM patients have insulin resistance and relative insulin deficiency.
Neonatal DM is hyperglycemia that occurs in the first 6 months of life.

Formulation of Management Plan

  • An individualized therapeutic alliance between the patient, patient’s family, physician & other members of the healthcare team
  • The care of the patient should be provided by a multidisciplinary team of specialists trained in care of pediatric diabetes mellitus (DM)
    • Includes nurses, dietitians, pharmacists, mental health professionals, etc
  • Preparing patient for self-management is one of the most important components of care
  • Plan development should consider:
    • Age, school/work schedules, physical activity & eating patterns
    • Culture, social status & personality
    • Presence of complications

Routine Assessment

Glycemic control

Maintaining glycemic control has been shown to decrease diabetic complications

  • There is compelling evidence that tight glycemic control reduces the risk of long-term complications from diabetes mellitus (DM)
  • Glucose control goals must be individualized while minimizing the risk of severe hypoglycemia & hyperglycemia & maintaining normal growth & development
  • Postprandial glucose monitoring & therapies targeting postprandial excursion may be required to reach glycosylated hemoglobin (HbA1c) goal
    • Recommended plasma glucose goals:
      • Preprandial - 90-130 mg/dL (5.0-7.2 mmol/L)
      • Bedtime/overnight - 90-150 mg/dL (5.0-8.3 mmol/L)
  • If severe or frequent hypoglycemia occurs, goals may need to be modified

Glycosylated hemoglobin (HbA1c)

  • Lowering HbA1c has been associated w/ a decrease in microvascular & neuropathic complications
    • Lower HbA1c may be associated w/ a lower risk of myocardial infarction (MI) & cardiovascular (CV) death
  • Management plan should be adjusted to achieve a normal or near-normal of HbA1c
    • Very young patients & those w/ comorbid conditions may be appropriately treated w/ less aggressive treatment goals
  • An HbA1c of <7.5% (58 mmol/L) is the recommended goal for type 1 diabetes in all pediatric age-groups
    • HbA1c goal of <7.0% (53 mmol/L) may be considered if this can be achieved w/o excessive hypoglycemia
  • An HbA1c of <6.5% (48 mmol/L) is the recommended goal for children & adolescents w/ type 2 DM
  • HbA1c should be performed routinely
    • Reflects glycemic control over the preceding 2-3 months, allowing better timing of therapy modifications
  • HbA1c should be tested every 3 months in patients who are not meeting treatment goals, at the beginning of therapy, or if there is a change in therapy
    • Patients who are meeting treatment goals & have stable glycemic control may test HbA1c every 6 months
    • Therapy should be intensified if blood glucose & HbA1c level goals are not met

Management of Diabetes Mellitus (DM) Complications

Growth Impairment

  • Evaluate height & weight based on growth chart every clinic visit. See Growth Charts Clinical Reference Table in MIMS Pediatrics

Diabetic Ketoacidosis

  • Monitor heart rate (HR), respiratory rate, blood pressure (BP), neurologic status, fluid input & output, evidence of hyper- or hypokalemia
  • Monitor capillary glucose hourly
  • Perform laboratory tests on electrolytes, blood glucose & blood gases every 2-4 hours
  • Give intravenous (IV) fluids to replace fluid deficit over 48 hours
    • Do not give hypotonic fluids, eg <0.45N NaCl, as initial therapy
  • Monitor Potassium levels & replace as soon as urine output is established
  • Give 0.05-0.1 u/kg/hour Insulin IV

Hypoglycemia

  • Determine frequency of hypoglycemia every clinic visit
    • Assess for unawareness of hypoglycemia & assess blood glucose
  • Treat w/ approximately 9 g of glucose for a 30 kg child & 15 g for a 50 kg child
  • Blood glucose should be measured after 10-15 minutes of treatment to confirm resolution of hypoglycemia
  • Treat severe hypoglycemia w/ 0.5 mg for children <12 years, 1 mg for children >12 years or 10-30 mcg/kg body weightt Glucagon intramuscular (IM)/IV/subcutaneous (SC) to increase blood glucose levels w/in 5-15 minutes

