MPN CH 31 The Child With a Metabolic Condition.pdf

The Child With a Metabolic Condition OBJECTIVES 1. Define each key term listed. 2. Relate why growth parameters are of importance to patients with a family history of endocrine disease. 3. List the symptoms of hypothyroidism in infants. 4. Discuss the dietary adjustment required for a child with dia...

The Child With a Metabolic Condition OBJECTIVES 1. Define each key term listed. 2. Relate why growth parameters are of importance to patients with a family history of endocrine disease. 3. List the symptoms of hypothyroidism in infants. 4. Discuss the dietary adjustment required for a child with diabetes insipidus. 5. Differentiate between type 1 and type 2 diabetes mellitus. 6. List three precipitating events that might cause diabetic ketoacidosis. 7. Compare the signs and symptoms of hyperglycemia and hypoglycemia. 8. Outline the educational needs of the child with diabetes mellitus, and the parents, with regard to nutrition and meal planning, exercise, blood tests, glucose monitoring, administration of insulin, and skin care. 9. Discuss the preparation and administration of insulin to a child, highlighting any differences between pediatric and adult administration. 10. List three possible causes of insulin shock. 11. Explain the Somogyi phenomenon. 12. List a predictable stress that the disease of diabetes mellitus has on children and families during the life stages of infancy, toddlerhood, preschool age, elementary school age, puberty, and adolescence. KEY TERMS antidiuretic hormone (p. 721) dawn phenomenon (p. 731) diabetes mellitus (DM) (p. 722) gestational diabetes mellitus (GDM) (p. 723) glucagon (p. 731) glycosuria (glī-kō-SYŪ-rē-ă, p. 724) glycosylated hemoglobin test (HgbA1c) (glī-kō-sī-lā-tĭd HĒ-mō-glō-bĭn tĕst, p. 725) hormones (p. 719) hyperglycemia (hī-pŭr-glī-SĒ-mē-ă, p. 724) hypoglycemia (hī-pō-glī-SĒ-mē-ă, p. 731) hypotonia (hī-pō-TŌ-nē-ă, p. 721) ketoacidosis (kē-tō-ă-sĭ-DŌ-sĭs, p. 725) lipoatrophy (lĭp-ō-ĂT-rō-fē, p. 730) 1383 polydipsia (pŏl-ē-DĬP-sē-ă, p. 724) polyphagia (pŏl-ē-FĀ-jhă, p. 724) polyuria (pŏl-ē-YŪ-rē-ă, p. 724) Somogyi phenomenon (sō-mō-gēē p. 731) target organ (p. 719) vasopressin (vāz-ō-PRĔS-ĭn, p. 721) http://evolve.elsevier.com/Leifer 1384 Integration of the nervous and endocrine systems The two major control systems that monitor the functions of the body are the nervous system and the endocrine system. These systems are interdependent. The endocrine, or ductless, glands regulate the body’s metabolic processes. They are primarily responsible for growth, maturation, reproduction, and the response of the body to stress. Fig. 31.1 depicts the organs of the endocrine system and outlines how this system in children differs from that in adults. Hormones are chemical substances produced by the glands. They pour their secretions directly into the blood that flows through them. An organ specifically influenced by a certain hormone is called a target organ. Too much or too little of a given hormone may result in a disease state. FIG. 31.1 Summary of some endocrine system differences between the child and the adult. The endocrine system consists of the ductless glands that release hormones. It works with the nervous system to regulate metabolic activities. (Art overlay courtesy Observatory Group, Cincinnati, OH.) Most of the glands and structures of the endocrine system develop during the first trimester of fetal development. Hormonal control is immature until at least 18 months of age, so infants are more prone to problems related to the functioning of the endocrine system. Maternal endocrine dysfunction may affect the fetus; therefore an in-depth maternal history is a valuable tool in data collection. The absence or deficiency of an enzyme that has a role in metabolism causes a defect in the metabolism process; this can result in illness. Most inborn errors of metabolism can be detected by clinical signs or screening tests that can be performed in utero. Lethargy, poor feeding, failure to thrive, vomiting, and an enlarged liver may be early signs of an inborn error of metabolism in the newborn. When clinical signs are not manifested in the neonatal period, an infection or body stress can precipitate symptoms of a latent defect in the older child. Unexplained mental retardation, developmental delay, convulsions, an odor from the body or from the urine, or episodes of vomiting may be subtle signs of a metabolic dysfunction. Phenylketonuria (PKU), galactosemia, and maple syrup urine disease are discussed in Chapter 14. Cystic fibrosis is discussed in Chapter 25. Radiographic studies to determine bone age are valuable diagnostic tools. Serum electrolytes and glucose, hormonal, and calcium level tests may be required. PKU testing of newborns is an 1385 important screening device for identifying an enzyme deficiency. Chromosomal studies and tissue biopsy are other diagnostic tools. Sexual maturation and skin texture, pigment, and temperature may be indicators of specific disorders. Thyroid function tests may be required. Ultrasonography is helpful in determining the size and character of adrenal glands, ovaries, and other organs. A 24hour urine specimen may provide important data. Genetic counseling can help prevent some disorders. Most endocrine dysfunctions involve chronic problems and call for long-term nursing management. The nurse must assess the effect on growth and development, advocate for early detection and intervention, and promote comprehensive follow-up care that will minimize complications. Nursing Tip Growth hormone is administered at bedtime to simulate the natural timing of hormone release. 1386 Disorders and dysfunction of the endocrine system Inborn errors of metabolism There are literally hundreds of hereditary biochemical disorders that affect body metabolism. The pattern of inheritance is generally autosomal recessive. These conditions range from mild to severe. Tay-Sachs Disease Pathophysiology Tay-Sachs disease involves a deficiency of lysosomal-beta-hexosaminidase, an enzyme necessary for the metabolism of fats. Lipid deposits accumulate on nerve cells, causing both physical and mental deterioration. This is a disease found primarily in the Ashkenazi Jewish population. It is an autosomal recessive trait carried by 1 in 25 of the Ashkenazi Jewish population. (McGovern and Desnick, 2016). Manifestations The infant with Tay-Sachs disease is normal until about age 5 to 6 months, when physical development begins to slow. There may be head lag or an inability to sit. The disease progresses, and when cherry-red deposits occur on the optic nerve, blindness may result. Mental retardation eventually develops because the brain cells become damaged. Most children with Tay-Sachs disease die before 5 years of age from secondary infection or malnutrition. Treatment and nursing care There is no treatment for this devastating disease. The nursing care is mainly palliative. Most care is administered in the home, with periodic hospitalization for complications such as pneumonia. Chapter 27 discusses the care of the dying child. Carriers can be identified by screening tests in the Ashkenazi population during the first trimester of pregnancy. Genetic testing and prenatal counseling have markedly reduced the occurrence of Tay-Sachs disease. 1387 Endocrine disorders Hypothyroidism Pathophysiology Hypothyroidism occurs when there is a deficiency in the secretions of the thyroid gland. It may be congenital or acquired. It is one of the more common disorders of the endocrine system in children. The thyroid gland controls the rate of metabolism in the body by producing thyroxine (T4) and triiodothyronine (T3). In congenital hypothyroidism, the gland is absent or not functioning. The symptoms of hypothyroidism may not be apparent for several months. The older child acquires juvenile hypothyroidism. It may be caused by a number of conditions, the most common being lymphocytic thyroiditis. Often it appears during periods of rapid growth. Infectious disease, irradiation for cancer, certain medications containing iodine, and lack of dietary iodine (uncommon in the United States) may predispose the child. The symptoms, diagnosis, and treatment are similar to those for congenital hypothyroidism. Because brain growth is nearly complete by 2 to 3 years of age, mental retardation and neurological complications are not seen in the older child. Manifestations The infant with hypothyroidism is very sluggish and sleeps a lot. The tongue becomes enlarged, causing noisy respiration (Fig. 31.2). The skin is dry, there is no perspiration, and the hands and feet are cold. The infant feels floppy when handled. This hypotonia also affects the intestinal tract, causing chronic constipation. The hair eventually becomes dry and brittle. If hypothyroidism is left untreated, irreversible mental retardation and physical disabilities result. 