Staged diabetes management a systematic approach - part 5 pdf

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 189Start Insulin Stage2 RA/N–0–RA/N–0 R/N–0–R/N–0 Calculate total dose at 0.3 U/kg based on current weight Distribution of daily dose RA/N or

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 185Insulin therapy

Because initiation of insulin is a major step in

di-abetes therapy, it may be helpful to review with

the patient and the family some key principles of

care and the Type 2 Diabetes Master DecisionPath

for Children and Adolescents (see Figure 5.15) It

is important to note that patients starting insulin

may need a revised food plan and exercise

pro-gram synchronized to insulin action, and referral

to a dietitian is strongly encouraged

improve glycemic control raises concerns about

hypoglycemia and weight gain While

hyper-glycemia may indeed be rectified, if insulin is

introduced too rapidly at high doses patients may

experience symptoms of relative or “true”

hy-poglycemia It is not uncommon to lower blood

glucose by >100 mg/dL (5.6 mmol/L) when

high-dose insulin is used In SDM, insulin is started

at the lowest safe dose and is adjusted slowly

so that HbA1c decreases at a rate of 0.5–1 per

15–30 mg/dL [0.8–1.7 mmol/L]) At this rate of

improvement there is time to address weight gain

issues For newly diagnosed patients with severe

hyperglycemia prior to the initiation of insulin,

there may have been modest weight loss (both by

volume of fluid loss and glucose excretion) Using

insulin to restore near-normal glycemia is often

accompanied by a 3–10 lb (1.5–5 kg) weight

gain This is normal and can be minimized by

modifying diet or increasing exercise/activity at

the start of insulin therapy As part of an intensive

regimen, the exogenous insulin may cause some

“hunger” There is a tendency to chase the insulin

with food, which results in added caloric intake

This can be prevented by maintaining the same

carbohydrate intake and moving the carbohydrate

to synchronize with insulin action and/or

adjust-ing the insulin regimen (For example, if due to

the peak action of intermediate-acting insulin the

patient experiences mid-afternoon hypoglycemia,

reduce the caloric intake at the midday meal and

use some of these calories [carbohydrate] for a

mid-afternoon snack The net effect is to maintain

the same caloric intake, but to distribute it moreeffectively to reduce hypoglycemia.)

diabetes is similar to that for type 1 diabetes cause the same insulins and regimens are used(although pump therapy is relatively rare in type

be-2 diabetes) Where the two differ is how the sulin is used to overcome the underlying defect

in-In type 1 diabetes the destruction of the pancreaticβ-cell results in an absolute insulin deficiency, re-quiring total reliance on exogenous insulin This israrely the case in type 2 diabetes Depending uponthe duration of disease and the severity of insulinresistance and relative insulin deficiency, exoge-nous insulin has varying functions Individualswith type 2 diabetes retain the ability to produceand secrete insulin although it may not be enough

to meet the metabolic demands of insulin tance The defect may be in the timing of insulinsecretion (defects in first-phase insulin secretion),amount of insulin that can be produced by the β-cell resulting in a relative insulin deficiency, orinsulin resistance Thus the choice of therapy firsttakes into consideration the underlying defects Inmost children and adolescents requiring insulin

resis-at diagnosis, the underlying defect is relresis-ated toboth a relative insulin deficiency and insulin re-sistance Thus, the exogenous insulin will have toaddress both of these defects and generally callsfor higher-dose insulin compared with a child oradolescent with type 1 diabetes

There are several approaches to insulin apy SDM divides each insulin regimen into twocomponents: basal or background and bolus ormeal related Combinations of basal and bolus in-sulin can be used for conventional and intensivemanagement In conventional insulin therapy, in-sulin action is matched to carbohydrate intake (seeChapter 3 for insulin action curves) This regi-men relies on a consistent schedule of food intakeand exercise/activity Since insulin is given to an-ticipate when food is ingested, it is important tomaintain a consistent eating schedule and carbo-hydrate intake that is synchronized to insulin ac-tion Typically the conventional regimens requirefewer injections and mixing of different types ofinsulin (see Table 5.3) Once the most popular

ther-Table 5.3 Selecting insulin: Stage 2, 3, or 4

Primarily fasting Primarily post-prandial Fasting and post-prandial Cannot detect

regimen, it is now being replaced by a more

phys-iologic insulin delivery regimen: intensive insulin

therapy In this regimen, insulin is altered to match

energy intake and expenditure The regimens

con-sist of three or more injections of insulin per day

and are co-ordinated with food intake and activity

level Because it comes closer to mimicking the

normal physiologic state, intensive insulin

ther-apy provides a better chance of optimizing blood

glucose control Typical of this approach are

fre-quent changes in insulin dose and more frefre-quent

SMBG The goal of both approaches is to

op-timize glycemic control with fewer episodes of

hypoglycemia

In general, regimens requiring administration of

insulin before meals and large snacks are far more

physiologic, generally require less total insulin,

and usually result in a more flexible schedule for

the patient Many physicians and patients are

con-cerned with the discomfort of multiple-injection

insulin regimens Studies have repeatedly shown

that the newer fine-gauge needles (30 and 31

gauge) are nearly painless if proper injection

tech-nique is followed Additionally, needleless insulin

delivery devices are available to help patients

with needle phobia Currently studies are

under-way testing the feasibility, safety, and efficacy

of inhaled insulin preparations, which may make

multiple insulin administration more acceptable to

patients (and health care providers)

For consistency, the insulin therapies supported

by SDM use pre-meal (bolus) and bedtime (basal)

as the times to administer insulin Whether basal

or bolus, conventional or intensive, generally

in-sulin may be given at four specific times

dur-ing a day related to meals, activity, and sleep

The times are before breakfast (fasting), midday

meal, evening meal, and at bedtime (3–5 hours

after the evening meal) The insulins are denoted

as short-acting regular (R), rapid-acting (RA),intermediate-acting (N), and long-acting glargine(G) SDM recommends writing out insulin regi-mens using these specific times and types of in-sulin For example, R/N–0–R–N denotes break-fast regular and intermediate insulin, no insulinbefore lunch, regular insulin before the eveningmeal, and intermediate insulin before bedtime SeeChapter 3 for a complete review of insulin actioncurves

Medical nutrition therapy is continued out all stages of therapy In newly diagnosedpatients, MNT is instituted along with insulininitiation and generally follows the carbohydratecounting method MNT with insulin follows thesame general principles as stated in the weightmanagement section of this chapter

through-Short-acting insulin: choosing between regular

or rapid-acting No clear criteria currently exist

for choosing between regular short-acting andrapid-acting insulin for type 2 diabetes However,

in clinical practice, some principles have emergedthat may be helpful in choosing between thesetwo forms of insulin For patients whose lifestylemakes food and activity planning very difficult,

RA, which is injected just prior to eating and has

a more predictable action curve (peak within 1 to

11/2hours, overall action 3 hours), is the preferredchoice For patients already under treatment forwhom regular insulin before each meal has notresulted in improved post-prandial glucose levels,replacement of R with RA is recommended Thismaintains the patient on the same number ofinjections For all other patients, at diagnosis or

in treatment, either R or RA could be used atthe same dose RA is preferred in SDM because

it is generally more predictable and can be moreeasily adjusted For children and adolescents withtype 2 diabetes the major criteria are twofold:

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 187convenience and predictability Fewer injections

of regular insulin are more convenient, but require

that meals and snacks be taken at the same time

each day R has a variable peak action and a

long-lasting “tail” that make it difficult to predict

its action curve RA insulin is more predictable

because of its shorter action curve, but would

require insulin administration prior to each meal

(and sometimes before snacks) Some would argue

that children cannot be expected to do this In

actuality children with type 1 diabetes have been

administering their own insulin throughout the

day, even in school When starting insulin in

a child with type 2 diabetes it may be helpful

for health professionals to consider the manner

in which a child with type 1 diabetes would be

treated

Intermediate or long-acting insulin: choosing

between N and glargine In general glargine is

su-perior to N in terms of both predictability and

convenience One injection per day of G at

bed-time should provide sufficient basal insulin for a

24 hour period without any peak action However,

some patients may require splitting the dose of G

for optimal basal insulin coverage In contrast, N

requires two injections and each may peak at

be-tween 6 and 9 hours after administration When

taking N it must be certain that food is available

during its peak action to prevent hypoglycemia

Patients tend to overreact, eating snacks

through-out the day to anticipate a hypoglycemic reaction

Starting insulin with a new diagnosis of type

initi-ation of insulin therapy should occur immediately,

without regard to symptoms, if fasting plasma

glu-cose is >300 mg/dL (16.7 mmol/L), casual plasma

glucose is >350 mg/dL (19.4 mmol/L), or ketones

are present At these high plasma glucose levels,

medical nutrition therapy alone or in combination

with an oral agent (metformin) will not normally

sufficiently lower the blood glucose level into the

target range Furthermore, patients with persistent

hyperglycemia at these levels experience glucose

toxicity Therefore they are at increased risk for

hyperglycemic hyperosmolar syndrome (HHS)

Fi-nally, some children may be developing type 1

diabetes, for whom insulin therapy will prevent abetes ketoacidosis

di-Determine whether insulin will be initiated on

an inpatient or outpatient basis

Many institutions have developed systems thatallow for the safe initiation of insulin on anoutpatient basis If resources for education andmedical follow-up are not available, the patientshould be hospitalized If the patient is at risk forHHS (see Chapter 10), if there is uncertainty as

to type of diabetes, or if the individual cannotcare for him or herself, consider hospitalizationimmediately

Preparing the patient to use insulin: multiple injections and insulin adjustment.

