children s health issues
Diabetes Mellitus (DM) in Children and Adolescents
Treatment of Diabetes in Children and Adolescents
Nutrition and exercise For type 1 diabetes, injections ofinsulin For type 2 diabetes,metforminby mouth and sometimes injections ofinsulinorliraglutide The main goal of diabetes treatment is to keep blood glucose levels as close to the normal range as can be done safely. However, no treatment completely maintains blood glucose at normal levels. When people try very hard to keep blood glucose levels normal, they increase the risk that their blood glucose levels will sometimes become too low. Low blood glucose is called Hypoglycemia and can be dangerous. Although advances in diabetes technology have improved quality of care and control of blood glucose, not all people have benefited. Low-income and non-Hispanic Black children remain at higher risk of complications and negative outcomes because of poor control of blood glucose. Children with diabetes should carry or wear medical identification (such as a bracelet or tag) to alert emergency care providers to the presence of diabetes. This information allows providers to start life-saving treatment quickly, especially in the case of injury or change in mental status. Children with either type of diabetes need to Make healthy food choices Lose weight if overweight Exercise regularly General nutritional managementand education are particularly important for all children with diabetes. Dietary recommendations for children with diabetes are based on healthy eating recommendations for all children and aim to maintain ideal body weight and optimal growth and to prevent short-term and long-term complications of diabetes. All children should eat regularly and not skip meals. Although most dietary regimens allow some flexibility in carbohydrate intake and meal times, having meals and scheduled snacks at about the same time each day and that contain similar amounts of carbohydrates is important for optimal glucose control. Because carbohydrates in food are turned into glucose by the body, variations in carbohydrate intake cause variations in blood glucose levels. Choosing healthy foods can help control blood glucose and protect heart health. Children should focus on eating fruits and vegetables, whole grains, and high-fiber foods (for example, foods that have at least 3 grams fiber or more per serving). Food should not contain many highly processed (refined) Carbohydrates , particularly candy, baked goods (such as cookies, donuts, and pastries), and sugary drinks. Children should have no more than 4 to 8 ounces of 100% fruit juice per day. They should avoid regular soda, sweetened iced tea, lemonade, fruit punch, and sports drinks altogether. Children also should avoid doses are matched to actual carbohydrate intake. Infants and preschool-aged children present a particular challenge to parents because they do not eat consistent amounts of food and because they may develop Hypoglycemia but may not be able to communicate symptoms of hypoglycemia to their parents. Intype 2 diabetes,lifestyle modifications focus on weight in the majority of children. Steps to improve food choices and manage food intake include eliminating sugary drinks, controlling portion size, switching to low-fat foods, and increasing fiber by eating more fruits and vegetables. Regular exercise is important because it improves glucose control and makes it easier to lose weight. Because vigorous exercise can cause a significant drop in blood glucose, some children with type 1 diabetes may need to consume some extra carbohydrates before and/or during a workout. Children with Diabetic Ketoacidosis (DKA) are usually treated in an intensive care unit. They often require fluids given by vein (intravenously) to correct dehydration. They often also need intravenous potassium solutions to correct low potassium levels. Children often require intravenous To prevent the development of DKA and minimize the need for hospitalization, children and families should use ketone test strips to check for ketones in blood or urine. Blood testing may be preferred in younger children and in others in whom it is difficult to obtain a urine sample, those who have frequent episodes of DKA, andinsulinpump users. Ketone testing should be done whenever children become ill (regardless of the blood glucose level) or when the blood glucose is high. High ketone levels may indicate DKA, especially if children also have abdominal pain, vomiting, drowsiness, or rapid breathing. To control blood glucose, children with type 1 diabetes take injections ofinsulin. When type 1 diabetes is first diagnosed, children are usually hospitalized. Children with type 1 diabetes are given fluids (to treat dehydration) andinsulin. They always requireinsulinbecause nothing else is effective. Children who do not have DKA at diagnosis typically receive two or more daily injections ofinsulin.Insulintreatment is usually begun in the hospital so that blood glucose levels can be tested often and doctors can changeinsulindosage in response. Less commonly, treatment is started at a regular doctor visit. Once children are released from the hospital, they must takeinsulinregularly. Doctors work with children and their family to determine whichinsulinregimen is best. There are several types