Children with Diabetes under 18 years by Maggie Stelmaschuk ( Bellefountaine )RD MSA CDE

1. Children with Diabetes under 18 years by Maggie Stelmaschuk (Bellefountaine )RD MSA CDE Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Journal of Diabetes, Vol 32, Sup 1

2. Children with Diabetes under 18 years by Maggie Stelmaschuk (Bellefountaine )RD MSA CDE

3. TYPE 1 and TYPE 2 DIABETES IN CHILDRENAND ADOLESCENTS 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Journal of Diabetes, Vol 32, Sup 1

4. Children are not little adults

5. Diagnosis is difficult for parents Loss of a healthy child

6. Type 1 Diabetes in Children and Adolescents Key Messages • Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis (DKA). • Management of pediatric DKA differs from DKA in adults because of the increased risk for cerebral edema. Pediatric protocols should be used. • Children should be referred for diabetes education and ongoing care to a diabetes team with pediatric expertise.

7. Type 1 Diabetes in Children and Adolescents 2008 CPG Recommendations Delivery of Care • All children with diabetes should have access to an experienced pediatric DHC team and specialized care starting at diagnosis [Grade D, Level 4 (1)]. 2. Children with new-onset type 1 diabetes who are medically stable should receive their initial education and management in an outpatient setting, providing appropriate personnel and daily telephone consultation service are available in the community [Grade B, Level 1A (2)].

8. : Network of Ontario Pediatric Diabetes Programs

9. 34 NOPDP members • 28 in Southern Ontario • 6 in Northern Ontario • 5 are academic sites functioning as tertiary diabetes programs • Northern Ontario Programs include: • Sioux Lookout, Thunder Bay, SSMarie, Timmins, Sudbury and North Bay.

10. Southern Ontario Pediatric programs • East • Ottawa BellevilleKingstonPembrokeToronto • TorontoScarboroughCentral WestKitchener BramptonBurlingtonCambridgeGuelphMississaugaOrangeville • Central South • Hamilton BrantfordSt. CatharinesCentral EastBarrieMarkhamOrilliaMarkhamOrilliaPeterboroughWhitby South West • London ChathamOwen SoundSarniaWindsor

11. Tertiary Programs in Ontario • Toronto Hospital for Sick Children • Ottawa Children’s Hospital of Eastern Ontario • Hamilton McMaster Children’s Hospital • London Children’s Hospital of Western Ontario • Kingston Hotel Dieu Hospital 1

12. Type 1 Diabetes in Children and Adolescents • To ensure ongoing and adequate metabolic control, pediatric and adult diabetes care services should collaborate to prepare adolescents and young adults for the transition to adult diabetes care [Grade C, Level 3 (100)].

13. Pediatric Care

14. Adult Care

15. Shared Care • Adult support is required usually up until 16 years of age • Skills can be achieved e.g. injections and blood testing • Cognitive reasoning is not developed well enough yet • E.g. Children might skip an injection to go play or a teen might not inject because of peer pressure

16. Type 1 Diabetes in Children and Adolescents • Children with persistently poor diabetes control (e.g.A1C >10%) should be referred to a tertiary pediatric diabetes team and/or mental health professional for a comprehensive interdisciplinary assessment [Grade D, Consensus]. Intensive family and individualized psychological interventions aimed at improving glycemic control should be considered to improve chronically poor metabolic control [Grade A, Level 1A (102,103)].

17. Type 1 Diabetes in Children and Adolescents Glycemic targets graduated with age • Glycemic targets should be graduated with age (Table 1): • Children <6 years of age should aim for an A1C of <8.5% [Grade D, Consensus]. Extra caution should be used to minimize hypoglycemia because of the potential association in this age group between severe hypoglycemia and later cognitive impairment [Grade D, Level 4 (101)]. • Children 6 to 12 years of age should aim for an A1C target of <8.0% [Grade D, Consensus]. • Adolescents should aim for the same glycemic targets as adults [Grade A, Level 1A (4)].

18. Differences in Children and Teens • Sensitivity to insulin • Children more sensitive to insulin • Insulin need changes over time • Teens requirements increase due to growth hormone and puberty hormones as well as volume of food intake • Activities and routine change daily

19. Differences in children and teens • Growth and development • Physical growth changes needs • Cognitive development needs to be considered • Need for independence • Risk Taking behavior • Peer pressure • School support • Need to teach the children not just the parents

20. Family Health • Is the family supportive? • Is it a single parent family or a blended family ? • Finances of the family • Mental health and addictions • Can’t choose the parents of these children • CAS ??

21. Type 1 Diabetes in Children and Adolescents Insulin therapy • Children with new-onset diabetes should be started on at least 2 daily injections of short-acting insulin or rapidacting insulin analogues combined with an intermediate or long-acting insulin [Grade D, Consensus].

22. Type 1 Diabetes in Children and Adolescents • Insulin therapy should be assessed at each clinical encounter to ensure it still enables the child to meet A1C targets, minimizes the risk of hypoglycemia and allows flexibility in carbohydrate intake, daily schedule and activities [Grade D, Consensus]. This assessment should include consideration of: • Increased frequency of injections [Grade D, Consensus] • Change in the type of basal (long-acting analogue) and/or prandial (rapid-acting analogue) insulin [Grade B, Level 2 • (17), for adolescents; Grade D, Consensus, for younger children]. • Change to CSII therapy [Grade C, Level 3 (104)].

23. Two injection times

24. Three injection times

25. Four injection times

26. INSULIN PUMP (CSII)

27. Syringes • Those on insulin pumps should know how to fill a syringe and inject with it • If they only use pens cartridges will outdate quickly • If they carry a syringe and they have their vial of rapid insulin they can use this to inject if the pump fails • Emergency insulin plans must be taught to all families to replace meal time insulin and basal insulin • Pens • Commonly used and ½ unit pens are excellent for kids who are sensitive to small doses of insulin and/or do not want to be on an insulin pump

28. Pattern Management • Should not just keep adjusting insulin for high or low blood sugars • Teach them how to look for 3 day patterns and adjust the insulin which is responsible for the problem.

29. Simple but often forgotten • Remind them that insulin works forward not backwards • Do not eliminate insulin because glucose is in target • Do not omit insulin

30. Insulin Sensitivity Factor • Calculate starting from total daily dose • 100/ TDD = ISF ( using rapid analogues) • ( 83/TDD if short acting insulin) • ISF is how much 1 unit of insulin drops blood glucose in mmol/L • If TDD is 50 units ISF = 100/50 =2 ie 1 unit of insulin drops glucose by 2mmol/l

31. With ISF • Think ahead • FBS is 5 H/NR is given to cover the next 4-5 hour time give base dose or I/CHO • If Pre-lunch is high correct with ISF and If Pre-lunch is high 3 days in a row without explanation fix the base dose or I/CHO at breakfast (pattern management)

32. Example ISF ½ unit drops glucose 5 mmol/lMust be individualized however once in place it is far superior to sliding scale

33. Pattern Analysis What to Fix With MDI premeal rapid insulin?

34. Carbohydrate Counting in Kids Why? Normalcy for kids • Insulin to Carb ratios can be developed • Eg 1 unit Rapid to 15 grams carbohydrate These ratios are individually adapted • No foods are forbidden • Denial results in disordered eating patterns • Social activities are normalized • No “special” foods for the kid with diabetes • “Mom’s nutrition rules don’t change” 1

35. Amount of Carbohydrate negotiated • Assess what they usually eat • Keep it as close as possible to that • Example might look like this • Breakfast 45 grams carbohydrate • Lunch 60 grams carbohydrate • After school snack 30 grams carbohydrate • Supper 75 grams carbohydrate • Night snack 45 grams carbohydrate

36. Developing Insulin to Carb ratio • Insulin to carb is the amount of carbohydrate which matches with 1 unit of insulin • Eg 1 unit is required to maintain BG in target for every15 grams of carb • Start with BG in target premeal • Eat known amount of carb and usual insulin • Test before the next meal and if in target that is correct • Do this more than once to check

