• 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

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 (HbA_1c) 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 (HbA_1c)

• Lowering HbA_1c has been associated w/ a decrease in microvascular & neuropathic complications
  • Lower HbA_1c 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 HbA_1c
  • Very young patients & those w/ comorbid conditions may be appropriately treated w/ less aggressive treatment goals
• An HbA_1c of <7.5% (58 mmol/L) is the recommended goal for type 1 diabetes in all pediatric age-groups
  • HbA_1c goal of <7.0% (53 mmol/L) may be considered if this can be achieved w/o excessive hypoglycemia
• An HbA_1c of <6.5% (48 mmol/L) is the recommended goal for children & adolescents w/ type 2 DM
• HbA_1c should be performed routinely
  • Reflects glycemic control over the preceding 2-3 months, allowing better timing of therapy modifications
• HbA_1c 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 HbA_1c every 6 months
  • Therapy should be intensified if blood glucose & HbA_1c level goals are not met

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