Diabetes mellitus in children

82 Diabetes mellitus in children

Overview/pathophysiology

Diabetes mellitus (DM) is the most common childhood endocrine disorder and one of the most costly chronic diseases of childhood. It is a disorder of carbohydrate metabolism marked by hyperglycemia and glycosuria, and it results from inadequate production or use of insulin. The major classifications seen in children are as follows:

• Type 1 DM: There is an absolute deficiency of insulin secretion resulting from destruction of beta cells, causing hyperglycemia and ketosis. This destruction is often an immune-mediated or related response. Previously it was called insulin-dependent DM (IDDM) or juvenile-onset diabetes. Historically, this was the primary type of diabetes seen in children. Currently, approximately 186,300 people younger than 20 have diabetes in the United States. Type 1 DM is found in 1 in every 400-600 children, and more than 15,000 children are diagnosed with type 1 DM each year. Children have been diagnosed with type 1 DM in infancy (CDC, National Diabetes Fact Sheet, 2007). About 75% of all newly diagnosed cases of type 1 DM occur in individuals younger than 18 yr old. These children are dependent on insulin for survival and to prevent diabetic ketoacidosis (DKA). Individuals diagnosed with type 1 DM in childhood have a high risk of early cardiovascular disease (CVD) and the American Heart Association ranks children with type 1 DM in the highest tier for risk of CVD.

• Type 2 DM: There is an insulin resistance with this type, so there is a relative, not absolute, insulin deficiency. Previously this was called non–insulin-dependent DM (NIDDM) or adult-onset DM. In the 1990s, there was an alarming epidemic of children developing type 2 DM. It is usually diagnosed between 10-19 yr of age, and some pediatric practices have reported greater than a ten-fold increase in this age group in recent years (Strayer et al, 2009). Previously, less than 5% of children were diagnosed with type 2 DM. The National Diabetes Fact Sheet for 2007 notes that about 3700 youth are diagnosed with type 2 DM annually. Being overweight is a strong risk factor for type 2 DM, and recent data from Child Stats in 2009 noted that about 15% of children 6-11 yr of age and 18% of adolescents 12-17 yr of age in the United States are overweight—two to three times the number in 1980. Sedentary lifestyle is another significant risk factor. There is also an increased risk of developing type 2 DM in African American, Hispanics/Latino American, and Native American populations (Strayer et al, 2009).

• Note: It can be difficult to distinguish between types 1 and 2 DM, especially because the prevalence of overweight in children continues to rise and autoantigen and ketones can be present in many patients with features of type 2 DM, including obesity and acanthosis nigricans (see description under Assessment) (American Diabetes Association [ADA], Standards of Medical Care in Diabetes, 2010).

• Mature-onset diabetes of youth (MODY): This type involves impaired insulin secretion with minimal or no defects in insulin action, usually in individuals younger than 25 yr old and symptomatic only with stress or infection.

• Cystic fibrosis-related diabetes (CFRD): This is the most common comorbidity in people with cystic fibrosis and occurs in about 20% of adolescents with cystic fibrosis (CF), and about 40%-50% of adults with CF have CFRD. Insulin insufficiency caused by partial fibrotic destruction of the islet mass is the primary defect (ADA, Standards of Medical Care in Diabetes, 2010).

• For information on other types, see the adult Diabetes Mellitus care plan, p. 348, and “Diabetes in Pregnancy,” p. 619.

Health care setting

Primary care, with possible hospital admission because of complications

Assessment

Signs and symptoms:

These are the same as in the adult DM care plan except children with type 2 DM usually have hypertension, dyslipidemia, acanthosis nigricans (hypertrophy or thickening of skin with gray, brown, or black pigmentation chiefly in axilla, other body folds, and sometimes on hands, elbows, and knees), and polycystic ovary syndrome. Females may have vaginitis because of long-standing glycosuria. DKA also may occur in children and adolescents.

Complications

Potential for acute crisis:

This is the same as in the adult DM care plan with the addition of idiopathic cerebral edema in resolving DKA, which occurs more often in children than in adults. The patient may have headache and lethargy or be asymptomatic. Symptoms can start with abrupt change in level of consciousness (LOC); pupils dilated, fixed, or unequal; papilledema; decorticate or decerebrate posturing; rapid progression to deep coma, respiratory arrest, or brain death (herniation of brain stem).

Long-term complications:

These are the same as in adults but the micro and macro complications are very aggressive in children with type 2 DM. They occur over a much shorter time frame. With type 1 DM, retinopathy most commonly occurs after puberty and after 5-10 yr of diabetes duration but has been reported in prepubertal children who have had diabetes for only 1-2 yr.

Note: Celiac disease occurs with increased frequency in patients with type 1 DM (1%-16% of individuals compared with 0.3%-1% in the general population) per ADA’s Standards of Medical Care in Diabetes (2010).

Diagnostic tests

The ADA published the Standards of Medical Care in Diabetes —2010. This and the 2005 ADA Statement Care of Children and Adolescents with Type 1 Diabetes define the following values:

Fasting plasma glucose:

Will reveal a value 126 mg/dL or higher. Fasting is defined as no caloric intake for at least 8 hr. This is the recommended test for children, and it should be confirmed by a second positive test on another day in an asymptomatic child.

• Normal plasma glucose: A value less than 100 mg/dL.