Blood glucose monitoring All patients or their

family caregiver should be performing SMBG,independent of the number of injections Thesedata are necessary for meaningful communica-tions between the patient and the health care pro-fessional The type of meter to be used for SMBGvaries However, SMBG should have these im-portant attributes First, the SMBG meter shouldhave a memory, making it possible to recordand store data for retrieval This also increasesthe accuracy and reliability of the patient’s infor-mation Second, the skills needed by the patientshould be simple, with regard to use of the de-vice Third, testing should be scheduled to coin-cide with meals, activity, and insulin adjustments

to optimize collecting data for clinical making Fourth, testing should take into accountthe need to adjust insulin doses based on changes

decision-in blood glucose

Unlike the case with oral agent regimens, tients or their caregivers are expected to play avery important role in the daily adjustments ininsulin dose There are two approaches to ad-justing treatment using SMBG data – pattern orimmediate response The two are meant to ad-dress most situations When they do not, it isgenerally necessary to collect more SMBG dataand to confirm that the patient’s behaviour isconsistent with the instructions Pattern responsesuggests that each individual has a consistentset of blood glucose/insulin relationships This

pa-consistency is characterized by predictable

pat-terns in which specific insulin doses are related

to known glycemic levels For example,

increas-ing the mornincreas-ing intermediate-actincreas-ing N insulin will

consistently result in a decrease in late-afternoon

(pre-evening meal) blood glucose levels

There-fore, the purpose of initial SMBG is to determine

whether such a pattern can be easily identified

When, after trial and error (even within 3 days)

such a pattern has been identified, treatment of

type 2 diabetes may follow a predictable path

Generally, however, identifying a specific pattern

takes substantially longer Because of changes

in food plan, exercise/activity, seasons, and so

on, patterns may change Therefore, the concept

of patterned response should be continually

re-assessed

Immediate response recognizes that an acute

sit-uation has developed requiring an immediate

ac-tion such as hypoglycemia (insulin reacac-tion),

hy-perglycemia, or an anticipated change in food plan

or exercise This occurs whenever blood glucose

is below 60 mg/dL (3.3 mmol/L) or greater than

250 mg/dL (13.9 mmol/L) Refer to

“Hospitaliza-tion for Problems Related to Glycemic Control”

in Chapter 10 for additional information

Insulin Stage 2, 3 or Physiologic Insulin

ado-lescents starting insulin therapy, the Type 2

Dia-betes Master DecisionPath (see Figure 5.15)

indi-cates three insulin regimens using rapid or

short-acting and intermediate or long-short-acting insulins

The conventional approach is to begin with Stage

2 and proceeds to the next stages if this

two-injection regimen fails to bring the patient into

glycemic control An alternative approach which

SDM has been found to be very effective is to

begin with bedtime long-acting (G) insulin with

subsequent addition of injections of RA before

each meal as needed for daytime management of

post-prandial hyperglycemia (i.e 0–0–0–G built

up to RA–RA–RA–G) Basically this is the most

physiologic of the insulin regimens supported by

SDM This section discusses each regimen

begin-ning with Stage 2 However, it should be noted

that children and adolescents generally have a

variable schedule characterized by ity Unless the scheduled can be fixed, it is recom-mended that the patient be given an opportunity

unpredictabil-to try the most flexible regimen – modified Stage

4 beginning with bedtime G This will require asubstantial number of SMBG tests over the firstseveral weeks to assure adequate insulin coveragefor each meal In the long term it should fit intothe variable schedule of most children

Insulin Stage 2: conventional (mixed)

ap-proach using the smallest number of injections.Its only major limitation is that the child or ado-lescent cannot skip meals and activity levels mustalso be regimented Following a thorough his-tory, physical, and laboratory evaluation and afterreview of the target blood glucose levels, the de-cision as to whether to hospitalize to start thepatient on an insulin regimen should be made Inmost cases hospitalization is unnecessary Assum-ing that insulin will be started on an ambulatorybasis, the time of insulin initiation becomes thenext question

Note: For all insulin therapies the startingdose formula has been carefully selected tomeet the immediate metabolic requirements

of the individual while reducing the risk ofhypoglycemia and severe hyperglycemia

Insulin Stage 2/Start R/N–0–R/N–0 or RA/N–0–RA/N–0

Morning insulin start If the first time the

pa-tient starts this therapy is in the morning, thetotal daily dose is calculated as 0.3 U/kg (seeFigure 5.19) The total daily dose is divided intotwo periods roughly associated with breakfast andthe evening meal (approximately 10 hours apart).The pre-breakfast dose is two-thirds of the to-tal daily requirement This is further divided intoone-third R or RA and two-thirds N The smallamount of R or RA is to cover breakfast Theintermediate-acting insulin is to cover lunch and

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 189

Start Insulin Stage2 RA/N–0–RA/N–0 R/N–0–R/N–0

Calculate total dose at 0.3 U/kg based on current weight

Distribution of daily dose

RA/N or R/N ratio

AM

2/3 1:2

MIDDAY

0 –

PM

1/3 1:1

BT

0 – Pre-mixed insulin may be used for patients unable to

draw insulin correctly or who have less than optimal

daily phone contact for 3 days, then office

visit within 1 week; 24-hour emergency

phone support needed

within 24 hours, then office visit in 2 weeks

within 1 week

Insulin Stage 2/Adjust

Start Medical Nutrition Therapy

At Diagnosis or from Oral Agent Stage, or

Oral Agent and Insulin Stage

If acutely ill, hospitalize and start insulin immediately;

otherwise, start insulin within 1 week and consider

hopitalization if outpatient (and caregiver) education

not available

Figure 5.19 Type 2 Insulin Stage 2/Start for

Chil-dren and Adolescents

the afternoon period Review the insulin action

curves described in Chapter 3 Note the likely

times of peak action Glucose excursions after

lunch will have to be measured by SMBG between

2 and 4 hours post-meal to determine whether

ad-equate insulin is available Daytime activity will

also affect blood glucose levels With adolescents

and children it is very important that SMBG be

done before and following activity to gauge the

impact of the physical activity on glucose level.

