Diabetes Type One in the Pediatric Patient

Diabetes is a very complex disease that effects all the system of the body. Often people only think about blood sugar when the think of diabetes, nut this disease is so much more complicated than just controlling blood sugar. This is especially true in the pediatric population. These youngsters are not old enough or mature enough to understand this complex disease and rely on the parents to help them manage this disease (Perry, 2010).

The pathophysiology of diabetes type one is a very complex process in which the body cannot metabolize glucose with insulin from an outside source (Hinkle, Brunner, Cheever, & Suddarth, 2014).

The islet cells in the pancreas do not produce insulin, therefore making it impossible for the glucose to enter cells (Hinkle, Brunner, Cheever, & Suddarth, 2014). If glucose cannot enter cells, then the cell cannot produce energy efficiently.  If glucose is not available a metabolic imbalance will take place. This metabolic abnormality will ultimately result in diabetic ketoacidosis (DKA) (Hinkle, Brunner, Cheever, & Suddarth, 2014).  This is a condition that can development in the absent of insulin therefore causing the body not to be able to use glucose. Signs and symptoms of DKA include, excessive thirst, excessive urination, nausea, vomiting, abdominal pain, weakness, fatigue, shortness of breath, fruity breath, and confusion (Hinkle, Brunner, Cheever, & Suddarth, 2014). Patients will most often present will hot and dry skin and may also appear flushed. Parents will often report that they noticed that the child was acting like their self and that the symptoms came on slowly (Hinkle, Brunner, Cheever, & Suddarth, 2014).  This unfortunately is how most type one diabetics are diagnosed. There is a somewhat sudden onset and a trip to the emergency department and parents are told that their child is in fact diabetic (Hinkle, Brunner, Cheever, & Suddarth, 2014).

The etiology of type one diabetes is not actually known. It is known though that many different factors can contribute to the development of type one diabetes (Hinkle, Brunner, Cheever, & Suddarth, 2014). It is thought that type one diabetes is cause by some genetic factor or that some viruses cause damage to the pancreas, Autoimmune causes are also thought to be a potential factor in the development of type on diabetes. No matter the cause of the disease the result is the same, the pancreas does not produce insulin (Hinkle, Brunner, Cheever, & Suddarth, 2014).

Type one diabetes is a worldwide disease, there are no hot spots and no one population is immune from its effects (Maahs, West, Lawrence, & Mayer-Davis, 2013).  The World Health Organization initiated the DIAMOND Project to study the epidemiology of type one diabetes in 1990 (Maahs, West, Lawrence, & Mayer-Davis, 2013). This project was formed to study the implications of diabetes type one world-wide. Initial numbers reported in child fourteen years or younger to be nineteen thousand one-hundred sixty-four case from a population of seven-five point one million children (Maahs, West, Lawrence, & Mayer-Davis, 2013). These numbers reflect an incidence rate of four-point five percent of the worlds population of children. The lowest number of cases was report in China with 0.1 per 100,000 per year and the highest in Venezuela of 36.5 per 100,000 (Maahs, West, Lawrence, & Mayer-Davis, 2013).  The children in the U.S, that were used for the study came from Pennsylvania, Alabama, and Illinois reported incidences of 10??“20 per 100,000 per year. Almost half of the European populations reported incidence between 5 and 10 per 100,000 per year with the remainder having higher rates (Maahs, West, Lawrence, & Mayer-Davis, 2013).  In the United States, a similar project was used to measure the epidemiology of type one diabetes the SEARCH for Diabetes in Youth (Maahs, West, Lawrence, & Mayer-Davis, 2013).  This study has been designed to identify incident and prevalent rates of diabetes among individuals less than 20 years of age. This was study designed with a goal of estimating the incidence and prevalence of diabetes in the U.S. by age, sex, race, and ethnicity. In 2002??“03, 1,905 youth with type one diabetes were diagnosed in the SEARCH study (Maahs, West, Lawrence, & Mayer-Davis, 2013).  This was from a population of more than 10 million person-years under this study. A person year is the number of people and how much time each person spends in the study, this is like man hours in the work place. Rates were highest in non-Hispanic white children and adolescents as compared to other race or ethnicities and were slightly higher in females as compared to males (RR, 1.028; 95% CI, 1.025??“1.030) (Maahs, West, Lawrence, & Mayer-Davis, 2013). The incidence rate of type one diabetes in 2002??“03 peaked in the age groups 5??“9 years and 10??“14 years and incidence per 100,000-person years by age group were as follows: 0??“4 years, 14.3; 5??“9 years, 22.1; 10??“14 years 25.9; 15??“19 years, 13.1 (Maahs, West, Lawrence, & Mayer-Davis, 2013).  The study also notes that the type one diabetes incidence rates from the SEARCH study are higher than previous US reports from Allegheny County 13, and from Philadelphia county14 for non-Hispanic white children and adolescents, but lower than that for African American children adolescents (Maahs, West, Lawrence, & Mayer-Davis, 2013).  While the SEARCH rates for Hispanic youth are like those reported for Puerto Rican children in Philadelphia14,15 but higher than that reported in Colorado in the same ethnicity in the 1980s. For non-Hispanic whites, the incidence rate of type one diabetes in SEARCH was greater than 20 per 100,000-person years as compared to 16.5 per 100,000 in Allegheny County in the early 1990s (Maahs, West, Lawrence, & Mayer-Davis, 2013).  However, techniques differ by study and must be considered when comparing incidence rates by study. In the SEARCH study the overall prevalence rate was 2.28 per 1000 youths surveyed under the age of 20. Which is 5,399 case in a population of 3.5 million (Maahs, West, Lawrence, & Mayer-Davis, 2013).