Immunization

  • Recommend receiving all pediatric immunizations according to local guidelines
  • Give vaccination against influenza to patients >6 months

Nephropathy

  • Treat confirmed & persistently elevated microalbumin levels w/ an angiotensin-converting enzyme (ACE) inhibitor titrated to normalization of microalbumin excretion
  • Educate patients on the importance of glycemic control & smoking cessation in reversing diabetic nephropathy
  • Prioritize normalization of BP if hypertension exist to delay progression of nephropathy
  • Low-density lipoprotein cholesterol (LDL-C) lowering therapy may offer some benefit
  • Refer patient to a nephrologist if medical treatment is unsatisfactory

Hypertension

  • Initiate pharmacotherapy once hypertension is diagnosed & confirmed
    • Consider using ACE inhibitors for the initial treatment of hypertension to lower BP to <130/80 mmHg or below the 90th percentile for age, gender & height
    • May use angiotensin receptor blockers if ACE inhibitor use is not tolerated
    • Consider adding other antihypertensives if target BP is not reached w/ ACE inhibitor alone
  • Treatment of high-normal blood pressure should include dietary intervention & exercise
    • Eliminate added salt to cooked foods & reduce consumption of foods w/ high sodium
    • Initiate pharmacotherapy if target BP is not reached w/in 3-6 months of lifestyle modification

Dyslipidemia

  • Repeat lipid panel every 3-5 years if LDL-C is <100 mg/dL (2.6 mmol/L)
  • Optimal glucose control, MNT & lifestyle modification should be the initial therapy
    • Includes wt loss & reducing amount of total fat & saturated fat, cholesterol in patients >2 years
  • After the age of 10 years, add LDL-C lowering pharmacotherapy to reach LDL-C goal of <100 mg dL if LDL-C is persistently >160 mg/dL & LDL-C is 130-159 mg/dL w/ one or more cardiovascular (CVD) risk factors after failure of lifestyle & diet modification for 6 months
    • Bile acid sequestrants, statins [beta-hydroxy-beta-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors] & Ezetimibe are approved for use in patients ≥10 years
    • Further studies are needed to determine recommendations for children w/ LDL-C values <130 mg/dL

Retinopathy

  • Schedule annual ophthalmological follow-ups after the initial examination, then every 2 years if cleared w/ ophthalmologist
  • Refer patient to ophthalmologist w/ expertise in diabetic retinopathy & its risks in the pediatric patient
    • May provide recommendations for laser photocoagulation surgesry
  • May recommend use of ACE inhibitors to slow progression of retinopathy

Neuropathy

  • Annual follow-up starting at age >10 years or post-puberty onset if diagnosed w/ DM for 3-5 years
  • Advise patient on proper nail & skin care, proper skills for feet care, & to use appropriate footwear
  • Inform the patient to consult physician if there are foot lesions showing signs of infection or poor healing

Thyroid Disease

  • Recheck thyroid-stimualting hormone (TSH) levels every 1-2 years for patients w/ normal TSH or if growth rate is abnormal
  • See Growth Charts Clinical Reference Table in MIMS Pediatrics
  • Treat patient w/ elevated TSH levels w/ thyroid hormone replacement therapy

Celiac Disease

  • Refer patient to gastroenterologist once celiac disease is confirmed
    • Recommend consultation w/ registered dietitian experienced w/ DM & celiac disease in pediatric patients
  • Screen periodically in patients negative for celiac disease
  • Impose gluten-free diet to DM patient diagnosed w/ celiac disease

Psychiatric Disorders

  • Screen patients ≥10 yearly annually for depression
  • Screen for psychiatric disorders in patients w/ difficulties in achieving treatment goals & w/ recurrent DKA
    • Patients w/ DKA are more likely to develop psychiatric disorders
  • Psychiatric support should be offered to the patient & family members suffering from psychosocial issues when managing diabetes
    • Tailor the psychiatric support according to the patient & family’s emotional, cultural, social & age-dependent needs

Eating Disorders

  • Mental health professional should screen for eating disorders w/ failure in treatment goals especially if patient is underweight
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