الأربعاء، 13 يناير 2010
الجمعة، 23 أكتوبر 2009
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Type 1 diabetes mellitus, one of the most common chronic diseases in childhood, is caused by insulin deficiency resulting from the destruction of insulin-producing pancreatic beta cells.
Although most children with type 1 diabetes present with the classic signs and symptoms of hyperglycemia without accompanying acidosis, a significant number present with diabetic ketoacidosis.
Now we will talk about the management of children and adolescents with type 1 diabetes, who either did not present with ketoacidosis or who have recovered from ketoacidosis.
GOALS OF TREATMENT :
Successful management of children with diabetes includes the following :
- Balancing strict glycemic control, which reduces the risk of long-term sequelae, and avoidance of severe hypoglycemia, which is more likely with stricter control. In children, targeted glycemic goals define what is thought to be the best balance between these long- and short-term complications.- Setting realistic goals for each child and family. The patient's age and developmental status, and the level of family involvement are important factors in establishing a practical management plan that can be implemented by the patient and family.- Maintaining normal growth, development, and emotional maturation. Increasing self-independent management as the child grows is an ongoing goal.
AGE-BASED CARE
The management plan of childhood-onset type 1 diabetes is dependent upon the age of the patient, which impacts the risk of hypoglycemia and development of self-management skills:
- Age-specific goals for glycemic control are based upon the risk of hypoglycemia.- The ability of the child to participate in self-management varies with the age, cognitive abilities, and emotional maturity of the child or adolescent.
The following discussion on age-based management is compatible with the American Diabetes Association (ADA) guidelines for the care of children and adolescents with type 1 diabetes.
Infants — Infants (younger than 1 year of age) with diabetes have the highest risk of severe hypoglycemia. Hypoglycemia is difficult to detect because infants are unable to communicate their symptoms and clinical signs are nonspecific (eg, poor feeding, lethargy, jitteriness, hypotonia).
Hypoglycemia can also lead to neurologic complications. Infants with severe hypoglycemia can present with seizures or coma, which may have permanent neurologic sequelae. In addition, repeated episodes of hypoglycemia may have deleterious effects on brain development and learning, especially in children younger than five years of age.
The frequent feeding schedule of infancy makes it challenging to develop a management plan that avoids episodes of hypoglycemia but provides sufficient glycemic control. In addition, the stress of implementing the daily care plan can have adverse effects on the parents.
Toddlers — The issues surrounding the care of toddlers (1 to 3 years of age) are similar to those in infants. The parents must learn and be responsible for the daily care of the patient and also learn to recognize episodes of hypoglycemia. Hypoglycemia is a constant concern because of the erratic food intake and activity levels of toddlers. It also can be difficult to distinguish developmentally normal episodes of oppositional behavior and temper tantrums from those of hypoglycemia. The parents must learn to measure blood glucose before ignoring a temper tantrum.
Preschool and early school-aged children — For the most part, parents still provide daily care for preschool and early school-aged children (3 to 7 years of age). However, some of these patients can begin to participate in their own care by testing their blood glucose or preparing materials. Often, such mastery behaviors are short-lived, as the children rapidly become bored and wish to forgo such responsibilities. The parents must be counseled that this behavior is normal and age appropriate. As these children enter daycare or school, childcare providers and school nurses must be involved in their diabetes care. For parents, sharing care with others including the patient may be difficult. Continued support by the care team is important to facilitate this transition. Shared care is appropriate at this age only under direct parental supervision.
School-aged children — School-aged children (8 to 11 years of age) can assume more of the daily management of their diabetes with adult supervision and support. They can learn to administer insulin injections on a routine basis, but still need significant assistance and supervision for nonroutine management decisions. All glucose testing and insulin administration should be under adult supervision. Early independent self-management in this age group with minimal or no adult supervision results in poorer glycemic control. Shared responsibility with appropriate adult supervision needs to be established for optimal care.
The diagnosis of diabetes has a psychological impact on these children, which may be manifested by depression and anxiety . Children may also have difficulty with social interactions because of the perception of being different from their peers. The parents and the diabetes team need to ensure that children attend school regularly and encourage participation in school activities to develop normal peer relationships.
Adolescents — Determining the appropriate extent of adult involvement during a normal developmental period of increasing independence and self-assertiveness is challenging. Although adolescents can be responsible for the daily management of their diabetes, minimal or no adult supervision results in poor glycemic control. However, parent-child conflict over daily management also leads to poor control. In contrast, shared management between the adolescent and parents has been associated with better glycemic control.
Before initiating sexual activity, adolescent girls should be given preconception counseling that includes the risks of diabetes complications to themselves and potentially the fetus. Use of contraception should be reviewed and encouraged
Type 1 diabetes mellitus, one of the most common chronic diseases in childhood, is caused by insulin deficiency resulting from the destruction of insulin-producing pancreatic beta cells.
