Paediatric Diabetes Update - Dr Jan Fairchild Paediatric Endocrinologist May 2017 - Women's and Children's Hospital
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Paediatric Diabetes Update Dr Jan Fairchild Paediatric Endocrinologist May 2017
Australian T1D Prevalence (0-14yrs)
> Prevalence 1/720 children (6,091children)
• 80 new cases per year at WCH
> 90% have T1D
> Peak age for onset 10-14yrs
• but can occur at any age from 6months
> M=F
> No difference across SES groups
(AIHW Data 2013)
Women's & Children's Hospital
Pathogenesis
Genetic predisposition
Environmental trigger/s
Autoimmune process
• T cell mediated destruction of β cells
Type 1 diabetes
• No current intervention available to halt the
autoimmune process and prevent T1D, but
multicentre trials at different stages
Women's & Children's Hospital
Pathogenesis
Women's & Children's Hospital
Classic presentation of T1Diabetes
> 2-6 week history of polyuria, polydipsia,
weight loss and excessive tiredness
> Bed wetting very common
> Usually no-one else in the family
with diabetes
> If DKA develops:
• Vomiting, abdominal pain
• Breathing difficulties
• Reduced consciousness
Women's & Children's Hospital
Misdiagnosis remains common
> Newly diagnosed diabetes in children is a
serious and potentially life threatening condition
> Misdiagnosis remains common at 1st
presentation especially in young children
• Polyuria - ? Urinary tract infection
• Bed wetting or polydipsia - ? Behavioural
• Vomiting / abdominal pain - ? Gastroenteritis or
acute abdomen
• Breathing difficulties - ?Asthma or pneumonia
Women's & Children's Hospital
Diagnosis easy if you think of it!
> If symptoms of diabetes present - check
fingerprick BGL or urine glucose
> If fingerprick BGL >11mmol/L (or >7mmol/L fasting)
or if urine glucose positive, refer to hospital
emergency department immediately
> Don’t send to pathology or wait for fasting bloods as
this delays treatment. No indication for OGTT
Fingerprick blood ketones a useful triage tool
Urine Ketones Blood Ketones (mmol/L)
negative 1.5
• Optium meter checks blood glucose and blood ketones
• If moderate to large ketones – need to assess for DKA
Women's & Children's Hospital
Diabetes awareness campaigns
reduce DKA rates
> Most GPs will very rarely see a child with 1st
presentation of diabetes, but it is such an
important diagnosis to make as early diagnosis
and referral will prevent diabetic ketoacidosis
(DKA) and potentially save lives
> Diabetes awareness campaigns targeting GPs
and schools have shown dramatic reduction in
DKA rates1,2 and led to the development of the
ISPAD DKA prevention resources which are
freely downloadable www.ispad.org
1.Vanelli et al Diabetes Care 1999
2. King et al Pediatric Diabetes 2012 Women's & Children's Hospital
Early referral will prevent DKA ISPAD posters freely available for the waiting room www.ispad.org Women's & Children's Hospital
Is it Type 2 Diabetes?
> T2D Consider T2D if risk factors present
>10yrs
Overweight/Obese (85%)
Family history T2D (>75%)
Acanthosis Nigricans
Mild symptoms generally but ketonuria in 33%
High risk ethnic groups
Diabetes type 10-14yrs 15-19yrs
AIHW 2012 All (Indigenous) All (Indigenous)
Type 1 87.9% (53.1%) 64.3% (32.8%)
Type 2 7.2% (44.6%) 30.5% (66.4%)
Women's & Children's HospitalMorbidity and Mortality in DKA
> DKA is the most common cause of diabetes
related deaths in childhood and
adolescence
> Most deaths in DKA are due to cerebral
oedema
occurs in 0.3-1% of cases of DKA
typically occurs 4 -12 hours after treatment is initiated,
> but may occur before treatment has begun or
anytime during treatment.
aetiology and pathophysiology is poorly understood
mortality rate 20-25%, significant morbidity in
survivors
Women's & Children's HospitalFrequency of DKA and precipitating
factors
> New onset T1D ~25% (15-70%)
• incidence higher in younger children Established T1D is 1-10 / 100 person years
• Insulin omission the cause in most cases
risk increased if poor metabolic control, previous DKA,
peripubertal or adolescent girls, pyschosocial problems
• Failure to follow sick day or pump delivery failure
guidelines
Intercurrent infection is seldom the cause if properly
educated about sick day management and 24 hr
diabetes helpline available
Women's & Children's HospitalChildren on insulin pumps at
increased risk of ketosis
> All vomiting in a child on an insulin pump
should be considered due to ketosis from
interrupted insulin delivery (blocked delivery
set) until proven otherwise!
