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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
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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)
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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
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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)
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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
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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
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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
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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
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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
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Why is hypoglycemia so detrimental in children?
- hypoglycemia unawareness
- brain development
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When should urine ketone checks be performed in children?
- when FBG > 250
- during sickness
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When should drug therapy be started for dyslipidemia in kids?
- when LDL is > 160mg/dL
- Statins approved over 10yo
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Why are toddlers and preschoolers with Type I diabetes not controlled as tightly as older kids?
high risk and vulnerability to hypolycemia
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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
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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
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How is Type II diabetes a growing epidemic in children?
- worldwide phenomenon
- rate of increase is unknown
- obesity is definitely causal
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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
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What are the signs of insulin resistance in children?
- Acanthosis nigricans (areas of dark skin)
- PCOS (Polycystic Ovary Syndrome)
- HTN
- High lipids
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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
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When and how should HTN be treated in kids with I diabetes?
- BP = 85 percentile or higher
- ACE inhibitor
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What is the role of pharmacotherapy in pediatric Type II diabetes?
not the main answer
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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
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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
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