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.

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%
  • ActionsImprove 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
  • 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
  • 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
  • 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

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
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