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Managing Clinical Problems in Diabetes, Case Study #23: Type 1 and Pre-Teens

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Jade, an 11-year-old girl, was admitted via the emergency department with hyperglycemia, ketonuria and a weight loss of 6 kg over the past 4 weeks. The only history of diabetes in her family is her maternal grandfather with type 2 diabetes. Arterial blood gases indicate that she is ketonic but not in DKA and she was admitted to a medical ward for stabilization….

Diabetes educator

It appears Jade has type 1 diabetes. Ultimately the diagnosis can be confirmed by measuring her GAD and IA2 antibodies and C-peptide. Her initial treatment is rehydration, correcting the hyperglycemia and ‘survival skills education’. Following intravenous rehydration and correcting the blood glucose levels using an insulin infusion, education on subcutaneous insulin should begin.

Survival skills education involves providing enough information and support for Jade and her family to manage safely at home following discharge (Queensland Health 2002; see Chapter 9). This could occur after 3-5 days of admission. The four areas include:

  1.  insulin administration
  2. blood glucose monitoring
  3. basic diet information
  4. hypoglycemia detection, treatment and prevention.

An understanding and ability for Jade and her family to perform basic activities around these areas are imperative before discharge. The type of education provided by the team needs to be adaptable, personalized and appropriate to Jade’s age, maturity and lifestyle. Often a diagnosis of diabetes at this time for the teenager and their family is characterized by confusion, fear, anger, denial, and disbelief. All of these emotions are normal responses to a diagnosis of type 1 diabetes in a child. Everyone in the family needs to be supported and introduced to the diabetes team, which usually includes a medical specialist, diabetes educator, dietitian and psychologist.

Where possible, Jade will be encouraged to undertake as much of her care as possible with the support and supervision of her family. Involving siblings is also important. Managing newly diagnosed children requires an enormous amount of hospital resources. It is important to find the balance between what the patient and family needs to know to get them out of hospital and manage the diabetes over the next few weeks. Young children require families to provide diabetes management and teenagers should not be expected to undertake all their care independently. However, the eventual transition to independent self-management is some years off for Jade and adult involvement is imperative. A recent study demonstrated that mothers’ diabetes knowledge directly correlated with variability in insulin injection times and blood glucose parameters. Children whose mothers had better knowledge had less variability in insulin injection times, more frequent blood glucose testing, and lower HbA1clevels (Chisholm et al. 2007).

Jade may initially be in a ‘honeymoon’ period with respect to her insulin requirements. That is, she will still be producing her own insulin for possibly the next 6 months and, therefore, require only a small dose of exogenous insulin. For example, daily or twice daily insulin, basal analogue or a basal and bolus analogue twice daily should be sufficient. It is rare that insulin is required at this stage 4-5 times/day. It is unlikely that an insulin pump would be used initially given the complexity of the system, the sheer volume of information the family needs to learn, and the number of changes to lifestyle for the entire family. The duration of the ‘honeymoon’ period appears related to a number of factors. On the whole they generally last around 6-7 months. Shorter honeymoon periods appear related to being aged younger than 5 years at diagnosis, presenting in DKA at initial diagnosis, and having a longer duration of symptoms before diagnosis (Abdul-Rasoul et al. 2006).

At this time a social worker may also be of help to outline the type of financial supports that could be available to the family to assist them to manage Jade’s diabetes. Other issues that need to be addressed include contacting Jade’s school to outline the role and expectations of the school, Jade, and her family with respect to managing her diabetes. Blood glucose meters are available free of charge to children with type 1 diabetes in Australia. Many diabetes health professionals encourage people with type 1 diabetes to use meters that also test blood ketone levels, especially during illness. These meters are also useful in emergency departments to enable early diagnosis of ketoacidosis and faster treatment (Nauheim et al. 2006).

Often, after parents research diabetes via the internet and books, they realize that severe hypoglycemia can result in cognitive impairment. Not surprisingly, this can result in great anxiety for parents and may lead to keeping BGLs higher than desired. Such anxiety may or may not be eased when parents are taught to administer glucagon. There is sometimes an expectation that teaching staff at schools should be trained to administer insulin and glucagon. However, the most appropriate response to such requests is to provide school staff with:

  • information and skills for basic hypoglycemia care;
  • the knowledge to recognize when an ambulance should be called;
  • policies outlining where Jade’s insulin should be stored; and
  • policies outlining when she is to self-administer.

Following hospital discharge, close ongoing contact and additional education are required. It is well established that ongoing education in the early period following diagnosis and discharge is critical to determining both quality of life and clinical outcomes (International Society for Pediatric and Adolescent Diabetes (ISPAD) 2000). It can be a fine line between creating a relationship of co-dependence with the diabetes team and empowering the patients and their families. A whole additional range of areas need to be addressed including:

  • sport with insulin and carbohydrate adjustment
  • sick day management
  • adjusting insulin doses
  • sleepovers and camps
  • birthday parties and other festive eating.

However, not all newly diagnosed patients live geographically close to a multidisciplinary pediatric diabetes team, and the diabetes team needs to engage with other health providers to assist these families such as the general practitioner, adult diabetes educator, and pediatrician.

Longer-term issues will include how puberty affects glycemic control, how to manage diabetes once the ‘honeymoon’ ends and risk behaviors such as smoking, alcohol and illicit drug taking. When there is no endogenous insulin left, there is often far more variation in blood glucose levels from injected insulin. Therefore, the child is at increased risk of severe hyperglycemia and DKA. Months after the diagnosis of diabetes, the ‘novelty’ (if there really was ever a novelty) wears off for the patient and his/her family. They often want their previous life and lifestyle back, where they eat what they want and do what they want without the daily restrictions of type 1 diabetes.