37. Example Insulin to Carb • Joel’s B G is 5.6 this morning • He takes 1 unit of insulin for 15 gmscarb for 3 days • BG before lunch is 9.2, 10.1 and 9.0 • He then can try 1 unit for 10 gmscarb for 3 days • BG before lunch is 6.5, 5.7 and 4.9 • His insulin to carb is 1unit per 10 gmscarb for breakfast. • Repeat test for other meals covered by rapid acting insulin

38. Canadian Diabetes Associatio 2008 Clinical Practice Guidelines for the Prevention and Sup 1

39. Type 1 Diabetes in Children and Adolescents Hypoglycemia • In children, the use of mini-doses of glucagon (20 μg per year of age to a maximum of 150 μg) should be considered in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate [Grade D, Level 4 (27)]. • Mini dose is 2 units if child is under 2 years • 1unit per year of age after that up to a maximum of 15 units. • If glucose is < 5mmol/L after 30 minutes repeat with twice the dose ie 4 units under 2 years and 2 unit increments per year of age up to maximum of 15 units • Repeat ever hour until blood glucose is going up • Then give 15 grams carbohydrate every hour Guidelines for Managing Sick Days For Children With Type 1 Diabetes, Advisory Committee NOPDP

40. Type 1 Diabetes in Children and Adolescents • In the home situation, severe hypoglycemia in an unconscious child >5 years of age should be treated with 1 mg of glucagon subcutaneously or intramuscularly. In children ≤ 5 years of age, a dose of 0.5 mg of glucagon should be given. The episode should be discussed with the diabetes healthcare team as soon as possible and consideration given to reducing insulin doses for the next 24 hours to avoid further severe hypoglycemia [Grade D, Consensus].

41. Type 1 Diabetes in Children and Adolescents Diabetic ketoacidosis 11.Targeted public awareness campaigns should be considered to educate parents and other caregivers (e.g. teachers) about the early symptoms of diabetes [Grade C, Level 3 (33)]. Comprehensive education and support services [Grade C, Level 3 (35)], as well as 24-hour telephone services [Grade C, Level 3 (36)], should be available for families of children with diabetes.

42. Type 1 Diabetes in Children and Adolescents 12. DKA in children should be treated according to pediatric-specific protocols [Grade D, Consensus]. If appropriate expertise/facilities are not available locally, there should be immediate consultation with a centre with expertise in pediatric diabetes [Grade D, Consensus]. 13.In children in DKA, rapid administration of hypotonic fluids should be avoided [Grade D, Level 4 (41)]. Circulatory compromise should be treated with only enough isotonic fluids to correct circulatory inadequacy [Grade D, Consensus]. Restoration of ECFV should be extended over a 48-hour period with regular reassessments of fluid deficits [Grade D, Level 4 (41)].

44. Insulin adjustment for Sick Days

46. Type 1 Diabetes in Children and Adolescents • Influenza immunization should be offered to children with diabetes as a way to avoid an intercurrent illness that could complicate diabetes management [Grade D, Consensus]. 27. Formal smoking prevention and cessation counselling should be part of diabetes management for children with diabetes [Grade D, Consensus].

47. Type 1 Diabetes in Children and Adolescents • Adolescent females with type 1 diabetes should receive counselling on contraception and sexual health in order to avoid unplanned pregnancy [Grade D, Consensus]. 29. Adolescent females with type 1 diabetes have a 2-fold increased risk for eating disorders [Grade B, Level 2 (69)] and should be regularly screened using nonjudgemental questions about weight and shape concerns, dieting, binge eating and insulin omission for weight loss [Grade D, Consensus].

49. TYPE 2 DIABETES IN CHILDRENAND ADOLESCENTS 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Journal of Diabetes, Vol 32, Sup 1

50. Type 2 Diabetes in Children and Adolescents Key Messages • Anticipatory guidance regarding healthy eating and active lifestyle is recommended to prevent obesity. • Regular targeted screening for type 2 diabetes is recommended in children at risk. • Children with type 2 diabetes should receive care in consultation with an interdisciplinary pediatric diabetes healthcare team. • Early screening, intervention and optimization of glycemic control are essential, as onset of type 2 diabetes during childhood is associated with severe and early onset of microvascular complications.