1	Diabetes in Young Children The Lollipop Brigade
2	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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4	Glycemic Targets Glucose values are plasma (mg/mL)
5	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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7	CHLA Type 1 DM
8	HbA1c Statistics for CHLA 2003 Type 1: Diabetes > 1 year, followed > 1 year Enrolled in Long-term study – total n 1375
9	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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15	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
16	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
17	Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs
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19	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
20	Insulin Glargine - Pharmacokinetics by Glucose Clamp
21	Insulin Detemir – Pharmacokinetics by Glucose Clamp
22	GHb, FBG, and Nocturnal Hypoglycemia in Children With T1DM (Plus Regular Insulin) (N=349)
23	Variable Basal Rate: CSII Program
24	A1c by Treatment type at CHLA:
25	Outcomes of Pump Therapy _{Kaufman, et al, Diabetes Metabolism and Reviews,2000} 6 month data 130 subjects
26	Results of Insulin Pump Therapy In Young Children Kaufman, et al, Diabetes Spectrum, 2001
27	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 for6 months, age 46.3 ± 3.2 months RESULTS— Mean HbA_1c 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/moderatehypoglycemia All subjects continued CSII after study completion
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29	CSII in Young Children CONCLUSIONS CSII is safe and well tolerated in young childrenwith diabetes and may have positive effects on QOL CSII didnot improve diabetes control when compared with injections The benefits and realisticexpectations of CSII should be thoroughly examined before startingthis therapy in very young children
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31	Use of CGMS to Improve Clinical Care
32	Mean Data for All Pts by Sensor
33	Result Summary: Treatment Changes
34	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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37	Intensive Management and Hypoglycemia HbA1c Association Is There Greater Risk of Hypoglycemia at Lower HbA1c Levels? Or with Intensive Regimens?
38	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
39	Analysis of data to determine bedtime BG level 167 nights Analyze the number of glucose values <40 and < 50 mg/dl through the night
40	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
41	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
42	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
43	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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45	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
46	"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
47	"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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51	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?
52	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
53	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
54	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?
55	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
56	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
57	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
58	Conclusion Ultimate Goals Of Diabetes Treatment