> Blood ketone testing will determine the
appropriate action Vomiting
If no ketones present correct with pump and
=
monitor Ketones
If ketones present do not correct with the
pump, give an injection and change set
Families have written instructions for
injections doses
> DKA should not occur if monitoring
regularly and following sick day protocols
Insulin pen must be available at all times
Women's & Children's HospitalKey points: Diabetic Ketoacidosis
> Rapid deterioration common in children
with newly diagnosed T1D
• Urgent referral to Emergency Department
• Phone Paediatric Endocrinologist if unsure
(WCH Switchboard 08- 8161 7000)
> Children are not small adults
• Need to recognise physiological differences
between child and adult, especially with
regard to fluid management
• Follow Paediatric DKA Protocol
http://cger.cywhs.sa.gov.au/cgu/clinical_guidelines/cywhs/dka.html
Women's & Children's HospitalContemporary T1D management
what has changed?
1960 -1990 2010 - 2017
> 1-2 injections per day > Multiple daily injections or
> Aggressive therapy pump therapy
unsafe and of > Continuous glucose
unknown benefit monitoring now
> HbA1c 9-14% Government funded
> Long term diabetes > HbA1c target 6.5-7.5%
complications evident > Adults who had
in adolescence successful intensive
management have low
risk of complications
Women's & Children's HospitalImpact of a decade of changing
treatment in children with T1D
Severe Hypoglycaemia Mean HbA1c
Bulsara et al. Diabetes Care 2004
Women's & Children's HospitalGoals of T1D management
> Avoiding severe hypoglycaemia and
diabetic ketoacidosis
> Maintaining optimal glucose control
• BGL targets pre and post meal
• HbA1c targets
• Minimising glucose variability
> A happy, well-adjusted child
…and family!
Women's & Children's HospitalIntensive therapy (MDI / Pumps)
now recommended for all ages
> More physiological insulin replacement
> Allows improved glycaemic control without
increased risk of hypoglycaemia
> Normalises eating
Reduces need for extra food at snack time
Reduces total daily dose / weight gain
Greater flexibility with diet, especially young children
> Increased education and support required
Women's & Children's HospitalWCH Diabetes Management
> Basal bolus insulin regimen from diagnosis
• < 8 years: Levemir BD, NovoRapid with meals
• ≥ 8 years: Lantus daily, Humalog with meals
> Carbohydrate counting (grams) and insulin:carb ratios
from diagnosis
• 50% of children with T1D are overweight
> Insulin pumps (45% pts at WCH 2016)
• Discussed from diagnosis and recommended during 1st year
• Some newer pumps have predictive low glucose suspend
function
> Continuous Glucose Monitoring Systems
• Government subsidised for those with
T1DThe Burden of Care
> Inherent burden of care and diligence
required to maintain optimal glycaemic
control has not changed (? increased)
• T1D unique in the level of patient input required
• Not surprising most don’t meet targets
• Not everyone willing or capable of using
intensive therapy
• Burnout common
Women's & Children's HospitalMental Health impacts of T1D
> Young people with diabetes have a higher
incidence of anxiety, depression,
psychological distress and eating
disorders than their healthy peers
> A lack of adequate psychosocial support
has negative effects on various outcomes,
including blood glucose control
> Children and young people with T1D and
their families should be offered timely and
ongoing access to mental health supports
Women's & Children's HospitalWCH Diabetes Service
> Provides multidisciplinary diabetes care for 700
children/adolescents with T1Diabetes
> Diabetes Team: 5 paediatric endocrinologists, 4
diabetes educators, 2 dietitians and trainees
> 24 hour consultant on-call service for families / GPs
• Call WCH Switchboard 08- 8161 7000
> Outreach services
• Pt Lincoln, Whyalla, Pt Augusta, Mt Gambier
> SA centre for new pump trials, vascular complications
and type 1 diabetes prevention trials & national
register
> NHMRC Centre of Research Excellence
www.endia.org.au
Women's & Children's HospitalResources
> NHMRC Guidelines Updated (2011): National
Evidence-Based Clinical Care Guidelines for Type 1
Diabetes for Children, Adolescents and Adults
http://www.nhmrc.gov.au/publications/synopses/cp102syn.
htm
> ISPAD Guidelines www.ispad.org
> WCH Intranet:
www.inside.cywhs.sa.gov.au/webs/endocrine_diab
etes
DKA Protocol
Mini-dose Glucagon protocol
Management of diabetes during surgery
Sick day management
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