Because weekdays (in school) and weekends

dif-fer substantially, it may be necessary to readjust

the insulin regimen The pre-evening meal insulin

is calculated as one-third of the total daily dose

equally split between R or RA and

intermediate-acting insulin and given as one injection before

the evening meal For example, a patient with a

current weight of 100 lb (45 kg) would receive 14

total units of insulin Of the 14 units, nine would

be given in the AM and five in the PM Of the

nine units in the AM, six units would be N andthree units would be R or RA The PM dose would

be three units N and two units R or RA (due torounding the R or RA was kept at less than 1:1ratio with the N) Note that if premixed insulins

is used it cannot easily be adjusted

Afternoon or evening insulin start If the

ther-apy is being started in the afternoon or evening,the starting dose is one-third the normal total dailydose (0.1 U/kg), which is equally divided between

N and R or RA insulin and administered just prior

to the evening meal The next day the patientwould be on the total daily dose (0.3 U/kg) as de-scribed above The patient should be taught bothinsulin administration technique and how to mon-itor blood glucose SMBG should be performedevery 4 hours until the next day If blood glucose

levels are >250 mg/dL (13.9 mmol/L), consider

additional small doses (1–2 units) of R or RAwith SMBG 2 hours after the insulin injection.This therapy is temporary Have the patient returnthe next morning to initiate daily insulin adminis-tration (see previous section)

Immediate follow-up Self-monitored blood

glu-cose is the best way to assess the impact of insulintherapy The minimum SMBG for this treatmentregimen is five times per day (before meals, atbedtime, and at 3AM) An evening snack may

be necessary to prevent overnight hypoglycemia.One or two carbohydrate choices taken from ear-lier in the day and moved to bedtime can beprovided as a snack

During the first several days it is imperative tomaintain glucose levels at a point that will avoidboth hypoglycemia and hyperglycemia Addition-ally, co-management with the various health pro-fessionals (nurse educator and dietitian, if avail-able) who will be involved in diabetes care must

be established This is especially important inambulatory management The guidelines for in-sulin adjustments begin immediately, along withmaking arrangements for follow-up diabetes andnutrition education and establishing target bloodglucose levels

Although near euglycemia is the overall goal oftreatment to prevent microvascular and macrovas-cular complications (see the end of this chapterand Chapters 8 and 9 for further information),

any improvement from baseline benefits

individ-uals with type 2 diabetes Setting the initial goal

at fasting <200 mg/dL (11.1 mmol/L) and

post-meal <250 mg/dL (13.9 mmol/L) is the first

step in ensuring eventual near-normal levels of

blood glucose This interim target was

estab-lished to promote the overall goal of gradual

(safe) reduction in blood glucose While any

im-provement in blood glucose is acceptable, the

overall long-term goal is to achieve near-normal

glycemic control Thus, it is appropriate to

re-act to consistent patterns of high blood glucose

with increased insulin after assessing adherence

issues

Medical nutrition therapy As with all

pharma-cologic therapies, medical nutrition therapy is part

of the overall treatment approach Start as if the

person were treated solely by nutrition therapy

(see Medical Nutrition and Activity Therapy/Start

and Weight Management Start for children and

adolescents) Modifying the nutrition therapy to

avoid hypoglycemia may be necessary To do this,

consider altering the timing of both food intake

and exercise to synchronize with the insulin

ac-tion curve Some initial weight gain may occur

with the introduction of insulin This is due to

the uptake and metabolism of glucose as glycemic

targets are being reached or as a result of

rehy-dration Subsequent weight gain, however, may

be due to chasing insulin with food or poor

adher-ence to MNT recommendation Since children and

adolescents are in an active growing period,

“nor-mal” weight gain needs to be differentiated from

weight gain due to the insulin regimen The key

is to utilize the growth-related curves and to

dif-ferentiate between symmetrical and asymmetrical

growth Individuals whose height and weight are

in the 90th percentile are experiencing

symmet-rical growth patterns, whereas individuals whose

weight is in the 90th percentile and height in

the 50th percentile are asymmetrical and likely

to have a BMI >85th percentile.

In SDM, alterations in the timing of meals,

snacks, and exercise are the principal tools by

which hyperglycemia and hypoglycemia are

pre-vented If persistent hyperglycemia or

hypogly-cemia do occur, immediately consider changing

the insulin regimen

Table 5.4 Insulin Stage 2 pattern adjustment

guidelines (see Figure 5.20 for letter designations)

Insulin Stage 2 Pattern Adjustments RA/N–0–RA/N–0 or R/A–0–R/N–0

BEDTIME (BT)

1–2 U (a,b) 1–2 U (a,k) 2–4 U (a,k)

Adjust insulin based on BG patterns

May increase or decrease dose by 1–2 U or 10% of dose Follow-up

Medical: weekly while adjusting insulin, then office visit within 1–2

pat-Follow these general principles:

• Look for a pattern – at least 3 days of similarblood glucose values

• Make initial adjustments to target the tently low blood glucose first Follow this bytargeting patterns of high blood glucose

consis-• Normally, target only one insulin at a time –either N, R, or RA) – at one time point (AM

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 191

How to Use These Tables

1 Find current insulin stage

2 Find the pattern of blood glucose problem (column)

3 Identify time of day (row) pattern occurs

4 Recommended adjustment is given where the column and row

intersect

5 See notes for additional considerations

Insulin Pattern Adjustments

Adjust insulin from 3 day pattern of typical schedule

Determine which insulin is responsible for pattern

Adjust by 1–2 units or 10% of dose

Adjust only one dose at a time

Correct hypoglycemia first

If total dose
1.0 U/kg, consider adding metformin

If hyperglycemia throughout day, correct highest average

target SMBG first; if all within 50 mg/dL (2.7 mmol/L) of

target, correct AM first

Notes

a Evaluate nocturnal hypoglycemia; check 3 AM BG

b Consider adjusting bedtime snack

c Consider adding or adjusting mid-morning snack

d Consider adding or adjusting afternoon snack

e Evaluate if prior activity is causing hypoglycemia

f Consider adding activity

g Consider decreasing mid-morning snack

h Consider decreasing afternoon snack

i No mid-morning snack usually needed with RA

j No afternoon snack usually needed with RA

k Use of regular insulin in place of rapid-acting (RA)

necessitates snacking If possible, use RA insulin in children

and adolescents.

Figure 5.20 Type 2 diabetes insulin adjustment

considerations for children and adolescents

Target blood glucose and insulin adjustments.

During the first several months of insulin

ther-apy, the patient should demonstrate improved

glycemic control HbA1c should drop by

approx-imately 0.5–1 percentage point per month and

mean SMBG 15–30 mg/dL (0.8–1.7 mmol/L) If

these rates are met, the same insulin doses are

kept If the rates are not met, increase the insulin

doses following the adjustment guidelines

Insulin Stage 2/Maintain

R/N–0–R/N–0 or RA/N–0–RA/N–0

al-terations to the insulin, food plan, and exercise

regimens are still likely to be required to

main-tain near-normal blood glucose levels To prevent

both hyperglycemia and weight gain, encourage a

schedule of blood glucose and weight monitoring

While neither need be as regimented as duringstart and adjust phases, both are required to de-tect either increasing blood glucose or weight At

a minimum, SMBG should occur prior to eachinsulin injection, with at least one daily 2-hourpost-prandial (at varying meals each day) Weightshould be monitored weekly Some changes in in-sulin dose and timing should be expected Thepatient might be provided with some general rulesfor making insulin adjustments based on consis-tent patterns of blood glucose

Moving to Insulin Stage 3 Insulin Stage 3/Start: from Insulin Stage 2 R/N–0–R–N or RA/N–0–RA–N

Three conditions can be addressed by InsulinStage 3 that may have been encountered in InsulinStage 2:

• morning fasting blood glucose consistentlyabove target range

• nocturnal hypoglycemia

• varying time of evening mealMorning fasting blood glucose may be high forseveral reasons The principal causes relate to ahigh bedtime glucose, early AM excessive glu-cose output (dawn phenomenon), Somogyi effect,insufficient exogenous basal insulin and lack ofadherence to MNT (large bedtime snacks) Oneconsequence of relative insulin deficiency may

be excess hepatic glucose production genesis) The second factor, high evening bloodglucose, is usually the result of a larger eveningmeal or proportionately higher carbohydrates atthe evening meal and at bedtime The third causefor high fasting plasma glucose, dyschronized in-sulin peak action, may result in low blood glu-cose from 2 to 4 AM and a rebound to hyper-glycemia (Somogyi effect) by morning The lat-ter is often the cause of nocturnal hypoglycemia.Alternatively, nocturnal hypoglycemia may resultfrom too much intermediate-acting insulin at din-ner coupled with insufficient bedtime snack If

(gluconeo-At Diagnosis or from Oral Agent Stage or Insulin Stage 2

If acutely ill, hospitalize and start insulin immediately;

otherwise, start insulin within 1 week and consider hopitalization

if outpatient (and caregiver) education not available

Start Insulin Stage 3 RA/N–0–RA–N R/N–0–R–N

Calculate total dose at 0.3 U/kg based on current weight

Distribution of daily dose

RA/N or R/N ratio

AM

2/3 1:2

MIDDAY

0 –

PM

1/6 –

BT

1/6 –

From Insulin Stage 2

Refer patient for nutrition and diabetes education

Follow-up

Medical:

Nutrition/

education:

if new insulin start, daily phone contact for 3

days, then office visit within 1 week; 24-hour

phone support needed

if changing therapies, phone or office visit

within 1 week, then office visit within 1 month

if new insulin start within 24 hours, other

wisewithin 1 week

Insulin Stage 3/Adjust

Start Medical Nutrition Therapy

If current total dose is
1.5 U/kg, consider decreasing

dose to 1.0 U/kg, otherwise use current total dose

At Diagnosis or New Insulin Start

Refer patient and caregiver for nutrition and diabetes education

Figure 5.21 Type 2 Insulin Stage 3/Start for

Chil-dren and Adolescents

adjustments to the Insulin Stage 2 regimen have

failed to overcome these problems, moving the

intermediate-acting insulin to at least 3 hours

af-ter the evening meal (this bedtime injection is

shown as BT in figures and tables) should

pro-vide some resolution Before doing this, however,

be certain that overinsulinization has not occurred

(>1.0 U/kg) If this is suspected, consider

reduc-ing the total daily insulin dose to 1 U/kg and

redistributing it according to Insulin Stage 3 (see

Figure 5.21)

To start Insulin Stage 3, move the current dose

of evening meal N insulin to bedtime Make

certain SMBG occurs at this time One or two

carbohydrate choices from earlier in the day can

be moved as a bedtime snack Readjust both the

evening R or RA and the morning R or RAafter 3 days on this regimen Most probably themorning R or RA will be reduced and the evening

R or RA will be increased The total daily doseshould still follow the pattern of a maximum of1.5 U/kg

Before beginning pattern adjustment, determinewhich insulin is responsible for the glucose pat-tern Intermediate-acting insulin (N) is meant toreach its peak near the morning to lower the fast-ing blood glucose value The overlap of R and

N between midnight and 2 AM may require justing the evening snack This should not bethe case in individuals using RA because of itsshorter action curve In addition, residual bedtime

ad-N may be present when the morning R or RA isadministered Measurement of blood glucose post-breakfast thus becomes important when startingStage 3

Insulin Stage 3

Most newly diagnosed patients do not start withthree injections because historically this is used

in patients who were started on Insulin Stage

2 and ultimately required bedtime acting insulin There is no reason that the three-injection regimen could not be used at diagnosis(this is often the case in gestational diabetes) IfInsulin Stage 3 is used at diagnosis, make certainthat a thorough history, physical, and laboratoryevaluation are completed and that the target bloodglucose levels are reviewed

intermediate-Note: For all insulin therapies the startingdose formula has been carefully selected tomeet the immediate needs of the individualwhile reducing the risk of hypoglycemia aswell as hyperglycemia

Insulin Stage 3/Start: at diagnosis R/N–0–R–N or RA/N–0–RA–N

Morning insulin start If the patient starts this

therapy in the morning, the total daily dose is culated as 0.3 U/kg (see Figure 5.21) The total

cal-TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 193daily dose is divided into three periods associated

with breakfast, the evening meal (approximately

10 hours apart), and bedtime (at least 3 hours

af-ter dinner) The pre-breakfast dose is two-thirds

of the total daily requirement This is further

di-vided into one-third R or RA and two-thirds N

The R or RA insulin is to cover breakfast and the

intermediate-acting insulin N is to cover lunch and

the afternoon period The evening dose is

calcu-lated as one-third of the total daily requirement

and evenly split between R or RA at dinner and

intermediate-acting insulin N at bedtime By

plac-ing N insulin at bedtime, its principal action is

moved closer to the morning

Afternoon or evening insulin start If the

ther-apy is being started in the afternoon or evening,

the starting dose is one-third the normal starting

dose (0.1 U/kg) equally split between N and R

or RA The short-acting insulin is given before

dinner and the intermediate-acting insulin before

bedtime The next day the patient would be on

the total daily dose as described above for

start-ing Insulin Stage 3 in the mornstart-ing The patient

or family caregiver should be taught both

in-sulin administration technique and how to monitor

blood glucose Blood glucose should be monitored

(SMBG) every 4 hours If blood glucose levels are

<250 mg/dL (13.9 mmol/L), consider additional

small doses (1–2 units) of R or RA with SMBG

an hour after the insulin This therapy is

tempo-rary Have the patient return the next morning to

initiate daily insulin administration (see previous

section)

During the first several days it is imperative to

maintain glucose levels at a point that will avoid

both hypoglycemia and hyperglycemia Have the

patient SMBG at least five times per day (before

meals, at bedtime, and at 3AM) Additionally,

co-management with the various health professionals

who will be involved in diabetes care must be

es-tablished If feasible a nurse educator and dietitian

should be incorporated into care as soon as

possi-ble The guidelines for insulin adjustments begin

immediately Along with making arrangements

for both nurse and dietitian follow-up, establish

target blood glucose levels

Table 5.5 Type 2 Insulin Stage 3/adjust for

chil-dren and adolescents (See Figure 5.20 type 2 betes insulin adjustment considerations for children and adolescents)

dia-Insulin Stage 3 Pattern Adjustments RA/N–0–RA/N–0 or R/A–0–R/N–0

BEDTIME (BT)

1–2 U (a,b) 1–2 U (a,k) 2–4 U (a,k)

Adjust insulin based on BG patterns

May increase or decrease dose by 1–2 U or 10% of dose Follow-up

Medical: weekly while adjusting insulin, then office visit within 1–2

The patient should realize that it will be necessary

to frequently adjust the morning short-acting sulin The first sign of too much morning R or RAwill be post-breakfast or midday hypoglycemia.Reduction in morning R or RA (see Table 5.5) willresolve this problem An additional adjustment

in-in breakfast carbohydrate in-intake or mid-mornin-ingsnack may be needed If the pre-evening meal glu-cose goes up, use the same formula as before, i.e.,raise the morning N This will increase the amount

of insulin available to cover carbohydrate intake

at lunch Alternatively, if the bedtime N lowersthe fasting blood glucose, the intermediate-actinginsulin requirements during the daytime may need

to be reduced If the pre-dinner blood glucose

is <70 mg/dL (3.9 mmol/L) for three

consecu-tive days, consider lowering the morning N Keep

in mind the impact of exercise on both whenthere is too much or too little insulin Exercise

in the mid-afternoon should be closely followed

by SMBG before and after the exercise period Ifpossible, avoid adding additional calories in or-der to prevent weight gain The third adjustmentsare related to the bedtime blood glucose levels

These are affected most by food intake at dinner

and by the amount of short-acting insulin used

In addition, many people snack from supper to

bedtime without having a discrete evening meal

This may influence the type of short-acting

in-sulin selected and/or the dose administered Blood

glucose at bedtime should not exceed 160 mg/dL

(8.9 mmol/L) Consider increasing R or RA

be-fore dinner or changing the meal content

Hyper-glycemia at bedtime will often result in a high

fasting blood glucose (see Insulin Stage 2 for

gen-eral principles)

Insulin Stage 3/Maintain

R/N–0–R–N or RA/N–0–RA–N

When patients reach their metabolic targets using

Insulin Stage 3, they enter the maintain

treat-ment phase In this phase changes in insulin,

food plan, and exercise regimens are likely to be

less frequent Despite this reduction in changes

to therapy, surveillance with SMBG is necessary

Because of the addition of a third injection and

perhaps fear of hypoglycemia overnight, some

pa-tients may add too many calories as part of the

evening snack A schedule of consistent weight

monitoring should be encouraged While neither

SMBG nor weight monitoring need be as

regi-mented as during start and adjust phases, both

are required to detect trends of either increasing

blood glucose or weight At minimum, SMBG

should occur prior to each insulin injection with

at least one post-prandial (at varying meals each

day) Because this would mean no fewer than

four tests a day, for patients who have maintained

their metabolic goal for at least 1 month,

con-sider alternate day testing or reducing the number

of tests to two a day at different times each day

Some changes in insulin dose and timing should

be expected Food plan should consider further

al-terations in timing and size; carbohydrate and/or

caloric intake should not increase by an

appre-ciable amount The patient should be reminded of

the general rules, such as relying on 3 day patterns

before changing insulin dose

Moving from Insulin Stage 3 to Physiologic Insulin Stage 4

if the fasting blood glucose is high, increase thebedtime N or G

Before initiating this regimen from Stage 3,make certain the total daily insulin dose has not

reached >1.5 U/kg, which is indicative of

overin-sulinization If overinsulization has occurred thetotal daily dose can be reduced to 1 U/kg (leav-ing room for subsequent adjustments) Begin byrecalculating the total daily dose at 1 U/kg Bed-time N should be recalculated so that it is 30 percent of the total daily dose The remaining 70 percent of the insulin should be given in the form of

