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Outline
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Diabetes in Young Children

The Lollipop Brigade
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What Will Be Discussed
  • What are the Targets for Young Children?


  • What are the Diabetes Regimens?


  • Is There a Greater Risk of Hypoglycemia?


  • What are the Developmental Issues ?







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Glycemic Targets
Glucose values are plasma (mg/mL)
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But What are the Goals?
  • To give your child a loving, supportive environment where each day is taken at a time (not each blood sugar)
  • Where your child can grow and thrive, learn and explore
  • Where blood sugars are corrected, not interrogated
  • Where the family is in balance – like a mobile
  • And where the long haul is what is important


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CHLA Type 1 DM
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HbA1c Statistics for CHLA 2003 Type 1: Diabetes > 1 year, followed > 1 year
Enrolled in Long-term study – total n 1375
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Evaluation of Young Children at CHLA
Kaufman, et al,  Pediatr Diabetes, 3:179-183, 2002.
  • Retrospective analysis of data
  • 147 children < 8 years of age
  • 2 year data from July 99 – July 2001


  • Study Question : Is HbA1c < 8.0 associated with more severe or assymptomatic hypoglycemia?
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Diabetes Management Principles
  • An effective insulin regimen
  • Monitoring of glucose
  • As flexible with food and activity as possible
  • Must remember
    • Young children need routine and rules
    • Young children need to develop autonomy
    • Young children need to explore and experience
    • Young children need to begin to make decisions
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Insulin management
  • Fixed dose regimens:
    • requires scheduled meals and snacks and is not flexible enough for most young children
  • Basal: bolus regimens:
    • MDI
      • useful only if child is willing to take frequent injections
    • Insulin pumps
      • child must be willing to wear the pump
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Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs
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Effectiveness of Postprandial Humalog in Toddlers
Rutledge, Chase, Klingensmith et al Pediatrics 100:968,97
  • Determine if postprandial rapid-acting insulin effective
  • Subjects < 5 years old
  • Results: 2-hour glucose excursions lower with postprandial Humalog compared to preprandial regular
  • Similar to preprandial Humalog
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Insulin Glargine - Pharmacokinetics by Glucose Clamp
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Insulin Detemir – Pharmacokinetics by Glucose Clamp
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GHb, FBG, and Nocturnal Hypoglycemia
in Children With T1DM
(Plus Regular Insulin) (N=349)
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Variable Basal Rate:
CSII Program
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A1c by Treatment type at CHLA:
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Outcomes of Pump Therapy
 Kaufman, et al, Diabetes Metabolism and Reviews,2000

6 month data 130 subjects
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Results of Insulin Pump Therapy
In Young Children
Kaufman, et al, Diabetes Spectrum, 2001
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A Randomized Controlled Trial of Insulin Pump Therapy in Young Children With Type 1 Diabetes
Larry A. Fox, et al Diabetes Care 28:1277-1281, 2005
  • 26 children randomly assigned to current therapy or CSII for 6 months, age 46.3 ± 3.2 months
  • RESULTS—
    • Mean HbA1c and BG did not change
    • Frequency of severe hypoglycemia, ketoacidosis, or hospitalization was similar between groups
    • Subjects on CSII had more fasting and predinner mild/moderate hypoglycemia
    • All subjects continued CSII after study completion
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CSII in Young Children
CONCLUSIONS
    • CSII is safe and well tolerated in young children with diabetes and may have positive effects on QOL
    • CSII did not improve diabetes control when compared with injections
    • The benefits and realistic expectations of CSII should be thoroughly examined before starting this therapy in very young children


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 Use of CGMS to Improve
Clinical Care
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Mean Data for All Pts by Sensor
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Result Summary:
Treatment Changes
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Result Summary: Glucose Changes
  • HbA1c reduced from 8.1 to 7.8% after only 30 days
  • Average glucose decreased from 167 to 156 mg/dl
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 Intensive Management and Hypoglycemia
HbA1c Association

  •  Is There Greater Risk of Hypoglycemia at Lower HbA1c Levels?
  • Or with
  • Intensive Regimens?
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Lack of Association Between
HbA1c and Hypoglycemia
  • Cox – no association in 78 pts with mean level of 10.25%
  • Bhatia, Wolfsdorf – incidence of 0.12/pt/yr in 196 pts with HbA1 11.4% (nl 5.4-7.4)
  • Daneman - 16% of 311 pts with HbA1 of 8.7%
  • Nordfelt, Ludvigsson – 146 pts intensive therapy, no increase in severe hypoglycemia
  • Levine- highest HbA1c tertile, 36/pt/yr


  • Kaufman et al Endocrinologist 9:342,99
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Analysis of data to determine
 bedtime BG level
  • 167 nights


  • Analyze the number of glucose values <40 and < 50 mg/dl through the night


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Results
  • 45 nights (27%) – at least one reading < 40 mg/dl
  • 59 nights (35%) – at least one reading < 50 mg/dl
  • For nights < 100 at HS – 86.4 minutes


  • No relation to A1c or regimen


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Adverse Events in Intensively Treated Children and Adolescents with Type 1
Nordfeldt, Ludvigsson Acta Pediatr 88:1184,99
  • 139 Subjects, ages 1-18 yrs on MDI
  • Mean HbA1c 6.9%
  • Severe Hypoglycemia - 0.17 events/pt/yr
    • Decreased from 1-2 injections
    • Correlated with previous severe hypoglycemia r=.38,p<0.0001
  • DKA rate 0.015 events/pt/yr


