Pediatric Type 1

Diabetes Mellitus
Chelsea Stegman and Kelly Davis
Test your Knowledge
Type 1 Diabetes Mellitus is a/an _____ disease.
a. Thyroid
b. Bacterial
c. Viral
d. Autoimmune
Test your Knowledge
Type 1 Diabetes is most commonly diagnosed amongst:
A. Overweight adults
B. Children and adolescents
C. Overweight children and adolescents
Type 1 Diabetes
Most often diagnosed in children, adolescents, or young adults.
Causes of type 1 diabetes are complex and still not completely understood
but type 1 diabetes can not be prevented.
People with type 1 diabetes are thought to have an inherited or genetic
predisposition to developing the disease
The disease process is believed to be stimulated by an environmental
trigger such as a virus, toxin, drug or chemical

Type 1 Diabetes: Etiology
T1DM is characterized by the autoimmune destruction of beta cells.
Patients with type 1 diabetes produce little or no insulin via beta cells due
to this destruction.
o Insulin is a hormone produced in the pancreas by beta cells.
o Insulin is needed to move blood sugar, glucose, into the cells where it
is stored and later used for energy.
o Without using insulin, glucose builds up in the bloodstream instead of
going into the cells.
o The body is unable to use this glucose for energy, which leads to the
symptoms of type 1 diabetes.

Symptoms:
Extreme thirst
Frequent urination
Drowsiness
Sugar in urine
Sudden vision changes
Increased appetite
Sudden weight loss
Fruity, sweet, or wine-like odor on breath
Heavy, labored breathing
Stupor and unconsciousness

Diabetic Ketoacidosis
Severe Hyperglycemia
Most commonly found in patients with T1DM
Individuals experiencing DKA experience weight loss due to decreased
blood volume (hypovolemia) and muscle metabolism
Precipitating factors include:
o Lack of blood glucose self monitoring
o Severe illness/infection
o Increased insulin needs with growth spurts
o Inappropriately stored insulin
Diagnostic Measures:
Symptoms of diabetes plus casual plasma glucose concentration greater
than/ equal to 200 mg/dL
Fasting plasma glucose greater than/ equal to 126 mg/dL
2- hour post-prandial glucose greater than/ equal to 200 mg/dL during an
oral glucose tolerance test (OGTT)

Diagnostic Measures:
T1DM
Islet Cell Cytoplasmic Autoantibodies (ICA antibodies)
Glutamic Acid Decarboxylase Autoantibodies (GADA antibodies)
Insulin Autoantibodies (IAA)
If an autoimmune disease is present in the family, their first-degree family
members may be at risk for developing the same or different autoimmune
disease.
Generally, T1DM is a childhood onset disease


Patient: Rachel Roberts
12 year old female
7th grade
Height: 5 60 in
Weight: 82 lbs 70 kg
BMI: 16.0 kg/m2
IBW: 89 lbs
Upon hospital admittance: acute-onset hyperglycemia
Serum glucose 724 mg/dL
Chief Complaints: Increased thirst, increased urination, slight weight loss
Diagnosis: Type 1 Diabetes Mellitus
Abnormal Lab Values:
Rachels Diagnosis
Rachel was diagnosed with T1DM due to:
Her symptoms of unexplained weight loss, polyuria, and polydipsia.
A serum glucose level of 724 mg/dL upon ER assessment (above
200).
The presence of B-cell destroying autoantibodies ICA, GADA, and
IAA.
Low C-peptide levels, indicative of low insulin secretion.
There is a history of autoimmune diseases in her family. Her mother
hyperthyroidism and her sister has Celiacs disease.

Rachels Nutritional Diagnosis
PES Statement 1: Altered nutrition-related lab values (NC 2.2) related to
Type 1 Diabetes Mellitus as evidenced by a blood glucose concentration of
greater than 110 mg/dL.
PES Statement 2: Unintended weight loss (3.2) related to inadequate
insulin due to Type 1 Diabetes as evidenced by a reported weight loss of 8
lbs.
Pharmacological Treatment
A physician prescribes a type of insulin, insulin dosage, and insulin
regimen per individualized case.
Rachel is prescribed a combination of Apidra prior to meals with glargine
given in the a.m. and p.m. Both are administered via insulin injection
Prescribed discharge dosages: 7 u glargine with Apidra prior to each
snack, which is a 1:15 insulin: carbohydrate ratio.

