Diabetes Mellitus in
Children and Adolescents
Maureen McGrath, PNP-BC, CDE
Emory-Children’s Center
Division of Endocrinology and Diabetes
DIABETES = Defect in Energy
Utilization
• Glucose is primary energy source of all cells
• Insulin is necessary to transport glucose into most
cells
• Insufficient insulin results in inadequate glucose
for energy inside cell, need alternative energy
source (fat)
• Insufficient insulin results in high extracellular or
blood glucose (hyperglycemia)
How the Body Uses Food as Fuel
Digestion of
Macronutrients
(CHO, FAT, PRO)
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Pancreas
(Insulin)
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GLUCOSE
Insulin
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Blood Stream
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Cell
PATHOPHYSIOLOGY
HYPERGLYCEMIA
Blood glucose increasing above the renal
threshold (~180 mg/dL) results in
glycosuria
• Glucose urinated out = polyuria
• Decreased extracellular water stimulates
thirst = polydipsia
• Lost glucose is lost calories and stimulates
hunger =polyphagia
Insulin:
Before and After
TYPE 1 DIABETES
• Most common presentation in children and
adolescents
• Autoimmune pathophysiology
• Prevalence: 1 of 350 children
• 3-5% risk in siblings; 30% for identical
twins
• Risk of ketoacidosis
• Dependent on insulin for survival
Type 1 diabetes: insulin deficiency
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Pancreas
(Insulin)
Glucose
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Blood Stream
Cell
TYPE 2 DIABETES
TYPE 2 DIABETES
• ~ 30% of children > 10 y.o. present with type 2
diabetes
– African-Americans, Latinos, Native Americans, Pacific
Islanders
• Insulin resistance associated with obesity and
acanthosis nigricans
• Prevalence: increasing
• Very strong family history
• May also have ketonuria and ketosis (ketosisprone type 2 DM)
• Treatment: lifestyle, metformin, insulin
Type 2 diabetes: insulin resistance
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Pancreas
(Insulin)
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GLUCOSE
Insulin
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Blood Stream
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Cell
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ACANTHOSIS NIGRICANS
PRESENTING SYMPTOMS
Symptoms %Type 1 %Type 2
(n=48)
(n=40)
Abdominal Pain
Dizziness
Headache
Nocturia
Polydipsia
Polyphagia
Polyuria
Visual Problem
Weight loss
46
15
33
71
96
69
94
17
71
33
33
43
65
85
60
88
20
40
P
value
>.10
>.10
>.10
>.10
>.10
>.10
>.10
>.10
.005
PRESENTING SYMPTOMS
and SIGNS
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•
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Vulvovaginitis, severe candida diaper rash
Vomiting
Dehydration
Difficulty breathing (Kussmaul respirations)
Fruity odor to breath (ketones)
Altered mental status
PATHOPHYSIOLOGY of
DIABETIC KETOACIDOSIS
(DKA)
• Low insulin  hyperglycemia and glycosuria,
insufficient suppression of lipolysis and ketogenesis
• Glycosuria  osmotic diuresis  polyuria 
dehydration  polydipsia
• Dehydration  increase in counter-regulatory
hormones, which leads to further hyperglycemia and
ketosis
• Hyperosmolarity  altered mental status
DIABETIC KETOACIDOSIS
• Hyperglycemia
Blood Sugar >300
• Acidosis
pH <7.3 or Bicarb <15
• Mortality
2-10%
DIAGNOSIS of DIABETES
MELLITUS
• Symptoms of diabetes and random glucose greater
than 200 mg/dl
• Fasting lab plasma glucose (not fingerstick) of >
126 mg/dL (2 separate occasions)
• OGTT 2 hour plasma glucose > 200 mg/dl
- fasting, 1.75 gm/kg, max 75 gm glucose load
• HbA1c of 6.5% or greater (lab verified)
• 5.7- 6.4% considered sign for increased risk
MANAGEMENT of TYPE 1
DIABETES
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Insulin
Glucose monitoring
Nutrition
Exercise
Sick Day management
Psychosocial
MANAGEMENT
of TYPE 2 DIABETES
• Eliminate symptoms of hyperglycemia
• Weight stabilization
• Improve cardiovascular risk factors
Hypertension
Hyperlipidemia
Hyperglycemia
• Psychosocial
• Oral meds/insulin
DIABETES SELF
MANAGEMENT EDUCATION
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Basic pathophysiology
Short and long term complications
Meal planning
Exercise guidelines
Blood glucose monitoring
Patient-centered goal setting
INSULIN
Insulin Action
Normal insulin delivery
This is a 24 hour representation of the insulin profile for
someone who does not have diabetes. The pancreas
releases insulin for each meal, but there is always a
constant background or basal amount present that has
nothing to do with food.
