Children with Diabetes

Learning Objectives
Identify T1DM & T2DM in youth
Implement management strategies specific to a
younger population
Apply screening and interventions for comorbidities
and complications
Facilitate the transition from pediatric to adult diabetes
care

Scope of Problem: Indonesia

Number of children diagnosed with diabetes has
increased more than 400% in last 3 years
Estimate: 3/1000 children are diabetic

Jakarta Globe. Nov 8, 2012. http://www.thejakartaglobe.com/news/indonesias-reported-diabetes-cases-spike/554909

Clinical Characteristics of T1DM and

T2DM in Children and Adolescents

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Clinical Characteristics of T1DM and

T2DM in Children and Adolescents

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Presenting Symptoms
Polyuria
Polydipsia
Blurring of vision
Weight loss
Glycosuria
Ketonuria
Vary from non-emergency to severe dehydration, shock
and ketoacidosis

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Identification of Ketoacidosis

Severe dehydration
Frequent vomiting, abdominal pain
Continuing polyuria despite dehydration
Weight loss
Flushed cheeks
Acetone on breath
Hyperventilation
Disordered senses (disorientation or semicomatose)
Decreased peripheral circulation with rapid pulse
Hypotension and shock with peripheral cyanosis

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Ketoacidosis: Management
Immediate assessment to confirm diagnosis:
History, clinical signs, biochemical features and investigations

As needed:
Resuscitation, IV therapy, insulin

Critical observations:
Regular and frequent measurements
Evaluation of progress

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

T1DM and The Honeymoon Period

Period of partial remission of the disease
Childs pancreas produces some insulin
Decreased demand for injected insulin (<0.5 units/kg
of body weight/day with HbA1C<7%)
Typically lasts between 6 weeks and 2 years
Family must be educated on the transient nature of this
period to prevent false hopes

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Managing T1DM in Children

Goals of Care
Gain glycemic control
Minimize acute complications
Prevent/delay chronic complications
Achieve normal psychosocial development

Tamborlane WV, et al. In: Therapy for Diabetes Mellitus and Related Disorders. ADA. 5th ed; 2009.
IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

BG and A1C Goals for T1DM by Age

ADA. Standards of Medical Care in Diabetes-2012. Diabetes Care 35(suppl 1).

Insulin Therapy for T1DM

Analog-based basal-bolus regimens
Continuous subcutaneous infusion of insulin
Multiple daily insulin injections

NPH-based regimens
May play a role for newly-diagnosed patients in honeymoon
period

Correct insulin dose: Achieves the best attainable glycemic

control without hypoglycemic events, leading to healthy growth
and development
Tamborlane WV, et al. In: Therapy for Diabetes Mellitus and Related Disorders. ADA. 5th ed; 2009.
IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Managing T2DM in Children

Goals of Care

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DM
Management strategy will depend on the level of symptoms

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DM: Symptomatic

If target
BG
achieved

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Management of T2DM: Asymptomatic

If not reaching BG targets

If not reaching BG targets

If not reaching BG targets

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Monthly
reviews of
progress
including
3 monthly
A1Cs

Overweight Children and Adolescents in

Indonesia

Over 3 years, the obesity prevalence increased in all

childrens age groups, with the largest increase in the 1518 year old female group
RISKESDAS 2010

Disease Management
Strategies: T1DM & T2DM

Medical Nutrition Therapy

Challenges:
Nutritional requirements vs. food preferences
Fitting in with friends
Body image concerns
Eating disorders
Parties, special events, overnight trips
Recommendations: Collaborate with pediatric dietitian;
adapt advice to cultural and family traditions as well as
the childs needs
Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009
IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Exercise for Youth with Diabetes

T1DM: Adjust snacks and insulin to level of physical
activity
T2DM: Encourage physical activity to counteract
sedentary lifestyle
Limit screen time (computer, video games, etc.)
Participate in group activities
Include family

Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Self-Management
Family involvement is important
Self-monitoring: Essential tool
Usually 4-6 times/day
Used to assess glycemic control and reduce the risks of acute
crises and long-term complications

Encourage adolescents to assume increasing

responsibility for diabetes management with parental
involvement and support

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Monitoring Sick Days

Provide patients with written guidance and counsel on
management of diabetes when sick, and when to seek
advice

Do not stop insulin; dose may need to be adjusted

More frequent monitoring of blood or urine ketones

Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.
IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Screening and Management

of Diabetes Comorbidities
and Complications in Youth

Recommendations: Nephropathy (T1DM)

Screening
Annual screening for microalbuminuria, with a random
spot urine sample for albumin-to-creatinine (ACR) ratio
Management
ACE inhibitor

ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S40.
IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Recommendations: Hypertension (T1DM)

Screening
BP should be monitored at every visit
Management:
Diet & exercise interventions
If target BP not reached within 3-6 months: ACE
inhibitors
Target:

<130/80 mmHg
or
<90th percentile for age, sex, and height
ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S40.