1388 FIG. 31.2 An infant with hypothyroidism. Note the large head and tongue, puffy face, and broad nasal bridge. The infant is not alert and feeds poorly. (From Kleigman RM, Stanton BF, St Geme JW et al [editors]: Nelson textbook of pediatrics, ed 20, Philadelphia, 2016, Elsevier.) Treatment and nursing care Early recognition and diagnosis are essential to prevent the developing sequelae. A screening test for hypothyroidism is mandatory in the United States and is performed at birth. This is generally part of an overall screen for other metabolic defects. Treatment involves the administration of the synthetic hormone called levothyroxine sodium (Synthroid, Levothroid). Hormone levels are monitored regularly. Therapy reverses the symptoms and prevents further mental retardation but does not reverse existing retardation; therefore early detection of congenital hypothyroidism is very important. The medication is taken at the same time each day, preferably in the morning. Parents are 1389 cautioned not to interchange brands. Children may experience reversible hair loss, insomnia, and aggressiveness, and their schoolwork may decline during the first few months of therapy. This is temporary. It may take 1 to 3 weeks for the medication to reach the full therapeutic effect. Medication is not to be discontinued, because hormone replacement for hypothyroidism is lifelong. Parents should be taught the signs and symptoms of overdose, which include rapid pulse rate, dyspnea, irritability, weight loss, and sweating. Signs of inadequate dosage or noncompliance are fatigue, sleepiness, and constipation. Parents are instructed about these issues and are advised to consult their health care provider before giving other medications. Common metabolic dysfunctions Other common metabolic dysfunctions, their manifestations, and their treatments are discussed in Table 31.1. Table 31.1 Metabolic Dysfunctions CNS, Central nervous system; SIADH, syndrome of inappropriate antidiuretic hormone. Diabetes Insipidus Pathophysiology Diabetes insipidus can be hereditary (autosomal dominant) or acquired as the result of a head injury or tumor. It is the consequence of posterior pituitary hypofunction that results in a decreased secretion of vasopressin, the antidiuretic hormone. A lack of antidiuretic hormone results in uncontrolled diuresis. The kidney does not concentrate the urine during dehydration episodes. Manifestations Polydipsia and polyuria are the initial signs. The infant cries and prefers water to milk formula. Loss of weight, growth failure, and dehydration occur rapidly. As the child grows older, enuresis may be a problem. Excessive thirst and the search for water overshadow the desire to play, explore, eat, learn, or sleep. Perspiration is deficient, and the skin is dry. Treatment and nursing care Treatment involves hormone replacement of vasopressin, in the form of desmopressin by 1390 subcutaneous injection or orally, or DDAVP (desmopressin acetate) nasal spray. Parents should be taught to monitor for signs of overdose, which include symptoms of water intoxication (edema, lethargy, nausea, central nervous system signs). Children with diabetes insipidus who are admitted to the hospital in an unconscious state and are unable to express thirst are at great risk. A medical identification bracelet should be worn. School personnel should be advised of the child’s needs. School protocol often limits children’s access to bathrooms and water fountains, even during or after physical activity. Such restrictions could be life-threatening to a child with diabetes insipidus. The child’s nurse should contact the school nurse and physical education instructors and educate parents concerning the child’s needs and the lifelong administration of the medication. Home care instructions should include recognizing the signs of water intoxication, dehydration, and hyponatremia. Diabetes Mellitus Pathophysiology Diabetes mellitus (DM) is a chronic metabolic syndrome (group of symptoms) in which the body is unable to use carbohydrates (CHO) properly, leading to an impairment of glucose transport (sugar cannot pass into the cells). The body is also unable to store and use fats properly. There is a decrease in protein synthesis. When the blood glucose level becomes dangerously high, glucose spills into the urine, and diuresis occurs. Incomplete fat metabolism produces ketone bodies that accumulate in the blood. This is termed ketonemia and is a serious complication. DM affects the physical and psychological growth and development of children because it requires lifestyle alterations (diet, glucose monitoring, and insulin administration). There are also many long-term complications related to hyperglycemia, that result in blindness, circulatory problems, kidney disease, and neuropathy, that loom in the future for these children. Treatment is designed to optimize growth and development and to minimize complications. Classification The major forms of diabetes mellitus have been classified according to those caused by a deficiency of insulin secretion because of pancreatic beta cell damage and those that are a consequence of insulin resistance. Type 1 diabetes is the most common metabolic disorder of children. Diabetes comes with a high degree of risk for long-term complications that may manifest in adulthood. Although there is a genetic susceptibility to type 1 diabetes, a large percentage of affected children have no known family history. Genetic studies have implicated chromosomes 6 and 11, but other genetic risk factors also have been identified, and environmental factors, such as viruses or stress, may play a role in triggering diabetes. Diet may also play a role in autoimmunity (e.g., the timing of introducing new foods in infancy), but no conclusive findings have emerged. Research is ongoing (Svoren and Jospe, 2016). The accepted criterion for diagnosing diabetes mellitus is a fasting blood glucose level of 126 mg/dL or higher after no caloric intake for 8 hours (Svoren and Jospe, 2016). The classifications of diabetes mellitus (Table 31.2) pertinent to pediatrics include: Type 1 (formerly known as insulin-dependent diabetes mellitus [IDDM] and juvenile-onset diabetes mellitus): Type 1 DM is an autoimmune condition that occurs when a child with a genetic predisposition is exposed to an environmental factor (e.g., a viral infection) that triggers the syndrome by causing destruction of beta cells in the pancreas, resulting in insufficient insulin production. Drugs, chemicals, and ionizing radiation may cause beta cell destruction in some cases (Svoren and Jospe, 2016). Type 2 (formerly known as non–insulin-dependent diabetes mellitus [NIDDM], adult-onset DM, or maturity-onset DM): Type 2 DM involves a resistance to insulin. It is often triggered by a sedentary lifestyle and obesity. It also occurs more frequently in certain ethnic groups, such as African Americans and Pacific Islanders, especially those who have hypertension and elevated blood lipid levels. Acanthosis nigricans (a dark pigmentation in the flexor creases of the skin) may be a cutaneous marker for patients with type 2 DM. Table 31.2 1391 Classification of Diabetes Mellitus Gestational diabetes mellitus (GDM) is the appearance of symptoms for the first time during pregnancy (see Chapter 5). Table 31.3 lists the clinical features of types 1 and 2 DM. Lifestyle intervention is the cornerstone of preventing or delaying the onset of type 2 diabetes mellitus in susceptible individuals. Table 31.3 Clinical Features of Type 1 and Type 2 Diabetes Type 1 Diabetes Mellitus Incidence More than 30 million Americans have diabetes mellitus. The frequency is increasing, with approximately 30,000 new cases being diagnosed in the United States (Svoren and Jospe, 2016). Symptoms of type 1 DM