COLLEGE OF NURSING

SILLIMAN UNIVERSITY
DUMAGUETE CITY

CARE OF CHILDREN WITH DIABETES MELLITUS

Prepared by:

Sophia Frantz B. Limcangco

Kazhan E. Pineda

Submitted to:

Asst. Prof. Leila Joy Cazon

A2 Clinical Instructor
Topic: Care of Children with Diabetes Mellitus
Time Allotment: 1hour

Topic Description: This topic deals with the principles and techniques on the Care of Children with Diabetes Mellitus

Central Objective: After the 1 hour ward class, the learners will be able to define diabetes, identify the difference between Type 1 and Type 2 Diabetes Mellitus in
children, the complications, and apply the nursing care management for the care of patients with DM.

Specific Objectives Content TA T-L Activities Evaluation

Method

At the end of the 1 hour ward

class session, the learners will
be able to: INTRODUCTION

A. Definition

1. Explain briefly the A. - It’s a chronic metabolic disorder characterized by hyperglycemia as a Case Video
definition of Diabetes cardinal biochemical feature, caused by deficiency of insulin or its action, Presentation along
manifested by abnormal metabolism of carbohydrates, protein and fat with PowerPoint Quiz to be
Mellitus and the basic
anatomy and Presentation of given on the
slides topic DM
physiology of the
affected organ B. Anatomy and Physiology of the Pancreas

a. Pancreas
- The pancreas is both an endocrine and an exocrine gland. It is a
wedge-shaped elongated gland which lies in the abdominal
 cavity.
- Structurally the pancreas can be divided into three regions: the
head, which lies over the vena cava in the C-shaped curve of the
duodenum; the body, which lies behind the duodenum; and the
tail, which is situated under the spleen.
- The pancreas is composed of two types of cell, exocrine and
endocrine cells.

b. Exocrine Function
- Pyramidal acinar cells are exocrine cells that compose the bulk of
pancreatic tissue. Groups of acinar cells form an acinus, and
groups of acini form grapelike lobules. The acini secrete the
digestive enzymes of the pancreatic juice.
- Pancreatic enzymes - these enzymes are released from the
pancreatic acinar cells and are involved in the digestion of
foodstuffs
- There are three main types of enzyme present in pancreatic juice:

i. Amylases, which break down carbohydrates into glucose and

maltose.

ii. Lipases, which are important in the early stages of fat

breakdown.

iii. Proteases, including trypsinogen, the precursor of proteolytic

trypsin.
c. Endocrine Function
- Endocrine cells, or the islets of Langerhan, make up 1% of the
pancreatic cells. They are most numerous in the tail region of the
pancreas. They consist of clusters of cells surrounded by
pancreatic acini.
- The major endocrine cells of the pancreas are alpha, beta and
delta cells, which secrete glucagons, insulin and somatostatin,
respectively.
- When the blood sugar level falls below normal levels, the alpha
cells are stimulated to secrete glucagon, which accelerates the
conversion of glycogen to glucose in the liver. When the blood
sugar level is above normal, the beta cells secrete insulin, which
promotes both the metabolism of glucose by tissue cells and the
conversion of glucose to glycogen, which is then stored in the
liver.

d. Insulin Function
- Beta cells have channels in their plasma membrane that serve as
glucose detectors. Beta cells secrete insulin in response to a rising
level of circulating glucose ("blood sugar").
- The actions of insulin on the global human metabolism level
include:

i. Control of cellular intake of certain substances, most

prominently glucose in muscle and adipose tissue (about ⅔ of
 body cells).

ii. Increase of DNA replication and protein synthesis via control

of amino acid uptake.

iii. Modification of the activity of numerous enzymes.

C. Types of DM

a. Type 1 Diabetes Mellitus

i. Definition

- Type 1 diabetes mellitus is a disorder that involves an absolute or relative

deficiency of insulin

ii. Incidence in Children

- Type 1 diabetes is equal in incidence in boys and girls and affects

approximately 1 of every 500 children and adolescents in the
United States (Sherr & Weinzimer, 2012).
-