Justification of Prescription
Injection is used because oral pills are only used with Type II Diabetes.
The lower dosage of insulin is due to the temporary honeymoon phase.
honeymoon phase: relative self-sufficient insulin production after
T1DM is clinically diagnosed and insulin treatment is initiated.
Glargine is given in the a.m. and p.m. for maintenance of the dawn
phenomenon that Rachel is experiencing.
dawn phenomenon: consistently high blood glucose levels in the
morning. This is a result of the lack of insulin injections while the
individual is sleeping.
Types of Insulin
Glargine
Onset of action: 2-4 hours.
Peak of action: peakless.
Duration of action: 20-24 hours.

Apidra
Onset of action: 5-15 minutes.
Peak of action: 30-90 minutes.
Duration of action: 3-5 hours.
Treatment: MNT
Daily kcals: 2400-2500
15-20% of kcals from protein
25-35% kcals from fat
50-60% kcal from carbohydrates. Insulin should be taken accordingly
to eliminate unsafe postprandial glucose responses.
Insulin Carbohydrate Ratio (ICR)- 1:15
Patient and parents are educated on the importance of carbohydrate
counting and are given literature on carbohydrate counting.


Treatment: MNT
Rachels active lifestyle should also be taken into account [she is a soccer
player]
Blood glucose levels should be monitored before and after exercise to
recognize hypoglycemic or hyperglycemic conditions.
She should consume an additional 15 g of carbohydrates for every
hour of moderate physical activity and 30 g for every hour of
strenuous activity.
She will not have a decrease insulin dosage levels prior to exercise
because of the regularity of her exercise regimen.
Prognosis
T1DM cannot be cured, yet it can be managed.
Prescribed insulin doses will most likely increase based on the transitory
nature of the current honeymoon phase.
Self monitoring of blood glucose should be done at home.
Purpose: to identify patterns and the ways in which food, exercise,
and other factors affect glycemic control.
Method: a drop of blood obtained via a finger prick is applied to a
chemically treated reagent strip.
This is recommended at least three times daily because hypoglycemia
and hyperglycemia are dangerous conditions. Rachel and her family
should be cognoscente of symptoms of hypoglycemia: rapid
heartbeat, weakness, shakiness, perspiration, and hunger.
Prognosis Continued
Rachel should attend routine follow-up visits with her physician and
dietitian to analyze laboratory values, diet logs, and adherence to glycemic
goals.
Microvascular and macrovascular complications generally occur 15-20
years after the onset of T1DM.
She is also at risk for nephropathy, retinopathy, and nervous system
damage.
The incidence is reduced through intensive treatment and strict adherence
to insulin regimens to prevent hypoglycemia or hyperglycemia.
Resources
(2004). Autoimmune Disorders. Emory University School of Medicine.
(2013). Calculating Insulin Dose. Retrieved November 17
th
, 2013 from University of California Diabetes Education Online
website: http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulin-
rx/calculating-insulin-dose/
(2013). Can Diabetes Pills Help Me. Retrieved 7 November 2013 from http://www.diabetes.org/living-with-diabetes/treatment-
and-care/medication/oral-medications/can-diabetes-pills-help-me.html
Bolli, G.B., Brunetti, P., De Feo, P., Fanelli, C., Perriello, G., Santeusanio, F., Torlone, E. (1991). The Dawn Phenomenon in
Type 1 (insulin-dependent) diabetes mellitus: magnitude, frequency, variability, and dependency on glucose
counterregulation
Coppieters, K. T., Van Belle T.L., & Von Herrath M. G. (2011). Type 1 Diabetes: Etiology, Immunology, and Therapeutic
Strategies. American Physiological Society. 91: 79-118
Nelms, Marcia, Kathryn P. Sucher, Karen Lacey, and Sara L. Roth. Nutrition Therapy and Pathophysiology. Belmont, CA:
Wadsworth, 2011. Print.
Strayer, D., & Schub, T. (2013). Diabetes Mellitus, Type 1.