Pediatric T1DM

Mari Fall, Maddy Lasell, Kasey Strouse, Sam To

Assessment
Our Patient: RR
12 year old female

admitted with acute-onset hyperglycemia

Chief complaint:

I have just gotten over strep throat a few days ago. I felt like I was well enough to go to soccer practice
today but after playing about 15 minutes, I just felt horrible. I sat down and they tell me I fainted I have
been really thirsty - thirstier than I have ever been in my whole life and then I have had to use the bathroom a
lot I even have to get up at night to go to the bathroom.
Onset
Fainted at soccer practice.

Serum glucose level of 724 mg/dL upon admission to

hospital
History / Family History
RR History: Family History:

Recently had strep throat Father: HTN

Nonsmoker Mother: Hyperthyroidism
Unexpected weight loss Sister: Celiac Disease
of 8 lbs.
Demographics
Single, 12 YO female in 7th grade

Household: Mother, sister (8), brother (4)

Parents are divorced, father lives in the city

Ethnicity: Caucasian
Vital Signs & Anthros
Temp: 98.6
Blood Pressure: 122/77
Height: 5
Weight: CBW = 82 lbs, UBW = 90 lbs, %UBW = 91.1 %, IBW = 100lbs,
%IBW = 82 %
Desired weight: 100 lbs

BMI: 16.045 (underweight)

Throat: dry mucous membranes without exudates or lesions
Chest/Lungs: respirations are rapid
Orders
Regular insulin 1 unit/mL NS 40 mEq KCl/liter @ 135 mL/hr. Begin infusion at
0.1 unit/kg/hr = 3/7 units/hr and increase to 5 units/hr. Flush new IV tubing
with 50 mL of insulin drip solution prior to connecting to patient and starting
insulin infusion.

NPO except for ice chips and medication. Gradually move to clear liquids and
eventually to consistent CHO diet.

Diabetes education for patient and parents after stabilized.

 Ref Range 5/4 1780 5/5 1522

Lab Results: Chemistry

Sodium (mEq/L) 136-145 126 ! 131 !
Glucose (mg/dL) 70-110 683 ! 250 !
Labs related to Type-1
Phosphate, inorganic 2.3-4.7 1.9 ! 2.1 !
DM highlighted in blue (mg/dL)
Osmolality (mmol/kg/H2O) 285-295 295.3 ! 304 !
Liver Lab Values w/ NL
Thyroid Lab Values w NL
HbA1C (%) 3.9-5.2 14.6 !
C-peptide (ng/mL) 0.51-2.72 0.10 !
ICA --- + !
GADA --- + !
IA-2A --- -
IAA --- + !
Lab Results
High Glucose: Hyperglycemia
High Hgb A1c: high blood glucose over last 3 month
Typically seen in newly diagnosed DM
High ICA (Islet Cell Antibodies): indicating destruction of insulin producing
cells
High IAA: indicating destruction of beta cells
Low C-Peptide: indicating low levels of insulin production in the body
High GADA: very sensitive marker for T1DM, measures for specific Islet Cell
Antigens
Lab results Ref Range 5/4 1780 5/5 1522
Urinalysis
Color - yellow
pH 5-7 4.9!
Protein (mg/dL) Neg 100 !
Glucose (mg/dL) Neg + !
Ketones Neg + !
Blood Neg Neg
Bilirubin Neg Neg
Leukocyte esterase Neg neg
Prot Chk Neg + !
WBC 0-5 3-4
Lab Results
High Protein: excessive urine protein spillage could be a sign of Diabetic
Nephropathy or Kidney Disease

High Glucose: Frequent urination to carry out excess sugar in the body

High Ketones: ketones are chemicals which appear in the urine and blood
when the body uses fat for energy.

pH drops leading to ketosuria

Nutrition-Related History
Recently lost weight
Appetite has been normal
Says she is hungrier than normal

Increased thirst and increased urination

Picky eater
Only eats chicken and fish
Only eats salad, broccoli, carrots, tomatoes, and asparagus for vegetables
Nutrition: Usual Intake
Breakfast: Cereal or Pop Tarts with milk

Lunch: Packs peanut butter and jelly sandwich or turkey and cheese sandwich, with
chips, carrots, and water

Snack: Cereal or granola bar (before soccer practice),

cereal, ice-cream, yogurt, apples, banana, popcorn, chips, or cookies

Dinner: Salad, meat, with pasta/potato/rice (when with mom),

orders pizza or chinese food (when with dad)
Calculations
CHO: 45-65% = 50 %
EER (Females 9 through 18 years old): 1,884.616 kcal x 50% = 942.3 kcals
PA factor = 1.16 942.3 kcals / 4 g/kcals = 235.5 g
EER: 1,884.616 kcals
Protein: 10-35% = 25%
1,884.616 x 25% = 471.15 kcals
Fluid intake: 471.15 kcals / 4 g/kcals = 117.8 g
Adolescents 40- 60 ml/kg = 50 ml 1.2 g/kg- 1.5 g/kg for athletes:
82 lbs / 2.2 kg/lb = 37.27 kg 1.2 g/kg x 37.27 kg = 44.7g
37.27 kg x 50 ml = 1,863.6 ml of fluid 1.5 g/kg x 37.27 kg = 55.9 g

Fat: 25-35% = 30%

1,884.616 kcals x 30% = 565. 3 kcals
565.3 kcals / 9 g/kcals = 62.8 g
Diagnosis
Medical Diagnosis and Intervention
Medical Diagnosis: New Diagnosis Type 1 Diabetes Mellitus
Idiopathic
Diagnosed by fasting plasma glucose levels higher than 126 mg/dL (683 mg/dL)

Medical Intervention: Change IVF to D5 45NS with 40MEq K @ 135 mL/hr.

