Diabetes%20mellitus%20(pediatric) Treatment
Principles of Therapy
- Maintain a balance between tight glucose control & avoiding hypoglycemia
- To eliminate polyuria & nocturia
- To prevent ketoacidosis
- To permit normal growth & development w/ minimal effect on lifestyle
Pharmacotherapy
Insulin Preparations
- Goal of therapy is to duplicate normal physiologic secretion of insulin
- May be used in both Type 1 & Type 2 diabetes mellitus (DM)
- Patient w/ severe hyperglycemia (random plasma/venous blood glucose ≥250 mg/dL), HbAIC >9%, &/or ketosis should be treated initially w/ Insulin to achieve metabolic control
- Insulin requirements are based on body weight, age & pubertal status
- Newly diagnosed Type 1 DM usually require approx 0.5-1 U/kg/day
- Both multiple-dose Insulin injections (MDI) & continuous subcutaneous Insulin infusion (CSII) should be offered at the time of diagnosis or if control of blood glucose is not achieved
- Younger children require lower doses
- Patients at puberty require 1.5 U/kg/day due to hormonal changes
- Prandial Insulin should be matched according to carbohydrate intake, premeal glucose, & physical activity
- Presence of diabetic ketoacidosis (DKA) & use of steroids also require higher doses
- Type 2 DM
- Initiate treatment in type 2 DM patients w/ severe hyperglycemia (>11.1 mmol/L), glycosylated hemoglobin (HbA1c) >8.5%, or signs/ symptoms of severe insulin deficiency (eg DKA, ketoacidosis) despite lifestyle modifications (balanced diet & regular exercise)
- Use during times of illness or stress to maintain glycemic control
- Use when patients are unable to maintain adequate control w/ diet, exercise & oral antidiabetic agents
- Patients, parents/caregivers need to be instructed on monitoring of blood glucose & educated to adjust Insulin dose based on blood glucose levels
- Especially during times of illness, changes in food intake & physical activity
- Signs & management of hypoglycemia must be explained
- Exact time course of each Insulin will depend on each particular preparation & site of injection
Short- & Rapid-Acting Insulins
- Acts as mealtime insulin
- Administer before meals, 30-60 minutes before meals, to mimic normal physiologic increases of insulin
- Regular insulin
- As a mealtime insulin, its use may be limited because the onset is not rapid enough to meet the quick, unpredictable increase in postprandial blood glucose
- Also considered a basal insulin as its duration of action may extend beyond the time required for food absorption
- Newer rapid-acting insulin analogues (eg Insulin aspart & Insulin lispro) seem to have better postprandial blood glucose control
- They have more rapid onset of action & shorter duration of action than Regular Insulin
- Premeal control before the next meal may be difficult due to the short duration of action if used alone w/o a long- or intermediate-acting Insulin
Intermediate- & Long-Acting Insulins
- Mimics normal physiologic basal insulin secretion
- Neutral protamine Hagedorn (NPH) & Lente Insulins produce significant hypoglycemic effect during the midrange of their duration
- Long-acting Insulins create more controlled postprandial glucose elevation & hypoglycemia between meals & are reduced at nighttime
- Usually given 1-2x/day
Insulin Combinations
- Patients often require MDI using combinations of short-, rapid-, intermediate- or long-acting insulin before meals & at bedtime for optimal control of blood glucose
- Clinical studies show that combination of 2-3 doses of short- or rapid-acting insulin w/ intermediate-acting insulin do not sufficiently achieve optimal glycemic control
- Combination of rapid-acting insulin & long-acting insulin may result in stable glycemic control & less hypoglycemia especially at night
- It allows coverage for snacks, however, requires intensive blood glucose monitoring, improved medical nutrition therapy (MNT) & careful insulin adjustment w/ exercise
Insulin Pump Therapy
- CSII consists of regular- & rapid-acting insulins administered subcutaneous (SC) in an external infusion pump
- Can be programmed to deliver constant amount of basal insulin & boluses of insulin for meals
- Increased physical activity can be managed by reducing amount of basal insulin
- May be used instead of multiple daily injections to provide intensive diabetes management
- Provides closer approximation of normal plasma Insulin profiles & increased flexibility regarding timing of meals & snacks compared
- Associated w/ improved metabolic control & reduced risk of severe hypoglycemia w/o affecting psychosocial outcomes in adolescents w/ Type 1 DM
- May improve metabolic control in children 7-10 years
- Consider a sensor-augmented low glucose threshold suspend pump in patients w/ frequent nocturnal hypoglycemia &/or hypoglycemia unawareness
Oral Antidiabetic Agent
Metformin
- A biguanide approved for nonketotic pediatric patients w/ Type 2 DM
- May be used as monotherapy or in combination w/ Insulin
- 1st line therapy for newly diagnosed type 2 DM-pediatric patients
- May also be used to prevent type 2 DM in patients w/ impaired glucose tolerance, increased fasting glucose, or HbA1c 5.7-6.4%