Although most children with type 1 diabetes present with the classic signs and symptoms of hyperglycemia without accompanying acidosis, a significant number present with diabetic ketoacidosis.
Now we will talk about the management of children and adolescents with type 1 diabetes, who either did not present with ketoacidosis or who have recovered from ketoacidosis.
GOALS OF TREATMENT :
Successful management of children with diabetes includes the following :
- Balancing strict glycemic control, which reduces the risk of long-term sequelae, and avoidance of severe hypoglycemia, which is more likely with stricter control. In children, targeted glycemic goals define what is thought to be the best balance between these long- and short-term complications.- Setting realistic goals for each child and family. The patient's age and developmental status, and the level of family involvement are important factors in establishing a practical management plan that can be implemented by the patient and family.- Maintaining normal growth, development, and emotional maturation. Increasing self-independent management as the child grows is an ongoing goal.
AGE-BASED CARE
The management plan of childhood-onset type 1 diabetes is dependent upon the age of the patient, which impacts the risk of hypoglycemia and development of self-management skills:
- Age-specific goals for glycemic control are based upon the risk of hypoglycemia.- The ability of the child to participate in self-management varies with the age, cognitive abilities, and emotional maturity of the child or adolescent.
The following discussion on age-based management is compatible with the American Diabetes Association (ADA) guidelines for the care of children and adolescents with type 1 diabetes.
Infants — Infants (younger than 1 year of age) with diabetes have the highest risk of severe hypoglycemia. Hypoglycemia is difficult to detect because infants are unable to communicate their symptoms and clinical signs are nonspecific (eg, poor feeding, lethargy, jitteriness, hypotonia).
Hypoglycemia can also lead to neurologic complications. Infants with severe hypoglycemia can present with seizures or coma, which may have permanent neurologic sequelae. In addition, repeated episodes of hypoglycemia may have deleterious effects on brain development and learning, especially in children younger than five years of age.
The frequent feeding schedule of infancy makes it challenging to develop a management plan that avoids episodes of hypoglycemia but provides sufficient glycemic control. In addition, the stress of implementing the daily care plan can have adverse effects on the parents.
Toddlers — The issues surrounding the care of toddlers (1 to 3 years of age) are similar to those in infants. The parents must learn and be responsible for the daily care of the patient and also learn to recognize episodes of hypoglycemia. Hypoglycemia is a constant concern because of the erratic food intake and activity levels of toddlers. It also can be difficult to distinguish developmentally normal episodes of oppositional behavior and temper tantrums from those of hypoglycemia. The parents must learn to measure blood glucose before ignoring a temper tantrum.
Preschool and early school-aged children — For the most part, parents still provide daily care for preschool and early school-aged children (3 to 7 years of age). However, some of these patients can begin to participate in their own care by testing their blood glucose or preparing materials. Often, such mastery behaviors are short-lived, as the children rapidly become bored and wish to forgo such responsibilities. The parents must be counseled that this behavior is normal and age appropriate. As these children enter daycare or school, childcare providers and school nurses must be involved in their diabetes care. For parents, sharing care with others including the patient may be difficult. Continued support by the care team is important to facilitate this transition. Shared care is appropriate at this age only under direct parental supervision.
School-aged children — School-aged children (8 to 11 years of age) can assume more of the daily management of their diabetes with adult supervision and support. They can learn to administer insulin injections on a routine basis, but still need significant assistance and supervision for nonroutine management decisions. All glucose testing and insulin administration should be under adult supervision. Early independent self-management in this age group with minimal or no adult supervision results in poorer glycemic control. Shared responsibility with appropriate adult supervision needs to be established for optimal care.
The diagnosis of diabetes has a psychological impact on these children, which may be manifested by depression and anxiety . Children may also have difficulty with social interactions because of the perception of being different from their peers. The parents and the diabetes team need to ensure that children attend school regularly and encourage participation in school activities to develop normal peer relationships.
Adolescents — Determining the appropriate extent of adult involvement during a normal developmental period of increasing independence and self-assertiveness is challenging. Although adolescents can be responsible for the daily management of their diabetes, minimal or no adult supervision results in poor glycemic control. However, parent-child conflict over daily management also leads to poor control. In contrast, shared management between the adolescent and parents has been associated with better glycemic control.
Before initiating sexual activity, adolescent girls should be given preconception counseling that includes the risks of diabetes complications to themselves and potentially the fetus. Use of contraception should be reviewed and encouraged
الاثنين، 19 أكتوبر 2009
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الأربعاء، 24 ديسمبر 2008
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