Canadian Diabetes Association Clinical Guidelines Type 1 Diabetes in Children Flashcards
What education topics must be included for children with new-onset type 1 diabetes and their families?
- Insulin action and administration
- Dosage adjustment
- Blood glucose and ketone testing
- Sick-day management
- Prevention of DKA
- Nutrition therapy
- Exercise
- Prevention, detection, and treatment of hypoglycemia
- Anticipatory guidance and lifestyle counseling especially during critical developmental transitions
- School, diabetes camp, psychological issues, substance use, driver’s license, and career choices
What is the recommended glycemic target for children <6yo with type 1 diabetes?
Hgb A1c <8.0
Fasting PG 6.0-10.0
What is the recommended glycemic target for children 6-12yo with type 1 diabetes?
Hgb A1c <7.5
Fasting PG 4.0-10.0
What is the recommended glycemic target for children 13-18yo with type 1 diabetes?
Hgb A1c <7.0
Fasting PG 4.0-7.0
What is the honeymoon period?
A period of up to 2 years post diagnosis with good glycemic control and low insulin requirements (<0.5U/kg/day)
What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for <15kg child?
5g carbohydrate
= 1 4g glucose tablet
= 2 3g dextrose tablets
= 40mL apple or orange juice
What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for 15-30kg child?
10g carbohydrate
= 2 or 3 4g glucose tablet
= 3 3g dextrose tablets
= 85mL apple or orange juice
What is the recommended carbohydrate treatment for mild to moderate hypoglycemia for >30kg child?
15g carbohydrate
= 4 or 3 4g glucose tablet
= 5 3g dextrose tablets
= 125mL apple or orange juice
What is the recommended dose for mini-doses of glucagon for mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrates?
10ug/year of age (min 20ug, max 150ug)
Additional double dose if BG has not increased in 20 minutes
What percentage of patients with new onset diabetes present in DKA?
15-67%
Which patients with established diabetes are at increased risk of DKA?
- Poor metabolic control
- Previous episodes of DKA
- Peripubertal and adolescent girls
- Children on insulin pumps or long-acting basal analogues
- Children with psychiatric disorders
- Difficult family circumstances
What percentage of cases of pediatric DKA are complicated with cerebral edema?
0.7-3%
What is the percentage of significant morbidity in patients with cerebral edema?
21-35%
What is the percentage of mortality in patients with cerebral edema?
21-24%
What are risk factors for cerebral edema?
- Younger age (<5yo)
- New onset diabetes
- High initial serum urea
- Low initial partial pressure of arterial carbon dioxide (pCO2)
- Rapid administration of hypotonic fluids
- IV bolus of insulin
- Early IV insulin infusion (within first hour of administration of fluids)
- Failure of serum sodium to rise during treatment
- > Use of bicarbonate
What immunizations are recommended in children with type 1 diabetes?
- Influenza
2. Pneumococcal
What percentage of adolescent females with type 1 diabetes have an eating disorder?
10%
vs. 4% of age matched peers without diabetes
In the management of DKA when should glucose be added into the IV solution?
PG 14.0-17.0 mmol/L
or PG falling >5.0 mmol/L/h
When should patients with type 1 diabetes be screened for autoimmune thyroid disease?
Serum TSH + TPO antibodies at diagnosis and q2y
When should patients with positive thyroid antibodies, thyroid symptoms or goiter and type 1 diabetes be screened?
Serum TSH + TPO antibodies q6-12m
When should patients with type 1 diabetes be screened for Addison’s disease?
As clinically indicated (unexplained recurrent hypoglycemia and decreasing insulin requirements) do 8am serum cortisol + serum Na & K
When should patients with type 1 diabetes be screened for celiac disease?
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
What percentage of patients with type 1 diabetes develop autoimmune thyroid disease?
15-30%
What percentage of patients with type 1 diabetes develop celiac disease?
4-9%
60-70% are asymptomatic
When should patients with type 1 diabetes be screened for nephropathy?
At 12yo q1y if diagnosed with type 1 DM >5y
When should patients with type 1 diabetes be screened for retinopathy?
At 15yo q1y if diagnosed with type 1 DM >5y
If diagnosed with DM <10y, good glycemic control, and no retinopathy can screen q2y
When should patients with type 1 diabetes be screened for neuropathy?
Postpubertal teens with poor metabolic control q1y if diagnosed with type 1 DM >5y
When should patients with type 1 diabetes be screened for dyslipidemia?
Screen at 12 and 17yo
If <12yo screen if
- BMI >95th %ile
- Family history of hyperlipidemia
- Premature cardiovascular disease
When should patients with type 1 diabetes be screened for hypertension?
Twice yearly
How should patients with type 1 diabetes be screened for nephropathy?
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
How should patients with type 1 diabetes be screened for retinopathy?
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
How should patients with type 1 diabetes be screened for neuropathy?
Question and examine for symptoms of numbness, pain, cramps and paraesthesia, as well as skin sensation, vibration sense, light touch and ankle reflexes
How should patients with type 1 diabetes be screened for dyslipidemia?
Fasting total cholesterol, HDL, TG, and calculated LDL
How should patients with type 1 diabetes be treated for nephropathy?
If teenager with persistent microalbuminuria over 12 months then start ACE inhibitors
What percentage of adolescents with type 1 diabetes have hypertension?
16%
What are the recommendations regarding insulin therapy?
- Children with new-onset diabetes should be started on at least 2 daily injections of bolus insulin combined with basal insulin
- 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
How should severe hypoglycemia in an unconscious child >5yo at home be treated?
Glucagon 1mg SC or IM
How should severe hypoglycemia in an unconscious child <5yo at home be treated?
Glucagon 0.5mg SC or IM
How should severe hypoglycemia in an unconscious be treated when IV access is available?
Dextrose 0.5-1g/kg IV over 1-3min
What is the initial dose of IV insulin in DKA?
Short acting insulin 0.1U/kg/h, 1h after starting fluid replacement therapy
