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- 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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- 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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- 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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- 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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- 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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- 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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- 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 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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- 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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- Is There Greater Risk of
Hypoglycemia at Lower HbA1c Levels?
- Or with
- Intensive Regimens?
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- 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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- 167 nights
- Analyze the number of glucose values <40 and < 50 mg/dl through
the night
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- 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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- 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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- 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
- Not correlated
- severe hypoglycemia, DKA, age, # of injections, # clinic visits
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- 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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- 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
- 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
- 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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- 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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- 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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- 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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- 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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- 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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- 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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- 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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