2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S150 Type 1 Diabetes in Children and Adolescents Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Margaret L. Lawson MD MSc FRCPC, Danièle Pacaud MD FRCPC and Diane Wherrett MD FRCPC KEY MESSAGES • Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis (DKA). • Management of pediatric DKA differs from DKA in adults because of the increased risk for cerebral edema. Pediatric protocols should be used. • Children should be referred for diabetes education and ongoing care to a diabetes team with pediatric expertise. Unless otherwise specified, the term “child” or “children” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age. INTRODUCTION Diabetes mellitus is the most common endocrine disease and one of the most common chronic conditions in children.Type 2 diabetes and other types of diabetes, including genetic defects of beta cell function such as maturity-onset diabetes of the young (MODY), are increasing in frequency and should be considered when clinical presentation is atypical for type 1 diabetes.This section addresses those areas of type 1 diabetes management that are specific to children. EDUCATION Children with new-onset type 1 diabetes and their families require intensive diabetes education by an interdisciplinary pediatric diabetes healthcare (DHC) team to provide them with the necessary skills and knowledge to manage this disease. The complex physical, developmental and emotional needs of children and their families necessitate specialized care to ensure the best long-term outcomes (1). Education topics must include insulin action and administration, dosage adjustment, blood glucose (BG) and ketone testing, sick-day management and prevention of diabetic ketoacidosis (DKA), nutrition therapy, exercise, and prevention, detection, and treatment of hypoglycemia.Anticipatory guidance and lifestyle counselling should be part of routine care, especially during critical developmental transitions (e.g. upon school entry, beginning high school). Healthcare providers should regularly initiate discussions with children and their families about school, diabetes camp, psychological issues, substance abuse, driver’s licence and career choices. Children with new-onset diabetes who present with DKA require a short period of hospitalization to stabilize the associated metabolic derangements and to initiate insulin therapy. Outpatient education for well children with new-onset diabetes has been shown to be less expensive than inpatient education and associated with similar or slightly better outcomes when appropriate resources are available (2). GLYCEMIC TARGETS As improved metabolic control reduces both the onset and progression of diabetes-related complications in adults and adolescents with type 1 diabetes (3,4) aggressive attempts should be made to reach the recommended glycemic targets outlined in Table 1. However, clinical judgement is required to determine which children can reasonably and safely achieve these targets. Treatment goals and strategies must be tailored to each child, with consideration given to individual risk factors. Young age at diabetes onset (
have failed to demonstrate an improvement in glycated hemoglobin (A1C) compared with MDI. However, almost all clinic-based studies of CSII in school-aged children and adolescents have shown a significant reduction in A1C with reduced hypoglycemia 12 to 24 months after initiation of CSII when compared to pre-CSII levels (15). Most, but not all, pediatric studies of the extended longacting insulin analogues detemir and glargine have demonstrated improved fasting BG levels and fewer episodes of nocturnal hypoglycemia with a reduction in A1C (16-18). GLUCOSE MONITORING Self-monitoring of blood glucose (SMBG) is an essential part of management of type 1 diabetes (19). Subcutaneous continuous glucose sensors have demonstrated good accuracy except when BG levels are in the hypoglycemic range (20-22). Continuous glucose sensors may be a useful tool for improving glycemic control in individuals on intensive therapy (23). NUTRITION All children with type 1 diabetes should receive counselling from a registered dietitian experienced in pediatric diabetes. Children with diabetes should follow a healthy diet, as recommended for children without diabetes in Eating Well with Canada’s Food Guide (24).This involves consuming a variety of foods from the 4 food groups (grain products, vegetables and fruits, milk and alternatives, meat and alternatives). There is no evidence that one form of nutrition therapy is superior to another in attaining age-appropriate glycemic targets. Appropriate matching of insulin to carbohydrate content may allow increased flexibility and improved glycemic control (25,26), but the use of insulin to carbohydrate ratios is not required.The effect of protein and fat on glucose absorption must also be considered. Nutrition therapy should be individualized (based on the child’s nutritional needs, eating habits, lifestyle, ability and interest) and must ensure normal growth and development without compromising glycemic control. This plan should be evaluated regularly and at least annually. HYPOGLYCEMIA Hypoglycemia is a major obstacle for children with type 1 diabetes and can affect their ability to achieve glycemic targets. Significant risk of hypoglycemia often necessitates less stringent glycemic goals, particularly for younger children. Severe hypoglycemia should be treated with pediatric doses of intravenous (IV) dextrose in the hospital setting, or glucagon in the home setting. In children, the use of mini-doses of glucagon has been shown useful in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate. A dose of 20 µg per year of age up to a maximum of 150 µg is effective at treating and preventing hypoglycemia, with an additional doubled dose given if the BG has not increased in 20 minutes (27,28). CHRONIC POOR METABOLIC CONTROL Diabetes control may worsen during adolescence. Factors responsible for this deterioration include adolescent adjustment issues, psychosocial distress, intentional insulin omission and physiologic insulin resistance. A careful multidisciplinary assessment should be undertaken for every child with chronic poor metabolic control (e.g. A1C >10.0%) to identify potential causative factors such as depression and eating disorders and to identify and address barriers to improved control (29,30). DKA DKA occurs in 15 to 67% of children with new-onset diabetes and at a frequency of 1 to 10 episodes per 100 patient years in those with established diabetes (31). As DKA is the leading cause of morbidity and mortality in children with diabetes (32), strategies are required to prevent the development of DKA. In new-onset diabetes, DKA can be prevented Table 1. Recommended glycemic targets for children and adolescents with type 1 diabetes Age (years) *Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available † In adolescents in whom it can be safely achieved, consider aiming toward normal PG range (i.e. A1C ≤6.0%, fasting/preprandial PG 4.0-6.0 mmol/L, and 2-hour postprandial PG 5.0–8.0 mmol/L) A1C = glycated hemoglobin PG = plasma glucose A1C (%) Fasting/ preprandial PG (mmol/L)
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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