Pediatric Diabetes (FL Autonomous Practice INITIAL Pharmacology)

In type I diabetes, the beta cells of the pancreas are progressively destroyed, and the remaining cells (usually less than 10%, if any) are unable to produce enough insulin to maintain normal blood glucose levels. The exact cause of type I diabetes is unknown, but an autoimmune response is considered the main factor in most cases, possibly following a viral illness or in combination with environmental and genetic factors. Regardless of what exactly triggers the rogue immune response, the majority of patients have circulating antibodies specifically targeting pancreatic beta cells (Khardori, 2022b).

Image 1:
Beta Cells

When insulin is unable to help glucose enter the body’s cells to be used as energy, blood levels of glucose rise, called hyperglycemia. In the short term, hyperglycemia causes symptoms including:

• Weakness
• Nausea
• Vomiting
• Headache
• Frequent urination
• Increased thirst

If hyperglycemia is left untreated, the body looks for other sources of energy and starts to break down stored fat into ketones. As ketone levels in the blood rise, they can upset the normal acid-base balance and lead to ketoacidosis, a life-threatening condition causing metabolic acidosis that can quickly lead to renal or other organ dysfunction and death (Kudva, 2020).

In addition to the emergent problems of untreated or severe hyperglycemia, chronic mild to moderate hyperglycemia (as is present with poorly managed diabetes) can cause a whole other host of issues. Excess glucose in the circulation causes chronic irritation to blood vessels, particularly the microvasculature of organs like the kidney and eyes, and can cause chronic conditions like retinopathy, renal disease, poor wound healing, cardiovascular disease, and neuropathy (Khardori, 2022b).

The only way to manage type I diabetes and prevent the cascade of problems from hyperglycemia is to administer synthetic insulin, dosed and timed to mimic the function of the pancreas in relation to glucose release as closely as possible(Khardori, 2022b).

Image 2:
Type I Diabetes

In type II diabetes, there is a combination of two main issues at work: insulin resistance and insufficient insulin production. Insulin resistance is a condition where the body is unable to use insulin as effectively as it should and some cells (particularly muscle and liver cells) are unable to have the appropriate amounts of glucose transferred into their cells for energy usage, leading to increased circulating glucose.

Normally, in the presence of hyperglycemia, the liver will store additional glucose while waiting on insulin to return levels to normal; however, with improperly functioning liver cells, additional glucose is erroneously released into the bloodstream, further contributing to hyperglycemia. In response to rising blood glucose levels, the beta cells of the pancreas produce more insulin in an attempt to correct this. The body, however, is still unable to use insulin effectively, and this only serves to exhaust the beta cells, eventually causing damage or destruction and a reduced number of functional beta cells, leading to insufficient insulin production and further hyperglycemia (Khardori, 2022a).

Image 3:
Type II Diabetes

The cascade of symptoms that follows is similar to those with type I diabetes, though slower to progress because the pancreas does still produce some insulin, and the body is able to utilize it in a reduced capacity, unlike the complete lack of insulin in type I diabetes. The exact reason insulin resistance develops is not well understood but seems to be in part related to excess body fat and a sedentary lifestyle (Khardori, 2022a).

Because some functions of pancreatic beta cells still remain, especially early on in the disease, type II diabetes can be managed with a combination of lifestyle modification and medications that help the body better utilize insulin and slow the release of glucose from the liver. The later-stage disease may need to be managed with insulin administration (Khardori, 2022a).

Monitoring glucose levels is an essential part of managing type I diabetes in children and helps determine immediate insulin needs, safety of the child (risk for hypoglycemia or hyperglycemia), and long-term patterns or trends in a child’s glucose control. Studies have shown a direct relationship between the frequency of glucose monitoring and long-term glycemic control (Chiang et al., 2018).