may occur at any time in childhood, but the rate of occurrence of new cases is highest among 5- and 7-year-old children and pubescent children 11 to 13 years of age. In the former group, the stress of school and the increased exposure to infectious diseases may be the precipitating event that triggers the onset. During puberty, rapid growth, increased emotional stress, and insulin antagonism of sex hormones may be implicated as contributing to development of diabetes. DM occurs in both sexes with equal frequency. The disease is more difficult to manage in childhood because the patients are growing, expend a great deal of energy, have varying nutritional needs, and face a lifetime of diabetic management. Young children with type 1 often do not demonstrate the typical “textbook” picture of the disorder. The initial diagnosis may be determined when the child develops ketoacidosis. Therefore the nurse must be particularly astute in subjective and objective observations. Manifestations Children with diabetes mellitus present a classic triad of symptoms: polydipsia (complains of excessive thirst), polyuria (excretes large amounts of urine frequently), and polyphagia (constantly hungry). The symptoms appear more rapidly in children. An insidious onset, with lethargy, weakness, and weight loss, is also common. The child who is toilet trained may begin wetting the bed or have frequent “accidents” during play periods, may lose weight, and is irritable. The skin becomes dry. Vaginal yeast infections may be seen in the adolescent girl. There may be a history of recurrent infections. The symptoms may remain unrecognized until an infection becomes apparent or coma results. Laboratory findings indicate glucose in the urine (glycosuria). Hyperglycemia (hyper, “above,” gly, “sugar,” and emia, “blood”) is also apparent. Hyperglycemia occurs because glucose cannot enter the cells without the help of insulin, so glucose remains in the bloodstream. The cells use protein and fat for energy; therefore protein stores in the body are depleted. The lack of glucose in the cells triggers the body to develop polyphagia, and the increase 1392 in glucose intake further increases glucose levels in the blood. Hyperglycemia is the cause of the many complications associated with uncontrolled diabetes mellitus. The honeymoon period When type 1 is initially diagnosed and the child is stabilized by insulin dosage, the condition may appear to improve. Insulin requirements decrease, and the child feels well. This phenomenon supports the parents’ phase of denial in accepting the long-term diagnosis of DM for their child. The “honeymoon period” lasts a short time (a few months), and parents must be encouraged to closely monitor blood glucose levels to prevent complications. Nursing Tip A period of remission, or the “honeymoon” phase of the disease, may occur within a few weeks of beginning insulin administration. There is a decline in insulin need and improved metabolic control. This phase, however, is temporary. Diagnostic Blood Tests Blood glucose A random blood glucose level may be obtained at any time and requires no preparation of the patient. The results should be within the normal limits for both nondiabetic patients and diabetic patients who have good control of their disease. A nonfasting random blood glucose over 200 mg/dL and classic symptoms are diagnostic of diabetes mellitus (Svoren and Jospe, 2016). Fasting blood glucose. A fasting blood glucose level is a standard and reliable test for diabetes. The blood glucose level is measured in the fasting patient, usually immediately on awakening in the morning. The results of the test will not be accurate if the patient is receiving a dextrose intravenous (IV) solution. If the child is known to have diabetes, food and insulin are withheld until after the test. If a person’s fasting blood glucose level is greater than 126 mg/dL on two separate occasions and the history is positive, the patient is considered to have diabetes mellitus and requires treatment. Glucose tolerance test. Another test to determine the amount of glucose in the blood is the glucose tolerance test (GTT). The results are plotted on a graph (Fig. 31.3). This procedure is time-consuming and therefore is no longer in routine use because the glycosylated hemoglobin test is fast and accurate and shows longer-term elevation of glucose levels. An oral glucose tolerance test is not recommended for children because the results are not as reliable as in adults (Svoren and Jospe, 2016). 1393 FIG. 31.3 The glucose tolerance test. Left, Normal; center, type 1 diabetes; right, type 2 diabetes. The graphs show the relationship between the ingestion of glucose and the level of plasma insulin during 4 hours in a normal person and in persons with type 1 and type 2 diabetes. (Modified from Waechter EH, Blake FG: Nursing care of children, ed 9, Philadelphia, 1976, Lippincott.) Glycosylated hemoglobin test (HgbA1c) reflects glycemic levels throughout a period of months. Values are found to be elevated in virtually all children with newly diagnosed diabetes. This study also helps to confirm the results of blood and urine tests performed either at home or by the health care provider. Glucose in the bloodstream constantly enters red blood cells and links with, or glycosylates, molecules of hemoglobin. The more glucose in the blood, the more hemoglobin becomes coated with glucose. The red blood cells carry this glucose until cells with fresh hemoglobin replace them. This process takes about 3 to 4 months. Values vary according to the measurement used. Values of 6.5% to 7.5% may indicate impaired glycemic control. Values greater than 10% indicate poor control. The target should be under 7.5% (Svoren and Jospe, 2016). Diabetic ketoacidosis Diabetic ketoacidosis (DKA) is also referred to as diabetic coma, although a person may have DKA with or without being in a coma. It is manifested by ketonemia and may be precipitated by a secondary infection. It may also occur if the disease proceeds unrecognized; this happens fairly often in children with diabetes. Even minor infections, such as a cold, increase the body’s metabolic rate and thereby change the body’s demand for insulin and the severity of diabetes. Ketoacidosis is the end result of the effects of insulin deficiency. Symptoms of ketoacidosis are compared with those of hypoglycemia in Table 31.4. Signs and symptoms include a fruity odor to the breath, nausea, decreased level of consciousness, and dehydration. Lab values include ketonuria, a decreased serum bicarbonate concentration (decreased CO2 levels), low pH, and hypertonic dehydration. Diabetic teaching should include this information. The symptoms range from mild to severe and occur within hours to days. The child with DKA is managed in the hospital setting with close monitoring of fluid, electrolytes, labs, and clinical status. Table 31.4 Hyperglycemia and Hypoglycemia 1394 CHO, Carbohydrate; IM, intramuscular; IV, intravenous. Treatment of type 1 diabetes mellitus and nursing care The three goals of treatment in type 1 diabetes mellitus are: 1. Ensure normal growth and development through metabolic control. 2. Enable the child to cope with a chronic illness, have a happy and active childhood, and be well integrated into the family. 