Pediatric Diabetes

  1. What are the differences between kids and adults in diabetes?
    • insulin sensitivity related to sexual maturity
    • physical growth demands more glucose
    • ability to provide self-care
    • unique neurologic vulnerability to hypoglycemia
    • care plans must include family dynamics and developmental stages
    • recommendations are based more on expert opinion d/t lack of studies
    • more prevalence of Type I
    • Type II comorbidities: NASH, PCOS, hirsutism, acne, amenorrhea
  2. What are the differences in complications of Type I and Type II diabetes?
    • Type I:
    • more retinopathy
    • more neuropathy
    • Type II:
    • more HTN
    • more microalbuminemia (nephropathy)
  3. How are the testing goals for Type I different from those for Type II diabetes?
    • Type I goals are not as strict as Type II goals in younger kids (<6)
    • Goals get stricter as age increases
  4. What are the different methods of insulin therapy in kids with Type I diabetes?
    • Split-Mixed
    • Basal Bolus
    • Continuous Subcutaneous Insulin pump (CSII - still basically basal bolus)
  5. How is split-mixed insulin therapy instituted in pediatric Type I diabetes?
    • Short-acting + NPH
    • 1 unit/kg divided into 2-3 injections/d (starts lower and works up to this)
    • 2/3 of daily dose in AM, 1/3 in PM
    • AM: 2/3 NPH, 1/3 short acting
    • PM: 50:50 NPH and short acting
    • NOT recommended post honeymoon
    • Not used often in peds
  6. How is basal bolus insulin therapy instituted in pediatric Type I diabetes?
    • Rapid-acting + long-acting
    • At least 4 injections/d
    • Pre-meal rapid-acting dose based upon:
    • current BG
    • anticipated carb intake
    • anticipated level of physical activity
    • Possible to dose erratic toddlers postprandial (pre-meal still better)
    • better glucose control
    • less nocturnal hypoglycemia
  7. How is Continuous Subcutaneous Insulin pump therapy instituted in pediatric Type I diabetes?
    • Another form of basal bolus
    • Requires carb counting
    • Must test 4-6 times/d and bolus
    • Used more in preadolescents and adolescents (but no best age to start)
    • Adult support and supervision still essential
    • Use is rapidly increasing
  8. How is insulin typically dosed in pediatric Type I diabetes?
    • 0.5-1 unit/kg/d or less during honeymoon
    • Typically end at 1 unit/kg/d
    • Up to 1.4 units/kg/d during puberty (increased insulin resistance, growth hormone, sex hormones)
    • Insulin Sensitivity Factor (ISF) for adjusting uncontrolled FBG:
    • 1800/TDD of insulin = approx effect of 1 unit of rapid-acting insulin
  9. How are sick days managed in pediatric Type I diabetes?
    • Primary goal: prevent DKA
    • Most common mistake is to hold all insulin
    • Perform frequent urine ketone checks - add insulin if present (15-30% of TDD for moderate, 25-30% if large)
    • May need to decrease insulin if child not eating or low sugars
  10. Why is hypoglycemia so detrimental in children?
    • hypoglycemia unawareness
    • brain development
  11. When should urine ketone checks be performed in children?
    • when FBG > 250
    • during sickness
  12. When should drug therapy be started for dyslipidemia in kids?
    • when LDL is > 160mg/dL
    • Statins approved over 10yo
  13. Why are toddlers and preschoolers with Type I diabetes not controlled as tightly as older kids?
    high risk and vulnerability to hypolycemia
  14. Why are 6-12yo with Type I diabetes not as tightly controlled as older kids?
    • risks of hypoglycemia
    • relatively low risk of complications prior to puberty
  15. Why are adolescents and young adults with Type I diabetes not as tightly controlled as adults?
    • still some risk of hypoglycemia
    • developmental and psychological issues
  16. How is Type II diabetes a growing epidemic in children?
    • worldwide phenomenon
    • rate of increase is unknown
    • obesity is definitely causal
  17. When should kids be screened for Type II diabetes?
    • Beginning at age 10 or puberty, whichever is less
    • When BMI is in 85th percentile or higher and 2 of the following are present:
    • family hx in 1st or 2nd degree relative
    • non-white race
    • signs of insulin resistance
  18. What are the signs of insulin resistance in children?
    • Acanthosis nigricans (areas of dark skin)
    • PCOS (Polycystic Ovary Syndrome)
    • HTN
    • High lipids
  19. When should children be screened for chronic complications in Type I diabetes?
    • A1c: at each visit
    • HTN: at each visit
    • Neuropathy: monofilament at each visit
    • Nephropathy: 10yo and 5yrs post-diagnosis, but urine albuminemia annually
    • Dyslipidemia: at diagnosis for > 2yo after glucose controlled if family hx present, otherwise after 12yo and q 5yrs
    • Retinopathy: 10yo and > 3-5yrs of DM duration; annually thereafter
  20. When and how should HTN be treated in kids with I diabetes?
    • BP = 85 percentile or higher
    • ACE inhibitor
  21. What is the role of pharmacotherapy in pediatric Type II diabetes?
    not the main answer
  22. How is mild hyperglycemia treated in pediatric Type II diabetes (FBG < 150; 2h OGTT < 300)?
    • Excercise and diet x 3-6mo, then:
    • if FBG > 100 and A1c > 6% - Metformin x 3-6mo, then
    • if still insuccessful, add another agent:
    • Sulfonylurea
    • TZD
    • Glitinide
    • alpha-glucosidase inhibitor
  23. How is severe hyperglycemia treated in pediatric Type II diabetes (FBG > 150; 2h OGTT > 300)?
    • BG under 350 and no DKA:
    • Metformin x 3-6mo
    • if unsuccessful, add Sulfonylurea, TZD, Glitinide, or alpha-glucosidase inhibitor
    • BG over 350 OR DKA:
    • Insulin until stable, then
    • Metformin x 3-6mo
    • if unsuccessful, add Sulfonylurea, TZD, Glitinide, or alpha-glucosidase inhibitor
Card Set
Pediatric Diabetes
Pediatric Diabetes