Transcript ISSUES IN PEDIATRIC DIABETES

CHILDREN
WITH
DIABETES
Donna LaFrate, MS, RN, CPNP, CDE
Joslin Diabetes Center
Children’s Diabetes Program
Statistics
2007
•
•
•
•
•
23.6 Million people
diagnosed with diabetes
7.8% of population
Diagnosed 17.9 Million
Undiagnosed 5.7 Million
New/over age 20 1.6 Million
New/under age 20 186,300
Statistics
• 2011
25.8 Million people
•
diagnosed with diabetes
•
8.3% population
• Diagnosed
18.8 million
• Undiagnosed
7.0 million
• New/over age 20 1.9 million
• New/under age 20 215,000
Type 1 diabetes
• 15,000 adults and 15,000 children
• Diagnosed with T1D annually
• (80 per day)
• T1D incidence under age 20 rose by
23% between 2001-2009
• T1D incidence worldwide among
children under 14 increases 3%
annually
Rising Incidence of Diabetes
Types of Diabetes
• Type 1 (formerly juvenile diabetes)
– Pancreas stops making insulin all
together( beta cell destruction)
– Usually diagnosed in youth, although
some people develop type 1 well into
their 30s+
• Type 2
– Pancreas makes some insulin, but either
can’t make enough or the insulin made
doesn’t work very well
– Traditionally described as adult-onset,
more youth are being diagnosed with
type 2
What is diabetes?
•
Type 1 diabetes
–
The pancreas stops making insulin
entirely. (autoimmune response)
–
Without insulin, the glucose can’t travel
from the blood into the cells.
–
Two things happen:
1. The cells begin to starve.
2. The level of glucose in the blood rises to
unhealthy levels.
–
• In a healthy body
– the stomach and digestive system
break down much of the food we
eat into glucose (or blood sugar).
– This glucose is released into the
blood stream.
– The pancreas secretes the
hormone insulin, which acts as a
key, unlocking the cells and
enabling glucose to enter and
provide fuel and energy to the
cells and tissues.
Diagnosis
1. Random plasma glucose>200mg/dl on 2
separate occasions & symptoms
(polyuria, polydipsia, unexplained weight
loss.
2. Fasting plasma glucose > 126 mg/dl on
2 separate occasions.
3. 2 hour plasma glucose>200 mg/dl during
glucose tolerance test.
Meghan 7 years
Megan is in 2nd grade.
She likes to draw,
color and collect Bratz
dolls.
She takes dancing
lessons and is in
Brownies.
Luis 10
Luis moved from Puerto Rico three
years ago.
He loves to play basketball.
Luis wants to be a lawyer when he
grows up so he can continue to
argue in English and Spanish.
Hakim 3
Diagnosed at 15 months,
Hakim has never known life
without diabetes.
He likes to play with cars
and trucks.
He loves to tease his 6
month old
baby sister.
Diabetes Management:
Blood Glucose Testing
• Tools:
–Glucose meter
–Glucose test
strips
–Lancet (with
lancet device)
Diabetes Management:
Blood Glucose Testing
• Use glucose reading to
determine:
–Food (carbohydrates)
Insulin (injection or pump)
–Whether intervention is required
–Whether exercise or sleep are
safe
Blood glucose monitoring
• Test at least 4 times a day, usually
before meals and bedtime
• Periodically test after eating, before
and after exercise and middle of the
night.
• Use insulin to carbohydrate ratios
and correction doses for high and low
glucose levels
Diabetes Management:
Medication
• Insulin
–Syringe
–Insulin Pen
–Insulin Pump
Basal Insulin
• Lantus : given once a day and
lasts up to 24 hrs
• Levimir: given once a day and lasts
12 up to 24 hrs
• Neither has a peak
• Novolog, Humalog and Apridra are
Bolus Insulin
• Novolog
• Humalog
• Apidra
• All are rapid acting, start to work in
10-15 minutes, start to peak at 1 hr
and last approximately 3 hours.
FUEL:
FOOD:
CARB
PROTEIN
FAT
~ 100%
minimal
minimal
BLOOD
GLUCOSE
Protein and Fat Raise Blood Sugar Minimally
They may affect the rate of digestion, delaying
entry of sugar into the blood
They require insulin for metabolism
Protein and fat have calories and affect general
health so choose them wisely
Carbohydrate Raises Blood Sugar the
Most
Almost 100% shows up as glucose in the
blood stream
Starts showing up in within 15 minutes;
almost all is glucose by 2 hours after
eating
Most carbohydrates raise blood sugar to
about
the same degree but can vary in time
How do you count
carbohydrates?
