PEDIATRIC DIABETES
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
Type 1 diabetes mellitus, previously known as juvenile diabetes, is a chronic and progressive metabolic disorder. The onset of pediatric type 1 diabetes mellitus can occur at any pre-pubertal age. School nurses, teachers or other personnel trained to perform diabetes care, as part of the interdisciplinary pediatric diabetes healthcare team (DHC), support glycemic monitoring, insulin administration and carbohydrate counting of meals, as well as educating the patient about their disease, its management and treatment. All health professionals, part of the interdisciplinary pediatric diabetes healthcare team, provide continuous support as patients grow independent and become more capable of self-management of the disease.
Continuing Nursing Education Course Director & Planners
William A. Cook, PhD, Director; Douglas Lawrence, MA, Webmaster;
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement
NurseCe4Less.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Credit Designation
This educational activity is credited for 8.5 hours. Pharmacology content is 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in all Continuing Nursing Education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Knowledge of diabetes research and medical management is important to safe care for the pediatric diabetic patient. Educating health teams and patients, as well as their caregivers, about medical management and lifestyle choices is integral to diabetic health and wellness.
Course Purpose
To provide nurses and associates knowledge of the main and less common forms of diabetes to support patients and families during treatment.
Learning Objectives
1. List current hypotheses for the cause of Type I DM.
2. Identify the types of neuropathy caused by pediatric diabetes.
3. Describe the role of beta cells in the pancreas.
4. Explain the relationship between Type I DM and autoimmune disorders.
5. Explain types of insulin, usage and various ways to administer insulin.
6. Describe the role of exercise in the management of pediatric diabetes.
7. Describe how diabetic ketoacidosis should be managed with children.
8. Explain how schools/day care centers can contribute child diabetes care.
9. Explain how carbohydrates impact pediatric diabetic management.
10. Identify the importance of medical identification.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates
Course Author & Director Disclosures
Jassin M. Jouria, MD; William S. Cook, PhD; Douglas Lawrence, MA; Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.
Start Date: 7/14/2014 Termination Date: 7/14/2017
Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course
1) What is the high blood glucose correction factor for a type 1 diabetic patient weighing 160 lbs?
a. 50 mg/dL
b. 45 mg/dL
c. 60 mg/dL
d. 65 mg/dL
2) Which type of diabetic neuropathy affects the heart, blood vessels and digestive system?
a. Focal neuropathy
b. Peripheral neuropathy
c. Autonomic neuropathy
d. Proximal neuropathy
3) Which type of insulin has a natural cloudy appearance?
a. Rapid acting insulin
b. Regular insulin
c. Intermediate acting insulin
d. Long acting insulin
4) Which of the following is intermediate acting insulin?
a. NPH
b. Glargine
c. Aspart
d. Lantus
5) What is the bolus insulin dose to cover a patient’s plans to consume 60 grams of carbohydrate for lunch. The patient’s Insulin: CHO ratio is 1:10.
a. 10U
b. 8U
c. 5U
d. 6U
6) Insulin absorption is fastest and most predictable injected in the:
a. Upper outer arm
b. Abdomen
c. Anterior lateral thigh
d. Buttocks
7) All of the following administration strategies minimize pain at the injection site of insulin EXCEPT:
a. Injecting insulin at warm temperature
b. Eliminating air bubbles in the syringe before injection
c. Keeping the muscles at the site of injection relaxed, when injecting
d. Penetrating the skin quickly
8) Which of the following strategies does not help pediatric patients overcome their fear of needles and injection?
a. Using a pillow for trial injections
b. Using a covered safety needle to conceal the needle
c. Allowing the syringe to rest on their skin before injection
d. Injecting insulin without looking at the injection site
9) The following is NOT a standard insulin self-administration route:
a. Subcutaneous injection with insulin pens
b. Subcutaneous injection with insulin prefilled syringes
c. Intramuscular injection with insulin pens
d. Subcutaneous infusion using CSII devices
10) Which of the following blood glucose test results is diagnostic for type 1 diabetes mellitus?
