12/17/2021

Current Practices in The Management

of Type 1 Diabetes in Children and
Adolescents: What to Do after DKA
resolved?

Bambang Tridjaja

Dysglycemia Hyperglycemia Long standing

HbA1c 5.7-6.4% OR
≥10% increase in A1c

(Couper et al. ISPAD Clinical Practice Consensus Guidelines 2018)

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● Majority of patients/parents: guilt, shock, worried,

denial, grief, confuse
● Education barriers: economical, cultural, religion,

The age, pubertal stage, psychological stage

●Brief basic: why & how

transition ● Management vs growth & development

phase ● Medical – insulin, OAD

● Nutritional
● Psychological approach: self management, life-
style, QoL
● Survival skills

STABILISATION
Transition
phase
SURVIVAL SKILLS

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Must do! Characteristics of T1DM and T2DM in children and adolescents

Type
determination

(Tao et al,2016)

WHO,2019
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WHO,2019
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WHO,2019
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Diabetic Ketoacidosis is evidence

of management failure
EDUCATE & EMPOWERING
MANAGE AS INDICATED
STANDARD MANAGEMENT GUIDELINE
(INTERNATIONAL.NATIONAL)
EMPATHIC APPROACH SEARCH FOR CAUSE

DIABETIC KETOACIDOSIS RECURRENT

NEW PATIENT KNOWN DIABETIC

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HbA1C goal of < 7.5% (58 mmol/mol) is

recommended across all pediatric age-
groups
Insulin

Exercise Metabolic
Nutrtion
Control

Education

MAIN EDUCATION THEME

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Survival tool kit

Insulin Logistic/Storage 4-8⁰C, room temperature
Regimen Tailor made, intensive*, pumps, CSII
Injection: Techniques, rotation sites
Nutrition Growth potential RDA normal child, “do” & “don’t”
Acute Complication Signs and symptoms Hypoglycemia, Nocturnal
Hypoglycemia, Hyperglycemia (Dawn
Phenomena, Somogyi), Hypoglycemic
unawareness
Management Prevention & therapy

DIABETIC TASK
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Survival tool kit

Monitoring/ HbA1c @ 3 months – standard metabolic
metabolic control control
Diary Recording daily BG and insulin
dose/adjustment
Blood glucose Before/after meals, night
Blood ketones Repeated BG>250 mg/dl
Any time BG>300 mg
Type 1 Diabetes Why need insulin
How insulin works

DIABETIC TASK
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Insulin
• Shelf live 2 years (4⁰C); 1 month at room temperature
• Subcutaneous: pen, pump, biosensor, nasal (?)
• Needle phobia: spring-loaded automatic injection, transjector system
• Intensive regimen: difference 2% of HbA1c
• Reduces risk of retinopathy 76%
• Reduces risk of nephropathy 39%
• Reduces neuropathy 70%
• 6 yrs intensive treatment positive long term effect in CVD morbidity and
mortality (30 yrs follow-up) despite “identical” HbA1c

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MAIN EDUCATION THEME -Insulin

Type Onset Peak Duration
(hrs) (hrs) (hrs)
Rapid Acting 0.15–0.35 1–3 3–5
•Lispro* 5-15 mnt 45-90 mnt 3-4
•Aspart* 10-20 mnt 1-3 jam 3-5
•Glulisine* 10 mnt 40-130 mnt 6
Short-acting / Regular 0.5–1 2–4 5–8
Intermediate-acting
•Semilente (pork) 1–2 4–10 8–16
•NPH 2–4 4-12 12-24
Long-acting
•Glargine 2-4 Tidak ada 24
•Detemir 1-2 6-12 20-24
Premix
•NPH + short acting 0.5 7-12 16-24
NPH + rapid acting* 0.15-0.35 7-12 6-24
(*Non-ISPAD) (ISPAD 2009)
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Target HbA1c
• HbA1c <53 mmol/mol (<7.0%) – examine @ 3 months!
• individualized with the goal of achieving a value as close to normal as possible while avoiding
severe hypoglycemia, frequent mild to moderate hypoglycemia, and excessive stress/burden for
the child with diabetes and their family.
• Factors that must be considered when setting an individualized target include, but are not limited
to:
 Access to technology, including pumps and CGM
 Ability to articulate symptoms of hypoglycemia and hyperglycemia
 History of severe hypoglycemia/hypoglycemic unawareness
 History of compliance with therapy
 Whether child is a high or low glycator
 Whether child has continued endogenous insulin production (eg, in the new onset or
“honeymoon” period of diabetes)