Recommendations: Dyslipidemia (T1DM)

Screening
If family history: Fasting lipid soon after glucose control
established
Otherwise: At puberty (10 years)
Management
Optimize glucose control, MNT, lifestyle changes
> Age 10: Add statin if,
LDL cholesterol >160 mg/dL (4.1 mmol/L) or
LDL cholesterol >130 mg/dL (3.4 mmol/L) and one
or more CVD risk factors
Target: LDL cholesterol <100 mg/dL (2.6 mmol/L)
ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S40-S41.

Recommendations: Retinopathy (T1DM)

Screening
Ophthalmologic examination
10 years of age; has had diabetes for 3-5 years
Routine follow-up as recommended by eye care
professional

ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

Recommendations:
Celiac Disease (T1DM)
Screening
Measure tissue transglutaminase or antiendomysial
antibodies, with documentation of normal total serum IgA
levels, soon after diagnosis
Repeat testing in children with symptoms or failure to
thrive
Management
Positive antibodies: Refer to a gastroenterologist
Confirmed celiac disease: Consult with a dietitian to
implement gluten-free diet

ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

Recommendations:
Hypothyroidism (T1DM)
Screening
Thyroid peroxidase, thyroglobulin antibodies at
diagnosis; TSH after metabolic control established

If normal, recheck every 1-2 years; or if patient develops

symptoms of thyroid dysfunction, thyromegaly, or an
abnormal growth rate

ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care 2012;35(suppl 1):S41.

Recommendations: Screening for

Complications T2DM

Hypertension: Routine BP checks

Dyslipidemia: Screen at diagnosis
Retinopathy: Annual eye exam
Nephropathy: Annual screening for microalbuminuria

ADA. Therapy for diabetes mellitus and related disorders. 5 th Edition. 2009.

How Good is Diabetes

Control in Indonesian Youth?

T1DM Self-Management in Indonesia

Results of qualitative in-depth interviews:
T1DM associated with fear, shame, sadness
Participants sought alternative medicine
Difficulty complying with self-management (especially
diet)
Suggest a buddy to help with self-management

(n=4 adolescents with T1DM)

Maylani AN, Wahyu YK. Int J Res Stud Psychol 2012;1(2):81-95.

Glycemic Control in Indonesian Youth

Study: 7 pediatric diabetes centers (n=69):
T1DM mean HbA1C=10.5%
85%/95% met ADA/EUDPG cut-off for inadequate control

T2DM mean HbA1C = 8.7%

All patients had HbA1C >8%

Study: Pediatric endocrinology centre (n=24):

8.2% had good metabolic control
Majority showed a low frequency of self-management

Batubara JRL, et al. Paediatr Indones 2002;42(11-12):280-6.

Batubara JRL, et al. Paediatr Indones 2001;41:256-9.

Diabetes Complications & Self-Monitoring

in Indonesian Youth
Complications:
5 out of 64 patients had recent hypoglycemia (8% in last 3
months)
11 out of 64 patients had chronic complications:
6 cases of neuropathy (9%)
2 cases of retinopathy (3%)
3 cases of microalbuminuria (5%)

Self-monitoring
59% of patients did blood glucose self-monitoring
8% of patients did urine glucose self-monitoring

36
Batubara JRL, et al. Paediatr Indones 2002;42(11-12):280-6.

Can Education Improve Outcomes?

Indonesian Data
Structured 6-month educational program:
Improved patients and parents knowledge significantly but
HbA1C at 3 months and 6 months did not improve

Two-day intensive diabetic camp:

Improvement in glycemic control at 3 months follow-up

Endyarni B, et al. Paediatr Indones 2006;46(11-12):260-5.

Soenggoro EP, et al. Paediatr Indones 2011; 51:294-7.