3. Prevent complications. Maintaining the blood glucose at consistently normal levels can minimize complications. Teaching ideally begins when the diagnosis is confirmed. A planned educational program is necessary to provide a consistent body of information, which can then be individualized. The patient’s age and financial, educational, cultural, and religious background must be considered. Many hospitals hold group clinics for diabetic patients and their relatives. These sessions are conducted by the multidisciplinary health care team and include the diabetes nurse educator, dietitian, and pharmacist. Patients who are living with the disease provide encouragement and help by sharing concerns. Health professionals become directly involved with the patient’s progress and can offer necessary feedback and support. Continuous follow-up is essential. Because children with diabetes are growing, additional dimensions of the disorder and its treatment become evident. Growth is not steady, but occurs in spurts and plateaus that affect treatment. Infants and toddlers may have hydration problems, especially during illness. Preschool children have irregular activity and eating patterns. School-age children may grieve over the diagnosis and ask, “Why me?” They may use their illness to gain attention or to avoid responsibilities. The onset of puberty may require insulin adjustments as a result of growth and the antagonistic effect of the sex hormones on insulin. Adolescents often resent this condition, which deviates from their concept of the “body ideal.” They have more difficulty in resolving their conflict between dependence and independence. This may lead to rebellion against parents and treatment regimens. The impact of the disease on the rest of the family must also be considered. Parents may feel guilty for having passed the disease on to their child. Siblings may feel jealous of the attention the patient receives. The sharing of responsibility by parents is ideal but not necessarily a reality. Some may have difficulty accepting the diagnosis and the more regimented lifestyle it imposes. Family members must cope with their individual reactions to the stress of the illness. Children must assume responsibility for their own care gradually and with a minimum of pressure. Overprotection can be as detrimental as neglect. Parents who have received satisfaction from their child’s dependence on them may need help “letting go.” The diabetic camp experience is helpful in this respect. A medical identification bracelet should be worn. The nursing management of childhood diabetes requires knowledge of growth and development, pathophysiology, blood glucose self-monitoring, nutritional management, insulin management, insulin shock, exercise, skin and foot care, infections, effects of emotional upsets, and long-term care. Nursing Care Plan 31.1 lists interventions for the child with diabetes. 1395 Nursing Care Plan 31.1 The Child with Diabetes Mellitus Patient data A 10-year-old boy is admitted with new-onset diabetes mellitus. An insulin regimen is prescribed. The child states that he wishes to return to a normal life with his peers. Selected Nursing Diagnosis Risk for poor health as a result of hypoglycemia or diabetic ketoacidosis (hyperglycemia) Selected Nursing Diagnosis Need for education pertaining to exercise Selected Nursing Diagnosis Need for education pertaining to safety Critical thinking question 1. A child comes to the clinic for follow-up after discharge from the hospital with a diagnosis of diabetic ketoacidosis. He states he is excited about returning to school and rejoining his cross-country team with his friends. His father states he wants his son to stay home and do more sedentary activities to prevent any more health problems. What is the best response of the nurse? 1396 Teaching plan for children with diabetes mellitus The patient and family are instructed about the location of the pancreas and its normal function. The nurse explains the relationship of insulin to the pancreas, differentiating between type 1 and type 2 diabetes. All information is provided gradually and at the level of understanding of the child and family. Audiovisual aids and pamphlets are incorporated into the session. If the patient is newly diagnosed, hospitalization offers opportunities for instruction. Blood glucose self-monitoring Patients can test their own blood glucose level in the home. While still being supervised by and consulting with the health care provider, the patient can make rational changes in insulin dosage (sliding scale dosage) based on home blood glucose tests, nutritional requirements, and daily exercise. This is of great psychological value to the child, adolescent, and parents because it reduces feelings of helplessness and complete dependence on medical personnel. Home glucose monitoring should be taught to all young patients and their caregivers. The patient not only must be skilled in the techniques but also should understand the results and how to incorporate them into daily regimens. This means involving the entire health care team in ongoing supervision, demonstrations, and support. Although instructions are included with the various products, patients need individual training. Glucometer systems can provide readouts and can automatically store data by time and date. Some also keep track of diet and the amount of exercise for the day. They can be connected to a computer for review or to an insulin pump. Records can be transmitted electronically to the health care provider. Obtaining blood specimens before meals and at bedtime has been simplified by the use of capillary bloodletting devices (e.g., Hamlet, Autolet, or Accu-Chek). These devices automatically control the depth of penetration of the lancet into the skin. The sides of the fingertips are recommended testing sites because there are fewer nerve endings and more capillary beds in these areas. The best fingers to use are the middle, ring, or little fingers on either hand. The finger will bleed more easily if the child washes the hands in warm water for about 30 seconds. To perform the test, a drop of blood is put on a chemically treated reagent strip. The test strip then is inserted into the glucometer, and the blood glucose reading appears. Methods of glucose monitoring provide different information. The fingerstick method of glucose monitoring shows the glucose level at a moment in time. The HgbA1c value shows a history of several weeks’ pattern of glucose control. Continuous glucose monitoring measures real-time levels within the interstitial tissues and shows trends in glucose levels but does not completely replace glucometers. Cost, convenience, and portability are factors to consider when selecting glucometers. Most products can be obtained at the local pharmacy, and the cost is generally covered by Medicaid and other forms of health insurance. Newer and more precise instruments are being developed constantly. Continuous glucose monitoring The continuous glucose monitor consists of a sensor placed under the skin in the abdomen that transmits interstitial blood glucose levels every 10 to 60 seconds to a monitor that can be worn on the clothing of the patient or to an electronic device, such as an iPhone. This glucose monitoring technique helps identify fluctuation and trends that cannot be picked up by the standard intermittent fingerstick measurements or HgbA1c test. The continuous glucose monitoring system is used to devise an individualized treatment plan for the patient. A continuous glucose monitoring system that can be used by children age 7 years or older has been in use for several years. Methods of insulin administration The insulin pump The insulin pump offers continuous, personalized subcutaneous insulin infusion without the need for frequent injections 1397 Closed loop system A closed loop wireless system provides glycemic control with minimum intervention by connecting the glucose monitor to an insulin pump that more closely mimics normal physiology. A pagersized, battery-powered, programmable pump holds a cartridge supply of insulin. A catheter attaches to a needle that is inserted into the subcutaneous tissue and is secured with tape. An insulin pump can deliver a personalized 24-hour cycle of insulin plus manual delivery of bolus doses as needed. When it is connected by wireless technology to a glucose monitor, changes in insulin doses can be programmed and automatic reminders for appropriate actions offered (Fig. 31.4). The closed loop system is designed to alarm and stop insulin delivery when interstitial glucose levels fall below a predetermined level or to provide a dose of insulin if the glucose level rises above a predetermined level (Svoren and Jospe, 2016). FIG. 31.4 The closed loop system involves both glucose monitor and insulin delivery catheters. These are attached to needles, which are inserted under the skin of the abdomen and secured. The system wirelessly communicates with a pager-sized insulin delivery device. This unit provides programmed 1398 amounts of insulin around the clock, and required changes are made by remote control. In addition, the system can provide reminders, such as the need to check blood glucose levels and health care provider appointments. (From Atkinson MA, Eisenbarth GS, Michels AW: Type 1 diabetes, Lancet 383:69–78, 2014; Kleigman RM, Stanton BF, St Geme JW et al [editors]: Nelson textbook of pediatrics, ed 20, Philadelphia, 2016, Elsevier.) A closed loop system does not completely eliminate the need for blood glucose monitoring checks, which are usually done before meals to determine the need for a bolus injection based on the food intake of the meal. Some models of closed loop insulin pumps/glucometers have wireless technology that uses a free smart phone app that shares information with the health care provider. Some models are waterproof to 12 feet. This combined technology can be used for children over 7 years of age who require a minimum of 8 units of insulin per day. The insulin pump may need to be disconnected for more than 2 hours if magnetic resonance imaging (MRI) is needed, and other sources of insulin must be provided. Intermittent administration of insulin Insulin is a specific drug for the control of DM. When injected into the diabetic patient, it enables the body to burn and store sugar. Current data emphasize the importance of blood glucose control in the prevention of microvascular disease. The dose of insulin is measured in units, and special syringes are used in its administration. U100 (100-unit) insulin is the standard form. It is important to teach the parents and child about the administration of insulin. Insulin cannot be taken orally, because it is a protein and would be broken down by the gastric juices. The usual method of administration is subcutaneous injection (Fig. 31.5). When injected at a 90-degree angle, the short needle enters the subcutaneous space. This technique may be easier for the child to learn because it takes less coordination to administer than a 45-degree angle technique. FIG. 31.5 Subcutaneous injection of insulin. 1399 Medication Safety Alert! Human insulin and pork insulin are not interchangeable. The site of the injection is rotated to prevent poor absorption and injury to tissues (Fig. 31.6). Injection model forms made from construction paper and site rotation patterns are useful. One suggested site rotation pattern is to use one area for 1 week. A different site within that area is used for each injection. Injections should be about 1 inch apart. In general, a child can be taught to perform self-injection after 7 years of age. The health care provider prescribes the type and amount of insulin and specifies the time of administration. 1400 FIG. 31.6 Sites of injection of insulin. (From McKinney ES, James SR, Murray SS, Ashwill JW: Maternalchild nursing, ed 5, Philadelphia, 2018, Saunders.) The young child and parents can use a doll or a simulator to practice self-injection (Fig. 31.7). 1401 FIG. 31.7 (A) By giving injections to dolls or puppets, children can be prepared for this procedure and may be less frightened by it. (B) A child 7 years of age or older can take the responsibility for self-injection, with proper supervision. (A courtesy Pat Spier, RN-C; B from McKinney ES, James SR, Murray SS, Ashwill JW: Maternal-child nursing, ed 5, Philadelphia, 2018, Saunders.) Insulin should not be injected into an area in which circulation is temporarily increased. In such areas, a more rapid than expected absorption and effect can trigger hypoglycemia. For example, a more rapid circulation to the legs can be expected in a child who is riding a tricycle; therefore the thigh should not be selected as a site for injection after such activity. If a teen returns from playing tennis, the upper arm is avoided as an injection site for the same reason. The dosage of insulin is determined by monitoring glucose levels and by insulin dose adjustment by the medical team, to avoid hypoglycemia or hyperglycemia that could result in serious longterm complications. Glucose control is obtained by administering insulin in a basal-dose bolus regimen, which involves the use of a combination of slow onset–long duration types of insulin with a rapid insulin as necessary for meals or snacks. For example, a once a day basal dose of long-acting insulin may be administered (e.g., glargine or Detemir), and a bolus of a shorter acting insulin (e.g., Lispro or Aspart) may be administered with meals. An alternate plan may include combining neutral protamine Hagedorn (NPH) insulin with a rapid-acting bolus at breakfast, a rapid-acting analog bolus at dinner, and a long-acting glargine at bedtime, which reduces the number of daily injections required. Blood glucose fingerstick monitoring is essential, because activity levels and snacks in young children will affect their insulin needs. Nutritional education also is essential. Illness, infection, and surgery require special modification of insulin dosages until the child returns to home care. Microneedles have been developed to administer insulin to intradermal sites rather than subcutaneous sites, for faster absorption. Intradermal injection of insulin is currently in use only for adults with type 2 diabetes mellitus (Kochba et al., 2016). The various types of insulin and their actions are listed in Table 31.5. The main differences between insulins are the amount of time required for the insulin to take effect, of peak action, and the duration of the protection provided. It is important to remember that the values listed in the table are only guidelines – the response of each diabetic child to any given insulin dose is highly individual and depends on many factors, such as stress, site of injection, local destruction of insulin by tissue enzymes, and insulin antibodies. 1402 Table 31.5 Types of Insulina a There are many combined mixtures of insulin available commercially. Synthetic insulin, free of animal impurities, is used for children. Lente and Ultra-Lente insulins are no longer used. b Do not mix with other insulins. Data from PDR staff: Physicians’ desk reference, Montvale, NJ, 2017, PDR Network. http://www.pdr.net. Accessed August 3, 2018; Clayton B, Willihnganz W: Basic pharmacology for nurses, ed 17, St Louis, 2016, Elsevier. Storage of insulin at extreme temperatures (below 2.2° C [36° F] or above 29.4° C [85° F]) can destroy it. Insulin’s potency can be reduced if the bottle has been opened longer than 1 month. The health care provider often orders a combination of short-acting and intermediate-acting insulin; for example, “Give 10 units of NPH insulin and 5 units of regular insulin at 7:30 a.m.” This offers the patient immediate and longer-lasting protection. NPH insulin may be administered in the same syringe as regular or crystalline insulin (Fig. 31.8). Stable, premixed insulins are available. Insulin “pens” and injectors for insulin are available alternatives for the traditional syringe technique of administering insulin. Insulin analogs (e.g., glargine and Detemir) more closely mimic human insulin. 1403 FIG. 31.8 Mixing insulin. This step-order process avoids the problem of contaminating the regular insulin with the intermediate-acting insulin. If contamination of the regular insulin does occur, the rapid-acting effect of this drug is diminished, and it is unreliable as a quick-acting insulin in an acute situation, such as diabetic ketoacidosis. (From Bowden VR, Dickey SB, Greenberg SC: Children and their families: the continuum of care, Philadelphia, 1998, Saunders.) Lipoatrophy (lipo, “fat,” and atrophy, “loss of”) and lipohypertrophy (lipo, “fat,” and hypertrophy, “increase of”) refer to changes that can occur in the subcutaneous tissue at the injection site. Proper rotation of sites and the availability of the newer purified insulins have helped to eliminate this condition. The child is taught to “feel for lumps” every week and to avoid using any sites that are suspicious. Medication Safety Alert! When mixing insulin, always withdraw the regular insulin first and then add the long-acting insulin into the syringe. Inhaled or oral insulin Inhaled insulin has been under study and appears effective. Continued study by the U.S. Food and Drug Administration (FDA) is needed to determine the long-term effects on lung tissue before it is released for general use. Oral insulin is currently under study but is not yet available for general 1404 use in pediatrics (Svoren and Jospe, 2016). An insulin patch is under development but has not yet been fully approved by the FDA. Insulin shock Insulin shock, also known as hypoglycemia (hypo, “below,” glyco, “sugar,” and emia, “blood”), occurs when the blood glucose level becomes abnormally low. Too much insulin causes this condition. Factors that may account for this imbalance include poorly planned exercise, reduced diet, and errors made because of improper knowledge of insulin and the insulin syringe. Children are more prone to insulin reactions than adults because: The condition itself is more unstable in young people. Children are growing. Children’s activities are more irregular. Poorly planned exercise is often the cause of insulin shock during childhood. Hospitalized patients who are being regulated must be observed frequently during naptime and at night. The nurse should suspect problems if there is difficulty rousing the patient or if the child is perspiring heavily. The symptoms of an insulin reaction, which range from mild to severe, are generally noticed and treated in the early stages. They appear suddenly in the otherwise well person. Examination of the blood would show a lowered blood glucose level. The child becomes irritable, may behave poorly, is pale, and may complain of feeling hungry and weak. Sweating occurs. Symptoms related to disorders of the nervous system arise because glucose is vital to the proper functioning of nerves. The child may become mentally confused and giddy, and muscular coordination is affected. If insulin shock is left untreated, coma and convulsions can occur. The immediate treatment consists of administering sugar in some form, such as ½ cup of orange juice, hard candy, a small box of raisins, or a commercial (glucose tablet) product. The patient begins to feel better within a few minutes and at that time may eat a small amount of protein or starch (sandwich, milk, cheese) to prevent another reaction. Glucagon is recommended for the treatment of severe hypoglycemia. It quickly restores the child to consciousness in an emergency; the child can then consume some form of sugar or a planned meal. The Somogyi phenomenon (rebound hyperglycemia) occurs when blood glucose levels are lowered to a point at which the body’s counterregulatory hormones (epinephrine, cortisol, and glucagon) are released. Glucose is released from muscle and liver cells, which precipitates a rapid rise in blood glucose levels. It is generally the result of chronic insulin use, especially in patients who require fairly large doses of insulin to regulate their blood glucose levels. Hypoglycemia during the night and high glucose levels in the morning are suggestive of the phenomenon. The child may awaken at night or have frequent nightmares and experience early morning sweating and headaches. The child actually needs less insulin, not more, to rectify the problem. The Somogyi phenomenon differs from the dawn phenomenon, in which early morning elevations of blood glucose occur in the absence of preceding hypoglycemia and may be a response to growth hormone secretion that occurs in the early morning hours. Together the Somogyi and dawn phenomena are the most common causes of instability in diabetic children. Testing blood glucose levels around 3 a.m. helps to differentiate the two conditions and aids in regulating the insulin dosage. Whenever the insulin regimen is changed, close monitoring of blood glucose levels is essential to detect the dawn and Somogyi effects, which are common with children. Continuous glucose monitoring systems may help deal with this phenomenon (Svoren and Jospe, 2016). Diet therapy for children with diabetes mellitus Nutrition management The triad of diabetes management consists of a well-balanced diet, precise insulin administration, and regular exercise. The importance of glycemic control in reducing the incidence of symptoms and complications of the disease has been established. The advent of blood glucose self-monitoring has affected food intake in that diets can be fine tuned and more flexible while the cornerstone of consistency (in amount of food and time of feeding) is maintained. Contrary to popular belief, there is no scientific evidence indicating that persons with diabetes require special foods. In fact, if it is 1405 good for the diabetic patient, it is good for the entire family. The nutritional needs of diabetic children are essentially no different from those of nondiabetic children. The timing of food consumption has to be correlated with the time and action of the type of insulin prescribed so that blood glucose levels will not be abnormally high or abnormally low. The goals of nutrition management in children are to ensure normal growth and development, to distribute food intake so that it aids metabolic control, and to individualize the diet in accordance with the child’s ethnic background, age, gender, weight, activity, family economics, and food preferences. The total estimated caloric intake is based on body size or surface area and can be obtained in standard tables. The recommended intake is 55% carbohydrates (mostly complex carbohydrates), 30% fat, and 15% protein (Svoren and Jospe, 2016). Most of the carbohydrate intake should consist of complex carbohydrates that absorb slowly and do not cause sudden and wide elevation of the blood glucose level. The various types of insulin monitors allow flexibility in diet intake and improve the quality of life. Dietary fat from animal sources should be limited and replaced with the polyunsaturated fats found in vegetables. Occasional excesses for birthdays or special occasions can be accommodated to prevent rebellion and to promote compliance. Special supplements may be required to accommodate the exercise patterns and growth needs of children. After a diet prescription is received from the health care provider, the dietitian assists the family in designing an individualized diet plan. The dietitian also explains the use of exchange lists. Carbohydrate counting provides flexibility in meal planning. In this system, one carbohydrate choice is equal to 15 g of carbohydrate. Generally, 1 unit of insulin covers 15 g of carbohydrate. A general nutrition plan can be created for a child using foods he or she likes, including snacks. The diet prescription usually includes carb values. Carb counting offers adolescents control and involvement in their need to maintain a positive self-concept and self-esteem that promotes compliance. The MyPlate food guide (http://www.choosemyplate.gov) may be used to guide the child and family concerning portion control and selection of foods. Education of the patient is ongoing. Too much information given at one time may overwhelm the parents and discourage the child. Well-informed nurses can offer much reinforcement and support. They can clarify terms such as dietetic, sugar free, juice packed, water packed, and unsweetened. Meal trays in the hospital provide an excellent opportunity for teaching. Children should bring their lunches to school. Respecting cultural patterns and personal preferences is important. The content of foods that are commonly found in fast-food chain restaurants is available through the American Diabetes Association. The importance of fiber in diets is well documented. In the diabetic patient, soluble fiber has been shown to reduce blood glucose levels, lower serum cholesterol values, and sometimes reduce insulin requirements. Fiber appears to slow the rate of absorption of sugar by the digestive tract. Raw fruits and vegetables, bran cereals, wheat germ, beans, peas, and lentils are good sources of soluble fiber. Safety Alert! Instruct the patient and family to read food labels carefully. The word dietetic does not mean diabetic. Dietetic merely means something has been changed or replaced; for example, the food may contain less salt or less sugar. Glycemic index of foods The glycemic index for selected foods has had an impact on the manipulation of dietary needs (Table 31.6). The index shows the impact of a portion of food on the blood glucose level compared to the same portion of pure glucose. The glycemic index may be higher for the liquid form (apple juice) than the same carbohydrate in solid form (whole apple). The fiber content of the food can lower the glycemic index value. Some chocolate may have a low glycemic index value, but the high saturated fat content limits its nutritional and health value. The glycemic load takes into account the amount of glucose in a food combined with the total carbohydrate content of a serving portion. Foods with a low glycemic index value (below 