Management of Diabetes: The Good News and the Bad

from Caring For Our Future, Spring 2004

By Carolyn Banion, MN, PNP, CDE

Diabetes is one of the most common chronic illnesses of childhood, affecting one in 400 children under the age of 18. Ninety percent of children with a diagnosis of diabetes have type 1 diabetes, which is caused by autoimmune destruction of the beta cells in a genetically susceptible individual. In recent years, there has been a dramatic increase in the incidence of type 2 diabetes in the pediatric population.

There are 14,000 new cases of type 1 diabetes diagnosed in children in the United States each year. At the Barbara Davis Center for Childhood Diabetes (BDC) we follow 2,500 children with diabetes and see approximately 300 a year with new onset diabetes. About 70 percent of these children are diagnosed, started on insulin therapy and educated (patient, parent and significant others) as outpatients; 30 percent present in some degree of diabetic ketoacidosis and require hospitalization.

Optimal diabetes management in children involves normalizing blood glucose levels by balancing food, medication and activity while promoting normal growth and development. Lack of proper management can lead to long-term complications, including retinopathy, nephropathy and neuropathy. Results from the Diabetes Control and Complications Trial (DCCT), which studied individuals 13 years of age through adulthood, provided evidence that normalizing blood glucose levels can significantly reduce these complications. But with tighter metabolic control comes the greater risk of hypoglycemia. The problem of hypoglycemia in the pediatric population is of special concern because the developing brain may be more vulnerable to hypoglycemic stress.

Better blood glucose control can be achieved through frequent glucose monitoring, intensive insulin regimens, improved delivery systems, dietary management and thorough and ongoing education. The challenge for care providers is to tailor treatment plans to patients and their families using the tools available, and to motivate them to carry out the day-to-day management tasks necessary for good control. Parental involvement is essential in diabetes management, even through the adolescent years.

Insulin

For many years, standard insulin therapy for children was a combination of short and long-acting insulin twice a day. At the onset of diabetes, this continues to be the standard of care. However, once there is complete beta cell failure, many children cannot achieve the desired level of control with only two injections daily and require three or more injections.

Regular insulin is still used in the inpatient setting for insulin drips, but in the outpatient setting Humalog and Novolog have replaced regular insulin. These quick-acting insulin analogs have an onset of action of 10 minutes. They can be given just before a meal or even immediately after a meal for very young children whose food intake may be unpredictable or for individuals who are carbohydrate (CHO) counting.

The newest insulin on the market is Glargine (Lantus). It has a duration of action of 24 hours and doesn’t have the peak that intermediate-acting insulin (NPH, Lente) has, resulting in less hypoglycemia. The bad news about Lantus is that it cannot be mixed in the same syringe with any other insulin because of its low pH. Many children are on a regimen of Lantus insulin once daily and multiple injections of Humalog or Novolog with each meal. This gives children more flexibility for eating, sleeping in and spontaneous activities. For children who cannot administer insulin with their lunches at school, they may take some NPH insulin with their morning injection of one of the quick-acting insulin analogs. The insulin used today is made by recombinant DNA technology and structurally is the same as that made by the human pancreas. In addition to regular, Humalog, Novolog, NPH, Lente, Ultralente, and Lantus insulin, premixed insulin that is a combination of a short and intermediate acting insulin (75/25 or 70/30) also is available.

Pumps, Pens and other Gadgets: An insulin pump is a microcomputer the size of a pager that constantly infuses quick-acting insulin into the subcutaneous tissue via a catheter that is inserted every two to three days by the patient. It more closely mimics the human body by constantly infusing insulin (basal rate). Each time the pump user eats or has a high blood sugar, he/she gives a bolus insulin dose by pushing buttons on the pump. The pump does not measure blood sugar. If used properly, pump therapy can result in improved control, gives patients more flexibility in their lifestyles and decreases the incidence of hypoglycemia. One of the biggest problems with patients on insulin pump therapy is remembering to bolus for food intake.

Insulin pens are pre-filled devices; to administer insulin, the patient “dials” in the dose. These are popular in the school setting and for all patients who are on multiple doses of a single kind of insulin. There are numerous injection aids available to make injections easier in certain circumstances.

The good news about insulin and insulin administration is that we have an armamentarium of insulin and devices for insulin delivery that makes it easier than ever to customize an insulin regimen for a child’s needs. The bad news is that no matter how good “insulin in the bottle” is, it is not as good as that made by the human body. Insulin must be administered with a needle so there is always some degree of discomfort, and blood sugars are never “perfect” no matter how much effort patients put into their diabetes management. The cost of a vial of insulin is $40 to $80. Pens are a more expensive way of administering insulin than a syringe, and pumps cost approximately $6,000 with necessary supplies costing about $150 more each month than using a vial of insulin and a syringe for insulin administration.

Blood Glucose Monitoring

Frequent blood glucose testing is the backbone to improved diabetes control. It is recommended that all children test their blood sugar before each meal and at bedtime, sometimes two hours after meals to determine if the dose of quick-acting insulin is correct and occasionally during the night to try to detect any nocturnal hypoglycemia. A general target blood sugar goal is 80-180mg%, allowing for higher blood sugars in the infant and toddler who cannot recognize hypoglycemia, and slightly tighter control for adolescents.

There are almost as many blood glucose monitors on the market as there are cars. Insurance often dictates the meter a patient uses or they choose based on the features most important to them. All meters require a small drop of blood. The newest meters give results in five seconds, and all have memories so results are stored and can be downloaded to a PC.

Blood glucose tests measure sugar control on a day-to-day basis. The HBA1C, a blood test that measures the average blood glucose level over the previous 90 days, is the most valuable way to monitor blood glucose levels over time and should be done every three months. The general goal is to keep this value less than 8 percent.

Patients are instructed to test for ketones when they are ill or have a blood sugar greater than 300mg%. This is done with a urine test or with a meter for testing blood ketones.

The good news about blood testing is that it improves control, it helps prevent both hypo- and hyperglycemia, and meters and required sample size get smaller all the time. The bad news is that it is invasive, it hurts, it is expensive ($3 to 6 a day), it is inconvenient, and there are constant decisions to be made about the results (“Do I eat? Do I give insulin? Is it ok to exercise?). Insurance usually provides coverage for diabetes supplies.

Meal Planning

Children with diabetes have the same nutritional requirements as those without. In 1994, the American Dietetic Association developed new dietary guidelines for diabetic individuals, making it no longer a “sin” for them to have sugar. Eighteen M&M’s may not affect the blood glucose much differently than an apple.

The latest trend in meal planning for children with diabetes is carbohydrate counting. CHO counting can be used with prescribed carbohydrate ranges for each meal and snack. Alternatively, patients can be given a CHO/insulin ratio, so that their insulin dose at each meal can be adjusted to the CHO content of their anticipated meal in addition to their pre-prandial blood glucose level.

The good news is that CHO counting and the use of CHO/insulin ratios allow more precision and greater flexibility in eating and lifestyle. The bad news is that the increased complexity and thought these calculations require adds to the daily burden of diabetes management.

What Does the Future Hold?

The field of childhood diabetes is moving forward rapidly with many exciting developments. In the research phase are insulins with different time-action curves, inhaled insulin, insulin pills and transdermal insulin. Research to develop a noninvasive blood glucose monitor has been in the works for many years. The dream of many patients is to have an “artificial pancreas,” a closed-loop system that combines continuous blood glucose sensing and insulin delivery. Research in islet-cell transplantation looks promising and is underway at many centers in the U.S., including the BDC.

There is lots of good news about the care and management of children with diabetes. We have the best tools ever to achieve tight metabolic control. Success depends a great deal on the patient’s or parent’s ability, knowledge and insight to constantly evaluate and adjust insulin doses, food intake and activity level so blood sugar levels are maintained as close to normal as possible.

Type 2 Diabetes in Children

Until recently, type 2 diabetes was thought to be an adult disease. But the diagnosis of type 2 diabetes is increasing rapidly in the pediatric population, mostly in adolescents, but also in younger children. This population is characterized by morbid obesity, a sedentary lifestyle and high caloric intake, risk factors very similar to those seen in adults with type 2 diabetes. Although there are many new oral agents for the treatment of type 2 diabetes in adults, long-term normal glycemia is doubtful without major changes in diet and lifestyle. TCH is involved with TODAY (Treatment Options in type 2 Diabetes in Adolescents and Youth), an NIH multicenter study evaluating different treatment strategies in this population. Call x3287 for more information.