Regular and ongoing involvement by a psychologist is vital. At each clinic visit Jade should have her height and weight plotted on a growth chart, which is an excellent additional marker to her general health and metabolic control (Silverstein et al. 2005). Thyroid function and coeliac antibodies should be measured if unexplained weight loss occurs.

Raised HbA1c may indicate more than just suboptimal blood glucose control. Researchers have identified a correlation between the rates of depression and high HbA1c levels (Hood et al. 2006). It may also be a ‘cry for help’ relating to other issues at home (see Chapter 8).

One thing to keep in mind, particularly for teenage girls with type 1 diabetes, is body image. Commencing insulin injections usually leads to an increase in weight. Over-treatment of insulin can cause significant weight gain, even obesity. If Jade experiences frequent hypos, and therefore eats a great deal more carbohydrate than she needs to correct blood glucose levels, and/or attains excellent control of her blood glucose levels, she may, for example be a size 10-12. Teenage girls are very perceptive about diabetes and insulin. Significantly many teenage girls with type 1 diabetes recognize that, if they take insufficient insulin and run their blood glucose levels high, such as between 20 and 30 mmol/L, their bodies will break down fat and protein for energy so that over time they may lose too much weight and achieve a dress size of 2-4. Significant weight loss is an unfortunate goal of many teenage girls regardless of whether they have diabetes or not, but diabetes gives them a way to achieve it.

Uncontrolled diabetes can also result in a delayed onset of puberty and skeletal maturation (Silverstein et al. 2005). Studies have demonstrated higher rates of both anorexia and bulimia in young girls with type 1 diabetes (Jones et al. 2000). It is very important that health professionals are aware of the language they use when educating and advising young people with diabetes. References to weight can have devastating results. During the middle to late teenage years, the psychologist may be the most integral health professional on the diabetes team.

Key points

  • The prevalence of diabetes is increasing globally and is linked to obesity.
  • Early diagnosis is important to improve health outcomes.
  • Type 2 diabetes is a slow progressive disease, complications are often present at diagnosis, and the symptoms may be vague and attributed to other causes.
  • Type 1 diabetes occurs less frequently than type 2 and usually occurs in young people, but it also occurs in older people.
  • Gestational diabetes increases the risk of type 2 diabetes.

References

Abdul-Rasoul M, Habib H, Al-Khouly M (2006) The ‘honeymoon phase’ in children with type 1 diabetes mellitus: frequency, duration and influential factors. Pediatric Diabetes 7: 101–107.

American Association of Clinical Endocrinologists (2003) Position Statement: Inpatient Diabetes and Metabolic Control (www.aace. com/newsroom/press/2006/index.php/r=20060201)

American Diabetes Association (2004) Nutrition principles and recommendations in diabetes. Diabetes Care 27(1): S26–S46.

Annon J (1976) Behavioural Treatment of Sexual Problems: Brief Therapy. Harper and Row, New York. Austroads (2006) Assessing fitness to drive: Austroads Guidelines for Health Professionals and Their Legal Obligations (2nd edn). APG56. Austroads, Sydney.

Bernstein L (2002) Post Menopausal Breast Cancer: Obesity and the Leptin Receptor. California Breast Cancer Research Program (www.cbcrp.org.research/PageGrant.asp/grant_id=1563).

Bethel MA, Sloan FA, Belsky D et al. (2007) Longitudinal incidence and prevalence of adverse outcomes of diabetes mellitus in elderly patients. Archives of Internal Medicine 167: 921–927.

Bosch J, Yusuf S, Gerstein HC et al. (DREAM Trial Investigators) (2006) Effect of ramipril on the incidence of diabetes. New England Journal of Medicine 355(15): 1551–1562.

Chiasson JL, Josse RG, Gomis R et al. (STOP-NIDDM Trial Research Group) (2002) Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP–NIDDM trial. Lancet 359: 2072–2077.

Chisholm V, Atkinson L, Donaldson C et al. (2007) Predictors of treatment adherence in young children with type 1 diabetes. Journal of Advanced Nursing 57(5): 482–493.

Chong J, Craid M, Cameron F et al. (2007) Marked increase in type 1 diabetes mellitus incidence in children aged 0–14 yr in Victoria, Australia, from 1999 to 2002. Pediatric Diabetes 8(2): 67–73.

Colagiuri S, Cull C, Holman R (UKPDS Group) (2002) Are lower fasting plasma glucose levels at diagnosis associated with improved outcomes? UK Prospective Study 61. Diabetes Care 25(8): 1418–1424.

Naunheim R, Jang TJ, Banet G et al. (2006) Point-of-care test identifies diabetic ketoacidosis at triage. Academic Emergency Medicine 13: 683–685.

Nissen S, Wolski K (2007) Effect of rosiglitazone on risk of myocardial infarction and death from cardiovascular causes. New England Journal of Medicine 356(24): 2457–2471.

Tenolouris N (2006) Overview of diabetes. Chapter 1 in Katsilambros N, Diakoumopoulou E, Ioannidis I et al. (eds) Diabetes in Clinical Practice. John Wiley and Sons, Chichester, pp 1–21.

Tuomilehto J, Lindström J Eriksson J et al. (Finnish Diabetes Prevention Study Group) (2001) Prevention of type 2 diabetes by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine 344: 1343–1350. United Kingdom Prospective Diabetes Study (UKPDS) 38 (1998) Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. British Medical Journal 317: 703–713.

World Health Organization (1999) Diagnosis and Classification of Diabetes Mellitus. WHO, Geneva.

Recommended reading

Dunning T (2003) Care of People with Diabetes. A Manual of Nursing Practice. Blackwell Publishing, Oxford.

Ganz M (ed) (2005) Prevention of Type 2 Diabetes. John Wiley andSons, Chichester.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #23

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK