Paediatric Diabetes Update - Dr Jan Fairchild Paediatric Endocrinologist May 2017 - Women's and Children's Hospital

Paediatric Diabetes Update

Dr Jan Fairchild
Paediatric Endocrinologist
May 2017

Australian T1D Prevalence (0-14yrs)
> Prevalence 1/720 children (6,091children)
   •   80 new cases per year at WCH
> 90% have T1D
> Peak age for onset 10-14yrs
   •   but can occur at any age from 6months
> M=F
> No difference across SES groups
                           (AIHW Data 2013)

                                        Women's & Children's Hospital

Pathogenesis

Genetic predisposition

Environmental trigger/s

Autoimmune process
   • T cell mediated destruction of β cells

Type 1 diabetes
   • No current intervention available to halt the
     autoimmune process and prevent T1D, but
     multicentre trials at different stages

                             Women's & Children's Hospital

Pathogenesis

               Women's & Children's Hospital

Classic presentation of T1Diabetes

> 2-6 week history of polyuria, polydipsia,
  weight loss and excessive tiredness
> Bed wetting very common
> Usually no-one else in the family
  with diabetes

> If DKA develops:
   • Vomiting, abdominal pain
   • Breathing difficulties
   • Reduced consciousness

                                Women's & Children's Hospital

Misdiagnosis remains common
> Newly diagnosed diabetes in children is a
  serious and potentially life threatening condition

> Misdiagnosis remains common at 1st
  presentation especially in young children
   • Polyuria - ? Urinary tract infection
   • Bed wetting or polydipsia - ? Behavioural
   • Vomiting / abdominal pain - ? Gastroenteritis or
     acute abdomen
   • Breathing difficulties - ?Asthma or pneumonia

                               Women's & Children's Hospital

Diagnosis easy if you think of it!
> If symptoms of diabetes present - check
  fingerprick BGL or urine glucose
> If fingerprick BGL >11mmol/L (or >7mmol/L fasting)
   or if urine glucose positive, refer to hospital
   emergency department immediately
> Don’t send to pathology or wait for fasting bloods as
  this delays treatment. No indication for OGTT

        Fingerprick blood ketones a useful triage tool

              Urine Ketones   Blood Ketones (mmol/L)

              negative        1.5
    • Optium meter checks blood glucose and blood ketones
    • If moderate to large ketones – need to assess for DKA

                                          Women's & Children's Hospital

Diabetes awareness campaigns
     reduce DKA rates
> Most GPs will very rarely see a child with 1st
  presentation of diabetes, but it is such an
  important diagnosis to make as early diagnosis
  and referral will prevent diabetic ketoacidosis
  (DKA) and potentially save lives

> Diabetes awareness campaigns targeting GPs
  and schools have shown dramatic reduction in
  DKA rates1,2 and led to the development of the
  ISPAD DKA prevention resources which are
  freely downloadable www.ispad.org

1.Vanelli et al Diabetes Care 1999
2. King et al Pediatric Diabetes 2012   Women's & Children's Hospital

Early referral will prevent DKA

ISPAD posters freely available for the waiting room
www.ispad.org                    Women's & Children's Hospital

Is it Type 2 Diabetes?
            > T2D  Consider T2D if risk factors present
                    >10yrs
                    Overweight/Obese (85%)
                    Family history T2D (>75%)
                    Acanthosis Nigricans
                    Mild symptoms generally but ketonuria in 33%
                    High risk ethnic groups

Diabetes type   10-14yrs         15-19yrs
AIHW 2012       All (Indigenous) All (Indigenous)

Type 1          87.9% (53.1%)    64.3% (32.8%)

Type 2          7.2% (44.6%)     30.5% (66.4%)
                                                    Women's & Children's Hospital

Morbidity and Mortality in DKA

> DKA is the most common cause of diabetes
  related deaths in childhood and
  adolescence

> Most deaths in DKA are due to cerebral
  oedema
       occurs in 0.3-1% of cases of DKA
       typically occurs 4 -12 hours after treatment is initiated,
          > but may occur before treatment has begun or
             anytime during treatment.
       aetiology and pathophysiology is poorly understood
       mortality rate 20-25%, significant morbidity in
        survivors

                                      Women's & Children's Hospital

Frequency of DKA and precipitating
factors
> New onset T1D ~25% (15-70%)
   • incidence higher in younger children  Established T1D is 1-10 / 100 person years

   • Insulin omission the cause in most cases
        risk increased if poor metabolic control, previous DKA,
         peripubertal or adolescent girls, pyschosocial problems

   • Failure to follow sick day or pump delivery failure
     guidelines
        Intercurrent infection is seldom the cause if properly
         educated about sick day management and 24 hr
         diabetes helpline available

                                    Women's & Children's Hospital

Children on insulin pumps at
          increased risk of ketosis
> All vomiting in a child on an insulin pump
  should be considered due to ketosis from
  interrupted insulin delivery (blocked delivery
  set) until proven otherwise!

> Blood ketone testing will determine the
  appropriate action                                               Vomiting
         If no ketones present correct with pump and
                                                                     =
          monitor                                                   Ketones
         If ketones present do not correct with the
          pump, give an injection and change set
         Families have written instructions for
          injections doses

> DKA should not occur if monitoring
  regularly and following sick day protocols
         Insulin pen must be available at all times

                                                       Women's & Children's Hospital

Key points: Diabetic Ketoacidosis
> Rapid deterioration common in children
  with newly diagnosed T1D
   • Urgent referral to Emergency Department
   • Phone Paediatric Endocrinologist if unsure
     (WCH Switchboard 08- 8161 7000)

> Children are not small adults
   • Need to recognise physiological differences
     between child and adult, especially with
     regard to fluid management
   • Follow Paediatric DKA Protocol
     http://cger.cywhs.sa.gov.au/cgu/clinical_guidelines/cywhs/dka.html

                                                Women's & Children's Hospital

Contemporary T1D management
what has changed?
1960 -1990                 2010 - 2017
> 1-2 injections per day   > Multiple daily injections or
> Aggressive therapy         pump therapy
  unsafe and of            > Continuous glucose
  unknown benefit            monitoring now
> HbA1c 9-14%                Government funded
> Long term diabetes       > HbA1c target 6.5-7.5%
  complications evident    > Adults who had
  in adolescence             successful intensive
                             management have low
                             risk of complications

                            Women's & Children's Hospital

Impact of a decade of changing
 treatment in children with T1D

Severe Hypoglycaemia            Mean HbA1c

                       Bulsara et al. Diabetes Care 2004
                                   Women's & Children's Hospital

Goals of T1D management
> Avoiding severe hypoglycaemia and
  diabetic ketoacidosis

> Maintaining optimal glucose control
  • BGL targets pre and post meal
  • HbA1c targets
  • Minimising glucose variability

> A happy, well-adjusted child
  …and family!

                          Women's & Children's Hospital

Intensive therapy (MDI / Pumps)
now recommended for all ages
> More physiological insulin replacement
> Allows improved glycaemic control without
  increased risk of hypoglycaemia
> Normalises eating
        Reduces need for extra food at snack time
        Reduces total daily dose / weight gain
        Greater flexibility with diet, especially young children
> Increased education and support required

                                   Women's & Children's Hospital

WCH Diabetes Management
> Basal bolus insulin regimen from diagnosis
   • < 8 years: Levemir BD, NovoRapid with meals
   • ≥ 8 years: Lantus daily, Humalog with meals

> Carbohydrate counting (grams) and insulin:carb ratios
  from diagnosis
   •   50% of children with T1D are overweight

> Insulin pumps (45% pts at WCH 2016)
   • Discussed from diagnosis and recommended during 1st year
   • Some newer pumps have predictive low glucose suspend
     function

> Continuous Glucose Monitoring Systems
   • Government subsidised for those with
     T1D

The Burden of Care

> Inherent burden of care and diligence
  required to maintain optimal glycaemic
  control has not changed (? increased)

   • T1D unique in the level of patient input required
   • Not surprising most don’t meet targets
   • Not everyone willing or capable of using
     intensive therapy
   • Burnout common

                               Women's & Children's Hospital

Mental Health impacts of T1D
> Young people with diabetes have a higher
  incidence of anxiety, depression,
  psychological distress and eating
  disorders than their healthy peers

> A lack of adequate psychosocial support
  has negative effects on various outcomes,
  including blood glucose control

> Children and young people with T1D and
  their families should be offered timely and
  ongoing access to mental health supports
                         Women's & Children's Hospital

WCH Diabetes Service
> Provides multidisciplinary diabetes care for 700
  children/adolescents with T1Diabetes
> Diabetes Team: 5 paediatric endocrinologists, 4
  diabetes educators, 2 dietitians and trainees
> 24 hour consultant on-call service for families / GPs
   • Call WCH Switchboard 08- 8161 7000
> Outreach services
   • Pt Lincoln, Whyalla, Pt Augusta, Mt Gambier
> SA centre for new pump trials, vascular complications
  and type 1 diabetes prevention trials & national
  register
> NHMRC Centre of Research Excellence
  www.endia.org.au
                              Women's & Children's Hospital

Resources

> NHMRC Guidelines         Updated (2011): National
  Evidence-Based Clinical Care Guidelines for Type 1
  Diabetes for Children, Adolescents and Adults
  http://www.nhmrc.gov.au/publications/synopses/cp102syn.
  htm

> ISPAD Guidelines www.ispad.org

> WCH Intranet:
  www.inside.cywhs.sa.gov.au/webs/endocrine_diab
  etes
        DKA Protocol
        Mini-dose Glucagon protocol
        Management of diabetes during surgery
        Sick day management

                               Women's & Children's Hospital