The effects of growth and development in children that have type one diabetes is an ongoing area of study. Insulin being a hormone and its most commonly known effect is to promote to utilization of glucose by being the key to glucose entering the cells. Insulin not only enables glucose to enter the cells it interacts with other hormones int the body (Giannini, Mohn, & Chiarelli, 2014). One hormone is growth hormone or GH (Giannini, Mohn, & Chiarelli, 2014). There has been a large amount of date that suggest insulin is main regulator of growth hormone. Insulin regulates GH receptors in the liver and regulates GH synthesis by modulating the GH post receptor events (Giannini, Mohn, & Chiarelli, 2014).  Low portal insulin concentrations, which are documented in children with type one diabetes results in hyper secretion of GH. The HG is there but, it is not able to bind to protein because of the lack of insulin, this is unlike a child who has normal levels of insulin in the bloodstream (Giannini, Mohn, & Chiarelli, 2014). This however does not usually have a great effect on growth, especially when treatment with insulin is not delayed. However, there are rare cases of major complications. Hepatomegaly, growth and puberty delay, and the presence of elevated transaminases and serum lipids levels. However, given the advancement in insulin treatment serous complications are becoming rarer than in years past (Giannini, Mohn, & Chiarelli, 2014).

The most common laboratory testing used to diagnose this condition are CBC, CMP, urinalysis, ABG, and anion gap will be checked (Hinkle, Brunner, Cheever, & Suddarth, 2014). Laboratory results most indicative of DKA would be, blood glucose greater than 250 hyperkalemia, hyperglycemia, increased hemoglobin and hematocrit if patient is dehydrated, anion gap greater than 10, serum bicarbonate less than 18, arterial blood PH 7.3 or less (Hinkle, Brunner, Cheever, & Suddarth, 2014). The urinalysis will also show positive ketones, increased specific gravity and maybe positive for glucose. CBC is used to get an overall idea about the blood cells make up. If the patient is in DKA, which is often how this disease is first diagnosed the patient is most likely dehydrated and the hemoglobin and hematocrit are most likely elevated (Hinkle, Brunner, Cheever, & Suddarth, 2014). CMP will measure the blood glucose level more accurate that a capillary blood glucose finger stick. BUN and creatinine levels will also be taken from the CMP, this is a great tool for measuring hydration status and renal function. Cues about blood PH can be taken from blood chemistry testing as well. If the C02 and sodium bicarbonate will give addition indicator of blood PH is no arterial blood gas studies are available (Hinkle, Brunner, Cheever, & Suddarth, 2014). Anion gap is a very definitive diagnostic test used to diagnose DKA. Lactic acid levels will also be draw as another measurement of overall chemistry. The urinalysis will show ketones, glucose, and possibly proteins if the patient is in DKA (Hinkle, Brunner, Cheever, & Suddarth, 2014).

Management of type one diabetes in children can be a very challenging endeavor, especially in younger children as rely heavily on the help of other to help them manage their disease. Medicine that is utilized for type one diabetic is insulin. There are many types of insulins that can be utilized for the management of type one diabetes (Perry, 2010). Rapid, short, intermediate, and long acting insulins are all medications that can be utilized for the management of blood sugar. (Perry, 2010).  Long acting insulins, such as Lantus or Levemir are given usually one a day but in some case can be given twice daily. These insulins mimic the bodies natural insulin production more than other type of insulin (Perry, 2010).   These insulins have not peak and have a duration of about twenty-four hours. Rapid actin insulting is used for before meals to help keep blood glucose levels from rising after food is consumed. Examples of rapid acting insulins are Humalog and Novolog (Perry, 2010).   This medication is typically used on a sliding scale basis. These can also be used in an insulin pump. An insulin pump is a device that delivers insulin via a small canula type device that is implant into the skin and stays in plane via an adhesive (Perry, 2010).   These are typical changed every 24-72 hours.  Intermediate insulin is another tool that can be used to help regulate blood glucose levels. These medications are typically given twice daily, one dose before breakfast and one dose before dinner. Examples of this would be NPH insulin (Perry, 2010).