A note on hypoglycemia: Hyperglycemia is the central concern for the risk of chronic complications of diabetes. However, patients also need to be aware of hypoglycemia as it can be more acutely problematic and life-threatening. Hypoglycemia can occur when insulin administration exceeds glucose availability, either due to increased activity/exercise or inadequate carbohydrate intake. Symptoms of hypoglycemia include (Mayo Clinic, 2022):

• Shakiness
• Confusion
• Heart palpitations
• Blurred vision
• Anxiety
• Decreased level of consciousness

Self-monitoring of Blood Glucose levels (SMBG) via finger stick is recommended up to 6-10 times daily and should be done before meals or snacks, before exercise, before bedtime, in the presence of symptoms of hypoglycemia, or more frequently during illness. The target range for blood glucose level is individualized to each client so as to promote a balance between quality of life and reduced incidence of hypoglycemia and hyperglycemia (Chiang et al., 2018)

Continuous Glucose Monitoring (CGM) is another potential method to monitor blood glucose levels and utilizes a temporary subcutaneous sensor that provides real time updates on blood glucose levels. CGM is only utilized by about 10% of all diabetic patients but is increasingly common among pediatric patients, particularly very young children between ages 2 and 5 (around 40%). The ability to monitor glucose frequently without the need for additional finger sticks is beneficial to the quality of life in pediatric patients where eating, snacking, and activity levels are more likely to be inconsistent, though no significant improvements in glycemic control have been noted with CGM use (Chiang et al., 2018).

Urine Ketone Monitoring should be utilized in children who are experiencing illness or prolonged periods of hyperglycemia. The presence or absence of ketones helps guide clinical decision-making about insulin therapy and whether or not additional care measures (to prevent or reverse metabolic decompensation) are needed for children with fever, nausea, vomiting, abdominal pain, or other acute symptoms (Chiang et al., 2018).

For children with type I diabetes, subcutaneous injection or infusion of insulin is integral to survival. For those who utilize injections, a combination of 1-2 administrations of long-acting insulin per day and administration of rapid-acting insulin with each meal or snack is the current standard. 

The onset of action for rapid-acting insulin is usually within 15-30 minutes, and the duration is 3-5 hours. The onset of action for long-acting insulin is 2-4 hours with a duration of 12-24 hours.Therefore, long-acting insulin is given either once or twice per day. Regular insulin and intermediate-acting insulin also exist but are not the current standard of care for pediatric patients utilizing injections. When used appropriately, these synthetics can mimic the body’s natural fluctuation in insulin secretion patterns throughout the day and night (Chiang et al., 2018). A comparison chart of the different types of insulin and their action is below (Table 1).

Of rising popularity among pediatric patients is continuous subcutaneous insulin infusion systems, or insulin pumps. These systems reduce the need for repeated injections throughout the day by inserting a cannula into subcutaneous tissue, which then delivers insulin from a programmable pump.

The pump delivers short-acting or rapid-acting insulin at a slow, continuous basal rate throughout the day and can also be set to give an appropriately dosed bolus with meals and snacks. Pump sites should be changed every 2-3 days or sooner if the site becomes irritated or damaged. This can lead to more freedom and fewer needle sticks which can improve compliance and autonomy for children and teens.

The difference in glycemic control between pump users and those preferring injections is small but does point to pump use as, resulting in lower hemoglobin A1Cs (HgA1C), lower rates of hypoglycemia, improved quality of life, and higher treatment satisfaction over time. Children who utilize insulin pumps in conjunction with continuous glucose monitoring had the biggest improvement in glycemic control and reduction of hypoglycemia (Chiang et al., 2018).

For patients with type II diabetes, insulin may be necessary in later stage disease if enough overwork and damage has occurred to the beta cells of the pancreas, and they are no longer able to meet the body’s needs for insulin. However, for most type II diabetic children, lifestyle management and non-insulin drug therapies are central to the treatment plan. Metformin, a biguanide, is the gold standard and works by decreasing the amount of glucose the liver creates and releases into the bloodstream, as well as helping the body use insulin more effectively.