ofinsulinregimens: Multiple daily injections (MDI) regimen using a basal-bolus regimen Insulinpump therapy Premixedinsulinregimen (less common) Most children who have type 1 diabetes should be treated with MDI regimens or withinsulinpump therapy. WithMDI regimens,a basal-bolusinsulinregimen is preferred. This regimen involves taking one injection of a longer-actinginsulin(basal dose) every day and then separate supplemental injections (bolus doses) of a short-actinginsulinimmediately before meals. Each bolus dose can be different depending on how much food the child is going to eat or what the blood glucose level is at that time. An advantage of the basal-bolus regimen is that it allows for flexibility as to when meals are eaten and how much is eaten. Fixed formsof MDI regimens are less commonly used. If a basal-bolus regimen is not an option (for example, if adequate supervision is not available, such as when an adult is not available to give injections at school or daycare), fixed forms of MDI regimens can be an option. In these regimens, children typically receive a specific (fixed) amount of shorter-actinginsulinbefore eating breakfast and dinner and a fixed dose of longer-actinginsulinat bedtime. Fixed regimens provide less flexibility, require a daily set schedule for meals, and have been largely replaced by basal-bolus regimens wherever possible. Ininsulinpump therapy,the basal dose ofinsulinis delivered through a small, flexible tube (catheter) that is left in the skin. Supplemental boluses that are given at mealtime or that are given to correct a high blood glucose level are given as separate injections of rapid-actinginsulinvia theinsulinpump. Insulinpump therapy is increasingly being used in children. Potential benefits include better glucose control, safety, and user satisfaction compared to MDI regimens. This therapy is preferred for younger children, such as toddlers and preschoolers, and overall offers an added degree of control to many children. Premixedinsulinregimensuse a fixed mixture of two forms ofinsulin: one that works quickly and lasts for only a few hours, and one that takes longer to work but lasts longer. The usual ratios ofinsulinare 70/30 (70% longer-acting and 30% shorter-acting) or 75/25. Children are given one injection at breakfast and one at dinner. An advantage of premixed regimens is that they require fewer injections and are easier to manage. However, premixed regimens have less flexibility with respect to timing and amount of meals and cannot be adjusted as frequently. Thus, these regimens do not control blood glucose levels as well as other regimens. Insulincan be injected in several ways: Vial and syringe Insulinpen Insulinpump Some children use avial and syringe. In this method, each dose ofinsulinis drawn up into a syringe from a vial and is injected under the skin, usually in the arm, thigh, or abdominal wall. Small syringes with very thin needles make the injections nearly painless. The amount ofinsulinthe syringe will hold varies depending on the amount ofinsulinneeded per injection. Young children often use syringes with 1/2 unit markings to allow for smaller adjustments in the doses ofinsulinto be used. Aninsulinpen,is a convenient way for many children to carry and useinsulin, especially for children who take several injections a day outside the home. The pen contains a cartridge that holds enoughinsulinfor several doses. The dose delivered on each injection is adjusted by turning the top of the pen. Another device is aninsulinpump,which automatically pumpsinsulincontinuously from a reservoir through a catheter that is left in the skin. The catheter site must be changed every 2 to 3 days. More and more children, even young children, are usinginsulinpumps. The pump more closely mimics the way the body normally deliversinsulin. Pumps are programmed to release small doses ofinsulincontinuously over 24 hours (called the basal dose) and can be triggered manually to deliver extrainsulin(called the bolus dose) with meals or to treat high blood glucose. Unlike other methods,insulinpumps use only short-actinginsulin. Children do not need longer-actinginsulinbecause they are continually receiving a small amount ofinsulinin the basal dose. The pump can be programmed to give different amounts ofinsulinat different times of day and night. pumps may be used with continuous glucose monitoring systems ( see Treatment ) to better track trends in blood glucose throughout the day. Newer For some children, the pump offers an added degree of control, whereas others find wearing the pump inconvenient or develop sores or infections at the catheter site. Children must rotate their injection and pump sites to avoid developing lipohypertrophy. Lipohypertrophy is an accumulation of fatty lumps of tissue under the skin. The lumps occur at injection sites that have been overused forinsulinand can cause blood glucose levels to vary because they can preventinsulinfrom being absorbed consistently. Children with type 2 diabetes usually are not treated in the hospital unless the diabetes is severe. Usually they are given drugs to lower blood glucose levels (antihyperglycemic drugs) at a regular doctor's office visit. Children with severe diabetes may need to be hospitalized to startinsulintreatment. Less commonly, children with type 2 