55) take longer to increase the glucose levels in the blood. Foods that have a high glycemic index value (above 70) increase the blood glucose more 1406 rapidly. Use of this knowledge enables a person to select optimal foods to eat before, during, and after exercise. The size of portions, the type of processing or cooking, and the combinations of foods have also been shown to have a bearing on glucose responses. Table 31.6 Glycemic Index of Selected Foods a Foods with a low glycemic index take a longer time to increase the glucose levels in the blood. Data from Atkinson F, Foster-Powell R, Brand-Miller J: International table of glycemic index and glycemic load values, Diabetic Care 31(12):2281–2283, 2008; Mahan L, Escott-Stump S: Krause’s food and the nutrition care process, ed 15, Philadelphia, 2017, Saunders. Nursing Tip Take snacks seriously – they are an important part of the day’s food supply. Nursing Tip Avoid the use of sorbitol or xylitol as artificial sweeteners in the diets of children with diabetes (Svoren and Jospe, 2016). Home management of children with diabetes mellitus Exercise Exercise is important for the patient with diabetes because it causes the body to use sugar and promotes good circulation. It lowers the blood glucose level, and in this respect it acts like more insulin. The diabetic patient who has planned vigorous exercise should carry extra sugar to avoid insulin reactions. The patient should also carry money for candy or a drink and, if possible, should also carry a cell phone. The blood glucose level is high immediately after meals, and the child can participate in active sports at such times. Games enjoyed directly before meals should be less active. The diabetic child is able to participate in almost all active sports. Poorly planned exercise, however, can lead to difficulties. 1407 Skin care The patient is instructed to bathe daily and dry well, especially between the toes. Cleansing of the inguinal area, axillae, perineum, and inframammary areas is especially important because yeast and fungal infections tend to occur at these sites. The skin is inspected for cuts, rashes, abrasions, bruises, cysts, or boils. These lesions are managed promptly. If skin is very dry, an oil (e.g., Alpha Keri) may be used in the bathwater. Adolescents are taught to use electric razors. Exposing the skin to extremes in temperatures is avoided. Injection sites are inspected for lumps. Foot care Although circulatory problems of the feet are less common in children, proper habits of foot hygiene must be established. Patients are instructed to wash and dry their feet well each day. The feet are inspected for interdigital cracking, and the condition of the toenails is checked. Nails are trimmed straight across. Socks are changed daily, and tight socks or large ones that bunch up are avoided. Shoes are replaced often as the child grows. Infections Immunizations against communicable diseases are essential (see Chapter 32). Meticulous skin care and care of needles and insulin equipment can prevent infections. Emotional upsets Emotional upsets can be as disturbing to the patient as an infection and may necessitate food adjustments, insulin adjustments, or both. Table 31.7 lists nursing interventions for stress on the child and family related to type 1 diabetes. Table 31.7 Nursing Interventions for Predictable Types of Stress on a Child with Type 1 Diabetes and on the Family 1408 Urine checks Routine urine checks for sugar are being replaced by the more accurate glucose blood monitoring. However, this procedure does not test for the acetone level, which the patient may need to determine, particularly during illness and when the blood glucose level is high. When urine checks are advocated for patients, saying urine “check” rather than “test” is less confusing to young children. Glucose-insulin imbalances The patient is taught to recognize the signs of insulin shock and ketoacidosis (see Table 31.4). Early attention to changes and daily record keeping are stressed. Many excellent teaching films and brochures are available. The child should wear a bracelet identifying him or her as having diabetes. Wallet cards are also available. Teachers, athletic coaches, and guidance personnel are informed about the disease and should have the telephone numbers of the patient’s parents and health care provider. Travel With planning, children can enjoy travel with their families, and older adolescents can travel alone. Before leaving on a trip, the child should be seen by the health care provider for a checkup and prescriptions for supplies. A written statement and a card identifying the child as having diabetes should be carried. Time changes may affect meals. Additional supplies of insulin, sugar, glucagon, and food are kept with the child. These are never checked with luggage, especially on an airplane, because they may be lost. If foreign travel is planned, parents must become familiar with the food in the visited area so that dietary requirements can be met. Electronic devices often have an airplane 1409 mode available. Local chapters of the American Diabetes Association or the Juvenile Diabetes Foundation can help vacationing families in an emergency. Follow-up care The child must see the health care provider regularly. The child should also be taught to visit the dentist regularly for cleaning of teeth and gums. Brushing and flossing daily are essential. Eyes should be examined regularly; blurry vision must not be ignored. There are many brochures, books, and journals that offer excellent suggestions and guidance at an age-appropriate level. Illness or surgery When illness occurs, close glucose monitoring and control are essential. Hyperglycemia causes diuresis and dehydration, and ketosis can involve vomiting. Counteracting regulatory hormones that are secreted during periods of stress interfere with the effectiveness of insulin, resulting in increased glucose levels. Modification of insulin doses may be necessary. The patient with diabetes usually tolerates surgery well. Insulin may be given before, during, or after the operation. If the patient is restricted to nothing by mouth, calories may be supplied by IV glucose. Details vary according to the procedure and the patient’s treatment for diabetes. Careful review of the patient’s history helps in formulating nursing care plans and provides a basis for teaching. Long-term complications The complications of diabetes mellitus include microvascular (mostly referring to kidney, eye, neurological, and circulatory problems) and macrovascular (which refers to peripheral vascular effects). Diabetic retinopathy (pathology of the retina) is the leading cause of blindness in the U.S. The risk is 91% for type 1 diabetic children and 78% for type 2 diabetic children (Svoren and Jospe, 2016). Therefore preventing hyperglycemia is essential in avoiding this complication. Routine eye exams should be scheduled; they are an important part of follow-up care. Nephropathy (kidney pathology) affects 20% to 30% of diabetic children. Stabilizing glucose levels and preventing the development of hypertension can reduce this risk. The American Diabetes Association recommends yearly screening of the albumin-creatinine ratio for children with type 1 or type 2 diabetes, especially after puberty. The nervous system is also affected by hyperglycemia. Adolescents should be assessed for peripheral neuropathy (decreased sensation). A decline in diabetic complications has been noted since the use of continuous glucose monitoring devices and insulin pumps (Svoren and Jospe, 2016). Prospects for the future Diabetic research is being conducted on many fronts. Pancreas transplantation has been performed in adults. Laser eye surgery has aided the treatment of complicated eye conditions. Such advances hold promise for resolving or eradicating the dilemma of diabetes in children. Type 2 diabetes mellitus Type 2 diabetes is thought to be caused by insulin resistance and reduced insulin secretion. It is precipitated by obesity, low physical activity, and a lipid-rich diet, resulting in insulin resistance. Type 2 diabetes mellitus occurs in 1.45 per 1000 people in the United States and is more prevalent in children and young adults (Svoren and Jospe, 2016). Risk factors include: Family history of type 2 diabetes mellitus Signs of insulin