Begin Apidra 0.5 u every 2 hours until glucose is 150-200 mg/dl. Begin
Glargine 6u at 9 pm. Progress Apidra using ICR 1:15. Continue bedside
glucose checks hourly. Notify MD if blood glucose >200 or <80
Apidra: onset: 15 minutes, peak: 1 hour, duration: 2 - 4 hours
Glargine: onset: 1.1 hours, peak: 5 hours, duration: 24 hours
Why Type-1 DM?
Type 1 DM:

Specific antibodies are present during diagnosis

ICA, IAA, GAD, etc.
First sign of T1DM in children & adolescents is ketoacidosis
Weight loss
Hyperglycemia, Glycosuria, Polyuria, Polydipsia, Polyphagia

Type 2 DM:
Heredity
Obesity
Sedentary lifestyle
Glucose Tolerance Test
Honeymoon Phase and Dawn Phenomenon
Honeymoon Phase: Period of time after T1DM diagnosis when insulin
production is variable.
Pancreas is still making small amounts of insulin, leading some to think they don't have
diabetes. This phase can last from a month to a year.

Dawn Phenomenon: Hormones involved in controlling circadian rhythms

(cortisol and growth hormones) stimulate gluconeogenesis. Results in
hypertension between 5:00 am and 9:00 am.
RR is experiencing Dawn Phenomenon. Fasting am BG is 240 mg/dL with goal range being
90-180 mg/dL.
Consult Dr. Cho about increasing insulin regimen due to Dawn Phenomenon
Nutrition Diagnoses
PES 1: Excessive intake of carbohydrate related to picky eating and
convenience foods as evidenced by usual intake record.

PES 2: Altered nutrition related labs related to newly diagnosed diabetes

mellitus as evidenced by high serum glucose, ICA, Hg A1C values.
Intervention
Intervention Strategies
PES 1 Goal: Reduce carbohydrate intake to 228-270 g.

Provide nutrition education on carbohydrates and carbohydrate counting.

Incorporate lean protein at each meal and snack to increase satiety and prevent
overconsumption of carbs.
Choose complex carbohydrate foods with high fiber content to increase satiety.

PES 2 Goal: To have serum glucose, ICA, and Hgb A1C values consistently within
normal limits.

Choose high fiber carbohydrate sources.

Provide nutrition education regarding importance of carbohydrate to insulin ratios.
Provide nutrition education on insulin injections to maintain a normal blood glucose level
between 90-180 mg/dL.
Additional Nutrition Education
Provide nutrition education regarding: Carbohydrate and insulin
management during sports
No insulin before working out because exercise already lowers BG and
increases insulin sensitivity.
Eat and refrain from insulin before heavy exercise
Check BG before, during, and after exercise
 Consistent CHO Diet Order:
70-80g Breakfast and Lunch
85-95g Dinner
3-15g Snack

Total kcal: 1,884.616 kcal

Nutrition Total pro:

Total fat:
55.9g
62.8g

Prescription
Total fluid: 1,863.6 mL

Focus on fiber-rich foods, limit simple

cho, eat lean proteins with all meals
and snacks, avoid sugar-sweetened
beverages.
Monitoring &
Evaluation
Monitoring Criteria for evaluation
Indicator: Current level of indicator: Criteria for Success:

Usual CHO Intake Excessive 228-270 g

BG High: 683 mg/dL Dr. Rec: 90-180 mg/dL

ICA (+) (-)

Hgb A1C High: 14.6% WNL: 3.9-5.2%

Follow-up
RDN to follow-up with patient in 1 month.
Patient to maintain food diary and BG log.
RDN to order CHEM-20 panel.
24 hR recall - breakfast

Time Diet Grams Exercise BG Insulin dosage - Recommended

of (mg/dL) patient took
CHO

7:30 am - 2 pop-tarts 129g - (pre) 5 u Apidra 8.64 u Apidra

-1 banana 150
-16 oz skim milk
with ovaltine (2
tbsp)

10:30
24 hR recall - Lunch

Time Diet Grams Exercise BG Insulin dosages Insulin dosage -

of CHO (mg/dL) - patient took recommeded

12 noon -2 slices of pepperoni 52.5g (pre) 180 6 u Apidra 3.5 u Apidra

pizza
-2 chocolate chip
cookies
-water
24 hR recall - Afternoon snacks
Time Diet Grams Exercise BG Insulin dosages - Insulin dosages -
of (mg/dL) patient took recommended
CHO

2 pm Granola bar 15g PE class -

30 minutes

4:30 -Apple 30g (pre) 2 u Apidra

pm -6 saltines with 2 110
tbsp peanut
butter

5-6:30 -16 oz Gatorade 30g Soccer (pre) 2 u Apidra

pm practice - 140
1.5 hours
 24 hR recall - Dinner
Time Diet Grams Exercise BG Insulin dosages - Insulin dosages -
of (mg/dL) patient took recommended
CHO

6:30 -Chicken with broccoli 91.5g (pre) 80 5 u Apidra 6.1 u Apidra

pm stir-fry (1 c fried rice, 2
oz chicken, c
broccoli)
-1 Egg roll
-2 c skim milk

8:30 -2 c ice cream 60g (pre) 4 u Apidra 4 u Apidra

pm -with 2 tbsp peanuts 150
Conclusion
Total CHO: 408g Current amount of Apidra:
Target Range: Currently takes 20u
228-270g CHO

Calculated Correction Dose:

Non-compliant with Should administer 22.2u
carb-counting diet when adequately following
carb-counting diet
Signed,
X Mari Fall, Dietetic Intern

X Maddy Lasell, Dietetic Intern

X Kasey Strouse, Dietetic Intern

X Samantha To, Dietetic Intern

Date: September 14, 2016