• Impaired fasting glucose: 100-125 mg/dL or impaired glucose tolerance if 2 hr postprandial plasma glucose is 140-199 mg/dL. Impaired fasting plasma glucose or impaired glucose tolerance should be monitored on a regular basis but losing weight and increased activity can prevent or delay onset of DM.

• Screening recommendations (ADA, Consensus Statement Type 2 Diabetes in Children and Adolescents, 2000) for type 2 DM:

• Overweight or at risk for overweight (body mass index greater than 85th percentile for age and sex, weight for height greater than 85th percentile, or weight greater than 120% of ideal for height).

• PLUS at least two of the following risk factors:

Family history of type 2 DM in first- and second-degree relatives.

Belonging to certain race/ethnic groups (Native American, African American, Hispanic/Latino American, Asian/South Pacific Islanders).

Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome).

If listed factors are present, testing should be done (1) every 2 yr starting at age 10 or (2) at onset of puberty if it occurs at a younger age. Preferred test is fasting plasma glucose.

Two-hour postprandial plasma glucose:

Will reveal a value 200 mg/dL or greater during oral glucose tolerance test. It is not usually done in children.

Random/casual plasma glucose:

Symptoms of diabetes (polyuria, polydipsia, polyphagia, unexplained weight loss) and a random/casual plasma glucose 200 mg/dL or greater are diagnostic of diabetes and no further testing is required.

Fasting lipid panel, if type 2 DM suspected:

Dyslipidemia is frequently seen in children in type 2 DM and also needs to be treated. Values vary depending on age of child and if reference range is in conventional units or international units.

Basic metabolic panel (electrolytes, glucose, blood urea nitrogen, creatinine):

Serum glucose will be elevated, usually greater than 250 mg/dL. Sodium and potassium may be lost because of osmotic diuresis. The higher the glucose level, the greater the dehydration and loss of electrolytes. Serum potassium may be normal on admission, but after fluid and insulin administration, rapid return of potassium to the cells decreases serum potassium, which necessitates monitoring for cardiac dysrhythmias. Blood urea nitrogen and creatinine likely will be elevated because of dehydration. Also, renal dysfunction occurs when serum glucose level rises to greater than 600 mg/dL.

Thyroid-stimulating hormone and thyroxine:

Thyroid hormone increases gluconeogenesis (synthesis of glucose from noncarbohydrate sources such as amino acids and glycerol) and peripheral use of glucose. Elevated or decreased value would impact carbohydrate metabolism and therefore plasma glucose. Normal range varies for children depending on their age and type of reference units reported. Autoimmune thyroid disease occurs in about 17%-30% of individuals with type 1 DM (ADA, Standards of Medical Care, 2010).

Ketones:

Elevated when insulin is not available and the body starts to break down stored fats for energy. Ketone bodies are by-products of this fat breakdown, and they accumulate in the blood and urine. Normal range for children is 0 with the qualitative test and 0.5-3 mg/dL (conventional units) or 5-30 mg/L (international units) with the quantitative test.

Nursing diagnosis:

Deficient knowledge

related to unfamiliarity with blood glucose monitoring

Desired Outcome: Within 48 hr of this diagnosis, child/family demonstrates and verbalizes accurate understanding of proper blood glucose monitoring and when to monitor for ketones.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess child’s/parents’ knowledge base about blood glucose monitoring.	Teaching can be more effective once child’s/parents’ knowledge/understanding has been established.
Discuss reasons for blood glucose testing.	Understanding purpose of performing tests facilitates adherence. Reasons for blood glucose testing include: – Allows child to relate “how I feel at this time” with actual blood glucose level. – Gives child/family some control. – Enables understanding of effects of food, exercise, insulin, and/or stress. – Enables adjustments in insulin or diet.
Demonstrate correct use of glucometer the child will use at home and proper technique for fingerstick.	There are many different models and strips available commercially. Each system functions a little differently, and it could be overwhelming having to learn a new system at home without assistance or guidance. General guidelines include: – Use side of finger, not tip for fingersticks. Sides of the fingers have fewer nerve endings and hurt less. In addition, using sides decreases loss of sense of touch in fingertips. – Clean hands with soap and warm water. Cleansing helps reduce risk of infection. Warm water facilitates circulation and hence blood flow. – Avoid regular use of alcohol to cleanse skin. Any trace of alcohol left on the skin will interfere with the chemical reaction involved in checking blood glucose. It is okay to use occasionally (e.g., at a picnic), but the finger must be dried carefully and the first drop of blood discarded. Repeated use of alcohol also can lead to thickening of the skin, making fingerstick more difficult and painful. – Hold hand down, not up, to facilitate blood flow.
Discuss when blood glucose testing should be done.	Knowledge and understanding facilitate adherence. – Testing normally should be done before each meal and bedtime snack. Checking blood glucose on a regular basis and documenting findings help determine if adjustments need to be made in insulin/diet/exercise/medication by assessing pattern of blood glucose levels. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Psychosocial support Care of the renal transplant recipient Polycythemia Hyperglycemic hyperosmolar syndrome Stay updated, free articles. Join our Telegram channel Tags: All-In-One Care Planning Resource Jul 18, 2016 \| Posted by admin in NURSING \| Comments Off on Diabetes mellitus in children Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access