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Day care management of diabetes mellitus in children
1. DAY CARE MANAGEMENT OF
DIABETES IN CHILDREN
Dr. C. Kannan
Department of pediatrics
MGMCRI
2. DIAGNOSTIC CRITERIA
⢠Symptoms with random blood glucose of >200mg/dl
(or)
⢠Fasting plasma glucose > or = 126mg/dl
(or)
⢠2hr blood glucose during the OGTT > or = 200mg/dl
(or)
⢠HbA1c > or= 6.5%
3. DIAGNOSIS
⢠Symptoms as mentioned above
⢠By diagnostic criteria based on blood sugar/ HBA1C
⢠Never from finger test method
⢠Never from single plasma value
⢠Never with underlying stress(infection/injury)
⢠Molecular genetic testing for monogenic DM
⢠Check for associated ketoacidosis
⢠Suspect Type II DM if child is obese
⢠Associated autoimmune diseases
⢠Auto immune thyroiditis (30%)
⢠Celiac disease (5 â 10%)
4. MONITORING
Education of care taker
⢠Pathophysiology of diabetes
⢠Symptoms and when to anticipate hypoglycemia
⢠Regular monitoring of
⢠Insulin administration technique/sites
⢠Various situations requiring various insulin doses
⢠Dietary deviations
⢠Minor intercurrent illness
⢠Unusual physical activity
5. MONITORING
⢠Frequency of RBS/HBA1C
⢠Prebreakfast
⢠Prelunch
⢠Presupper
⢠Bedtime
⢠If required 2 hours of postprandial
⢠During initial period/if nocturnal hypoglycemia anticipated
⢠At 12 am
⢠At 3 am
6. MONITORING
⢠Dose adjustments
⢠10-15% of insulin can be adjusted according RBS variations
⢠Target blood sugar
Age in years Pre meal 30 day average HBA1C
<5 100-200 180-250 7.5-9.0
5-11 80-150 150-200 6.5-8.0
12-15 80-130 120-180 6.0-7.5
16-18 70-120 100-150 5.5-7.0
8. ABILITY OF CHILDREN
Preschool child
⢠Unable to do anything
Elementary school child
⢠By 8 years able to do finger test
⢠By 10 years able to administer insulin under supervision
Middle school child
⢠Administers insulin under supervision
⢠Self monitors blood glucose under usual circumstances
High school child
⢠Administers insulin without supervision
⢠Self monitors blood glucose under usual circumstances
9. MONITORING
Education for school teachers/school workers
⢠All teachers who are teaching him and 1 or 2 school workers
⢠Clearly explained about the
⢠Nature of illness
⢠Insulin requirement
⢠Importance of frequent monitoring/diet plan
⢠Acute complications
⢠Teacher should maintain a log and hand over it to parents
10. MONITORING
⢠Child should be allowed
⢠To have snacks
⢠To do finger test Any time in the class room
⢠To administer insulin
⢠Child should allow to miss school any day with doctorâs note
⢠If needed school should privacy area for
⢠Finger test
⢠Insulin administration
⢠Special attention during
⢠Field trips
⢠Extra curricular activities
⢠Sports events
12. INSULIN
⢠Started as soon as possible to avoid metabolic decompensation and DKA
⢠Maintain dynamic relationship between
⢠Physical activity
⢠Insulin administration
⢠Carbohydrate intake
⢠Basal bolus insulin regimen preferred (units/kg/day)
Age No DKA DKA
Pre pubertal 0.25-0.50 0.75-1.0
pubertal 0.50-0.75 1.0-1.2
Post pubertal 0.25-0.50 0.8-1.0
16. BASAL BOLUS INSULIN REGIMEN
⢠Longer acting form of insulin
⢠To keep blood glucose levels stable
⢠Through periods of fasting
⢠Separate injections of shorter/rapid acting insulin
⢠To prevent rises in blood glucose resulting from meals
17. BASAL BOLUS INSULIN REGIMEN
⢠A long acting insulin (Glargine)
⢠Basal insulin- preferably morning/bedtime with
⢠Rapid acting insulin ( Aspart, Lispro)
⢠Given before each meal and snack.
20. DOSAGE
Day 1
⢠<5 years - 0.1U/kg
⢠5 years/above - 0.2U/kg
⢠Regular insulin every 2 hours until blood glucose <120mg/dl
⢠Then 4th hourly
21. DOSAGE
Day 2
⢠0.5 to 1U/Kg/day
⢠Twice daily regimen
⢠More dose in the mornings and less in the evening
⢠Basal bolus regimen
⢠50% as rapid acting + 50% as long acting
⢠70% as regular insulin + 30% as long acting
⢠Given as 3-4 pre meal boluses
⢠With night time/breakfast intermediate or long acting insulin
22. HYPOGLYCEMIA
⢠More common in infancy and toddlers
⢠Unpredictable/wide swings in glucose levels
⢠Result from unbalanced insulin effect
⢠Longstanding DM Neuropathy Low catecholamines
Hypoglycemia No early response
Mild hypoglycemia
⢠Once in a weak
⢠Pallor Sweating Apprehension
⢠Tremors Hunger Irritability and tachycardia
23. HYPOGLYCEMIA
Moderate hypoglycemia
⢠Few times a year
⢠Drowsiness personality changes,
⢠mental confusion impaired judgement
Severe hypoglycemia
⢠Once in few years
⢠Inability to seek help
⢠Seizures
⢠coma
24. MANAGEMENT OF HYPOGLYCEMIA
⢠Avoid tighter glucose control
⢠Explain parents when to anticipate hypoglycemia
⢠Sports/gym activities
⢠Document/maintain blood glucose log
⢠Emergency glucose source in hand - candy/ juice
⢠Glucose 5-10 g can be given
⢠Check CBG 15-20 min later
⢠Minidose Glucagon can be given IM
⢠0.5 mg <20 kg/1 mg >20 mg
25. DAWN PHENOMENON
Early morning
⢠Increase in blood glucose levels due to decline in insulin levels.
Overnight
⢠Growth hormone secretion
⢠Increased insulin clearance
Normal child
⢠Physiological compensation by more insulin output
⢠which does not happen in a diabetic child
27. SICK DAY PATHOPHYSIOLOGY
⢠Infections disrupt the glucose control
⢠Hyperglycemia osmotic diuresis dehydration
⢠DKA ketosis-emesis dehydration
Anorexia
Hypoglycemia
28. SICK DAY MANAGEMENT
Management during intercurrent illnesses
⢠Adequate hydration (ORS)
⢠More frequent monitoring
⢠Adequate glycaemic control by dose adjustment
⢠Prompt management of fever
⢠Underlying illness should be detected early and managed
⢠Detection of ongoing dehydration and Ketoacidosis
29. SICK DAY MANAGEMENT
If ketones (-)
⢠5-10% of total daily insulin (or) 0.5-1U/kg
⢠Short acting every 2-4 hours based on blood glucose levels
If ketones (+)
⢠10- 20% of total insulin (or) 0.1 U/kg of insulin
⢠Every 1 hour.
30. NUTRITIONAL GUIDELINES
Age KCAL required / Kg Body weight
⢠Children
⢠0-12 months 120
⢠1-10 years 100 â 75
⢠Young women
⢠11-15 years 35
⢠>/= 16 years 30
⢠Young men
⢠11-15 80-55
⢠16-20
⢠Sedentary 30
⢠Average activity 40
⢠Very physical activity 50
31. NUTRITIONAL GUIDELINES
⢠Carbohydrate 55%
⢠Fat 30%
⢠Protein 15%
⢠75% of carbohydrates should come from complex starch
⢠Avoid glucose from refined sugars
⢠Avoid sweetened carbonated beverages
⢠Fibre rich diets are advised
⢠Fats derived from plants are advised
⢠Select diet based on personal taste
32. NUTRITIONAL GUIDELINES
⢠Carbohydrate Vary (depends upon fibre content)
⢠Fibre >20g/day
⢠Protein 12-20
⢠Fat <30
⢠Saturated <10
⢠Polyunsaturated 6-8
⢠Monounsaturated Remainder of fat allowance
⢠Cholesterol 300 mg
⢠Sodium 3-4 g
33. NUTRITIONAL GUIDELINES
⢠Prevent overweight and starvation
⢠Periodic growth monitoring
⢠High protein may leads to Diabetic nephropathy
⢠3 snacks/day for younger children
⢠Adolescents- include mid-afternoon and bedtime snacks