a. Random whole-blood glucose concentration > 200 mg/dL
b. Fasting whole-blood glucose concentration 120 mg/dL
c. An HB1AC value of more than 6.5%
d. All of the above
Introduction
Pediatric diabetes can be a scary and life-changing diagnosis. However, with proper management, patients with pediatric diabetes can live long, full lives. Patients with pediatric diabetes—and their parents and caregivers—will take their cues from health care professionals when it comes to managing diabetes. Having an in-depth knowledge of the pathophysiology and management techniques of diabetes will allow health clinicians to provide reassuring knowledge and treatment options to their patients. Knowledge and information are powerful tools for every member of the healthcare management team to provide optimal care and a high quality of life for the patient.
Type 1 diabetes mellitus, previously known as juvenile diabetes, is a chronic and progressive metabolic disorder wherein the body is unable to produce insulin to meet its energy needs. The condition is a result of autoimmune destruction of the beta cells in the pancreas. As its former name suggests, the disease has an early onset, usually before 18 years of age. Once diagnosed, an individual will require lifelong insulin treatment and monitoring for complications.
Type 1 diabetes mellitus is also known as insulin-dependent diabetes mellitus (IDDM) because the pancreas is completely unable to produce insulin, as opposed to type 2 diabetes mellitus, which is where the pancreas produces insufficient amounts of insulin to sustain the energy requirements of the body.
According to the CDC, type 1 diabetes is caused by mechanisms much different from those that cause type 2 diabetes mellitus. Despite prolific research into the origins of the disease, the exact etiology of both types of diabetes remains unclear. Nevertheless, studies in the recent years have primarily pointed out its onset as following exposure to environmental stimuli such as a virus and certain dietary factors in genetically predisposed individuals. However, because of the very early onset of the disease in pediatric populations, the role of genetic factors is also a very important consideration.
The onset of pediatric type 1 diabetes mellitus can occur at any pre-pubertal age, however, the peak incidence usually increases with age until mid-puberty and then declines. This means that the majority of these patients are school-age children whose care and wellbeing is entrusted to the school and day care personnel for the majority of their day. In this case, it is the school nurses, teachers or other personnel trained to perform diabetes care, as part of the interdisciplinary pediatric diabetes healthcare (DHC) team, who are responsible for them especially when it comes to glycemic monitoring, insulin administration and carbohydrate counting of meals. They are also partly responsible for educating the patient about their disease, its management and treatment.
It is important for all health professionals, not just nurses, who are part of the interdisciplinary pediatric diabetes healthcare (DHC) team to be able to provide continuous counseling as patients grow older, and lean toward independent and self-management of the disease. The course is intended to enhance and reinforce the knowledge of health professionals on type 1 diabetes mellitus in pediatric patients, especially with regards to their diagnosis, management, treatment and overall long-term health education.
Pathophysiology
Type 1 diabetes mellitus is a result of the autoimmune destruction of the beta cells of the pancreas.
Hypotheses
Current studies have several hypotheses on the etiologic origins of the disease, pathologic mechanisms and presentation, and progression to microvascular comorbidities. The pathophysiologic mechanisms at play primarily involve both genetic and environmental factors, and are discussed in detail below.
Genetic Factors
The genetic component of this form of diabetes is complex and involves multiple genes but there is also high risk among siblings, especially monozygotic twins.1 A study by Tseck, et al. found dizygotic twins to possess a 5-6 percent concordance rate for type 1 diabetes mellitus2 while monozygotic twins are half more likely to have similar diagnosis upon reaching 40 years old.3
Children of parents with type 1 diabetes mellitus are also at greater risk for the same disease themselves. However, the risk differs depending on which of the parents has the disease. Those with mothers who have diabetes possess the relatively small risk of 2-3 percent to develop the disease themselves, as compared to those with fathers who have diabetes, which increases their risk of developing it to 5-6 percent. However, if both parents have diabetes, the risk for a child to also develop diabetes increases to about 30 percent. Additionally, the risk is relatively greater if the onset of the parent(s) disease happened prior to the age of 11 years old, and relatively lesser if the onset happened at a later age.