- Actions: Improve insulin action at the liver which decreases hepatic glucose production
- Increase peripheral glucose uptake & utilization
- Effects: Significantly reduces HbA1c & improves fasting plasma glucose (FPG) & postprandial blood glucose
- Maintains or decreases weight, decreases low-density lipoprotein cholesterol (LDL-C) & triglycerides (TG)
- May also normalize ovulatory abnormalities in patients w/ polycystic ovarian syndrome (PCOS)
- Contraindicated in patients w/ moderate to severe renal insufficiency
- Should not be given to patient w/ ketosis because it may precipitate lactic acidosis
- May be started once the child recovers from ketosis after treatment by rehydration & w/ Insulin
- Insulin should be added whenever glucose control cannot be achieved after 3-6 months of Metformin therapy
Non-Pharmacological Therapy
Diabetes Management Education
- Healthcare providers expert in childhood diabetes mellitus (DM) should educate the patient & family about DM
- An individualized Diabetes Medical Management Plan (DMMP) should be developed by the healthcare provider for the parent/guardian’s, child’s, & school staff’s use during school days
- Education should be personalized to the needs of the patient & the family, culturally sensitive & paced to accommodate individual needs
- For infants & toddlers, parents must assume the responsibility of daily management
- Severe hypoglycemia w/ seizures or coma are highest in infants
- Measurement of blood glucose must be done first before ignoring a temper tantrum
- For preschooler patients, education should be directed towards the parents & caregivers
- For school-aged patients, education should still be directed towards parents & may include patient
- School-aged patients can begin to assume some of the daily management tasks & those listed in the DMMP
- For adolescent patients, education should be directed to the patient w/ the parents
- For infants & toddlers, parents must assume the responsibility of daily management
- The family must learn the “basics”
- Monitor the child’s blood glucose & urine ketones
- Prepare & inject the correct Insulin dose subcutaneous (SC) at the proper time
- Recognize & treat low blood glucose reactions
- Have basic meal plan
- The behavior of the family towards diet is an important factor to help w/ child obesity
- The following should be avoided:
- Eating-out
- Skipping breakfast
- Preparing sumptuous meals
- Serving large meal portions
- The following should be avoided:
- Written materials covering these basic topics help the family during the first few days
- They should receive ongoing education regarding the prevention of complications of diabetes
- Inform the patient & their family about the general health problems & complications of smoking
- Encourage children & adolescents to stay away from cigarette smoking
- Offer smoking cessation counselling & treatment to patients who already learned to smoke
- Diabetes management education is associated w/ improved patient knowledge on DM, improved self-care behavior, improved clinical outcomes like lower glycosylated hemoglobin (HbA1c) & improved quality of life
Monitoring of Blood Glucose
- Recommended in most patients w/ DM & is associated w/ improved HbA1c, ease of medication adjustment, avoidance of hypoglycemia & increased lifestyle flexibility
- Benefits will be increased when patients adjust dietary choices, medication & activity in response to blood glucose levels
- Calibration & control solution need to be used on a regular basis based on manufacturer’s recommendations
- Patients should be aware if value given by glucometer is based on whole blood glucose or calibrated to plasma glucose
- Plasma glucose is the level measured by most labs
- Patients need to be instructed on how to use the data to modify nutrition, exercise & pharmacotherapy, & maintain glycemic control
- Healthcare provider should monitor patient’s technique
- Monitoring of blood glucose should be done more often when modifying therapy
- Testing may be needed 6-8x/day; should be individualized based on patient’s glycemic status
- Daily fasting blood glucose measure is recommended for patients on long-acting Insulin therapy
- Blood glucose monitoring may be done using 2 techniques: self-monitoring blood glucose (SMBG) or HbA1C
Self-monitoring blood glucose (SMBG)
- Recommended timing for SMBG in patients on multiple dose Insulin (MDI) or Insulin pump therapy
- Prior to meals/snacks
- Pre-exercise or physical activity
- Before bedtime
- When hypoglycemia is suspected
- After administration of anti-hypoglycemic agents
- Prior to participating in critical activities
- For non-Insulin-treated patients, studies show that SMBG is helpful in HbA1C lowering w/in 6 months duration
Continuous glucose monitoring (CGM)
- May be helpful in pediatric patients treated w/ intensive Insulin regimen together w/ SMBG
- The real-time sensor alarms in CGM devices are helpful tools in monitoring hypo/hyperglycemia
- Studies have shown a decrease in HbA1c for patients frequently using the device
