Pediatric Primary Care (101 page)

E.  Physical findings.

1.  Ketonuria, ketonemia, glucosuria.

2.  Vomiting.

3.  Dehydration.

4.  Slow, labored breathing, flushed face and cheeks.

5.  Mental confusion, lethargy.

6.  Fruity odor to breath.

7.  High blood glucose levels.

8.  Monilial vaginitis in adolescent females.

F.  Diagnostic tests.

1.  Fasting plasma glucose, casual plasma glucose.

2.  Urine for ketones and glucose.

3.  Electrolytes and pH.

4.  Blood urea nitrogen.

5.  CBC.

G.  Differential diagnosis.

1.  Hypoglycemia.

2.  Salicylate intoxication.

3.  Sepsis.

4.  Intracranial lesions.

H.  Treatment.

1.  Multidisciplinary approach involving family with pediatric endocrinologist, PNP, diabetic nurse educator, social worker, nutritionist.

2.  Educate child and family in stabilizing blood sugars, diabetes management. Due to complexity of illness, management requires incorporation into daily life.

3.  Treatment replaces insulin that child is unable to produce—the cornerstone of management.

4.  Insulin dosage is tailored to child's blood glucose and HbA1c levels
Table 29-1
.
Diabetic control: based on HbA1c levels, clinical symptoms. HbA1c levels provide information on glycemic control during past 60 days.

5.  Insulin is categorized by peak of onset.

6.  Various insulin injection devices available.

Table 29-1
HbAlc and Glycemic Targets

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

I.  Follow up.

1.  Review medical, nutritional, insulin therapy, daily blood glucose monitoring
(Table 29-2
).

2.  Follow up every 3 months to review management plans, physical/ psychosocial needs
(Table 29-3
).

J.  Complications.

1.  Ketoacidosis.

2.  Vaginal yeast infections.

3.  Retinopathy.

4.  Nephropathy.

5.  Neuropathy.

6.  Lipid profile.

7.  Eating disorders.

K.  Education.

1.  Prevention of diabetic ketoacidosis.

2.  Knowledge of onsets of action, peak action, duration of action of five types of insulin
(Table 29-4
).

3.  Recognition of hypoglycemia and hyperglycemia.

4.  Management of hypoglycemia: evening protein or fat snack to prevent hypoglycemia.

Table 29-2
Principal Adjustments in Basic or Set Insulin Dose

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

5.  Prevention of long-term complications.

6.  Role of exercise in management: Exercise improves glucose utilization.

7.  Insulin therapy and monitoring of glucose levels.

8.  Meal planning, nutrition: Eat meals and snacks within 1 hour of usual time.

9.  School issues and coping skills.

10. Monitoring weight: Maintain ideal body weight.

Table 29-3
The Outpatient Visit for Patients with Diabetes

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

Table 29-4
Onset of Action, Peak Action, and Duration of Action in Five Types of Insulin

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

V.  TYPE 2 DIABETES

A.  Chronic metabolic disorder characterized by insulin resistance.

B.  Etiology.

1.  Most common clinical factor for type 2 diabetes is obesity/body mass index (BMI) > 85% for age and sex.

C.  Occurrence.

1.  Female-to-male ratio is 1.7:1 regardless of race. Youths between 8-19 years of age.

D.  Clinical findings.

1.  Obesity.

2.  Polyuria.

3.  Polydipsia and weight loss.

4.  Vaginal infection as chief complaint.

5.  Dysuria.

6.  Family history.