The genetic component of diabetes is also apparent in the important difference seen in its frequency of occurrence among various ethnic groups. Type 1 diabetes mellitus is very common in individuals with European ancestry, with those from northern Europe significantly more affected compared to those from the Mediterranean region.4 It is most uncommon among people of East Asian descent.5
Studies on genome-wide association found several loci linked with diabetes, although there were not enough causal relations found. The regions most commonly linked to other autoimmune diseases, the major histocompatibility complex (MHC), is also where various susceptibility loci for diabetes, specifically, class II human leukocyte antigen (HLA) DR and DQ haplotypes (the detected amino acids involved in the disease process), are found.6,7,8
A list of DR-DQ haplotypes linked to greater risk for diabetes type I is found below, in hierarchical order:6
· DRB1*0301 - DQA1*0501 - DQB1*0201 (odds ratio [OR] 3.64)
· DRB1*0405 - DQA1*0301 - DQB1*0302 (OR 11.37)
· DRB1*0401 - DQA1*0301 - DQB*0302 (OR 8.39)
· DRB1*0402 - DQA1*0301 - DQB1*0302 (OR 3.63)
· DRB1*0404 - DQA1*0301 - DQB1*0302 (OR 1.59)
· DRB1*0801 - DQB1*0401 - DQB1*0402 (OR 1.25)
Approximately 90-95 percent of young children diagnosed with the disease are carriers of the HLA-DR3 DQB1*0201, HLA-DR4 DQB1*0302, or both. Children who carry haplotypes DR3 and DR4 heterozygotes are the most susceptible. As mentioned previously, the individuals who carry the aforementioned haplotypes and therefore, at most risk, are primarily of European descent. There is not enough study data on other ethnic populations.
An important gene that plays a role in the pathophysiology of type 1 diabetes mellitus is the insulin gene (INS). It encodes for the pre-proinsulin peptide, which is close to a variable number of tandem repeats (VNTR) polymorphism at chromosome 11p15.5.9 Various VNTR alleles can promote both resistance and susceptibility to type 1 diabetes mellitus via their action on insulin gene (INS) transcription in the thymus gland.
Environmental factors
Environmental triggers may also contribute to the development of type 1 diabetes mellitus. These triggers include viruses such as enterovirus,12 mumps, rubella, and coxsackievirus B4, toxic drugs and chemicals, cytotoxins, and exposure to cow’s milk during infancy.13
It is important to remember that a combination of factors may be at play, instead of just one. A study by Lempainen, et al. found that evidence of an enterovirus infection as early as 1 year of age was tied to the appearance of type 1 diabetes mellitus–related autoimmunity among children exposed to cow's milk before the age of 3 years old. This finding strongly suggests a relationship between the two factors. In addition, the finding also offers a possible explanation for the conflicting findings obtained in studies that only studied these factors individually.14
The finding of one meta-analysis points to a weak but important linear elevation in the risk of pediatric type 1 diabetes mellitus associated with increasing maternal age.15 However, there is insufficient evidence to support any substantial increase in type 1 diabetes mellitus risk in children after preeclampsia complications during pregnancy.16
A study by Simpson, et al. based in Denver, Colorado, followed children at increased risk of diabetes since 1993 and did not find any link between vitamin D intake nor 25-hydroxyvitamin D levels during childhood to be linked with autoimmune destruction of the islets of Langerhans nor progression to type 1 diabetes mellitus.17 Another risk factor for the development of type 1 diabetes mellitus may be upper respiratory infection during the first year of life. A data analyzed 148 children who were carriers of genetic markers of the disease and found that upper respiratory infections in the first year of life were linked to greater risk for type 1 diabetes mellitus.18,19