  • MDI effective and safe


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How Well Are We Doing? Metabolic Control in Patients with Diabetes
Thomsett, Shield, Batch, Cotterill J Pediatr & Child Health 35:479,99 Brisbane
  • 268 < 19 yrs mean 11.2 yrs
  • Duration 4.4 0-16 yrs
  • Mean HbA1c 8.6+1.4%, range 5.2-14%
  • Puberty 8.7+1.5%, Prepubertal 8.5+1.2%
  • 33% < 8.0%
  • HbA1c correlated
    • insulin dose, duration
  • Not correlated
    • severe hypoglycemia, DKA, age, # of injections, # clinic visits
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Prediction of Hypoglycemia
  •        Good Predictors


  • Weighted assessment of low BG for 2-3 wks
  • Nighttime BG < 100-108 mg/dl
  • Age < 5-7 yrs
  • > 2 previous episodes
  • Daily dose > 0.85 U/kg
  • Duration > 2 yrs
  • > 2 consecutive low BG in 2 wks
  • > 4 BG < 50 mg/dl in 2 wks
  •         Poor Predictors


  • Glycated hemoglobin level
  • Number of insulin injections
  • Intensive vs conventional treatment









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Babies and Toddlers
0-3
  •  Physical
  • Rapid growth
  • Erratic eating and sleeping
  • Cognitive
  • Differentiates self
  • Learns language to represent objects/people
  • Moral Development
  • Judgments based on personal preference
  • Physical
  • Greater mastery of gross and fine motor skills


  • Cognitive
  • Egocentric/Classifies objects by a single feature
  • Magical thinking/Simple
  • Moral Development
  • Judgment of good/bad based on punishment/ reward
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"Emotional and Sense of Self"
  • Emotional and Sense of Self
  • Begins to recognize that others' feelings are different from own
  • Begins to have sense of self
  • Social
  • Parallel play
  • Responsibility
  • Total care by parents/ caretakers



  • Emotional and Sense of Self
  • Sex role differentiation
  • Likes to help
  • Wants to do things by self
  • Deference to authority
  • Social
  • Cooperative play
  • Responsibility
  • Child begins to have some responsibility with adult assistance


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"School"
  • School
  • At home/daycare Beginning to learn routines
  • Adjusting to different caretakers


  • Extra-Curricular Activities
  • Babysitters


  • Incentives
  • Immediate and concrete


  • School
  • Entering school /Separation from parents
  • Learning routines, rules outside of home
  •  School readiness skills


  • Extra-Curricular Activities
  • School aftercare                         Playdates
  • Incentives
  • Immediate and can be symbolic (stickers, stars, etc)


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Case Study 1
  • Ana is a two-year old recently diagnosed
  • Very spirited toddler
  • Fights blood glucose testing by screaming, hiding and clenching her fists.


  • What should this family do with this challenge?


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Issues by Developmental Status
  • Challenges of Diabetes Management:  Testing
  • Factors Contributing to the Challenge:
  • Normal Growth and Development
  • Family Dynamics
  • Developmental Tasks:
  • Moral Development
  • Emotional Development
  • Incentives


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Solution
  • Ana’s judgment about glucose testing based on personal preference – she did NOT like fingersticks
  • Not possible to “convince” Ana she needs to test her blood
  • Parents worked together and developed matter-of-fact attitude
  • Committed to routine, no bargaining, stalling, chasing
  • Parents provided immediate and concrete incentives - a hug, a “good job”, let her pick finger, read book as reward
  • Picked meter capable of alternate site testing,  very small sample and results in five seconds
  • Within a very short time, Ana willingly participated


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Case 2
  • Terrel, 4-year old, type 1 for ten months and celiac disease
  • BG testing 8-10 times per day, MDI, on gluten-free diet with few management problems at home
  • Problems occurred in pre-school
  • In school, regular episodes of hypoglycemia
    • Continuous activity
    • Not as much blood testing
    • Skipped snacks related to less supervision

  • What does family do?


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DEVELOPMENTAL ISSUES
  • Challenges of Diabetes Management:  Testing, Hypoglycemia, Nutrition
  • Factors Contributing to the Challenge:  Normal Growth and Development, School
  • Developmental Tasks:
  • Physical; Moral Development; Emotional Development; Responsibility; Incentives
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Solution
  • At age four, Terrel likes to help, wants to do things by himself and adapts well to routines
  • He is able to understand the meaning of low blood glucose and the importance of eating his carbohydrates
  • In the school setting, he needs supervision while at the same time he needs to learn to take some responsibility for participating in testing and eating
  • Incentives he likes - praise, stickers and providing choices
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Solution
  • Every day before snack and recess
    • BG test
    • Choose a gluten-free snack provided by mother
  • After the snack
    • Pick a small prize from a treasure chest
    • Terrel liked being involved
  • He was more inclined to eat and check
    • Getting a prize an extra incentive
  • In a short time, this routine became the norm and  hypoglycemia resolved



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Conclusion
Ultimate Goals Of Diabetes Treatment