Synopsis of General Pediatric Practice

Seckin Ulualp

• Publisher: Bentham Science Publishers
• Year: 2017
• Print ISBN: 9781681085210
• eBook ISBN: 9781681085203
• Topic: Medicine
• Subtopic: Pediatric Medicine

This textbook provides a brief review of pediatric medicine practice. This book covers the diseases and disorders commonly seen in routine practice. The chapters cover pediatric disorders such as obesity, gastroesophageal reflux, asthma, bronchiolitis, pneumonia, allergy, sinusitis, diabetes, thyroid disorder, epistaxis, otitis media, hearing loss, laryngomalacia, obstructive sleep apnea, central sleep apnea, laryngomalacia, stridor, tonsillitis, haemophilia, autism, and anxiety.
Key features of this textbook include:
- Reader friendly format which explains etiology, pathophysiology, and disease management
- 21 chapters covering common pediatric disorders encountered by medical professionals
- Contributions by several experts in pediatric subspecialties
This textbook is a suitable reference for medical students, interns, residents, and specialists including pediatricians, family medicine practitioners, otolaryngologists as well as subspecialists such as pediatric cardiologists, pulmonologists, endocrinologists, otolaryngologists and allergists.

Synopsis of Management of Diabetes Mellitus Types 1 and 2

Eric Velazquez, Bethany A. Auble^*

Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA

Abstract

Diabetes involves pancreatic dysfunction due to autoimmune destruction of the beta cells and insulin deficiency. The prevalence and incidence of Type 1 and Type 2 are increasing in the general population. Type 1 Diabetes often begins in childhood and requires lifelong insulin replacement therapy and monitoring of blood glucose levels. Long and short-acting insulin allows for adjustment of therapies around patients’ lives, but close medical observation and a good patient-provider relationship is necessary for optimal management. Type 2 Diabetes is characterized by severe insulin resistance and partial deficiency that has become more prevalent in pediatric patients, often occurring around puberty. Therapy involves lifestyle changes to promote active weight loss, healthy eating habits, and exercise. Few pharmacological therapies are approved, but many are being studied for pediatric use.

Keywords: Artificial Pancreas, Bariatric Surgery, Closed Loop Control, Continuous Glucose Monitoring, Continuous Subcutaneous Insulin Injection, Glucagon, Insulin, Lifestyle Changes, Metformin, Multiple Daily Insulin Injections, Type 1 Diabetes, Type 2 Diabetes.

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^* Corresponding author Bethany A. Auble: Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA; Tel: [phone]; Fax: [phone]; Email: [email protected]

INTRODUCTION

Diabetes Mellitus is a life-altering diagnosis, requiring adjustment of a patient’s life and schedule. In pediatric patients, it also changes the entire family’s focus. Loss of insulin-secreting beta cells results in loss of glycemic control with subsequent hyperglycemia in Type 1 diabetes. Insulin replacement therapy remains the mainstay of current therapy. Advances in insulin pumps, continuous glucose monitors, and closed loop control systems have resulted in long-term improved glycemic control. New advancements in pancreatic transplant, stem cell therapy, biomarker screenings, and prevention strategies are being published yearly. Type 2 Diabetes requires an alternative approach to management with a

strong emphasis placed on diet, exercise, and lifestyle modifications. The medical therapies for the treatment of Type 2 Diabetes are a growing field of research, but pharmacotherapy must be combined with lifestyle changes if lasting health improvements are to be achieved.

Epidemiology

In the United States, the prevalence of Type 1 Diabetes is estimated for 0.25% of the population [1]. From 2001–2009, prevalence of Type 1 diabetes increased by nearly 20%, with projections suggesting that from 2010 to 2050, the number of youth with Type 1 diabetes may triple. In this same time period, the prevalence of Type 2 diabetes increased by nearly 30% and accounts for 45% of newly diagnosed cases of diabetes in the pediatric population. Projections suggest that from 2010 to 2050, a nearly 4-fold increase might occur of patients with Type 2 diabetes. While still relatively uncommon, the rates of new cases of type 2 diabetes were greater among peripubertal individuals aged 10–19 years than in younger children, with higher rates among U.S. minority populations than in non-Hispanic whites.

Physiology

The pancreas is both an exocrine gland and an endocrine gland. Endocrine cells are located within scattered Islets of Langerhans and divided into three categories: alpha-cells (produce glucagon), beta-cells (produce insulin and amylin) and delta-cells (produce somatostatin). Insulin stimulates cells to uptake free glucose, glycogenesis in the liver, and uptake amino acids, proteins and fat from the bloodstream. Humans are born with a varying amount of beta-cells, and even within these cells, there is variation to susceptibility to auto-immune attack [2]. In Type 1 Diabetes, autoimmune destruction of beta-cells produces gradual dysregulation of glucose and its symptoms develop after >80-90% of cells are lost. Type 2 Diabetes is caused by the relative deficiency of insulin due to severe peripheral tissue resistance.

Glucagon works primarily in the liver to convert glycogen into glucose to raise blood glucose. Its function becomes dysregulated in type 2 diabetes, leading to postprandial hypersecretion, worsening overall hyperglycemia. Amylin is a neuroendocrine peptide hormone that is co-secreted with insulin, uses the same processing enzymes, and works to suppress release of glucagon, slows digestion and slows rate of insulin entering the bloodstream. The benefit of delayed gastric emptying is creating a slower rise, and overall lower peak level of blood glucose [3]. Somatostatin is a peptide hormone that has many GI effects but is active in slowing gastric emptying, suppressing insulin and glucagon release, and suppressing exocrine pancreatic secretions. Incretins are small hormones released by intestinal mucosa that stimulate insulin release, delay gastric emptying and inhibit glucagon release. While native molecules have short half-lives, synthetic versions last much longer and are being looked at as therapeutic alternatives.

TYPE 1 DIABETES MELLITUS

The “event” of stage II most likely is not a single event but some combination of environmental and genetic triggers. The time period of stage III-IV is highly variable, the reasons for why are being closely studied [2]. Patients most often present with classic symptoms of onset: polyuria, polydipsia, hyperglycemia and ketonuria during Stage V (some present in full diabetic ketoacidosis). The “honeymoon period” between Stage V and VI is called such as very low supplemental insulin is required to maintain normoglycemia (Fig. 1).

Fig. (1))
The Eisenbarth model for the development of Type 1 Diabetes is divided into six stages: 1. Genetic Predisposition, 2. Triggering “Event,” 3. Activation of Autoimmune Response, 4. Immunologic Response with progressive loss of insulin secretion with maintenance of normal blood sugar level, 5. Symptoms develop, but residual insulin secretion is maintained, 6. Loss of residual insulin secretion to a point of glucose dysregulation [4].

Hemoglobin A1c is the form of hemoglobin produced through nonenzymatic glycation within red blood cells. Production varies directly with plasma glucose levels. Monitoring concentration allows for idea of average glucose levels over the life span of the red blood cells (roughly 2-3 months). The ADA treatment guidelines recommend: HbA1C <7.5% in pediatrics, <7% in adults (lower for pregnant women), reduction in hypoglycemic events and prevention of long-term complications of poor glycemic control. Most adults are not meeting the ADA HbA1c goal, and patients 13-25 years old actually have the worst control based on HbA1c levels [5].

Multiple Daily Injection Insulin Regimens

Multiple Daily Injection (MDI) insulin regimen is the standard therapeutic approach of Type 1 Diabetes and involves calculating daily insulin requirement, basal insulin amount, carbohydrate coverage dosing, and meal-time sliding-scale bolus doses. Total daily insulin dose is highly variable, but is generally determined by the patient’s pubertal status (Table 1).

Table 1 Types of Insulin.

Insulin Type	Examples	Onset of Action	Peak Effect	Duration of Action
Rapid-Acting	Insulin Lispro (Humalog), Insulin Aspart (NovoLog) Insulin Glulisine (Apidra)	15-20 minutes	30-90 minutes	1-4 hours
Regular-Acting	Novolin R and Humulin R	30-45 minutes	2-3 hours	5-8 hours
Intermediate-Acting	NPH (Humulin N, Novolin N)	2-4 hours	4-10 hours	4-12 hours
Long-Acting	Insulin glargine (Lantus) Insulin detemir (Levemir)	2-4 hours	No peak 8-10 hours	20-24 hours Dose-related

Use of a basal/bolus dosing regiment attempts to establish patterns that most closely approximate normal human physiologic release of insulin. Advantages for this style of dosing include: improved glycemic control, lower HbA1c, and may reduce hypoglycemic events overnight. Pre-meal injections allows for a more flexible meal-time schedule to accommodate lifestyle. The addition of carbohydrate coverage dosing allows for freedom of meal choice (e.g. high-carbohydrate meal will need more insulin; a low-carbohydrate meal will need less). Disadvantage of basal-bolus dosing of insulin is that multiple injections throughout the day are needed, and frequent glucose checks are also required. The number of fingerstick blood glucose checks and injections can be distressing to some patients. With the advent of insulin pump therapy, new basal-bolus approaches became possible (Table 2).

Table 2 Calculation of Insulin Requirements.

	Insulin	Dose Calculation	Calculation for 20 kg Child	Dose
Total Daily Insulin Dose		0.5 – 1.0 units/kg/day	0.5 x 20 = 10 units/day	10 Units
Basal Dose	Glargine Detemir	50% of total 50% of total divided into twice a day dosing	50% x 10 = 5 units	5 Units
Meal-time Glucose Correction	Lispro, Aspart Regular	1800 / Daily Dose 1500/ Daily Dose	1800 / 10 = 180 1500 / 10 = 150	1 unit for every 180 mg/dL > ideal glucose 1 U for every 150 mg/dL > ideal gluc...

Table of contents

• Welcome
• Table of Contents
• Title Page
• BENTHAM SCIENCE PUBLISHERS LTD.
• PREFACE
• List of Contributors
• Update on the Management of Otitis Media
• Contemporary Management of Children with Hearing Loss
• Overview of Management of Recurrent Tonsillitis
• Therapies for Pediatric Chronic Rhinosinusitis
• Practical Management of Children with Stridor
• Update on the Management of Laryngomalacia
• Synopsis of Management of Diabetes Mellitus Types 1 and 2
• Pediatric Type 2 Diabetes Mellitus
• Practical Guide for Management of Children with Obesity
• Current Concepts in the Management of Hyperthyroidism
• Recent Advances in Pediatric Asthma
• Evaluation and Treatment of Bronchiolitis
• What is New with Management of Pediatric Central Sleep Apnea?
• Practical Considerations in the Treatment of Pediatric Obstructive Sleep Apnea
• State of the Art of the Diagnosis and Management of Gastroesophageal Reflux Disease
• Essentials of Sickle Cell Disease Management
• Management of Recurrent Epistaxis
• Update on Management of Allergic Rhinitis
• The Management of Pediatric Allergic Emergencies
• Autism Spectrum Disorder: What a Pediatrician Should Know
• Treating Anxiety in Children