ISPAD Clinical Practice Consensus Guidelines 2018

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Blood glucose and A1C goals for children and adolescents

with type 1 diabetes

A lower goal (<7.0% [53 mmol/mol]) is reasonable if it can be achieved without excessive
hypoglycemia (ADA,2018)
Key concepts in setting glycemic goals:
• Goals should be individualized, and lower goals may be reasonable based on a benefit-risk assessment.
• Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness.
• Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C
levels and to assess preprandial insulin doses in those on basal-bolus or pump regimens.

(ADA,2018)

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Daily Glycemic target

Abbreviations: ADA, American Diabetes Association; BG, blood glucose; CGM, continuous glucose monitoring; HbA1c, hemoglobin A1c; ISPAD, International
Society for Pediatric and Adolescent Diabetes; NICE, National Institute for Health and Care

ISPAD Clinical Practice Consensus Guidelines 2018

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type, intensity and duration of the

activity

the amount of insulin on board

Exercise
management stress/anxiety levels

individual's response to exercise may or

may not be predictable on repeated
exercise occasions

Chetty et al. Front. Endocrinol., 14 June 2019 | https://doi.org/10.3389/fendo.2019.00326

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BG is best measured
 during the day, before meals and snacks;
 at other times (eg, 2-3 hours after food intake) to determine appropriate meal insulin doses and
show levels of BG in response to the action profiles of insulin (at anticipated peaks and troughs of
insulin action).
 in association with vigorous exercise (before, during, and several hours after) so that changes may
be made in glycemic management;
 at bedtime, during the night and on awakening to detect and prevent nocturnal hypoglycemia
and hyperglycemia as well as optimize basal insulin;
 before driving a car or operating hazardous machinery;
 to confirm hypoglycemia and to monitor recovery;
 during intercurrent illness to prevent hyperglycemic crises
 at least 6 to 10 times a day and regular

ISPAD Clinical Practice Consensus Guidelines 2018

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MONITORING OF GLYCEMIC CONTROL

Home self-monitoring of glucose:
• tracks immediate and daily levels of glucose control ;
• helps to determine immediate and ongoing basal and bolus insulin
requirements;
• detects hypoglycemia and assists in its management;
• assists in the appropriate management of hyperglycemia; and
• helps guide insulin adjustments to decrease glucose fluctuations.

ISPAD Clinical Practice Consensus Guidelines 2018

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Diabetic Ketoacidosis is evidence

of management failure
EDUCATE & EMPOWERING
MANAGE AS INDICATED
STANDARD MANAGEMENT GUIDELINE
(INTERNATIONAL.NATIONAL)
EMPATHIC APPROACH SEARCH FOR CAUSE

DIABETIC KETOACIDOSIS RECURRENT

NEW PATIENT KNOWN DIABETIC

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Recurrrency DKA Indonesia

RSCM: 12/17 = recurrent case Surabaya: 24/31 = recurrent case

Management of an episode of DKA is not complete until its cause has been identified and an attempt
made to treat it.
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Predictors of Recurrent DKA

INSULIN DEFICIENCY • Access to health care/insurance
• Insulin omission
• Availability • Mistaken understanding of
• Storage / expired date honeymoon period
• Unofficial drug store – economic problems • Non-medical resources of
• Adherence: psychological, cultural, consultation
• Insulin pump therapy
• Neglected – impaired family
• Health system inequalities dynamic
• Age (under-5)
• previous episodes of DKA,
• female gender (peripubertal or
adolescent), • psychiatric disorders including
• Infection (incompatible with sick day eating disorders
rules) • poor metabolic control
PSYCHIATRY ASSESSMENT
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NATURAL CINICAL HISTORY OF

DIABETES MELLITUS TYPE 1
“NORMAL”
GROWTH &
DEVELOPMENT

PARTIAL PROGRESSION
DIAGNOSIS
REMISSION /
PREDIABETES (WITH/WITHOUT SICK DAYS
HONEYMOON
DKA)
PERIOD AGE

Needs less
COMPLICATION
PREVENTION
NUTRITION ACTIVITY

INSULIN ADJUSTMENT

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THANK YOU

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