Nursing management of diabetes type one can be challenging, especially if the patient is not compliant with diet and or medication regimens. Education of the patient, and in the pediatric population the parents is key to improving outcomes for the patient. For example, and eight-year-old is not capable of handling these on their own. The parents and family must be involved to make the treatment and management of the disease successful (Lasecki, Olympia, Clark, Jenson, & Heathfield, 2008).  The child will require some guidance and at school, and the school nurse would be an integral part in help the child to succeed (Tolbert, 2009). This would ring especially in the newly diagnosed child. Occupational therapist could also help in the transitioning of a child's lifestyle after a diagnosis. Kids that go a camp that is especially designed for kids with diabetes have been shown to be more successful in treatment and lead happy healthier lives (Cheung, Cureton, & Canham, 2006).

Dietic and nutrition counseling would be especial necessary to the success of the treatment and a positive patient outcome.

The Prognosis of type one diabetes depends on how the disease is managed. Before the discovery of insulin is disease was fatal within a short time frame of a few weeks to months (Copenhaver & Hoffman, 2017). With discovery of insulin this disease is manageable. Even with modern treatment the average life expectancy of people with diabetes is ten year less than that of healthy people who do not have diabetes (Copenhaver & Hoffman, 2017). However, with tight glucose control the risk of neuropathic complication is grater reduced. These patient despite tight glucose control still have a ten times more likely chance of cardiovascular complications from the disease (Copenhaver & Hoffman, 2017).

Health promotion activities and education needs, and children have diabetes is very complex. Education concerning insulin administration, regular exercise, consistent meal times, and what to do when the child is ill (Perry, 2010). Consult to outpatient diabetes education classes in newly diagnosed patients will help the child and family to be successful in the management of type one diabetes (Tolbert, 2009). The nurse at the child school can also help the child transition to a life with diabetes in the newly diagnosed, or even a child who has had this disease for some time (Tolbert, 2009). The child's pediatrician is a great resource to assist with this disease if there is no endocrinologist available to the child because of geographic location or financial limitations. More specifically the child and the parent need to be taught how check the child's glucose level using a finger stick (Perry, 2010). Insulin administration education should be broken down in to very simple explanations (Perry, 2010). Demonstrating how to inject into an orange is an effective way to teach the child and parents alike. Healthy meal planning and consistency of meals and carbohydrate intake are vital to managing glucose (Perry, 2010). Additionally, education the family on how to manage sick days is very important since this is when a lot of diabetics run into trouble (Perry, 2010).

References:

1. Cheung, R., Cureton, V. Y., & Canham, D. L. (2006). Quality of Life in Adolescents With Type 1 Diabetes Who Participate in Diabetes Camp. The Journal of School Nursing,22(1), 53-58. doi:10.1177/10598405060220010901
2. Copenhaver, M., & Hoffman, R. P. (2017, October). Type 1 diabetes: Where are we in 2017? Retrieved November 27, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682377/
3. Giannini, C., Mohn, A., & Chiarelli, F. (2014). Growth Abnormalities in Children with Type 1 Diabetes, Juvenile Chronic Arthritis, and Asthma. International Journal of Endocrinology,2014, 1-10. doi:10.1155/2014/265954
4. Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarths textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins.
5. Lasecki, K., Olympia, D., Clark, E., Jenson, W., & Heathfield, L. T. (2008). Using behavioral interventions to assist children with type 1 diabetes manage blood glucose levels. School Psychology Quarterly,23(3), 389-406. doi:10.1037/1045-3830.23.3.389
6. Maahs, D. M., West, N. A., Lawrence, J. M., & Mayer-Davis, E. J. (2013). Epidemiology of Type 1 Diabetes. Retrieved November 27, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682377/
7. Perry, S. E. (2010). Maternal child nursing care. Maryland Heights, MO: Mosby Elsevier.
8. Tolbert, R. (2009). Managing Type 1 Diabetes at School: An Integrative Review. The Journal of School Nursing,25(1), 55-61. doi:10.1177/1059840508329295

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