Other potential classes of medication can be considered by a child’s endocrinologist as needed, though these are more commonly used in adult patients due to the risk of cardiovascular disease, hypoglycemia, and other significant side effects. These classes include (Steinberg and Carlson, 2019):

• GLP-1 Receptor Agonists: Decrease appetite, slow gastric emptying, and promote beta cell health in the pancreas
• DPP-IV Inhibitors: Promote insulin production in the body
• SGLT-2 Inhibitors: Increase glucose excretion in the urine
• Sulfonylureas: Stimulate pancreatic beta cells to produce more insulin
• Thiazolidinediones: Decrease the storage of glucose in the liver and decrease insulin resistance

It is important for diabetic children and their parents to understand why maintaining close control over glucose levels is so important, particularly when children may not feel symptomatic until levels are very high. Diabetes research repeatedly shows that the duration and severity of hyperglycemia have a direct relationship to the risk of developing microvascular complications. This risk is particularly high for children who are diagnosed young and have many decades of life ahead of them, during which they can develop progressive microvascular and organ damage.

Hemoglobin A1C levels should be monitored at 3-month intervals for all children with diabetes. A goal of < 7.5% is ideal for most patients, though this can be adjusted for individual cases. Additional information from CGMs, such as the time spent in a target range for glucose, as well as the frequency of hypoglycemia, should also be considered (Chiang et al., 2018).

Dietary management is perhaps one of the most complex parts of pediatric diabetes management, as many factors must be accounted for. Factors that must be considered include (Chiang et al., 2018):

• Food preferences (and changes over time)
• Accessibility to food
• Family attitudes
• Growth and development
• Potential eating disorders
• Literacy and numeracy for accurately understanding nutrition facts

A family approach is most effective, with all family members participating in a healthy eating plan. Caloric intake should be consistent with current growth and development needs, with a focus on fruits, vegetables, legumes, whole grains, and dairy as the primary source of carbohydrates over foods containing added sugars. Emphasis should be placed on consistency rather than total accuracy when counting carbohydrates, which can be anxiety-inducing for parents and children if they have never considered portions or carbohydrate content before.

Studies indicate that over or underestimating carbohydrate content by up to 10 grams or 15% is unlikely to have a major effect on glycemic control. A dietitian specializing in pediatric diabetes and frequent visits to check in and reevaluate as children grow is an integral part of diabetes management (Chiang et al., 2018).

Normal childhood experiences like eating out at restaurants, attending birthday parties, and having dessert can absolutely be accomplished with proper planning, such as checking menus ahead of time or planning that cupcake into the carbohydrate count for the day. Building confidence and teaching children to participate in their care early on can help with the feasibility and comfort level of going to a friend’s house or somewhere new as well (Chiang et al., 2018).

Physical activity and participation in active play and sports are not only beneficial for overall health and weight management but are also a necessary part of childhood and contribute to positive development, self-esteem, social interactions, and the creation of healthy habits going into adulthood. It is recommended that all children with diabetes participate in at least 60 minutes of moderate to vigorous physical activity each day. The benefits of physical activity, however, must be carefully planned and balanced against the risk of both hypoglycemia and hyperglycemia that can occur with exercise (Chiang et al., 2018).

In non-diabetic individuals, hormonal and metabolic changes that occur during and after exercise are naturally mediated by the body’s ability to control both the peripheral uptake and hepatic release of glucose. For diabetic patients, this intuitive function of the body does not exist. Synthetic insulin inhibits glucose production in the liver and increases glucose uptake peripherally, as does increased activity levels, leading to hypoglycemia if available carbohydrates are not adequate. The risk of hypoglycemia can occur during or immediately after exercise, but also up to 6-12 hours later due to what is called a “lag effect” in hormone fluctuations following exercise. One of the main ways to manage this risk is by anticipating periods of increased activity or exercise and decreasing the amount of insulin given with the meal prior to exercise, or even decreasing the basal rate following activity. This is useful for scheduling sports practice or games when the timing and intensity of activity are known ahead of time. For children who are playing freely, more frequent monitoring of glucose levels before, during, and after activity is necessary, as well as familiarity with the symptoms of hypoglycemia and prompt treatment if hypoglycemia occurs (Chiang et al., 2018).

Conversely, high-intensity exercise can also lead to inadequate insulin delivery to the cells and increase the hepatic release of glucose, leading to hyperglycemia, though this is less common and, overall, of less immediate risk than hypoglycemia. Intense activity should be postponed if the patient has a glucose level of > 350 mg/dL prior to activity. Monitoring glucose levels before, during, and after activity can help detect hyperglycemia as well (Chiang et al., 2018).

Exercise or sports participation should not be avoided simply because patients are worried about resulting hypoglycemia or hyperglycemia, and doing so could cause isolation or feelings of frustration or depression in children and teens. Education about how activity and exercise might affect blood glucose levels and how to anticipate these changes or address them once they occur can help instill confidence in patients and their families so that they may participate in desired activities and sporting events with their peers.

Though nutrition and activity levels are some of the most commonly discussed facets of diabetes management, one of the biggest factors related to quality of life for diabetic children and teens is mental health.

Social adjustment may be a primary concern for children or teens, and navigating this issue varies by age and developmental stage (ADA, 2021).

For very young children, building a trusting relationship with caregivers is the primary focus(ADA, 2021). Developing familiarity and decreased fear over frequent injections and glucose checks can take time and feel traumatic for families at first. Preschool and early school age children may experience increased separation anxiety or fear of being with other caregivers and also have the added challenge of rapidly changing physical abilities and the increasing need to explore their environment (ADA, 2021).

Later, elementary-aged children should begin developing some comfort and autonomy with their own care while still being closely supervised by an adult (ADA, 2021). They may begin branching out into various activities or sports and will need to balance the desire to participate with the proper management of their diabetes needs. Middle school-age children will begin to develop a strong sense of individual identity and may want to take on more responsibility for their care (but should not be trusted to go completely without supervision)(ADA, 2021). “Fitting in” with peers becomes increasingly important, and trying to minimize the needs of diabetes care or even rebel against previous regimens and vigilance may occur. Older teens usually begin to develop a more consistent sense of responsibility and a greater understanding of the long-term implications of the disease. They continue to expand their interests and sense of identity and can figure out where their diabetes management fits into that (ADA, 2021).

Starting around age 7, all diabetic children should be screened for depression and anxiety regularly as they grow, as the risk of mental health issues is greater for children with chronic illnesses compared to healthy peers. Tools such as the Pediatric Symptom Checklist (PSC) and the Patient Health Questionnaire (PHQ) can be used to help screen for mental health-related concerns as well as consistently including discussions of mental health in routine care. Beginning around age 10-12, screening for eating disorders should also be included. Clinicians should assist families with open and effective communication so that emerging conflicts or problems can be detected and addressed early on and reduce the risk of more serious mental health problems and reduced quality of life (ADA, 2021).

Caregivers and family members have their own unique challenges to navigate, even though they are not the actual patient. Understanding the ways this disease affects the entire family unit is imperative to comprehensive nursing care. Parental depression rates are high among people with diabetic children, particularly in the first few years following diagnosis. Risk factors for parents or other family members who may be more likely to struggle include low socioeconomic status, food insecurity, housing problems, low literacy or numeracy, and poor support systems.

Similar to the needs of the client at each age, the needs of the caregivers vary by the child’s age and developmental level as well (ADA, 2021):

• Parents/caregivers of very young children may feel overwhelmed with fear of complications, particularly with pre-verbal children who cannot communicate symptoms. There is increased stress in an already demanding phase of childcare.
• Parents/caregivers of preschool-aged children must deal with close monitoring of varied food intake and also learn to navigate leaving the child in the care of others.
• Parents/caregivers of elementary-aged children must begin teaching children to share in the responsibilities of diabetes care and begin relying on the child to communicate symptoms. Flexibility with new activities and experiences is necessary.
• Parents/caregivers of middle school-aged children must cope with increased conflict around diabetes management and guide children with increased autonomy and decision-making while still ultimately being responsible for making sure their child is safe.
• Parents/caregivers of older teens must balance supervising care with allowing increasing levels of autonomy and providing their teen with the necessary knowledge to transition care completely onto them in young adulthood.

School performance also needs to be assessed as an indicator of how well a child and family are handling the challenges of life with diabetes (ADA, 2021). Frequent health-related absences, symptoms of hypoglycemia, or struggling socially all have the potential to cause academic difficulty for the diabetic child. Adequate education and support from teachers, administrators, and school nurses can help a child feel safe and confident at school while also minimizing time spent outside of the classroom and promoting optimum learning (ADA, 2021).

In addition to consistent care from an endocrinologist, children with diabetes should also attend regular primary care appointments and follow regular anticipatory guidance for their developmental level. Vaccines should be administered according to the current Advisory Committee on Immunization Practices (ACIP) guidelines, including annual influenza vaccines. Growth and development should be monitored as usual and can be used as additional indications of glycemic control. Overweight and obesity are common in type II diabetes and should be closely monitored, but there is also a rising number of type I diabetes patients who are overweight and obese as well. Awareness and screenings for additional autoimmune disorders like thyroid imbalance, Celiac disease, and systemic lupus erythematosus (SLE) should also be considered, and appropriate diagnostics ordered when indicated (ADA, 2021).

Hypoglycemia (blood glucose < 70 mg/dL) is an unavoidable risk with type I diabetes management and may include symptoms of shakiness, confusion, heart palpitations, blurred vision, anxiety, and decreased level of consciousness. Glucose monitoring and insulin administration are imperfect regimens for even the most consistent patients, and hypoglycemia will invariably occur. In addition to frequent glucose monitoring, patient education about symptoms and management of hypoglycemia are the most important factors in timely recognition and treatment. Patients and their caregivers should be educated on possible symptoms of hypoglycemia and asked about the occurrence of any of these symptoms and what blood glucose level they occur at each of their visits. If patients are experiencing blood glucose levels below 70 mg/dL without symptoms, this is indicative of hypoglycemia unawareness, and their glycemic goals should be adjusted upwards to avoid the risk of undetected hypoglycemia (Chiang et al., 2018).

When hypoglycemia does occur, 15 grams of oral glucose (in the form of a tablet or gel) or a 15-gram carbohydrate snack is the preferred treatment as long as patients are alert and able to eat. Blood glucose levels should be checked again 15 minutes after the glucose administration or snack. If still hypoglycemic, the 15-gram treatment should be repeated until blood glucose normalizes again. Patients should also consider adjusting the next meal and insulin administration to prevent a recurrence of hypoglycemia (Chiang et al., 2018).

For patients who have altered levels of consciousness or are unable to eat, glucagon injections should be given intramuscularly. Caregivers should be given education on how to prepare and administer glucagon and to carry a glucagon kit with the patient always (Chiang et al., 2018).

A note on alcohol when caring for teens: Alcohol consumption is considered a high risk for teens with diabetes. Small amounts of alcohol may cause blood glucose to rise, but excessive alcohol intake actually has the potential to cause hypoglycemia. Large amounts of alcohol impair liver function, which reduces the amount of glucose released by the liver. A normally functioning pancreas would adjust the release of insulin accordingly, but exogenous insulin continues to work in the body of a diabetic patient, causing blood glucose to continue to drop. Symptoms of hypoglycemia can mimic those of being intoxicated, so a teen with diabetes may appear to be drunk or even passed out when they are actually experiencing dangerously low blood glucose and risk of death. Teens, particularly those heading to college, should be regularly counseled on this risk and advised to avoid drinking excessively, check blood glucose frequently if drinking alcohol, and talk to their peers about signs of hypoglycemia and what to do if they seem to be hypoglycemic (Johns Hopkins Medicine, n.d.).

Nursing care for patients with hypoglycemia includes swift and accurate detection of symptoms of hypoglycemia, appropriate and quick administration of oral glucose or IM glucagon, frequent monitoring of blood glucose levels, and education for home management of hypoglycemia (Chiang et al., 2018).

Diabetic ketoacidosis (DKA) is a common presentation of patients with a new diagnosis of type I or type II diabetes. DKA occurs when inadequate production or usage of insulin makes the body unable to utilize available glucose and instead turns to stored fat for energy. Blood glucose levels rise, as do circulating ketone levels (a byproduct of fat metabolism), triggering metabolic acidosis.

Diagnostic criteria for DKA include (Raghupathy, 2015):

• Blood glucose level > 200 mg/dL
• Venous pH of < 7.3 and/or
• Bicarbonate (HCO3) level of < 15 mmol/L

For patients monitoring at home, urine ketones of > 2+ are also indicative of DKA. Symptoms of DKA may include (Raghupathy, 2015):

• Dehydration
• Tachycardia
• Tachypnea
• Kussmaul’s respirations with fruity-smelling breath
• Nausea
• Vomiting
• Abdominal pain
• Drowsiness
• Confusion
• Decrease in level of consciousness. 

Alternative conditions such as pneumonia, acute abdominal processes (appendicitis, peritonitis, etc), and meningitis should be ruled out (Raghupathy, 2015).

The severity of DKA and accompanying symptoms is related to the level of acidosis, as follows(Raghupathy, 2015):

• Mild DKA: Venous pH < 7.3 and/or HCO3 < 15 mmol/L
• Moderate DKA: Venous pH < 7.2 and/or HCO3 < 10 mmol/L
• Severe DKA: Venous pH < 7.1 and/or HCO3 < 5 mmol/L

As acidosis progresses, organ function (particularly renal) may deteriorate, and complications such as cerebral edema, severe hypotension, respiratory failure, and death may result if untreated. Hospitalization with fluid and electrolyte replacement, IV insulin administration with frequent glucose monitoring, and respiratory support, if needed, should be initiated as quickly as possible. Children under age 2 are at increased risk of severe complications and cerebral edema and should be admitted to a pediatric intensive care unit (PICU) (Raghupathy, 2015).

Cerebral edema is one of the leading causes of death for children experiencing DKA and occurs in 0.5-0.9% of all pediatric DKA episodes. Risk factors for cerebral edema include newly diagnosed patients under age 5, initial venous pH of < 7.1, dehydrated patients, persistent hypernatremia, and high blood urea at presentation. Warning signs that cerebral edema may be occurring include (Raghupathy, 2015):

• Restlessness
• Irritability
• Abnormal pupillary response
• Headache
• Bradycardia
• Increasing hypertension
• Recurrence of vomiting
• Decorticate posturing
• Decerebrate posturing
• Cheyne-Stokes respirations
• Increased drowsiness

Frequent neurological checks and Glasgow Coma Scale (GCS) assessments are necessary for patients with DKA (Raghupathy, 2015).

Risk factors for DKA include (Raghupathy, 2015):

• Poor glycemic control
• Non-compliance with or omission of insulin
• Previous episodes of DKA
• Persistent nausea and vomiting with gastroenteritis
• Eating disorders
• Family and social challenges
• Insulin pump failure
• Poor access to healthcare or being underinsured

Nursing care of patients experiencing DKA includes managing continuous insulin infusion, hourly blood glucose checks, every 2–4-hour lab work, frequent monitoring of vitals and neurologic assessments, and quick recognition and action for deteriorating condition or decreasing level of consciousness. In the outpatient setting, nurses should be educating patients about the risks for and signs of developing DKA as well as frequent home blood glucose monitoring and urine ketone monitoring as needed (Raghupathy, 2015).

While hypoglycemia and DKA are serious potential acute complications that may worry parents or children with diabetes, there are many potential long-term complications caused by chronic hyperglycemia and its effect on the microvasculature. Issues such as kidney damage, retinopathy and vision loss, neuropathy, poor wound healing, and chronic foot wounds are among the most common conditions resulting from microvascular damage. It is rare to see these issues in children prior to puberty or with a diagnosis of less than 2 years. Typically, these complications occur in older children who have been living with diabetes for more than 5-10 years. Because of this delay in symptoms or noticeable damage to the microvasculature, it can be difficult to get children and their families to understand these risks and the importance of prevention in the form of good glycemic control. Early and frequently repeated education on these topics is necessary (Chiang et al., 2018).

Diabetic kidney disease (DKD) should be screened with an annual assessment for albumin in the urine starting at age 10 or puberty (whichever is first). Kidney damage related to chronic exposure to hyperglycemia and/or concomitant hypertension leads to large protein molecules (such as albumin) being able to leak through the damaged renal cells when they would not normally be able to pass through. Blood pressure management with an ACE inhibitor or angiotensin receptor blocker (ARB) may reverse or delay increased albumin excretion. Risk factors for DKD include (Chiang et al., 2018):

• Smoking
• Family history of DKD
• A parent with essential hypertension
• Poor glycemic control 

Seeing an ophthalmologist for an initial eye exam at age 10 or puberty (whichever is first) is recommended for diabetic patients and should be repeated annually. Hypertension, albuminuria, hyperlipidemia, poor glycemic control, and smoking all increase the risk of retinopathy, but ACE inhibitors may slow the progression (Chiang et al., 2018).

A thorough foot exam should be done annually for diabetic children starting at age 10 or at puberty (whichever is first) and should assess reflexes, proprioception, vibration sensation, and assessment of pain or wounds. Risk factors for diabetic neuropathy include (Chiang et al., 2018):

• Obesity
• Hyperlipidemia
• Hypertension
• Smoking
• Poor glycemic control

Hyperglycemia, in combination with hypertension and hyperlipidemia, increases the incidence of atherosclerosis of the larger blood vessels, which in turn leads to cardiovascular disease, cerebrovascular disease, and peripheral vascular disease, comprising the leading causes of morbidity and mortality in diabetic adults. While cardiovascular disease and associated symptoms are not expected complications of diabetes in childhood, studies do show that children with type I diabetes may have subtle cardiovascular abnormalities within the first 10 years of diagnosis, with around 14% having two or more risk factors(Chiang et al., 2018).

People with diabetes are twice as likely to suffer from hypertension as people without diabetes, and hypertension adds additional risk to vascular disease and other complications of diabetes. Blood pressure should be routinely measured at every visit for pediatric patients, with special attention to an appropriately sized cuff as the patient grows. Systolic or diastolic pressure at or above the 90th percentile for age should have the measurement repeated to confirm. For pressure consistently high on 3 separate occasions, a diagnosis of hypertension may be made. Initial treatment is aimed at dietary and exercise modifications. If no improvement is made after 3-6 months, pharmacological therapy may be needed in the form of ACE inhibitors or angiotensin receptor blockers. Treatment goals are BP below the 90th percentile for age (Chiang et al., 2018).

Hyperlipidemia is common in diabetic patients and, in part, responsible for the vascular damage and changes experienced by these patients. Initial fasting lipid panels should be obtained when a patient is first diagnosed or reaches age 10 (whichever comes last) and then remeasured every 3-5 years if within normal limits.

For abnormal lipids, initial management should center on better glycemic control and dietary modifications. Statins may be considered for patients older than 10 years who have failed to improve their cholesterol through the above measures after 6 months. For diabetic children with significant family history of dyslipidemia, fasting lipids may be collected as young as 2 years of age (Chiang et al., 2018).

Cigarettes and e-cigarettes increase many of the risk factors diabetic patients already face in regard to vascular health. Routine screening for use of tobacco products is recommended for all diabetic patients starting at age 11. Counseling on the risks of smoking, the need to avoid starting smoking, and cessation support for those patients who do smoke is an important part of diabetes risk management (Chiang et al., 2018).

Jacob is a 14-year-old patient with type I diabetes diagnosed at age 5. He presents for a routine endocrinology check and is noted to be 182 pounds (82nd percentile), height of 70” (50th percentile), BP of 110/72, HgA1C of 8%, and reports of frequent swings between hyperglycemia and hypoglycemia. He uses an insulin pump and checks capillary blood glucose levels before meals, snacks, and as needed. He completed a PHQ-9 which has a score of 12 (with scores between 10-14 indicating moderate depression). He tells the nurse that he had tried out and made the basketball team but had to sit out repeatedly at early morning practices due to hypoglycemic episodes. He had become discouraged with this issue and quit the team after only 2 weeks. As a result, he felt he was missing out on an enjoyable activity with his friends. He reports a variable meal schedule since starting high school and states that he has been taking over more responsibility for his own carbohydrate counting and insulin administration since he is now away from home more often. He typically skips breakfast, eats a protein snack mid-morning, eats a school lunch where he “guesses” on carbohydrates, and then has a balanced meal for dinner where his parents help him with the carbohydrate count.

The nurse understands that there are multiple intertwined areas where glycemic control and quality of life goals are not being met and could be resolved with further education. First, and most importantly, this patient is attempting to transition to more autonomy over his diabetes care which is an important milestone for teenagers. However, he does seem to need more guidance and supervision before he can fully assume responsibility, as evidenced by his irregular meal schedule and inconsistent carbohydrate counting. The nurse coordinates a visit with the dietitian to help him better understand carb counting while at school and the importance of meals at regular intervals.

The nurse also notes that this patient is nearing the overweight percentiles and could benefit from getting back into basketball for weight management, improved activity levels, and to promote quality of life through peer interaction and team participation. A plan is made with the patient to eat breakfast before practice and adjust his insulin administration accordingly for the increased period of activity so that he does not become hypoglycemic. A plan to monitor his blood glucose level before, halfway through, and after practice is made but this feels like too much for Jacob. The nurse then arranges for him to trial a continuous glucose monitor so that he can be more aware of his glucose levels in real time during exercise.

The nurse also coordinates with a therapist who specializes in teens with chronic illnesses and Jacob agrees to trial 8 weeks of therapy.

At his next follow-up appointment 3 months later, Jacob is doing well. He is eating breakfast each morning and a snack after basketball practice. The CGM is working well for him and has provided him much more awareness of his glucose levels during activity. He has not had any more episodes of hypoglycemia at basketball and is enjoying his time with friends on the team. The dietician helped him create a list of common foods he likes to eat at the school cafeteria as well as a checklist for carbohydrate counts for him to reference and easily calculate his insulin needs while at school. This has been working well for him and he feels more confident and is experiencing fewer episodes of hyperglycemia. He has been seeing the therapist and reports learning some useful tools but not always remembering to implement them. He has lost a few pounds from basketball and eating more carefully and his HgA1C is 7.5%. His PHQ-9 score is 5.

The nurse’s quick recognition of several common barriers to good glycemic control and quality of life for teenagers helped coordinate a multidisciplinary team to improve this patient’s outcomes. His irregular meal schedule and weak ability to count carbs for himself were directly linked to hypoglycemic episodes during basketball practice which in turn was impacting his ability to socialize and participate in sports like his peers. A continuous glucose monitor provided even more flexibility and freedom for Jacob to feel like he could be an active participant and not just focus on his diabetes. Increased activity and weight management improves his overall health and reduces the risk of complications as well. It is also important to take mental health concerns seriously, and while improving his participation in basketball may have been enough to help with the emerging symptoms of depression, referral to a therapist was a good, proactive choice.

Weaknesses in this plan include a lack of inclusion of parents in the education about how to proceed with placing more responsibility on Jacob for his diabetes management. They may have been unsure how to approach the transition of care or unaware that Jacob was struggling, so further education for them would be beneficial. A support group for parents of diabetic children may benefit them as well. A potential referral to adolescent mental health could be considered but is not strictly necessary as his PHQ-9 score did improve in just a few months.