resistance Acanthosis nigricans (a dark pigmentation of the flexure creases of the skin and back of the neck) Hypertension Increased lipids (hyperlipidemia) Repeated vaginal monilial (Candida) infections, resulting from chronic glycosuria Obese is a BMI of 30 or higher. Class I 30–34.9; class II 35–39.9; and class III 40+ Twins more often are at risk for type 2 diabetes mellitus due to intrauterine growth restriction (see Chapter 5), as are infants born with a low birth weight who gain rapidly in the first few months 1410 of life. These infants are more prone to weight gain later in life. However, the combination of obesity, poor diet, lack of adequate exercise, smoking, some psychiatric conditions, and some medications that induce weight gain (e.g., fluoxetine) also contributes to the risk factors for the development of type 2 diabetes (Svoren and Jospe, 2016). The oral glucose tolerance test has little value in diagnosing type 2 diabetes. In 2010 the American Diabetes Association added an HgbA1c of 6.5% or higher in obese adolescents as a diagnostic criterion. However, conditions such as iron-deficiency anemia, sickle cell disease, or thalassemia can alter the HgbA1c. A fasting serum insulin also is not diagnostic of type 2 diabetes or prediabetes. Many adolescents remain asymptomatic for years because the hyperglycemia is moderate and signs and symptoms are not dramatic. The American Diabetes Association recommends that all adolescents who are overweight and have at least two risk factors for diabetes mellitus be screened by an HgbA1c test every 2 years after puberty. Asymptomatic adolescents are often not diagnosed until diabetic ketoacidosis occurs. Treatment guidelines for type 2 diabetes mellitus include lifestyle changes to reduce obesity and antidiabetic medication, such as metformin, which is the only oral antidiabetic agent approved for children and adolescents. Newer antidiabetic drugs have been developed for adult use, but the risks and benefits must be closely evaluated before use in the pediatric setting. A combination therapy of metformin and insulin may be required for adequate glucose control. When metformin is prescribed, the creatinine level and kidney and liver function should be monitored, and metformin should be temporarily discontinued during radiologic tests that include IV iodized contrast dyes. Blood glucose monitoring and family education and support are essential to follow-up care. Nutrition counseling should be focused around patient and family food preferences and should include fruits and vegetables, a decrease in fats, and a reduction in sugary drinks. Moderate to vigorous physical activity for 1 hour per day and fewer than 2 hours of nonacademic screen time per day are recommended (Svoren and Jospe, 2016). Nutrition Considerations Diet Therapy in Pediatric Metabolic Disorders Get Ready for the NCLEX® Examination! Key Points 1411 The two major systems that control and monitor the functions of the body are the nervous system and the endocrine system. The term inborn error of metabolism refers to a group of inherited biochemical disorders that affect body metabolism. Screening programs for early detection of inborn errors are important because some conditions can cause irreversible neurological damage. Diabetes mellitus type 1 is the most common endocrine disorder of children. The body is unable to use carbohydrates properly because of a deficiency of insulin, which is an internal secretion of the pancreas. The symptoms of diabetes mellitus appear more rapidly in children. Three symptoms are polydipsia, polyuria, and polyphagia. Insulin resistance causes type 2 diabetes mellitus. It is precipitated by obesity, a lipid-rich diet, and inactivity, and it is becoming more prevalent in children. The mainstays of the management of diabetes mellitus are insulin replacement, diet, and exercise. Diabetic ketoacidosis is a serious complication that may become life-threatening. The Somogyi phenomenon and the dawn phenomenon are common causes of glucose instability in children. Self-management to maintain glucose control and to prevent complications is a major goal of education of the child with diabetes mellitus. A continuous glucose monitoring system can be programmed to meet individual needs. An insulin pump provides subcutaneous doses of insulin controlled by a computerized monitor. The glycosylated hemoglobin test (HgbA1c) reflects glucose control through time. Sugar substitutes such as sorbitol and xylitol should not be provided to children. A child with diabetes insipidus requires unlimited access to water. Growth hormone is administered at bedtime to simulate the natural time of hormone release. A deficiency in the secretions of the thyroid gland is termed hypothyroidism. It may be congenital or acquired and necessitates lifelong treatment by the oral administration of a synthetic thyroid hormone. Additional Learning Resources Go to your Study Guide for additional learning activities to help you master this chapter content. Go to your Evolve website (http://evolve.elsevier.com/Leifer) for the following learning resources: Animations Answer Guidelines for Critical Thinking Questions Answers and Rationales for Review Questions for the NCLEX® Examination Glossary with English and Spanish pronunciations Interactive Review Questions for the NCLEX® Examination Patient Teaching Plans in English and Spanish Skills Performance Checklists Online Resources American Diabetes Association: http://www.diabetes.org 1412 Diabetes Public Health Resource: http://www.cdc.gov/diabetes/index.htm International Society of Pediatric and Adolescent Diabetes: http://www.ispad.org Review Questions for the NCLEX® Examination 1. What is an important aspect of a teaching plan for the parent of a child with hypopituitarism? 1. The child should be enrolled in a special education program at school. 2. The routine administration of growth hormone should be performed at bedtime. 3. All family members should have an endocrine workup. 4. The routine medication should be administered before the school day starts. 2. A child who has diabetes mellitus asks why he cannot take insulin orally instead of by subcutaneous injection. The best response of the nurse would be that: 1. pills are only for adults. 2. digestive enzymes destroy insulin. 3. insulin can cause a stomach ulcer. 4. insulin interacts with food in the stomach. 3. What may indicate a need for insulin in a diabetic child? 1. Diaphoresis and tremors 2. Red lips and fruity odor to the breath 3. Confusion and lethargy 4. Headache and pallor 4. The nurse teaches the diabetic child to rotate sites of insulin injection so as to: 1. prevent subcutaneous deposit of the drug. 2. prevent lipoatrophy of subcutaneous fat. 3. reduce the pain of injection. 4. increase absorption of insulin. 5. all of the above 5. While teaching the child with type 1 diabetes mellitus how to prevent hypoglycemia during afternoon volleyball practice, the nurse should reinforce teaching that includes: a. eat extra food at lunch time. b. administer a smaller dose of insulin at midday. c. drink half a cup of orange juice before practice. d. check the blood glucose before practice. 1. a and b 2. a and d 3. c and d 4. all of the above 6. The family of a child with diabetes insipidus states that the school is planning a field trip and asks the nurse for advice. Which of the following needs should be emphasized by the nurse? The child should: a. have access to a bathroom b. have free access to a water supply c. not eat food containing salt d. have a dose of glucose available during activity 1. c and d 2. b and d 3. a and b 4. all of the above 1413 References ☆ Kochba E., Levin B., Raz I., Cahn A. Improved insulin pharmacokinetics using a novel microneedle device for intradermal delivery in patients with type 2 diabetes. Diabetes Technology & Therapeutics. 2016;18(9):525–531. August 2016 https://www.ncbi.nlm.nih.gov/pubmed/27500713. McGovern M., Desnick R. Liposomal storage disorders. In: Kliegman R., Stanton B., St Geme J., Schor N., eds. Nelson textbook of pediatrics. 20 ed. Philadelphia: Elsevier; 2016 2016. Svoren B., Jospe N. Diabetes mellitus. In: Kliegman R., Stanton B., St Geme J., Schor N., eds. Nelson textbook of pediatrics. 20 ed. Philadelphia: Elsevier; 2016 2016. ☆ “To view the full reference list for the book, click here” 1414