Canadian Diabetes Association Clinical Guidelines Type 1 Diabetes in Children

Question 1

What education topics must be included for children with new-onset type 1 diabetes and their families?

Answer 1

1. Insulin action and administration
2. Dosage adjustment
3. Blood glucose and ketone testing
4. Sick-day management
5. Prevention of DKA
6. Nutrition therapy
7. Exercise
8. Prevention, detection, and treatment of hypoglycemia
9. Anticipatory guidance and lifestyle counseling especially during critical developmental transitions
10. School, diabetes camp, psychological issues, substance use, driver’s license, and career choices

Question 2

What is the recommended glycemic target for children <6yo with type 1 diabetes?

Answer 2

Hgb A1c <8.0

Fasting PG 6.0-10.0

Question 3

What is the recommended glycemic target for children 6-12yo with type 1 diabetes?

Answer 3

Hgb A1c <7.5

Fasting PG 4.0-10.0

Question 4

What is the recommended glycemic target for children 13-18yo with type 1 diabetes?

Answer 4

Hgb A1c <7.0

Fasting PG 4.0-7.0

Question 5

What is the honeymoon period?

Answer 5

A period of up to 2 years post diagnosis with good glycemic control and low insulin requirements (<0.5U/kg/day)

Question 6

What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for <15kg child?

Answer 6

5g carbohydrate

= 1 4g glucose tablet
= 2 3g dextrose tablets
= 40mL apple or orange juice

Question 7

What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for 15-30kg child?

Answer 7

10g carbohydrate

= 2 or 3 4g glucose tablet
= 3 3g dextrose tablets
= 85mL apple or orange juice

Question 8

What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for >30kg child?

Answer 8

15g carbohydrate

= 4 or 3 4g glucose tablet
= 5 3g dextrose tablets
= 125mL apple or orange juice

Question 9

What is the recommended dose for mini-doses of glucagon for mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrates?

Answer 9

10ug/year of age (min 20ug, max 150ug)

Additional double dose if BG has not increased in 20 minutes

Question 10

What percentage of patients with new onset diabetes present in DKA?

Answer 10

15-67%

Question 11

Which patients with established diabetes are at increased risk of DKA?

Answer 11

1. Poor metabolic control
2. Previous episodes of DKA
3. Peripubertal and adolescent girls
4. Children on insulin pumps or long-acting basal analogues
5. Children with psychiatric disorders
6. Difficult family circumstances

Question 12

What percentage of cases of pediatric DKA are complicated with cerebral edema?

Answer 12

0.7-3%

Question 13

What is the percentage of significant morbidity in patients with cerebral edema?

Answer 13

21-35%

Question 14

What is the percentage of mortality in patients with cerebral edema?

Answer 14

21-24%

Question 15

What are risk factors for cerebral edema?

Answer 15

1. Younger age (<5yo)
2. New onset diabetes
3. High initial serum urea
4. Low initial partial pressure of arterial carbon dioxide (pCO2)
5. Rapid administration of hypotonic fluids
6. IV bolus of insulin
7. Early IV insulin infusion (within first hour of administration of fluids)
8. Failure of serum sodium to rise during treatment
9. > Use of bicarbonate

Question 16

What immunizations are recommended in children with type 1 diabetes?

Answer 16

1. Influenza

2. Pneumococcal

Question 17

What percentage of adolescent females with type 1 diabetes have an eating disorder?

Answer 17

10%

vs. 4% of age matched peers without diabetes

Question 18

In the management of DKA when should glucose be added into the IV solution?

Answer 18

PG 14.0-17.0 mmol/L

or PG falling >5.0 mmol/L/h

Question 19

When should patients with type 1 diabetes be screened for autoimmune thyroid disease?

Answer 19

Serum TSH + TPO antibodies at diagnosis and q2y

Question 20

When should patients with positive thyroid antibodies, thyroid symptoms or goiter and type 1 diabetes be screened?

Answer 20

Serum TSH + TPO antibodies q6-12m

Question 21

When should patients with type 1 diabetes be screened for Addison’s disease?

Answer 21

As clinically indicated (unexplained recurrent hypoglycemia and decreasing insulin requirements) do 8am serum cortisol + serum Na & K

Question 22

When should patients with type 1 diabetes be screened for celiac disease?

Answer 22

As clinically indicated (recurrent GI symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia, or poor metabolic control) do TTG + IgA levels

Question 23

What percentage of patients with type 1 diabetes develop autoimmune thyroid disease?

Answer 23

15-30%

Question 24

What percentage of patients with type 1 diabetes develop celiac disease?

Answer 24

4-9%

60-70% are asymptomatic

Question 25

When should patients with type 1 diabetes be screened for nephropathy?

Answer 25

At 12yo q1y if diagnosed with type 1 DM >5y

Question 26

When should patients with type 1 diabetes be screened for retinopathy?

Answer 26

At 15yo q1y if diagnosed with type 1 DM >5y If diagnosed with DM <10y, good glycemic control, and no retinopathy can screen q2y

Question 27

When should patients with type 1 diabetes be screened for neuropathy?

Answer 27

Postpubertal teens with poor metabolic control q1y if diagnosed with type 1 DM >5y

Question 28

When should patients with type 1 diabetes be screened for dyslipidemia?

Answer 28

Screen at 12 and 17yo If <12yo screen if 1. BMI >95th %ile 2. Family history of hyperlipidemia 3. Premature cardiovascular disease

Question 29

When should patients with type 1 diabetes be screened for hypertension?

Answer 29

Twice yearly

Question 30

How should patients with type 1 diabetes be screened for nephropathy?

Answer 30

First am (preferred) or random ACR Abnormal ACR requires confirmation with repeat first am ACR 1m later, if abnormal do timed, overnight or 24h split urine collection for Alb excretion rate Repeated sampling q3-4m over 12m

Question 31

How should patients with type 1 diabetes be screened for retinopathy?

Answer 31

Standard field, stereoscopic colour fundus photography with interpretation by trained reader (gold standard) OR Direct ophthalmoscopy or indirect slit lamp fundoscopy OR Digital fundus photography

Question 32

How should patients with type 1 diabetes be screened for neuropathy?

Answer 32

Question and examine for symptoms of numbness, pain, cramps and paraesthesia, as well as skin sensation, vibration sense, light touch and ankle reflexes

Question 33

How should patients with type 1 diabetes be screened for dyslipidemia?

Answer 33

Fasting total cholesterol, HDL, TG, and calculated LDL

Question 34

How should patients with type 1 diabetes be treated for nephropathy?

Answer 34

If teenager with persistent microalbuminuria over 12 months then start ACE inhibitors

Question 35

What percentage of adolescents with type 1 diabetes have hypertension?

Answer 35

16%

Question 36

What are the recommendations regarding insulin therapy?

Answer 36

1. Children with new-onset diabetes should be started on at least 2 daily injections of bolus insulin combined with basal insulin 2. If A1C targets are not being met treatment options include: a) increase frequency of injections b) change in the type of basal and/or bolus insulin c) change to continuous SC insulin infusion therapy

Question 37

How should severe hypoglycemia in an unconscious child >5yo at home be treated?

Answer 37

Glucagon 1mg SC or IM

Question 38

How should severe hypoglycemia in an unconscious child <5yo at home be treated?

Answer 38

Glucagon 0.5mg SC or IM

Question 39

How should severe hypoglycemia in an unconscious be treated when IV access is available?

Answer 39

Dextrose 0.5-1g/kg IV over 1-3min

Question 40

What is the initial dose of IV insulin in DKA?

Answer 40

Short acting insulin 0.1U/kg/h, 1h after starting fluid replacement therapy