Care of Children and Adolescents With Type 1 Diabetes (2)

Posted on December 8, 2009

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Table 4—

Plasma blood glucose and A1C goals for type 1 diabetes by age group

Values by age Plasma blood glucose goal range (mg/dl)


Rationale
Before meals
Bedtime/

overnight

A1C
Toddlers and preschoolers (<6 years) 100–180 110–200 <8.5 (but >7.5) % • High risk and vulnerability to hypoglycemia
School age (6–12 years) 90–180 100–180 <8% • Risks of hypoglycemia and relatively low risk of complications prior to puberty
Adolescents and young adults (13–19 years) 90–130 90–150 <7.5%* • Risk of hypoglycemia
• Developmental and psychological issues
Key concepts in setting glycemic goals:
• Goals should be individualized and lower goals may be reasonable based on benefit–risk assessment
• Blood glucose goals should be higher than those listed above in children with frequent hypoglycemia or hypoglycemia unawareness
• Postprandial blood glucose values should be measured when there is a disparity between preprandial blood glucose values and A1C levels
  • *

    * A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia

Table 3—

Components of the initial visit

Medical history


• Symptoms, and results of laboratory tests related to the diagnosis of diabetes
• Recent or current infections or illnesses
• Previous growth records, including growth chart, and pubertal development
• Family history of diabetes, diabetes complications, and other endocrine disorders
• Current or recent use of medications that may affect blood glucose levels (e.g., glucocorticoids, chemotherapeutic agents, atypical antipsychotics, etc.)
• History and treatment of other conditions, including endocrine and eating disorders, and diseases known to cause secondary diabetes (e.g., cystic fibrosis)
• Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
• Use of tobacco, alcohol, and/or recreational drugs
• Physical activity and exercise
• Contraception and sexual activity (if applicable)
• Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
• Review of Systems (ROS) should include gastrointestinal function (including symptoms of celiac disease) and symptoms of other endocrine disorders (especially hypothyroidism and Addison’s disease)
• Prior A1C records*
• Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs*
• Results of past testing for chronic diabetes complications, including ophthalmologic examination and microalbumin screening*
• Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia*
• Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients’ use of data*
Physical examination


• Height, weight, and BMI calculation (and comparison to age and sex-specific norms)
• Blood pressure determination and comparison to age-, sex-, and height-related norms
• Funduscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination
• Abdominal examination (e.g., for hepatomegaly)
• Staging of sexual maturation
• Evaluation of pulses
• Hand/finger examination
• Foot examination
• Skin examination (for acanthosis nigricans SMBG testing sites and insulin-injection sites*)
• Neurological examination
Laboratory evaluation


If clinical evidence for DKA:
• Serum glucose, electrolytes, arterial or venous pH, serum or urine ketones
If signs and symptoms are suggestive of type 2 diabetes:
•Evidence of islet autoimmunity (e.g., islet cell [ICA] 512 or IA-2, GAD, and insulin autoantibodies)
• Evidence of β-cell secretory capacity (e.g., C-peptide levels) after 1 year, if diagnosis is in doubt
• A1C
• Lipid profile
• Annual screening for microalbuminuria
• Thyroid-stimulating hormone (TSH) levels
• Celiac antibodies at diagnosis or initial visit if not done previously
Referrals and screening


• Yearly ophthalmologic evaluation.
• Medical nutrition therapy (by a registered dietitian)
• As part of initial team education and on referral, as needed; generally requires a series of sessions over the initial 3 months after diagnosis, then at least annually, with young children requiring more frequent reevaluations
• Diabetes nurse educator
• As part of initial team education, or referral as needed at diagnosis; generally requires a series of sessions during the initial 3 months of diagnosis, then at least annual reeducation
• Behavorial specialist
• As part of initial team education, or referral as needed optimally for evaluation and counseling of patient and family at diagnosis, then as indicated to enhance support and empowerment to maintain family involvement in diabetes care tasks and to identify and discuss ways to overcome barriers in successful diabetes management
• Depression screening annually for children ≥10 years of age, with referral as indicated
  • *

    * Pertain only to previously diagnosed patients, at time of initial referral, assuming prior medical management.

http://care.diabetesjournals.org/content/28/1/186.full#T2

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