INSULINS
U-100 Human Recombinant DNA or Analog
Insulin
Onset
Peak
Duration
Humalog
(Lispro)
Novolog
(Aspart)
Apidra
(glulisine)
NPH
5 min
1-2 hrs
3-4 hrs
5 min
1-2 hrs
3-4 hrs
30 min
2-4 hrs
4-6 hrs
1 hour
6-8 hrs
10-12 hrs
Levemir
(Detemir)
Lantus
(Glargine)
1-2 hours
6-8 hrs
Dose-dep
1-3 hrs
None
24 hrs
Basal/Bolus Regimens
(physiologic/MDI/BBT)
This shows the basal/bolus regimen with the background or
basal insulin as the thick black line at the bottom. Meal or
bolus doses are delivered in varying amounts and times
according to meals.
INSULINS
Mixed
• Novolog 70/30
• Humalog 75/25
• Humalog 50/50
Two or three injections/day
People on this injection regimen would be getting shots at breakfast and
supper.

The breakfast shot combines a short-acting insulin which covers just that
meal.
 The intermediate-acting insulin mixed in the same shot covers lunch
and the hours until supper.

The supper shot covers the evening meal and the nighttime hours.
Why only two or three
injections per day?
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School issues
Injection avoidance
Possibly non-specialty care
Adherence issues
– Lack of parental supervision
– Developmental issues
» Age-inappropriate expectations
» Teenagers (away from parental support and
supervision)
Ways to Give Insulin- Injections
Insulin can be injected with a standard
vial and syringe or by using a pre-filled
insulin pen.
Ways to Give InsulinInsulin Pumps
Insulin pumps are computers that deliver insulin
continuously instead of taking multiple injections.
•Deliver programmed insulin (bolus)
•Deliver pre-programmed insulin delivery (basal)
•Do not measure glucose levels
Pump Sites
Catheter- small plastic tube that remains under the skin.
• Pump sites generally changed
every 3 days
• Pumps can be disconnected
for activities and/or showers
• Sites may have to be changed
more frequently as the catheter
falls out, becomes untaped
Real-time Continuous Glucose Monitoring
TREATMENT of TYPE 2
DIABETES - DRUGS
INSULIN
• Initial Rx if DKA, FBS > 250 mg/dl or if
symptomatic
• Large dose may be needed because of
insulin resistance
• Often use 70/30
• Used in combination with oral agent
TREATMENT of TYPE 2
DIABETES- DRUGS
• Biguanide - metformin
• Sulfonylurea - Glipizide, Glyburide,
Glimepiride
• Meglitinide - Repaglinade (Prandin)
• α-Glucosidase inhibitor - Acarbose
• Thiazolidinedione - Avandia, Actos
METFORMIN (Glucophage)
• Inhibits hepatic glucose production,
also decreases elevated androgens
• No hypoglycemia
• Doesn’t cause weight gain
• Anorexia, gastrointestinal symptoms
– Helpful if taken with food
• Risk of Lactic Acidosis
USUAL INITIATION OF
THERAPY
• Education and Monitoring
- If ketotic or FBS >300 start insulin
• Nutrition and Exercise Guidelines
• Evaluation over 3 months,
º If on insulin and meeting guidelines, progress
to Metformin and decrease insulin
º If not on insulin and not meeting guidelines,
progress to Metformin
GLUCOSE MONITORING
• BG should be checked before all meals and
bedtime
• Additional checks as needed
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Physical activity
Driving
Sick days
Snacks
GLUCOSE MONITORING
Meters
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Memory for 30-120 days (3-4xdaily)
Small blood volumes (0.3, 0.6, 1.0, 1.5μl)
Rapid results (5-10 seconds)
Use of sites other than fingers
• Serum ketone monitoring
– Measurement of serum β hydroxybutyrate
American Diabetes Association- BG and
HbA1c goals for T1DM by age group
Age
Before
Meals
Bedtime/
Overnight
HbA1c
< 6 years
100-180
110-200
7.5-8.5%
6-12 years
90-180
100-180
<8%
90-150
<7.5%
13-19 years 90-130
Diabetes Care, 2010
SPECIFIC TREATMENT
GOALS for TYPE 2 DIABETES
• FBS < 140 mg/dl, HgbA1C < 7%
• LDL cholesterol < 100 mg/dl
• BP < 90% for age
Annual Screening
TIDM
•
Family history of hypercholesterolemia * If
LDL < 100 screen every 5 years.
T2DM
•
Lipid Panel yearly
•
Annual microalbumin/creatinine ratio: age 10
and TIDM for 5 years,
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Microalbumin/creatinine ratio at diagnosis
and yearly
•
Annual ophthalmologic exam: age 10 and 3-5
years of TIDM
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Dilated eye exam at diagnosis and yearly
•
Screen for Thyroid Peroxidase and
Thyroglobulin, Transglutaminase or
Endomysial Abs at diagnosis
•
Liver function every 6 months if on
metformin
•
TSH q 1-2 yrs
* TC >240 and/or Cardiac Event < 55 Screen age
>2 otherwise begin screen at > 12.
NUTRITION
Why Carbohydrate Counting?
• More Precise Meal Planning Method
• Greater Flexibility with Food Choices
• Only One Main Nutrient Counted
• Better Blood Glucose Control
NUTRITION PRINCIPLES
• 50-55% carbohydrates, 15-20% protein, 30% fat
• Sufficient calories for growth
• Pattern of food distribution
-Exchanges
-Carbohydrate counting
• Distributed as 3 meals and 2-3 snacks
• Individualize plan
CARBOHYDRATE COUNTING
• Insulin dose is tied to amount of carbohydrate
• Read total carbohydrates on food label, not sugar
• Most children don’t need to eat a particular
number of carbs per meal
• Those on basal/bolus regimens or insulin pumps
can vary insulin dose with amount of carbohydrate
Carbohydrates:
These are examples of 15 gram portions
• 1 sm. apple, orange or
peach
• 15 grapes
• ½ large banana
• ½ cup (4 oz.) juice
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½ cup pasta
3 oz. Baked potato
1 slice bread
½ cup cereal
1 cup milk
3 cups popcorn
The Misconception About Sweets
A Carb is a Carb is a Carb - but there are Healthy Carbs:
fruits, vegetables, whole grains
MANAGEMENT of TYPE 2
DIABETES - NUTRITION
• Prevent further weight gain
• Decrease energy intake
to 65-80% if BMI > 40
or 90% if BMI >30 and <40
• CHO 50-55%,fat 30%, protein 10-15%
EXERCISE
EXERCISE
Recommendations
• More monitoring, better control
• Extra carbohydrates if BG normal-low
15gm per 30 min intense exercise
• No exercise if BG >300 or ketonuria
• Goal for people with diabetes is 150
minutes per week of moderate-intensity
aerobic exercise
MANAGEMENT of TYPE 2
DIABETES - EXERCISE
• Increase physical activity
• Decrease sedentary behavior
MANAGEMENT of
HYPOGLYCEMIA
• Prevention
-Meals on time
-Exercise pre-treatment
• Monitoring Blood Glucose
• Treatment – give 15 g CHO, wait 15 min.