Psychosocial Concerns

Emotional Dynamics
Peers

Teachers

Responsible
Concerned

Confused
Concerned

Adolescent
Patient
with
Diabetes
Parents
Confused
Concerned/Fearful
Guilty
Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Siblings
Jealous of the
attention
Concerned
Responsible

Diabetes Education
Need multidisciplinary team including family, teachers,
and peers
Routine assessment and education:
Disease management: Including knowledge, insulin
adjustment, problem-solving, treatment adherence
Developmental progress in physical, academic, and
psychosocial development

IDF/ISPAD. Global Guideline for Diabetes in Childhood and Adolescence. 2011.

Diabetes at School
Teachers/staff may require education about diabetes
Parents can help
Meet with staff
Provide basic education if necessary
Provide training on what to do in an emergency
Ensure that supplies are available

Adapted from Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Adolescent Challenges
Puberty can have a physiological impact on glycemia
Self-image and body issues
Risk-taking behaviours, exposure to smoking and
drugs
Protectiveness of parents versus adolescent desire for
independence
Recommendations: Use communication skills that are
patient-centered, supportive and confidential
Adapted from Childs BP, et al. (eds.) Complete Nurses Guide to Diabetes Care. ADA. 2nd ed; 2009.

Promoting a Successful
Transition from Pediatric to
Adult Diabetes Care

Why is the Transition to Adult Care

Important?
Young adults are vulnerable and at high risk of falling
through the cracks
Poor glycemic control
Psychosocial issues
Reproductive health issues
Substance use and abuse
ADA Joint Position Statement. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult
Diabetes Care Systems. Diabetes Care 2011;34:2477-2485.

Evolving Targets: From Adolescence to

Adulthood

ADA. Standards of Medical Care in Diabetes. Diabetes Care 2012;35(1):S11-S63.

Long-Term Impact of Glycemic Control:

From Adolescence to Adulthood
Diabetes Control and
Complications Trial
(DCCT):
Subset of patients 1317 years of age
Intensive insulin vs.
conventional therapy
Follow-up 4-9 years
later

vs.

DCCT Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in
adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Ped 1994;125(2):177-88.

Summary: Factors Influencing Poor

Transition

Undetected
and untreated
complications

McGill M. Horm Res 2002;57(suppl 1):66-68.

Transition Goals
Provide effective process for transition of care from
pediatric to adult centres
Achieve glycemic control to prevent complications and
maximize functioning
Provide education, skills training, and transition support

ADA Joint Position Statement. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult
Diabetes Care Systems. Diabetes Care 2011;34:2477-2485.

What This Means for Adolescents

As adolescents grow up, they must learn to
Accept responsibility
Make independent decisions
Have financial independence
They might
Be unwilling (or unable) to see a pediatric diabetes
health care team
Be leaving home for school/work
Become pregnant and receive care from an adult
diabetes health care team

Why Do Some Patients Have Difficulty

with the Transition?
Fear of leaving the pediatric care team they know
Lack of preparation for transition
Lack of trust in the adult health care system

Transition: Educational Needs

Steps for Successful Transition:

Pediatric Team
Begin transition process during adolescence
Work with the patient and family to create a plan
Identify appropriate adult diabetes health care teams
for transition
Create transition clinic days
Write a transition plan
Develop a clinical summary document
Weissberg-Benchell J. Transitioning from pediatric to adult care. Diabetes Care 2007;30:2441-2446.

Steps for Successful Transition:

Adult Team
Interact with pediatric diabetes team
Consider needs of young adults
Include family members as requested by patient
Obtain/create developmentally-appropriate teaching
materials

Weissberg-Benchell J. Transitioning from pediatric to adult care. Diabetes Care 2007;30:2441-2446.

Summary
Management plan:
Address psychosocial factors unique to adolescents
Diet and self-monitoring information
Education directed to patient, family, teachers, and peers

Promote optimal glycemic management and

screening for complications to prevent complications
or allow for early intervention

Summary
Plan for transition from pediatric to adult diabetes care
to include:

Methods to ensure follow-up and adherence

Education on adult topics
Promotion of glycemic control
Screening and prevention of complications
Screening and management of psychosocial issues
Education and support for disease self-management

Case Study: Mr. K.L.

18-year-old male with T1DM

Current regimen: Premixed insulin 25/75 32-0-30
Physical examinations: Within normal limits
Laboratory examinations:
Hb 13.2 mg/dL; Leu 6,000; Thrombosit 280,000; AST 30 ALT
28; BUN 40; Creatinine 0.6; HbA1C 8.8%

He feels glucose control is fine and rarely visits the

doctor
He often self-adjusts his insulin dose

Case Study: Questions

What issues should be considered with regard to his
transition from pediatric to adult care?
What strategies can be used to address these issues?