R or RA before each meal Thus, for the 100 lb(45 kg) child whose current Stage 3 Insulin wascomprised of 55 U reduce this to 45 U and give

15 U as bedtime N and 10 U as R or RA beforeeach meal If the plan is to change to G insulinthen reduce the total daily dose by 20 per cent (45

- 9), resulting in 36 U for this 100 lb child Nextdivide the total dose into 50 per cent (18 U) of G

at bedtime and 6 U of R or RA before each meal.This per cent is a reverse of the earlier regimens

In this case R or RA is used to cover all mealrelated increases in blood glucose, while bedtime

N or G is used to provide a basal insulin

Physiologic Insulin Stage 4: basal/bolus approach

Multiple injection regimens are far more justable and will most likely result in a more flex-ible schedule for the patient Dividing the insulininto smaller doses reduces the chance of localdiscomfort and provides a more consistent timeaction profile Additionally, regimens with moreinjections generally require less insulin overall

ad-If Insulin Stage 3 failed to move the patientinto the maintain phase of therapy after 6 months

TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS 195

of experimentation, or if the patient at diagnosis

is willing to try a more intensive regimen then a

four-injection regimen should be considered The

patient and family should already have been

intro-duced to the Type 2 Diabetes Master DecisionPath

for Children and Adolescents, and alternate

thera-pies, requiring an increased number of injections,

should have been discussed Stage 4 is the most

physiologic regimen and offers the patient more

flexibility regarding timing of meals Staged

Di-abetes Management encourages providers to

dis-cuss the advantages of Stage 4 with their patients

and family caregivers, especially those starting

in-sulin at diagnosis or after metformin has failed

Physiologic Insulin Stage 4/Start: at

diagnosis

R–R–R–N or G or RA–RA–RA–N or G

If starting Stage 4 at diagnosis, ask the patient to

do SMBG four times/day (before each meal and at

bedtime (plus overnight one to two times during

the first week) Two approaches can be used to

initiate this therapy: formula or experiential (see

Figure 5.22) For the formula method calculate the

total daily dose at 0.3 U/kg If using N insulin,

calculate the amount as 30 per cent of the total

daily dose (of all insulins) Divide the remaining

70 per cent equally and administer as either R or

RA before each meal Thus, for a 100 lb (45 kg)

child, 14 total units of insulin would be given

Five units (rounded from 4.5) of N would be given

at bedtime and 3 units of R or RA would be given

before each meal If using G insulin, 50 per cent of

the total dose (7 units) would be given at bedtime

as G and 2 units (rounded) of R or RA would be

given before each meal, resulting in a total of 13

units Adjustments to this regimen may be made

after 3 days of a consistent pattern

If the plan is to follow an experiential approach,

start with N or G at bedtime calculated at 0.1 U/kg

(0–0–0–G or N) During the next 7–10 days

make 1–2 unit adjustments in the dose until 0.3

U/kg has been reached or fasting plasma glucose

(without any hypoglycemia is reduced by at least

60 mg/dL (3.2 mmol/L)) Next, review all blood

At Diagnosis or from Oral Agent Stage or another Insulin Stage

If acutely ill, hospitalize and start insulin immediately; otherwise, start insulin within 1 week and consider hospitalization if outpatient (and caregiver) education not available

Start Insulin Stage 4

RA–RA–RA–N or G R–R–R–N or G

Calculate total dose based on 0.3 U/kg current body weight Start BT N at 30% of total dose or BT G at 50% of total dose Equally distribute remainder of total dose (as RA or R) before each meal (may be readjusted based on food plan)

if changing therapies, phone or office visit

with-in 1 week, then office visit withwith-in 1 month

if new insulin start, within 24 hours, otherwise within 2 weeks

Insulin Stage 4/Adjust

Start Medical Nutrition Therapy

At Diagnosis or New Insulin Start

•

•

•

e.g 100 kg pt  5 U RA–5U RA–5U RA–15U G

From other insulin stage If current total dose is
1.5 U/kg, consider decreasing to 1.0 U/kg

For BT N insulin: Start BT N at 30% of current total dose and equally

For BT G insulin

Reduce current total insulin dose by 20%

Distribute remaining insulin as 50%BT G and 50% RA or R Distribute RA or R equally before each meal (may be readusted based on food plan)

e.g current total dose = 90 Units; new total dose  72 Units

Distributed as 12 U RA–12U RA–12 U RA–36 U G

Figure 5.22 Type 2 Physiologic Insulin Stage 4/

Start for Children and Adolescents

glucose values to identify the pattern of blood cose that consistently is highest over more than

glu-3 days (e.g midday, PM, or bedtime) Add aninjection of RA or R insulin (0.1 U/kg) to the pre-ceding meal Thus if the pre-evening-meal BG isconsistently the highest add RA or R insulin prior

to the mid-day meal The new regimen would be0–RA–0–G Adjust this insulin every 3 days by1–2 units until 0.2 U/kg or the pre-evening-meal

BG has reduced by least 60 mg/dL (3.2 mmol/L).Repeat this for the next highest blood glucose pat-tern Eventually, the patient will be on a regimen

of RA–RA–RA–G at the minimum amount ofinsulin necessary to physiologically mimic insulinrequirements

This gradual introduction of pre-meal insulin

based on SMBG data reinforces the experiential

aspects of diabetes self-management The child or

adolescent quickly learns how small increments

of insulin given at the appropriate time affect

BG level By relying on low-dose basal insulin

initially to improve fasting plasma glucose, an

added benefit is that the patient begins the day

with improved glucose levels Meal related BG

excursions become less dramatic By identifying

the most serious pattern of hyperglycemia first,

the insulin can be targeted and thereby used more

sparingly The result is generally a total insulin

dose of <1 U/kg.

Physiologic Insulin Stage 4/Adjust

R–R–R–N or G or RA–RA–RA–N or G

Because this regimen allows for targeting the

in-sulin action to particular postprandial blood

glu-cose excursions, make certain that SMBG occurs

before each insulin administration The blood

glu-cose value determined at that point will help

de-cide how well the insulin given before the last

meal worked and will help calculate the insulin

to be given at the current meal Start by

identi-fying the highest blood glucose Increase by 1–4

units the insulin prior to the high blood glucose

(see Table 5.6) Continue until this blood

glu-cose is lowered to within target Now find the

next highest blood glucose Repeat until all blood

glucoses are within target For example, if the

highest blood glucose is fasting, then increase N

or G by 1–4 units Once the fasting has been

resolved, turn to the next blood glucose that is

persistently highest Assume it is the

pre-evening-meal blood glucose Increase the midday R or RA

by 1–4 units

Physiologic Insulin Stage 4/Maintain

R–R–R–N or G or RA–RA–RA–N or G

Upon reaching their glycemic targets, patients

enter the maintain treatment goal phase

Nor-mally, fewer alterations to insulin, food plan,

Table 5.6 Type 2 Physiologic Insulin Stage

4/Ad-just for Children and Adolescents (See Figure 5.20 type

2 diabetes insulin adjustment considerations for dren and adolescents)

chil-Insulin Stage 4 Pattern Adjustments RA–RA–RA–N or G R–R–R–N or G

BEDTIME (BT)

1–2 U (a,b) 1–2 U (a,k) 2–4 U (a,k)

Adjust insulin based on BG patterns

May increase or decrease dose by 1–2 U or 10% of dose Follow-up

Medical: weekly while adjusting insulin, then office visit within 1–2

a schedule of blood glucose and weight toring At a minimum, SMBG should be doneprior to each insulin injection with at least onepost-prandial (at varying meals each day) Be-cause this would mean no fewer than four tests

moni-a dmoni-ay, for pmoni-atients who hmoni-ave mmoni-aintmoni-ained theirmetabolic goal for at least 1 month, consideralternate-day testing or reducing the number oftests to two a day at different times each day.Some changes in insulin dose and timing should

be expected Monitor weight at least weekly Foodplan should consider further alterations in tim-ing and portion size, keeping in mind that thetotal caloric intake should not increase apprecia-bly The patient should be reminded of the generalrules for changing insulin doses – a minimum of

3 days of the same pattern Patients and caregiversshould be reminded to contact their healthcareprovider if blood glucose levels begin to rise.HbA1c should continue to be determined every3–4 months

METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS 197

Metabolic syndrome in children and adolescents

In this section the macrovascular and

microvascu-lar diseases that comprise the metabolic syndrome

(insulin resistance syndrome) in children and

ado-lescents are highlighted A more complete review

of all associated complications of diabetes is

pro-vided in Chapters 8 and 9

The exact number of children and adolescents

with the metabolic syndrome is unknown

Cur-rently, there are seven separate disorders that may

be included in the syndrome:

1 overweight–obesity

2 acanthosis nigricans

3 polycystic ovary syndrome

4 hyperglycemia–pre-diabetes or type 2

dia-betes

5 dyslipidemia

6 hypertension

It is unclear as to how many children and

ado-lescents have one or more of these disorders

Since a child with any one of these disorders

is then at increased risk for the others, it is

in-cumbent upon health care providers to maintain

close surveillance of any child or adolescent who

has evidence of metabolic syndrome SDM

pro-vides an assessment guide and a Master

Deci-sionPath for insulin resistance, which reviews the

steps and tests that should be part of the

com-prehensive, ongoing surveillance Surveillance

be-gins with evaluation of BMI All children whose

BMI <85th percentile for age and gender should

be evaluated annually for the other elements of

the metabolic syndrome Similarly, all individuals

with acanthosis nigricans should be evaluated for

co-morbidities associated with insulin resistance

In both instances, they should be immediately

screened for hyperglycemia, hypertension, renal

disease, and dyslipidemia For females,

discov-ery of PCOS should be followed by these tests;

alternatively, if other insulin resistance disorders

are discovered first, female adolescents should beevaluated for PCOS

Assessment for metabolic syndrome

Figure 5.23 contains a comprehensive assessmentfor the metabolic syndrome in children and ado-lescents Briefly, assessment for the followingconditions is required

Overweight Irritability,

fatigue, sleep apnea, depression

BMI
85th centile for age and gender

per-
120% ideal body weight

Pulmonary hypertension Central adiposity

Refer to BMI Tables, A–7,

A–11

See Medical Nutrition Therapy and Activity Therapy Guidelines

Acanthosis nigricans

Often none

or cosmetic

Dark, thickened skin due to hyper- keratosis of the skin folds;most common

in young individuals

of color, clinical sign

of insulin resistance

Consider obtain -ing fasting insulin level to ascertain if hyperinsulinemic

Polycystic ovary syndrome (PCOS)

rhea, hirsutism, acne, infertil- ity, rapid weight gain, acanthosis nigricans

Oligomenor-Increased total testosterone, hir- sutism, acanthosis nigricans, obesity, hyperinsulinemia, dyslipidemia, oligomenorrhea, amenorrhea, acne

See PCOS Practice Guideline and Master Decision Path

Hyperglycemia Often none

Secondary enuresis

Pre-diabetes: FPG

100–125 mg/dL (5.6–6.4 mmol/L)

CPG or OGTT 2 hour value

140–199 mg/dL (7.7–11.0 mmol/L)

Diabetes: FPG

126 mg/dL (7.0 mmol/L) and/or

CPG 200 mg/dL (11.1 mmol/L)

on two occasions

See Screening and Differential Diagnosis

Complication Patient

Complaints Clinical Evidence Action

Figure 5.23 Assessment for insulin resistance

syn-drome in children and adolescents

Determination of the weight status of children

and adolescents requires use of specially designed

growth and BMI charts (Figure 5.3 and 5.4) See

the beginning of this chapter for a full discussion

of weight management

Acanthosis Nigricans

Insulin resistance in peripheral tissue induces a

chronic state of hyperinsulinemia The high

lev-els of insulin cause cells found in the skin called

keratinocytes to proliferate and produce excessive

amounts of keratin This hyperkeratosis results in

a symmetrical, velvet-like, dark

hyperpigmenta-tion of the skin folds on the neck and under the

arms, in the arm folds and behind knees The

con-dition is more often diagnosed in people of colour

Polycystic ovary syndrome (PCOS)

PCOS is a chronic condition that is usually

mar-ked by anovulation, infertility, and

hyperandro-genism Patients present with irregular menstrual

cycles, oligomenorrhea, or amenorrhea and will

report excessive vaginal bleeding They are often

obese and have hirsutism Another early indicator

of PCOS is facial acne that does not respond

read-ily to treatment In adolescents of colour there is

a high correlation between PCOS and acanthosis

nigricans due to hyperandrogenism

Hyperglycemia

Children and adolescents with insulin resistance

may not have elevated blood glucose Although

they produce as much as twice the normal amounts

of insulin, initially this is sufficient to overcome

hyperglycemia related insulin resistance

How-ever, eventually such individuals will become

hy-perglycemic if they remain obese and insulin

re-sistant There is no way, however, to predict when

this occurs, therefore surveillance is necessary

Dyslipidemia

Insulin resistance is often marked by decreasedHDL cholesterol and elevated triglycerides Thisdyslipidemia has been associated with fatty streaksand fibrous plaques found in the coronary arteries,contributing to increased risk for cardiovasculardisease

Hypertension

The exact cause of hypertension in children withinsulin resistance is unknown It may be related tounderlying kidney disease, obesity, hyperinsuline-mia, hyperglycemia, or other, as yet undiscoveredfactors What is known is that detection is im-portant Determination of hypertension in childrenand adolescents is a function of age, gender, andheight Generally there are no symptoms at pre-sentation

Renal disease

Concern about hypertension in obese children is inpart a reflection of the results of some studies thatindicate a close association between renal diseaseand insulin resistance Since it is uncertain as towhether kidney disease and hypertension occurindependently it is important to screen for bothentities

Children and adolescents Master DecisionPath for insulin resistanceAny child discovered to have any of the conditionsthat are correlated with insulin resistance or any ofthe risk factors should undergo an annual assess-ment for the other correlates This can be carriedout efficiently and systematically by following theSDM Master DecisionPath for Metabolic Syn-drome (Figure 5.24) In most cases obesity will

be the first of the correlates to be noticed Asmentioned in an earlier section clinical obesity

is defined as exceeding the 95th percentile BMI

METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS 199

YES YES

issues (adherence, support)?

Reassess at each visit

Follow Weight Management for Children and Adolescents

Follow Type 2: Practice Guidelines for Children and Adolescents

Follow Hypertension Practice Guidelines for Children and Adolescents

FollowMicroalbuminuria Screening, Detection and Treatment for Children and Adolescents

Follow Dyslipidemia Practice Guidelines for Children and Adolescents

Follow PCOS Practice Guidelines for Children and Adolescents

Follow Psychoeducational Assessment

Figure 5.24 Children and Adolescents Master

De-cisionPath for Insulin Resistance Syndrome

based on age and gender It is recommended,

how-ever, that any child above the 85th percentile BMI

be evaluated on an annual basis for the other

cor-relates of insulin resistance The next step is to

screen for type 2 diabetes This is done by

ei-ther capillary blood glucose or plasma glucose in

a laboratory The screening test can only serve to

determine who needs further evaluation To be

di-agnosed with diabetes, two tests on different days

are required Afterwards the child will fall into

one of three categories: overt diabetes, impaired

glucose homeostasis (pre- diabetes) or normal

glycemia The definitions are not age dependent

and are the same for adults Next is measurement

for hypertension This requires three blood sure measurements on separate days and meetingthe age, gender, and height criteria Although inmost cases hypertension (HTN) would signal theneed to evaluate for renal disease, in children sus-pected of insulin resistance screening for microal-buminuria should be carried out without regard

pres-to blood pressure Renal disease can be assessedinitially with a semiquantitative test strip or byquantitative measure in the laboratory If positive,more detailed examination is in order Finally, inadolescent females with any suspicion of insulinresistance determine whether they have a history

of oligomenorrhea, amenorrhea, or signs of perandrogynism

hy-SDM provides specific Practice Guidelines andDecisionPaths for each of the disorders on theMaster DecisionPath In the following section thekey elements of each path as they refer specif-ically to children and adolescents are discussed.Greater detail is provided in the chapters devoted

to metabolic syndrome

Hypertension

Hypertension Practice Guidelines

As with most co-morbidities associated with sulin resistance, both the detection and the treat-ment of HTN are modified for children andadolescents Hypertension Practice Guidelines forchildren and adolescents are shown in Figure 5.25

years of age should be evaluated for hypertension(HTN) at least annually If the blood pressure (BP)meets the criteria for HTN (adjusted for age, gen-der, and height), then a full diagnostic series ofBPs should be undertaken Children with risk fac-tors such as obesity, type 2 diabetes, renal disease,

or dyslipidemia should be screened at each visit.Generally, HTN in children is without symptoms,thus risk factor assessment is important

tech-nique is essential The patient should be allowed

to rest at least five minutes in the office and

Diagnosis

Annual blood pressure measurement children 2 years of age

Average systolic and diastolic 95th percentile for age and gender (see BP Tables) on 3 or

more occasions; use height percentiles rather than chronologic age.

