and education process. Lastly, contact dermatitis is possible in patients with susceptible skin. It is possible to perform patch testing prior to use in children with tape sensitivities (ADA et al., 2022c). There are now two types of insulin pumps that are paired with CGM devices (ADA et al., 2022d). The first type enables suspension of insulin if below threshold glucose levels are detected or predicted. The second type is a hybrid closed-loop system, also referred to as an automated insulin-delivery system. Closed-loop systems require minimal input from the user, and insulin is delivered in a more automated manner. This technology pairs CGM with insulin pumps and automatically adjusts insulin doses in response to CGM data using an algorithm. Current systems still require entry of carbohydrates as well as manual adjustments for exercise (ADA et al., 2022c). A single-center study followed over 100 pediatric patients on automated and nonautomated CSII therapy for 1 year (Bombaci et al., 2022). This study demonstrated superiority of glycemic control with automated hybrid closed-loop systems compared to other methods of CSII therapy. A similar study demonstrated improved glycemic control and diabetes-specific quality of life (Abraham et al., 2021). As this technology is improved to be more discreet and comfortable to wear, these devices may be incorporated into pediatric diabetes care to limit the burden of manual glycemic control. Case study: Lucy Lucy is interested in trying an insulin pump to minimize the number of insulin injections required throughout the day. After discussing her options and reviewing her insurance coverage, she is prescribed a hybrid closed-loop system insulin pump, paired with a continuous glucose monitor. Question What are benefits of this system, as compared to basal–bolus Insulin pumps, especially those paired with continuous glucose monitors, offer many benefits and simplify diabetes Hypoglycemia Hypoglycemia, a life-threatening adverse event associated with insulin therapy, must be promptly detected and treated (ADA et al., 2022b). Early symptoms include irritability, shakiness, confusion, and hunger. If unrecognized or untreated, these symptoms can progress to loss of consciousness, seizure, and death. Young children are especially vulnerable to developing more severe symptoms, as they often have hypoglycemia unawareness. In a conscious patient, the preferred treatment of hypoglycemia (blood glucose <70 mg/dL) is administration of 15 to 20 grams of glucose or an equivalent, easily digested carbohydrate. Examples include: ● Glucose tablets (~3 to 4 tablets) injections? Discussion Evidence-based practice! A recent study compared the effectiveness of honey, fruit juice, and sugar cubes as primary treatment of hypoglycemia in children and adolescents with type 1 diabetes mellitus (Erbas et al., 2020). Each treatment was administered at equal carbohydrate doses based on severity of hypoglycemia. Honey and fruit juice resulted in recovery of hypoglycemia 15 minutes postingestion at a rate of 95% and 98%, respectively. Sugar cubes resulted in a recovery rate of 84.7% at 15 minutes postingestion. This difference was found to be statistically significant and may aid in selection of hypoglycemia treatment. ● Glucose gel (~1 tube) ● Fruit juice (~4 ounces) ● Skittles (~15 pieces) ● Honey or syrup (1 tablespoon)
Evidence-based practice! Many caregivers of children with type 1 diabetes mellitus struggle with a fear of hypoglycemia, which can greatly impact quality of life. A recent trial evaluated the impact of a continuous glucose monitor (CGM) with a low glucose suspend feature (Verbeeten et al., 2021). Intervention with a CGM significantly reduced fear of hypoglycemia, as measured via standard questionnaires. Interestingly, the decline in fear did not correlate with CGM adherence. As previously discussed, illnesses and other stressors may require increased blood glucose monitoring. In patients who are ill, including vomiting, or in patients with blood glucose readings >300 mg/dL, it is recommended to check urine ketones. When there is a deficiency in insulin, the body uses lipids for energy rather than glucose. This produces ketones, which are byproducts of fatty acid metabolism, and accumulation of ketones may lead to DKA (Lapolla et al., 2020). In DKA, urine ketones are typically moderate or large positive (≥2+). This result warrants a call to a physician’s office for further instruction. Ketones are generally cleared through reinstitution of insulin treatment but may require hospitalization if patients progress with life-threatening symptoms, including dehydration and mental status changes. Fluids should always be encouraged to help clear ketones and to maintain adequate hydration. management. Studies demonstrate improved diabetes-specific quality of life, superior glycemic control, and reduced incidence of hypoglycemia. These are all potential benefits that should be discussed with Lucy and her mother when making the switch in management. Although prandial insulin doses do not require separate injections, patients still must perform carbohydrate counting and insulin sensitivity factor/insulin-to-carbohydrate ratio dose calculations. As simplified as this method of management may be, effective treatment still relies on user adherence to therapy. Compliance with the insulin pump should be enforced to maximize the benefit of this intervention. Carbohydrate sources with a concomitant lipid component, such as candy bars, should be avoided, as these foods may result in a delayed response secondary to prolonged intestinal absorption (Erbas et al., 2020). After 15 minutes, a blood glucose level should be repeated. If persistently low, treatment with an addition 15 to 20 grams of glucose should be repeated. Once the hypoglycemia is resolved, the patient should eat a meal or snack to prevent future hypoglycemic episodes. Glucagon should be prescribed for all pediatric patients at risk of moderate to severe hypoglycemia, defined as blood glucose <54 mg/dL (ADA et al., 2022b). Glucagon works via stimulation of adenylate cyclase, which increases cyclic adenosine monophosphate. This mechanism results in hepatic glucogenolysis and gluconeogenesis and, therefore, increases blood glucose levels without ingestion of exogenous glucose. Glucagon is available in multiple dosage forms. ● Glucagon powder requiring reconstitution for intramuscular injection; this dosage form requires extra training and equipment ● Ready-to-inject subcutaneous glucagon ● Intranasal glucagon: Although a less invasive method of administration, this dosage form is only FDA-approved in patients 4 years of age and older Dosing of glucagon varies depending on patient age, weight, and dosage form. Whenever possible, caregivers should be provided with a ready-to-use formulation. If required, the glucagon powder for reconstitution necessitates preparation prior to administration. The emergency kit comes with a vial of glucagon powder and a prefilled syringe containing sterile water
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