for injection. Prior to use, the sterile water for injection must be injected into the glucagon vial. Still inserted, the syringe and vial should then be gently shaken until the powder is completely dissolved. Once clear in appearance, the reconstituted liquid should be withdrawn back into the syringe with any air bubbles expelled. Then the glucagon can be injected into the patient. After administration, to reduce the chance of choking, it is important to turn the unconscious person onto their side in case they vomit. Emergency medical help should be called as soon as possible for ongoing management. When the patient is awake and able, they should ingest a rapid-acting source of glucose to prevent future events.
Healthcare Consideration : All patients at risk for moderate to severe hypoglycemia should be prescribed glucagon. In a recent study of diabetes caregivers, users identified that intranasal glucagon was easier to use and prepare than injectable glucagon needing reconstitution (Settles et al., 2022). If patients qualify for a prescription, based on age and insurance coverage, intranasal glucagon may be a preferred option for hypoglycemia. If children experience hypoglycemia with altered mental status or multiple episodes of blood glucose levels <54 mg/dL, providers should consider modifying HbA1c goals to minimize hypoglycemic risk (ADA et al., 2022b). Other interventions for prevention include bedtime snacks, basal insulin adjustments throughout the day for patients receiving CSII, or increased frequency of glucose monitoring. Hybrid closed-loop systems in patients who qualify are also effective in decreasing frequency of hypoglycemia. strenuous activity may impact blood glucose levels, and monitoring is vital to prevent hypoglycemia or ketosis. Blood glucose should be measured before, during, and after exercise. Exercise-specific glycemic targets pre- and post-activity may be recommended to account for anticipated fluctuations in blood glucose levels. It is recommended to postpone exercise in patients with hyperglycemia or ketosis, as exercise may worsen these conditions. Specific targets may vary per patient, but in general, glucose levels above 350 mg/dL, moderate to large urine ketones, and β -hydroxybutyrate greater than 1.5 mmol/L are all indications to delay vigorous activity (ADA et al., 2022e). Continuous glucose monitoring is helpful during activity participation, and insulin pumps can be programmed to provide lower basal rates during and immediately following periods of exercise. Rapid-acting carbohydrates, such as fruit juice, candy, or glucose tablets, should be readily available during activities, preferably in serving sizes of 15 grams. When packing for trips away from home, it is recommended that extra supplies be packed in case of emergency. In addition to insulin supplies, rapid-acting carbohydrates, glucose, and a glucose monitor, it is recommended that the patient wear a medical identification card and carry phone numbers to contact the diabetes treatment team. For vacations and long-term trips, the CDC has many tips for travel (CDC et al., 2022a). Patients and their caregivers should ensure that they have enough supplies to last for the duration of the excursion. This may entail refilling prescriptions in case they are due to run out. The CDC (2022a) recommends patients buy travel insurance in case a flight is missed or medical care is needed while away. For long flights, it is recommended to schedule an appropriate meal or carry-on food and snacks that can be counted or used for hypoglycemia. Diabetes supplies should be taken in a carry-on bag, since checked bags may be stored in low temperatures that can alter the stability of the insulin. A letter from a physician stating that the patient has diabetes and needs specific supplies may be helpful for security at the airport and can ensure an exemption from the maximum fluid limits for rapid-acting carbohydrates, such as juice. Finally, an insulin pump or CGM should not be taken through the X-ray machine, as this may damage the devices. Patients should request a hand inspection as alternative screening. While at their destination, patients should be mindful of time differences and changes in food intake that may alter glucose control.
Other considerations Medical nutrition therapy is an essential aspect of type 1 diabetes care in the pediatric patient (ADA et al., 2022e). An experienced registered dietitian should be involved from diagnosis to counsel the patient and their family on nutritional care, including carbohydrate counting. The ability to read a food label, accurately weigh macronutrients, and calculate grams of carbohydrates per meal is essential for insulin dosing and glycemic control. In a study of children with diabetes, use of dietary strategies, including tracking calories and counting carbohydrates, was associated with a lower mean HbA1c level (Sauder, 2020). This effect was sustained for more than 10 years postdiagnosis. Although the study relied on self-reported dietary strategies, its results demonstrate significant impact on glycemic control, independent of medication therapy. While there is no specific diet that is recommended for children with T1DM, there are several recommendations to follow. Children should eat a well-balanced, nutritious diet with a variety of foods, including fruits and vegetables. Ideally, children should eat three meals daily and up to two snacks in between meals. A regular diet helps to maintain glucose control, as skipping meals can result in hypoglycemia. Unhealthy foods, such as cookies, candy, and soda, should be consumed in moderation, and other carbohydrate sources should be prioritized. Fiber aids in slowing the absorption of sugar, which can help prevent spikes in blood glucose levels. Along with fiber, fluids, especially water, are important for hydration, digestion, and prevention of constipation. While a healthy diet is recommended in any patient with T1DM, this is especially important for children who are growing and developing. Sugar alcohols, which are typically used to create “sugar-free” foods, are not necessarily carbohydrate free and have adverse effects, including diarrhea, which may impair nutrient absorption. It is important to counsel patients and their caregivers to read nutrition labels and limit consumption. In addition to improved glycemic control, dietary interventions aid in the maintenance of a healthy body mass index (BMI), which is helpful in the prevention of diabetes-related complications, in conjunction with regular physical activity. The recommended goal for children with type 1 diabetes is 60 minutes of aerobic activity, ranging from moderate intensity such as dancing to vigorous intensity such as running, plus muscle- and bone-strengthening activities 3 days per week (ADA et al., 2022e). While routine exercise is important,
TYPE 1 DIABETES MELLITUS: PSYCHOLOGICAL BARRIERS TO SUCCESS
Providers should regularly assess patients for psychosocial distress, and screening for disordered eating should begin between 10 and 12 years of age (ADA et al., 2022e). A recent study found that patients with insulin nonadherence or elevated HbA1c were also more likely to have elevated psychosocial variables, including depression and anxiety (Brodar et al.,
2021). In this study, of the patients who screened positive for at least one psychosocial variable, only 27.2% screened positive for depressive symptoms. This highlights the importance of broadening the scope of evaluation beyond depression. More than half of the adolescents in the study screened positive for low intrinsic motivation to manage their diabetes, which
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