Rule out renal parenchymal disease, coarctation of the aorta or renal artery stenosis, use of street drugs or ETOH, anabolic steroids, diet drugs, tobacco use/cigarette smoking, oral contraceptive pills (OCP), use of chronic cold remedies and excess caffeine or sport drink intake.

Consider secondary causes such as: with decreased potassium, consider hyperaldosteronism;

heck TSH to rule out hyper- or hypothyroidism; if positive clinical features consider screening for Cushing’s with 24 hour UFC; consider pheochromocytoma

• Diabetes, IGT, or IFG

or renal insufficiency or failure

Medical nutrition and activity therapy alone or in combination with pharmacologic agents (ACE inhibitor, angiotensin II receptor blocker, calcium channel blocker, low-dose diuretic, b-blocker); caregiver participation; cardiovascular conditioning, weight loss when appropriate;

BP 90th percentile for gender, age and height percentile (BP Tables)

2 yrs of age, adult standards apply (30 mg albumin/g)

Self-monitor blood pressure 4 times per day (twice prior to prescribed medication) while in adjust phase with oscillometric home blood pressure monitor; one time per day during maintain phase; blood presssure at every office visit

consider 24 hour ambulatory blood pressure monitoring

Figure 5.25 Hypertension Practice Guidelines for Children and Adolescents

should be seated at the time of the measurement

The cuff size should be appropriate and

care-fully placed Measurement should be made at least

twice with 2–5 minutes between determinations

If there is any suspicion that the in-office BP may

be compromised by patient anxiety provide thepatient with a means of monitoring BP at home(SMBP) The accurate assessment of BP is clearly

a necessity if appropriate interventions are to beinstituted

METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS 201

% 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th

Age (yr) 1

10%

98 102 99 103 101 104 102 106 103 107 105 109 107 111 109 113 111 115 113 117 115 119 117 121 119 123 121 125 122 126 123 127 123 127

25%

99 103 101 104 102 106 103 107 105 108 106 110 108 112 110 114 112 116 114 118 116 120 118 122 120 124 122 126 123 127 124 128 124 128

50%

101 104 102 106 103 107 104 108 106 110 107 111 109 113 111 115 113 117 115 119 117 121 119 123 121 125 123 127 124 128 125 129 126 130

75%

102 106 103 107 104 108 106 109 107 111 109 113 110 114 112 116 114 118 116 120 119 122 121 125 123 126 124 128 126 130 127 120 127 121

90%

103 107 104 108 105 109 107 111 108 112 110 114 112 115 114 117 116 119 118 122 120 124 122 126 124 128 125 129 127 131 128 132 128 132

95%

104 108 105 109 106 110 108 111 109 113 111 114 112 116 114 118 116 120 118 122 120 124 123 126 124 128 126 130 128 131 129 132 129 133

5%

52 56 57 61 61 65 64 68 66 71 69 73 71 75 72 76 74 78 75 79 76 81 78 82 79 83 80 84 80 85 81 85 81 85

10%

52 56 57 61 61 65 64 68 67 71 69 73 71 75 72 77 74 78 75 79 77 81 78 82 79 83 80 84 81 85 81 85 81 86

25%

53 57 58 62 61 66 65 69 67 71 69 74 71 75 73 77 74 79 76 80 77 81 78 82 79 84 80 85 81 85 82 86 82 86

50%

53 58 58 62 62 66 65 69 68 72 70 74 72 76 74 78 75 79 77 81 78 82 79 83 80 84 81 85 82 86 82 87 83 87

75%

54 58 59 63 63 67 66 70 69 73 71 75 73 77 74 79 76 80 77 81 79 83 80 84 81 85 82 86 83 87 83 87 83 88

90%

55 59 60 64 64 68 67 71 69 74 72 76 74 78 75 79 77 81 78 82 79 83 81 85 82 86 83 87 83 88 84 88 84 88

95%

55 60 60 64 64 68 67 71 70 74 72 76 74 78 76 80 77 81 78 83 80 84 81 85 82 86 83 87 84 88 84 88 85 89

Rosner et al., Pediatrics 1996; 98: 653–654

Figure 5.26 Female blood pressure level percentile by age and percentile of height

Children and adolescents can be placed in one

of four BP categories: normal, high risk, HTN,

and severe HTN With the exception of severe

HTN, the criteria for HTN under the age of 18

are based on age and gender adjusted for height

(Figures 5.26 and 5.27) Normal BP is both

sys-tolic and diassys-tolic BP below the 90th percentile

High risk are either systolic or diastolic by

be-tween the 90th and 95th percentiles; HTN is the

average systolic and diastolic BPs taken on three

separate occasions≥95th percentile Severe HTN

(requiring referral to a cardiologist) is dependent

solely on age range For example, an 8 year oldboy whose height places him in the 50th percentile

would have normal BP if the BP <111/74 mmHg;

he would be at high risk if the systolic BP were

≥111 to 115 mmHg or the diastolic BP were ≥74

to 78 mmHg; if he exceeded an average BP of

116/81 mmHg but not <129/85 mmHg, he would

be HTN If he exceeds 129/85 mmHg on anyoccasion he would be considered to have severeHTN Since there may be underlying (or contem-poraneous) causes other than insulin resistance a

% 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th 90th 95th

Age (yr) 1

10%

95 99 99 103 102 106 104 108 105 109 106 110 107 111 109 113 110 114 112 116 114 118 116 120 119 122 121 125 124 128 127 131 129 133

25%

97 101 101 105 103 107 105 109 107 111 108 112 109 113 110 114 112 116 113 117 115 119 118 122 120 124 123 127 126 130 129 133 131 135

50%

99 103 103 107 105 109 107 111 109 113 110 114 111 115 112 116 114 118 115 119 117 121 120 124 122 126 125 129 128 132 131 134 133 137

75%

101 105 104 108 107 111 109 113 111 114 112 116 113 117 114 118 116 119 117 121 119 123 121 125 124 128 127 131 130 133 132 136 135 139

90%

102 106 106 110 109 112 110 114 112 116 113 117 114 118 116 119 117 121 119 123 121 125 123 127 125 129 128 132 131 135 134 138 136 140

95%

103 107 107 110 109 113 111 115 113 117 114 118 115 119 116 120 118 122 119 123 121 125 124 128 126 130 129 133 132 136 134 138 137 141

5%

49 54 54 58 59 63 63 67 66 71 70 74 72 77 74 79 76 80 77 81 77 82 78 83 78 83 79 83 80 84 81 86 83 88

10%

49 54 54 59 59 63 63 68 67 71 70 75 73 77 75 79 76 81 77 82 78 82 78 83 79 83 79 84 80 85 82 86 84 88

25%

50 55 55 60 60 64 64 68 68 72 71 75 73 78 75 80 77 81 78 83 79 83 79 84 80 84 80 85 81 86 82 87 85 89

50%

51 56 56 61 61 65 65 69 69 73 72 76 74 79 76 81 78 82 79 83 80 84 80 85 81 85 81 86 82 86 83 88 86 90

75%

52 57 57 62 62 66 66 70 69 74 73 77 75 80 77 82 79 83 80 84 81 85 81 86 81 86 82 87 83 87 84 89 87 91

90%

53 58 58 63 63 67 67 71 70 75 74 78 76 81 78 83 80 84 81 85 81 86 82 87 82 87 83 87 84 88 85 90 87 92

95%

54 58 58 63 63 68 67 72 71 76 74 79 77 81 79 83 80 85 81 86 82 87 83 87 83 88 83 88 84 89 86 90 88 93

Rosner et al., Pediatrics 1996; 98: 653–654

Figure 5.27 Male blood pressure level percentile by age and percentile of height

thorough evaluation is needed (generally by a

car-diologist)

children is similar to that in adults The use of

medical nutrition therapy (MNT) to manage HTN

is the cornerstone of treatment Weight

manage-ment, reduction in sodium intake, and increased

physical activity are crucial elements Replacing,

reducing and restricting foods and drinks high in

sodium, carbohydrate, and/or fats is a

fundamen-tal strategy MNT is the same as would be used

in diabetes and dyslipidemia Generally MNT as

a solo therapy is reserved for children in the atrisk category For children meeting the criteria

for HTN, pharmacological therapy plus MNT is

recommended (Figure 5.28) ACE inhibitors arethe preferred therapy as they provide a renal pro-tective benefit However, angiotensin II receptorblockers, calcium channel blockers, low-dose di-uretics, and β-blockers are acceptable Physicalactivity should be part of therapy after completing

a fitness evaluation

agreed upon targets (treat-to-target) is a hallmark

METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS 203

Child or adolescent with

hypertension

History, physical exam, and laboratory

evaluation by provider; rule out

secondary causes of hypertension

Persistent microalbuminuria?