diabetes develop severe dehydration or, as in type 1 diabetes, DKA. Metforminis the main drug given by mouth (orally) for children and adolescents. It is started at a low dose and often increased over several weeks to higher doses. It can be taken with food to prevent nausea and abdominal pain. Liraglutideandexenatideare injectable drugs that can be given to children over 10 years of age who have type 2 diabetes. These drugs may lower HbA1c levels and may also reduce appetite and promote weight loss. They may be given to children who are takingmetforminbut whose HbA1c level is not in the target range or they can be given instead ofmetforminto children who cannot tolerate that drug. Other drugs used for adults with type 2 diabetes may help some adolescents, but they are more expensive, and there is limited evidence for their use in children. Insulinis given to children who are hospitalized.Insulincan often be stopped after several weeks once glucose levels return to normal after treatment withmetformin. Children whose type 2 diabetes is not controlled bymetforminand/orliraglutideneed to takeinsulin. About half of adolescents with type 2 diabetes ultimately requireinsulin. Some children who lose weight, improve their food choices, and exercise regularly may be able to stop taking the drugs. Low blood glucose ( Hypoglycemia ) occurs when too much To treat hypoglycemia, children are given sugar in any form, such as glucose tablets, hard candies, glucose gel, or a sweet drink, such as a glass of fruit juice. If children are unable to eat or drink (for example, because they are confused, disoriented, are having a seizure, or are unconscious), an injection ofglucagonis given. If untreated, severe hypoglycemia causes weakness, confusion, and even coma or death. In adults, adolescents, and older children, episodes of hypoglycemia rarely cause long-term problems. However, frequent episodes of hypoglycemia in children younger than 5 years of age may impair intellectual development. Also, young children may not be aware of the warning symptoms of hypoglycemia. To minimize the possibility of hypoglycemia, doctors and parents monitor young children with diabetes particularly closely and use a slightly higher target range for their blood glucose level. Type 1 diabetes treatment can help children because they sound an alarm when glucose falls below a specified range. The frequency of monitoring depends on the type of diabetes. Intype 1 diabetes,blood glucose levels should be checked up to 6 to 10 times per day and should be measured before all meals and before a bedtime snack. A fingerstick glucose test is most often used to monitor blood glucose. Most blood glucose monitoring devices (glucose meters) use a drop of blood obtained by pricking a fingertip (fingerstick) with a small implement called a lancet. The lancet holds a tiny needle that can be jabbed into the finger or placed in a spring-loaded device that easily and quickly pierces the skin. The drop is placed on a test strip and the test strip is read by a machine. The machine reports the result on a digital display. Because exercise can lower glucose levels for up to 24 hours, glucose should be measured more frequently on days children exercise or are more active. Sometimes levels need to be measured during the night. Intype 2 diabetes,blood glucose levels should be measured regularly but typically less often than in type 1 diabetes. Several factors determine the frequency of self-monitoring, including children's glucose levels between meals and after eating. The frequency of monitoring should increase to at least 3 times a day if children do not have good control of their glucose, during illness, or when symptoms of hypoglycemia or hyperglycemia are felt. Once glucose is controlled, home testing is limited to a few between-meal and after-meal blood glucose measurements per week. Once experience is gained, parents and many children can adjust theinsulindose as needed to achieve the best control. In general, by 10 years of age, children start to become interested in testing their own blood glucose levels and injectinginsulinthemselves. Parents should encourage this independence but make sure the child is being responsible. Doctors teach most children how to adjust theirinsulindosage in accordance with the patterns of their home blood glucose records. Children with either type of diabetes typically see their doctor several times a year. The doctor evaluates their growth and development, reviews blood glucose records that a family member keeps, provides guidance and counseling about nutrition, and measures glycosylated hemoglobin levels (hemoglobin A1C— see Diagnosing diabetes ). The doctor usually screens for long-term Continuous glucose monitoring (CGM) systemsare an increasingly common method of monitoring blood glucose levels and can replace routine self-monitoring of blood glucose for some children. In CGM systems, a small glucose sensor placed under the skin measures blood glucose levels every 1 to 5 minutes, 24 hours a day. They transmit real-time results of blood glucose levels wirelessly to a device that may be built into aninsulinpump or to a wireless monitor that can be worn on a belt. The systems also record results for the doctor to review. Alarms on CGM systems can be set to sound when blood glucose levels drop too low or climb too high, so the devices can help people quickly identify worrisome changes in blood glucose that they can treat right away. Use of CGM devices may help lower HbA1c levels. Two types of CGM systems are currently available: real-time CGM and intermittently scanned CGM. Real-time CGMcan be used in children 2 years of age and older. This type of system automatically transmits a continuous stream of glucose data to the user in real time, provides alerts and active alarms, and also transmits glucose data to a receiver, smartwatch, or smartphone. Real-time CGM should be done as close to daily as possible for maximum benefit. Intermittently scanned CGMcan be used in children 4 years of age and older. This type of system provides the same type of glucose data as real-time CGM but requires the user to purposely scan the sensor to obtain information and does not have alerts and alarms. Intermittently scanned CGM should be done frequently, at least once every 8 hours. Children who use a CGM device need to be able to measure blood glucose with a fingerstick to calibrate their monitor and to verify glucose readings if they do not match their symptoms. Although CGM devices can be used with anyinsulinregimen, they are typically worn byinsulinpump users. When used in conjunction with aninsulinpump, the combination is known as sensor-augmented pump therapy. This therapy requires manual adjustment ofinsulindoses based on CGM data results. Other CGM systems are integrated with a pump and can also lower theinsulindose if blood glucose drops too low. This integration can reduce the number of episodes where blood glucose drops too low, even when compared to sensor-augmented pump therapy. Closed-loopinsulinpumps can be used in children 2 years of age and older. They automatically provide the right amount ofinsulinby using sophisticated computer algorithms that are on a smartphone or similar device and link a CGM sensor to aninsulinpump to determine blood glucose levels and controlinsulindelivery. Current closed-loop systems are not truly automated because they require users to manually provideinsulinfor meals and snacks and make adjustments for exercise. These systems help to more tightly controlinsulindosing and limit episodes where blood levels ofinsulinare too high or too low. A fully automated closed-loop system, sometimes known as an artificial pancreas, continues to be evaluated and is not commercially available. Children with type 1 diabetes always needinsulininjections, regardless of whether they lose weight or change their diet. Some children with diabetes do very well and control their diabetes without undue effort or conflict. In others, diabetes becomes a constant source of stress within the family, and control of the condition deteriorates. Adolescents may have particular problems controlling their blood glucose levels because of Hormonal changes during puberty: These changes affect how the body responds toinsulin. As a result, higher doses are usually needed during this time. Adolescent lifestyle: Peer pressure, increased activities, erratic schedules, concern about body image, or eating disorders may interfere with the prescribed treatment regimen, particularly their meal plan. Experimentation with alcohol, cigarettes, and illicit drugs: Adolescents who experiment with these substances may neglect their treatment regimen and may be at greater risk of complications of diabetes (such as hypoglycemia and DKA). Conflicts with parents and other authority figures: Such conflicts may make adolescents less willing to follow their treatment regimen. Thus, some adolescents need a parent or another adult to recognize these issues and give them the opportunity to discuss problems with a health care practitioner. The practitioner can help make sure adolescents remain appropriately focused on keeping their blood glucose levels under control. Parents and health care practitioners should encourage adolescents to check their blood glucose levels frequently. An adolescent benefits if the doctor considers the adolescent’s desired schedule and activities and takes a flexible approach to problem solving by working with the adolescent rather than imposing solutions. Mental health issues affect children with diabetes and their families ( see Mental health problems ). The realization that they have a lifelong condition may cause some children to become sad or angry, and sometimes even deny that they have an illness. A doctor, psychologist, or counselor needs to address these emotions to secure the child’s cooperation in adhering to the required regimen of meal plan, physical activity, blood glucose testing, and drugs. Failure to resolve these issues can lead to difficulties controlling blood glucose. Summer camps for children with diabetes allow these children to share their experiences with one another while learning how to become personally more responsible for their condition. For the treatment of diabetes, the child’s primary care doctor usually enlists the aid of a team of other professionals, possibly including a pediatric endocrinologist, dietitian, diabetes educator, social worker, or psychologist. Family support groups may also help. The doctor may provide parents with information to bring to school so that school personnel understand their roles. 