- Should be offered to patients w/ type 1 DM w/ frequent severe hypoglycemia, impaired hypoglycemia awareness w/ complications (seizures, anxiety), those unable to recognize or communicate about hypoglycemia symptoms, neonates/infants/pre-schoolers, & children participating in high-level physical activities
Diabetes Medical Management Plan (DMMP)
- An individualized management plan for children that can be used during school days & school activities
- Both the student & the school staff should be informed & instructed about a child’s DMMP
- Includes instructions for the following:
- Blood glucose monitoring
- Insulin administration
- Meals & snacks
- Hypoglycemia & hyperglycemia (symptoms & treatment)
- Abnormal glucose & ketone levels (checking & appropriate actions)
- Physical activity
- Emergency situations & emergency contact list
- Parents should provide the school w/ materials & medications to be used for the DMMP
Medical Nutrition Therapy (MNT)
- Integral component of DM prevention & management
- MNT should be provided at diagnosis & annually thereafter, by an individual experienced w/ the nutritional needs of the growing child & the behavioral issues that have an impact on adolescent diets
- Consult w/ a dietitian experienced in pediatrics & DM to discuss MNT
- Base MNT on recommended dietary intakes appropriate for age, gender, physical activity & growth rate. See Growth Charts in MIMS Pediatrics
- Conduct a complete medical exam prior to prescribing any low-calorie diet
- Evaluate height, weight, body mass index (BMI) & MNT plan annually
- Individualize MNT according to food preferences, cultural influences, physical activity patterns, family eating patterns, etc
- Calorie intake of overweight/obese patients should be based on patient’s energy requirements by direct measurement thought indirect calorimetry
- MNT alone or in combination w/ appropriate Insulin therapy averts or relieves symptoms of hyperglycemia in patients w/ diabetes
- Nutritional practices may influence the development of long-term complications of diabetes
- General goals of MNT
- Attain optimal metabolic outcomes
- Blood glucose levels in normal range, lipid profile, HbA1c <7% & blood pressure (BP) which reduces risk of vascular disease
- Prevent & treat diabetic comorbidities [eg obesity, cardiovascular (CV) disease, hypertension, dyslipidemia, etc]
- Improve overall health
- Attain optimal metabolic outcomes
- MNT goals in Type 1 DM
- Provide enough energy for growth & development in young DM patients
- Insulin needs to be integrated into the meal routine & to be based on food choices
- Patient should be taught flexibility of Insulin dosing & timing
- MNT goals in Type 2 DM
- Decrease energy intake & increase expenditure of energy as most Type 2 DM patients are overweight/obese
- A macronutrient diet of ≥900-≤1,200 kcal/day is recommended for children 6-12 years of age
- ≥1,200 kcal/day for patients ages 13-18 may help improve weight & body composition
- Reduce Insulin resistance & improve metabolic status especially in young DM patients
- For overweight/obese youth w/ Type 2 DM, assist w/ appropriate changes of physical activity & eating habits
- Increased fruits & vegetable in a child’s diet may help decrease risk for obesity; dairy & calcium-rich should is essential & should be included in their diet
- High-calorie containing beverages & fatty foods should be monitored & restricted in overweight pediatric patients
- Short-term restriction of high-carbohydrate diet (up to 20-60 grams) may help w/ weight management
- Decrease energy intake & increase expenditure of energy as most Type 2 DM patients are overweight/obese
Physical Activity
An exercise program that suits individual’s age, fitness, aptitude & interest should be prescribed
- Regular exercise has been shown to improve blood glucose control, reduce CV risk factors, contribute to wt loss & improve well-being
- Pre-exercise evaluation should be done to identify diabetic complications, macrovascular, microvascular & neurological conditions
- A minimum of 60 minutes of moderate-to-vigorous physical activity daily is recommended
- Type 1 DM
- Hypoglycemic reaction may occur during or w/in hours after exercise
- Monitor blood glucose before exercise
- Intake of 15 g of carbohydrate is suggested, less in younger children, for a blood glucose level below target range before exercise
- Additional 15 g of carbohydrate may be necessary for vigorous physical activity >30 minutes
- Monitor blood glucose hourly during prolonged vigorous exercise
- Monitor blood glucose after exercise for carbohydrate intake & prospective insulin dose adjustment
- Monitor blood glucose before, during & after subscribing to new sports or physical activities
- Type 2 DM
- Long-term exercise has proven to help prevent & treat type 2 DM
- Moderate physical activity (eg walking) of at least 150 minutes/week may help prevent or delay type 2 DM
- At least 60 minutes/day of moderate to strenuous exercise is recommended to reduce BMI & improve glycemic control
- Exercise has been shown to decrease peripheral insulin resistance
- Decrease screen time (watching tv, playing video games, computer use) to a maximum of 2 hours/day