In the early weeks to months postdiagnosis, children with T1DM may experience an unpredictability in their blood glucose levels. This is likely secondary to what is referred to as the “honeymoon phase” in which the pancreas still secretes some insulin (Zhong et al., 2020). This may make early insulin dosing challenging, and blood glucose levels should be closely monitored to prevent hypoglycemia. Patients and their caregivers should be educated that this phase is not indicative of the patient’s pancreas recovering. Eventually, the phase will end, and patients will become more completely dependent on exogenous insulin. Throughout the course of the child’s life, the insulin regimen will need to be routinely evaluated and modified. Adjusting an insulin regimen entails reviewing the patient’s blood glucose trends and identifying outlying values. Based on these trends, an adjustment in either basal insulin, ISF, or ICR can be determined. Some patients even require meal-specific ratios depending on the time of day. Insulin regimens should be individualized, and, especially with a growing pediatric patient, will need to be adjusted continuously over time. As a general rule, basal insulin needs adjustment if the patient’s overnight and fasting blood glucose is consistently out of range. Insulin sensitivity factor and ICR values may need adjustment if postprandial insulin is out of range. This may even require a meal-specific adjustment. For instance, if only the patient’s lunchtime preprandial glucose is consistently elevated, adjustments may be required for breakfast insulin dosing. Finally, if a patient’s preprandial blood glucose values are appropriate, but their HbA1c is elevated, postprandial blood glucose values may need to be measured to assess this discrepancy. Individuals who experience early morning hyperglycemia must undergo further evaluation prior to insulin dose adjustment. This hyperglycemia may either be secondary to the “Somogyi effect” or the “dawn phenomenon” (Peng et al., 2022). The Somogyi effect is an elevation in blood glucose in response to a preceding episode of hypoglycemia. This likely occurs when patients are hypoglycemic in the late evening, and subsequent Treatment: Insulin dosage forms and administration There are three major categories of insulin delivery methods available on the market for pediatric patients. ● Insulin vials for administration via insulin syringes ● Insulin pens ● Insulin vials for administration via insulin pump Choosing between the above delivery systems will depend on commercial availability, insurance coverage, and patient dexterity (ADA et al., 2022c). Utilizing the first and oldest method, patients or their caregivers withdraw insulin from a vial using a needle and syringe for subcutaneous injection. Syringes with attached needles are preferred to enhance dosing accuracy (Frid et al., 2016). Care must be taken to appropriately measure the dose and ensure no air bubbles are present. Insulin vials should be inspected prior to use to ensure there are no precipitates. Best practice dictates drawing up air into the syringe at a volume equivalent to the intended dose. After insertion of the needle into the vial, the air should then be pushed from the syringe into the vial before withdrawing the insulin dose. Then the injector should invert the vial and withdraw insulin into the syringe. If air bubbles appear in the syringe, tapping the syringe should help move them to the end for expulsion. If air bubbles are present upon injection, the patient may be underdosed. Insulin syringes differ from other medication syringes, as the marking are in units rather than milliliters. This enables more precise dosing, but it is important to make patients aware that other syringe types are not interchangeable or equivalent. Insulin vials are typically refrigerated until opened and then stored at room temperature while in use for a maximum of 30 days or per manufacturer guidance. A new insulin vial should be allowed to warm to room temperature prior to administration to reduce potential for pain upon injection. On a hot day, insulin should be stored in an insulated container, such as a lunch box, but care should be taken not to accidentally freeze insulin by placing it on ice.
hyperglycemia is noted in the early morning hours. Alternatively, the dawn phenomenon occurs spontaneously in the absence of nocturnal hypoglycemia. This phenomenon is part of typical diurnal changes and thought to be related to an abnormal rise in growth hormone prior to waking. This leads to a rise in blood sugar that cannot be naturally counteracted with endogenous insulin in patients with T1DM. Monitoring overnight blood glucose values is essential to distinguish between these two underlying pathologies. Once identified, appropriate insulin dose adjustments can be made. For patients experiencing the Somogyi effect, the evening dose of insulin may need a reduction to prevent nocturnal hypoglycemia. For those experiencing the dawn phenomenon, an adjustment in the dose or timing of basal insulin may be required. Another consideration is that insulin regimens are designed for patients functioning in their average day-to-day life. If patients experience illness or other stressors, the regimen may need a temporary adjustment. When a child becomes sick, blood glucose levels can become difficult to manage. Intake of food and fluids typically decrease, and stress on the body may induce metabolic changes. Maintaining hydration and ingesting carbohydrates are vital in prevention of ketosis and DKA. It is important to more frequently monitor blood glucose levels during this time to treat hyperglycemia and prevent hypoglycemic episodes. Patients should have a predetermined “sick day plan” in the event of illness with explicit instructions for management. This plan should include frequency of blood glucose monitoring, instructions for fluid and carbohydrate intake, and guidance on when to seek help from a healthcare professional. If complications develop, patients may need to see their doctor or go to an emergency department for higher-level management. Concerning signs and symptoms include moderate to high ketone levels in the urine, multiple hypoglycemic episodes, severe vomiting or diarrhea, or altered mental status. Self-Assessment Quiz Question #6 Rob is receiving insulin glargine for his basal dose once daily and insulin lispro for prandial doses. After a few weeks of logging his blood glucose values, he returns for a follow-up visit. His mother reports adherence with the prescribed regimen, but the preprandial dinnertime values are consistently high. All other values are usually in an acceptable range. Which of the following insulin doses may need adjustment? a. Basal insulin glargine dose. Insulin pens work similarly, but the patient does not need to withdraw the dose into a syringe. Instead, the syringe and insulin supply are combined into a single device. First, the pen must be primed to ensure unobstructed flow and complete delivery of the desired dose. This is accomplished by dialing the dose to a small volume (i.e., 2 units) and pushing the thumb depressor until at least one drop of insulin appears. After priming the pen, the desired dose is dialed and directly injected via an attached subcutaneous needle. As with syringe injections, a new needle must be used for each injection. While many patients find the insulin pens simpler to use, they are not always affordable or accessible. b. Breakfast-time prandial insulin lispro dose. c. Lunch-time prandial insulin lispro dose. d. Dinner-time prandial insulin lispro dose.
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Book Code: AUS3024
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