Aside from screening for complications and achieving good glycemic control, another form of preventative medicine is immunization. Patients with T1DM are at increased risk of invasive Streptococcus pneumoniae infections. Due to this increased risk, children with T1DM qualify for broader pneumococcal immunization coverage. All children are recommended to receive the pneumococcal conjugate vaccine per the CDC Immunization Schedule (CDC et al., 2022b). In addition to the conjugate vaccine, children 2 years of age or older should receive the 23-valent pneumococcal polysaccharide vaccine. Rob is at risk for several complications, but he is not at risk for retinopathy in the immediate future, as this risk develops over time. Children with new-onset type 1 diabetes should be screened for thyroid disease, celiac disease, hypertension, and dyslipidemia soon after diagnosis and regularly thereafter. Rob is too young and has had diabetes for too short a time to be screened for nephropathy, retinopathy, or neuropathy, but these are chronic concerns related to his diagnosis. The best management is prevention, and patients should be counseled about complication prevention early in their diagnosis.
Healthcare Consideration: Approximately 17%–30% of patients with type 1 diabetes mellitus are also diagnosed with autoimmune thyroid disease. Shortly after diagnosis, children should be tested for antithyroid peroxidase and antithyroglobulin antibodies. Once the patient is normoglycemic and stable, thyroid-stimulating hormone concentrations should also be measured. If findings are within normal limits, repeat testing should occur every 1 to 2 years or sooner if signs or symptoms of thyroid dysfunction develop (ADA et al., 2022d). Case study: Rob Rob meets criteria for a diabetes diagnosis, and his mother is made aware. She is understandably overwhelmed and has many questions. She shares that her father-in-law has issues with his vision and asks if Rob is at immediate risk of developing complications. Question: What are complications that Rob could develop now and in the future, and what screening should be completed shortly after his
diagnosis? Discussion:
TYPE 1 DIABETES MELLITUS: MANAGEMENT
Goals of therapy Glycemic control, often monitored via HbA1c levels, is the goal of therapy for all patients with diabetes. Hemoglobin A1C approximates average serum glucose levels over a 3-month period and is a useful marker of treatment efficacy, along with daily glucose logs (ADA et al., 2022b). Strict glycemic control minimizes the risk of long-term complications but may increase the risk of hypoglycemia for patients at risk, especially young patients unable to identify and convey symptoms of hypoglycemia. The goal HbA1c should be set at <7% (estimated average plasma glucose <154 mg/dL) for most patients, but this goal should be individualized depending on the patient’s risk of developing hypoglycemia. For instance, young patients, typically those <6 years old, may have a goal HbA1c of <7.5% (ADA et al., 2022e). Achieving glucose control in young children is especially challenging, since development may impact metabolic processes. Glycemic control equates to minimized hyperglycemic periods and prevention of hypoglycemia. Chronic hyperglycemia increases risk of microvascular and macrovascular complications associated with diabetes. Hyperglycemia may progress to DKA, which is acutely life threatening and requires advanced management. Glycemic extremes, including DKA, may negatively impact brain development and cognition (Nevo- Shenker & Shalitin, 2021). Recent studies demonstrate alterations in brain structure and cognitive scores in pediatric patients with chronic hyperglycemia and in those with early onset diabetes. Several mechanisms are postulated, but the impact is Treatment: Insulin calculations and adjustments Glycemic control is achieved via administration of exogenous insulin along with optimized nutrition and physical activity. Since the advent of exogenous insulin, outcomes for patients with T1DM have changed dramatically (ADA et al., 2022d). As time progresses, regimens are fine-tuned to mimic physiologic insulin release, and technology is advancing to minimize manual intervention. Insulin requirements must be individualized for the patient, but general estimates can be made upon diagnosis. The typical total daily dose of insulin is weight-based, ranging from 0.4 to 1 unit/kg/day. For patients in whom the development of hypoglycemia is concerning, many providers opt to start at the lower end of the range and titrate up based on blood glucose trends, as needed. Of the total daily dose, approximately 50% is given as a basal dose with the remaining 50% as prandial
likely multifactorial. Severe hypoglycemia may result in seizures, loss of consciousness, or even death. Recent studies suggest these events may also impact cognitive development. Although T1DM’s impact on brain development may be worrisome for caregivers of newly diagnosed children, these findings can be used to enforce the importance of strict glycemic control throughout childhood and adolescence. Self-Assessment Quiz Question #2 As part of Rob’s workup, his hemoglobin A1c was measured, which resulted at 10%. You discuss that the typical goal is set at <7%, but some patients may require adjusted goals. Which of the following should be considered when setting a hemoglobin A1c goal? a. The patient’s eating habits. b. The patient’s ability to express himself. c. The caregiver’s level of education. d. The initial fasting plasma glucose level. Despite the known risks of poor glycemic control, recent data from a large registry of U.S. patients report that a goal HbA1c of <7% was only achieved by 17% of enrolled children and adolescents (Foster et al., 2019). This poor control persisted despite the increased adoption of new technology. Although these data may not be reflective of the total population, they signal that action should be taken to improve diabetes education and management in children. doses. Basal dosing of insulin is administered either via a long-acting formulation, which is given once or twice daily, or continuously using a rapid-acting formulation. These two methods mimic the natural release of insulin throughout the day and provide coverage during periods of fasting. Prandial insulin is administered at multiple points throughout the day to control blood glucose after meals and snacks. Ideally, prandial injections are administered about 15 minutes before a meal, as this timing best coincides insulin onset with food absorption; however, young children and picky eaters should receive insulin after meals and snacks to prevent an overdose. If a dose is calculated and administered to cover a full meal, but the child only eats half of the portion, they are at risk for hypoglycemia. Exact administration times will vary by regimen and the pharmacokinetics of the prescribed insulin.
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