T
The secret to carb counting
1. Note the serving size
2. Read the “Total Carbohydrate”
Carbohydrate and Label
Claims
1 Oatmeal Raisin Cookie
=17 grams carbohydrate
1 Sugar Free Oatmeal
Cookie
=16 grams carbohydrate
1 FF Oatmeal Raisin Cookie
=25 grams carbohydrate
Carbohydrate
Protein
Fat
Correction Factor
A formula to calculate a plus or
minus
dose when BG is higher or lower
than
pre-meal target
Correction Factor (CF):
the amount one unit of insulin will
lower or raise the BG.
Target BG Ranges
• Usually, 80 –180 mg/dl range
Before meals, 80-150 mg/dl
2 hours after meals, 180 mg/ dl
• Variation for grades K to 3 or 4;
100-200 mg/dl (MD or PCP
decides)
Insulin to carbohydrate ratio 1:15
• Correction factor/ insulin sensitivity
factor 1:50
• Target: 120 mg/dl.
• Carbs: 60 (1 unit per 15) =4 units
• BG:220(1 unit lowers BG 50)=2 units
Total bolus dose
= 6 units
Hyperglycemia (High BG)
• Can be caused by
– Skipping an insulin dose or not enough
insulin
– Eating more than or exercised less than
planned
– Stress of an illness like cold or flu
– Growing
– Other stress
• Can be serious if extremely elevated
(can lead to ketoacidosis), or if
consistently elevated (poor control
which can lead to complications)
Hyperglycemia
Symptoms
– Frequent urination
– Extreme thirst
– Lethargy
– Nausea/vomiting
– Unusual hunger
– Blurry vision
– Stomachache
– Hyperactivity
– Irritability
Treating Hyperglycemia
• Exercise can usually lower blood
glucose.
• If consistently elevated, meal
plan and/or insulin regimen may
be altered.
• If substantially elevated (usually
>250 mg/dl), need to test for
ketones in the urine.
• DO NOT exercise if ketones are
present (glucose and ketones
will increase).
Hypoglycemia
• Symptoms
–
–
–
–
–
–
–
–
–
Shakiness
Nervousness
Impatience
Sweating
Irritability,
sadness, anger
Fast heartbeat
Lack of
coordination
Headache
Confusion
– Chills and cold
sweat
– Hunger
– Stubbornness or
combativeness
– Tingling or
numbness of lips
or tongue
– Strange behavior
– Light-headed or
dizziness
– Lose
consciousness
Treating Hypoglycemia
• Check blood sugar
• Quickest way to treat is with 15
grams of simple carbohydrate: ½
cup fruit juice, 4-6 oz regular (not
diet) soda, 4-6 glucose tabs or
glucose gel, Skittles
• Wait ~15 minutes and check blood
sugar again
• Repeat the treatment if BS is still
low and still having symptoms
Diabetes Management:
Glucagon
Exercise
• Children and adolescents with Type 1
DM should adhere to the CDC and
American Academy of Sports
Medicine recommendations of
minimum of 30-60 min of moderate
physical activity daily.
Physical Activity Guidelines
• Blood glucose monitoring before
exercise is recommended .
• If blood sugar less than 100,
administer 15 grams of CHO for
every 30 minutes of activity.
• These goals can vary for each child,
parents will know best.
CSII
Insulin pump therapy
CSII Benefits
• Decreases hypoglycemia
• Increases flexibility in lifestyle:
Sleeping in
Eating with friends
• Improves control for preconception
and pregnancy
CSII Benefits
• Improves blood glucose control
• Decreases incidence and
progression of complications
• Provides precise dosage delivery
• Can adjust for hormonal changes
in glucose levels
• Improves control during exercise
• Simulates normal insulin delivery
• Pump automatically delivers
programmed basal
• User delivers a specific insulin dose
(bolus) when food (carbohydrate) is
eaten or bg is high
• The user may increase, decrease, or
stop insulin delivery as situations
demand
• Pumper learns to “think like a
pancreas”
Pump Myths
•
•
•
•
•
•
•
Easy, no more injections …EVER!
Less time consuming
Less BG monitoring
Perfect blood glucose
No complications
Hospital stay required
Surgical procedure needed
Pump Facts
• Pager sized “Mini-computer”
• Pre-programmed insulin delivery
• Uses an cartridge and infusion set
• Short-acting or fast acting insulin
only
• No surgery necessary
• Glucose levels are not measured
by pump
Insulin Delivery With the Pump
Basal Rates
12mn - 0.175 units / hour
3am
- 1.125 units / hour
6am
- 0.25 units / hour
6pm - 0.35 units / hour
3am
12
am
Joslin Diabetes
Center 2014
6am
6pm
Calculating Basal Doses
For example:
Long acting
10 units
Lantus/Levemir
(subtract 20%) divided by 24
hours/day.
This is 8 divided by 24 equals 0.35
units per hour for the initial basal
Joslin
Diabetes
rate.
Center 2014
Bolus
Insulin as Basal Rate and Bolus
Bolus insulin for meal
Average blood insulin level from basal
Time
Joslin Diabetes
Center 2014
Meal Time Insulin
Bolus
The insulin required at meal or snack
times
Joslin Diabetes
Center 2014
Animas Ping
Medtronic Minimed
Joslin Diabetes
Center 2014
OmniPod
Joslin Diabetes Center
2008
Tandem t:slim
Joslin Diabetes
Center 2008
An infusion set is the link between your insulin pump and
your body.
Reservoir
Cannula
Housing
Cannula
Adhesive
Serter™ Device
Tubing
Infusion set cannulas
Connected
Disconnected
Advanced features
•
Extended Bolus: You can give some insulin now as a bolus
and program the remainder of insulin to be delivered over a
set amount of time. Can be helpful for high fat foods- Pizza
Joslin Diabetes
Center 2014
Advanced features
Temporary Basal: Set Duration and % of Basal
Adjustment
Example: Decrease % of basal for activity
Joslin Diabetes
Center 2014
Advanced features
Basal Pattern: Monday-Friday vs Weekend
Different Basal requirements for different days
Joslin Diabetes
Center 2014
Current Monitoring Tools
6:00
AM
Blood Glucose Meter
(Fingerstick)
HbA1c
9:00
AM
12:00
PM
Continuous Glucose
Monitoring (CGM)
American Diabetes
Association National Diabetic
Intensive Management and
A1c
Intensive management attempts
to decrease blood glucose
variability
A1c test alone is not enough to
measure good blood glucose control
Target Blood
Glucose
Range
Patient A – A1c of 7%
Patient B – A1c of 7%
Patient C – A1c of 7%
A1C Test – American Diabetes Association:
http://www.bddiabetes.com/u
s/news/blood_sugar_a1c_test
http://www.diabetes.org/type-1-diabetes/a1c-test.jsp
Sept 2007
Illustrative purposes only
Reveals Overall Pattern
American Diabetes
Association National Diabetic
Effect of Real-time Sensing
American Diabetes
Association National Diabetic
SA
American Diabetes
Association National Diabetic
Continuous Glucose Monitoring
(CGM)
Personal Products
GlucoWatch®
Seven™ System
MiniMed Paradigm®
REAL-Time System
Guardian® RT
Continuous Glucose
Monitoring System
GlucoWatch is a registered Trademark of Animas Corporation
Seven™ System is a registered Trademark of DexCom ™, Inc Corporation
Abbott Navigator
How the System Works
• Glucose sensor is inserted in
subcutaneous tissue and can
be worn for up to 3 days
• Glucose sensor is connected
to the transmitter
• Glucose sensor sends glucose
values to the transmitter
• Transmitter then sends these
values wirelessly to the
insulin pump every 5
minutes, where data can be
viewed and acted on* in real* Fingerstick measurements are required for sensor calibration (every 12
time
hours) and prior to therapy adjustments
Value
of CGM
• Ability to see interaction between
medication, food choices, exercise,
etc
• Ability to view overnight trends
• Download historical data
• Improved communication with the
Health Care Provider
• Audible high and low blood sugar
alerts
• Better control and piece of mind
Priceless!
American Diabetes
Association National Diabetic
Whats in the
Future?
Questions
???
HAVE A PURR-FECTLY
WONDERFUL DAY!!