(
30 mg/g on 3 or more occasions)

See Microalbuminuria Screening,

Detection and Treatment

YES

Start ACE Inhibitor or Angiotensin II Receptor

Blocker

Captopril, enalapril, or ramipril because of renal

protective effects unless baseline hyperkalemia;

impaired renal function, especially bilateral renal

artery stenosis; drug interactions; previous drug

reactions; specific indication for another agent;

likelihood of short-term follow-up is low;

pregnancy and lactation

Starting dose (see Antihypertensive Therapy

Choices)

If ACE inhibitor or angiotensin II receptor

blocker contraindicated, select from a different

class of antihypertensive (see

Antihypertensive Therapy Choices)

If currently on diuretic therapy, reduce dose or

stop for 3 days prior to initiating ACE inhibitor

Monitor blood pressure with oscillometric home

blood pressure monitor

Ace inhibitors: repeat potassium and creatinine

in one week Re-evaluage therapy if increased

potassium (
5.7 mEq/L) or serum creatinine

(0.4–0.5 mg/dL), persistent dry cough,

hypotension, rash, leukopenia

See Medical Nutrition Therapy/Assessment

Move to Hypertension Drug Therapy/Adjust

Start Anti Hypertensive Therapy:

The list of drugs below is the recommended order in which the therapies should be selected.

With diabetes:

ACE inhibitor/ARBs Calcium channel blocker Beta blocker (Assess for hypo- glycemia)

Diuretics Vasodilators

Without diabetes:

Dihydroperidone ACE inhibitor/ARBs Beta blocker Diuretics Vasodilators

Educate patient and givers:

care-Hypertension is a chronic disease

Importance of taking medications as prescribed May feel tired initially

Do not stop medication without consulting provider Medication side effects Refer to registered dietitian

If no contraindication (renal, cardiac) refer to activity therapy

Figure 5.28 Hypertension Drug Therapy Start/

Treatment for Children and Adolescents

of the SDM approach For children with insulin

resistance it is vital that BP be returned to below

the 90th percentile (or less than 130/80 mmHg

in children over 11 years of age) This has been

shown to reduce the risk of renal disease or slow

its progression in cases where it already exists.14

Because of the close association between these

disorders screening for microalbuminuria and, if

negative, yearly surveillance is recommended

of BP has been considered the basis for most

decisions related to diagnosis and treatment,

re-cent evidence suggests that a far more accurate

and reliable method is home or self-monitoring

BP (SMBP) Because this method provides vital

information related to hourly and daily excursions

in BP and more closely resembles BP under mal conditions, it is recommended as part of SDMmonitoring for children in the high-risk, HTN,and severe HTN categories The use of oscillo-metric monitors should begin with an in-officedemonstration and evaluation of technique againstin-office BP determinations by sphygmomanome-ter or office-based oscillometric device Once it

nor-is clear that the patient or caregiver can operatethe device, a testing schedule of 4/day at varyingtimes should be initiated As many of the deviceshave an onboard memory, the patient need notkeep records The data can be offloaded in the of-fice If this is not available then patients can use

a logbook to record their values Generally, theaccumulated data are averaged and the same BPcriteria as mentioned above are used For a com-plete discussion of how to interpret BP data fromself-monitoring devices see Chapter 9 on HTN

patients should have 24-hour telephone accessand should be seen at least monthly In themore severe cases, weekly contact and review

of self-monitored BPs will assure timely ventions should the current therapy be inade-quate Quarterly visits and annual reassessmentfor co-morbidities of insulin resistance are recom-mended Special attention to weight, blood glu-cose, HDL cholesterol, triglycerides, and protein-uria is essential

inter-Hypertension Drug Therapy/Start Treatment

Most antihypertensive drugs have had limitedtesting in children and adolescents, thus care-ful surveillance for contraindications is neces-sary Following the history and physical examina-tion make the selection of pharmacological agentbased on whether the child has diabetes and/orunderlying renal disease If the child was notevaluated for all disorders associated with insulinresistance, first complete the steps in the Mas-ter DecisionPath for Insulin Resistance Beforeselecting the therapy also make certain that the pa-tient and family understand the significance of the

clinical findings, the goal of treatment and the

im-portance of the antihypertensive drug and SMBP

It is imperative that all of those involved in the

child’s care agree on the target BP, how it is to

be measured and how long it will take to reach

As best as possible, determine the role of each

family member and the patient related to

admin-istering the antihypertensive agent and measuring

BP Finally, it should be made very clear that

some antihypertensive drugs may fail to achieve

the agreed upon goal; under such circumstances,

the family should be informed that there are many

alternative drugs

For children >2 years of age and non-pregnant

adolescents with diabetes and/or renal disease, the

first drug of choice is an ACE inhibitor; for those

>13 years of age either an ACE (non-pregnant

only) or ARB may be initiated (Figure 5.28)

Both antihypertensive agents have renal

protec-tive functions as well as BP lowering ability For

individuals without diabetes or renal disease

di-hyroperiodones are recommended For all drugs

generally begin at the lowest dose based on body

weight

Independent of the medication, all patients and

their caregivers should be taught about HTN, the

importance of the medication, the role of medical

nutrition therapy, and the contraindications or side

effects Within one week of initiation of and

ACE-I repeat both potassium and creatinine measures

Check for any indication of persistent cough,

hypotension, rash, or leukopenia If these occur

consider switching to an ARB

As soon as feasible, MNT should be initiated

following the weight management protocols

pro-vided by SDM The focus of MNT is to optimize

the effectiveness of the pharmacological

inter-vention by reducing foods high in salt, lowering

the carbohydrate load, and preventing

unneces-sary weight gain or, in obese children, promoting

weight control

Finally, SMBP should be encouraged The

vari-ability in BP throughout the day and from day to

day is a major factor associated with underlying

cardiovascular disease Little is known about the

patterns of BP in children and adolescents

How-ever, it has been well established that SMBP is

a reliable and accurate indicator of BP control

Some studies have demonstrated that it is morereliable and accurate than in-office measurements,correlating very well with ambulatory 24-hourmonitoring The optimal schedule for SMBP isfour tests daily at varying times over a period

of one month This provides adequate data todetermine whether the therapy is successful andwhether there are any BP patterns that require at-tention As with in-office measurements, the goal

is to maintain the patient below the 95th percentilefor both systolic and diastolic BP

Hypertension Drug Therapy/Adjust

The principal strategy by which SDM operates

is to set a mutual goal with the patient andfamily within a set timeframe Initially, the goal

is to achieve consistent BPs ≤90th percentile (asmeasured by SMBP) within 4 weeks and sustainthis over a period of 6 months (Figure 5.29) Ifthis is accomplished and corroborated by four in-office BP measurements over the 6 months, thepatient enters the Maintain Phase of treatment.The antihypertensive drug therapy can now be re-examined and slowly withdrawn SMBP should beused to confirm that as the medication is reduced

BP values remain within target The justificationfor regular visits during this period is to makecertain that microalbumin levels remain withinthe normal range If they do not, then ACE-Itherapy should continue (see MicroalbuminuriaScreening, Detection and Treatment for Childrenand Adolescents)

If BP levels do not achieve the initial target,then consider whether the key factor is adherence

to the regimen In many cases the initial emotionalstress from the diagnosis may result in both patientand family dysfunction This, in turn, may lead to

a lack of adherence to taking medications and tomonitoring BP Often the root cause is a lack ofunderstanding about the disease process, the goals

of treatment, and the effect of non-adherence (seeAdherence DecisionPath) The first step is to as-sess whether the patient and family still agree withthe goals that were mutually established at the firstvisit Often, after a period of time to reflect on thechanges in lifestyle required by treatment and to