-Glucose tabs, glucose gel
-Glucagon Emergency Kit
MANAGEMENT of ILLNESS
KETOSIS
• Prevention
- Never omit insulin even if vomiting or NPO
- Monitoring blood glucose
- Monitor urine or blood for ketones if
BG >300 or if ill
• Treatment
- Consultation with diabetes team – may use
Zofran or phenergan if vomiting
-Fluids and insulin
COMPLICATIONS of
HYPERGLYCEMIA
• Diabetic Nephropathy- majority of kidney failure
and transplants
• Diabetic Retinopathy- majority of blindness
• Diabetic Neuropathy- painful or decreased
sensation (contributes to foot disease), abnormal
stomach function (gastroparesis), impotence
• Increased risk for coronary heart disease and
stroke
Huge expense!
PREVENTION OF
COMPLICATIONS
• DCCT-1993
Control of hyperglycemia prevents or
delays retinopathy, nephropathy
• Treatment of microalbuminuria
ACE inhibitor prevents progression and
may decrease protein excretion
PSYCHOSOCIAL
DEVELOPMENTAL ISSUES
• Toddler/Preschooler
– At initial diagnosis, often fearful
– Struggles over control, including food
– Behavior can be reflected in glucose levels
• School Age
– Very concrete and task-oriented
– Often want to do own BG checks, may be more
hesitant with self-injections
DEVELOPMENTAL ISSUES
• Teens
– increasing age associated with decreased
adherence to exercise, injection
regularity, diet and monitoring
– external interests (peers, school, sports)
take precedence over diabetes
ADOLESCENT
DEVELOPMENT
• Social/Behavioral Development
– 25% of teens surveyed falsify BG results
so as not to be judged
– 25% of teens surveyed miss injections
due to forgetting
ADOLESCENT
DEVELOPMENT
Health Belief Model
• Adolescents with diabetes who perceived
high benefits to regimen were more likely to
adhere to it
• Adherence was highest when benefits/costs
were high and threat was low
• When perceived threat is too powerful,
adherence decreases
ADOLESCENT
PSYCHOSOCIAL ISSUES
• Depression is more common
• Eating disorders at higher incidence
• Insulin omission for weight loss very
common
MAJOR ROLES of the PNP
• Recognition of signs and symptoms and risk
groups of diabetes in children
• Reinforcing the prescribed plan and regular
f/u with specialists
• Helping parents understand normal
developmental issues (i.e. adolescent’s
decrease in adherence to regimen is related
to normal developmental issues and is not
“pathologic”)
MAJOR ROLES of the PNP
• Addressing the grief involved in a new
diagnosis (up to 40 % of mothers are
clinically depressed in the first 2 years after
diagnosis)
• Advocating for parents with school
• Normalizing child’s daily life as much as
possible (i.e. encouraging parents to allow
normal activities)
MAJOR ROLES of the PNP
Focus on Type 2 DIABETES
• Weight stabilization
• Improve cardiovascular risk factors
Hypertension/microalbuminuria
Hyperlipidemia
Hyperglycemia
Smoking
IDENTIFYING CHILDREN AT
RISK for TYPE 2 DIABETES
• Obesity- BMI >85% for age
weight >120% for height
• Family history in 1st or 2o relative
• Race/ethnicity (American Indian, African
American, Hispanic, Asian/Pacific Islander)
• Condition associated with insulin resistance
Acanthosis Nigricans
Hypertension
Dyslipidemia
Polycystic Ovary Syndrome
TESTING at RISK CHILDREN
• How- Fasting Blood Sugar
• Who- 8 years old or pubertal child
• When- every 2 years
• Type 1 DM TrialNet – natural history study
for 1st degree relatives of people with type 1
diabetes
PREVENTION of TYPE 2
DIABETES in CHILDREN
• Anticipatory Guidance
- Breast feeding, Nutrition
• Healthcare Maintenance
• Community Involvement
- Nutrition and Exercise in Schools