iii. Etiology and Disease Process

- The disease apparently results from immunologic damage to islet

 cells in susceptible individuals
2. Differentiate the two - Children with the disorder have a high frequency of certain
types of DM, human leukocyte antigens (HLAs), particularly HLA-DR3 and
incidence, and disease HLA-DR4, located on chromosome 6, that may lead to
process in children susceptibility.
- Children with the disorder have a high frequency of certain
human leukocyte antigens (HLAs), particularly HLA-DR3 and
HLA-DR4, located on chromosome 6, that may lead to
susceptibility.
- Disease Process: 1. If glucose is unable to enter body cells
because of a lack of insulin, it builds up in the bloodstream
(hyperglycemia).
2. As soon as the kidneys detect hyperglycemia (greater
than the renal threshold of about 160 mg/dl), the
kidneys attempt to lower it to normal levels by
excreting excess glucose into the urine, causing
glycosuria, accompanied by a large loss of body fluid
(polyuria)
3. Excess fluid loss, in turn, triggers the thirst response
(polydipsia), producing the three cardinal symptoms
of diabetes: polyuria, polydipsia, and hyperglycemia.
4. Because body cells are unable to use glucose but still
need a source of energy, the body begins to break
down protein and fat.
5. If large amounts of fat are metabolized this way,
weight loss occurs and ketone bodies, the acid end
product of fat breakdown, begin to accumulate in the
bloodstream (creating high serum cholesterol levels
 and ketoacidosis) and spill into the urine as ketones
6. Potassium and phosphate, attempting to serve as
buffers, pass from body cells into the bloodstream
7. Important electrolytes are loss from the result of this
process
- Untreated diabetic children, therefore, lose weight, are acidotic
due to the buildup of ketone bodies in their blood, are dehydrated
because of the loss of water, and experience an electrolyte
imbalance because of the loss of potassium and phosphate in
urine.
- Because large amounts of protein and fat are being used for
energy instead of glucose, children lack the necessary
components for growth; they therefore remain short in stature and
underweight.

iv. Therapeutic Management

3. Briefly explain each
- Therapy for children with type 1 diabetes involves five measures:
of the levels of
insulin administration, regulation of nutrition and exercise, stress
amputation from
management, and blood glucose and urine ketone monitoring.
upper to lower
- Therapy for children with type 1 diabetes involves five measures:
extremities.
insulin administration, regulation of nutrition and exercise, stress
management, and blood glucose and urine ketone monitoring.

The regulation of Insulin:

- Therapy for children with type 1 diabetes involves five measures:

insulin administration, regulation of nutrition and exercise, stress
 management, and blood glucose and urine ketone monitoring.
- The insulin given for emergency replacement this way is regular
(short-acting) insulin such as Humulin-R because this is the form
that takes effect most quickly. After 24 hours, as the child’s
serum glucose returns to normal, oral feedings may replace the
IV route. Further management in the days after this first crucial
24-hour period is based on serum glucose determinations.
- A child may remain on regular insulin given SC alone (given
three or four times a day) for the first 1 or 2 days. Typically,
intermediate-acting insulin is then added as soon as oral fluids are
taken, usually on the second day of therapy.

v. Nutrition

- An insulin-to- carbohydrate ratio is then calculated individually for each child

depending on age and activity to guide insulin administration.

- An overall meal pattern should include three spaced meals that are high in fiber
plus a snack in the midmorning, midafternoon, and evening to keep carbohydrate
amounts as level as possible during the day.

Be certain you understand your child’s insulin-to-carbohydrate ratio and how to use
 this to plan meals. As a rule, foods high in carbohydrates are fruit and vegetables,
“starchy foods” such as bread or pasta, milk and yogurt, and “sugary” foods such as
candy bars or cake.

• Be aware of food portions. The total carbohydrate on a package of pasta refers to

what one serving of pasta will contain, not the whole box of pasta.

• Provide three meals throughout the day, plus three snacks. A total daily caloric
intake divided to provide 20% as breakfast, 20% as lunch, 30% as dinner, and 10%
as morning, afternoon, and evening snacks help distribute carbohydrates throughout
the day.

• Do not use dietetic food. This food is expensive and not necessary.

• Urge your child not to omit meals. Getting him to eat at every meal calls for

creative planning so he likes the foods served and eats readily.

• Maintain a positive outlook by stressing the foods your child is allowed to eat, not
4. Enumerate the
those he should avoid.
different
complications with • Steer clear of concentrated carbohydrate sources, such as candy bars, and be sure
their respective signs to include foods with adequate fiber, such as broccoli, because fiber helps prevent
and symptoms. hyperglycemia.

• Keep complex carbohydrates available to be eaten before exercise, such as

swimming or a softball game, to provide a sustained carbohydrate energy source to
prevent hypoglycemia.

• Teach children about carbohydrate counting as early as possible so they can wisely
select what to eat at school or at a friend’s home and can begin independent self-
care.
b. Type 2 Diabetes Mellitus

i. Definition

- T2D, characterized by diminished insulin secretion, is a separate disease from type

1 diabetes because it is not caused by autoimmune factors (Sherr & Weinzimer,
2012).

- Usually, children with T2D do not need daily insulin because their disease can be
managed with diet alone or with diet and an oral hypoglycemic agent.

ii. Incidence in Children

- Once thought to occur only in older adults, T2D is now seen as

early as in overweight school-aged children (Caprio, 2012).

- Other influencing factors are a strong family history of diabetes;

children from African, Hispanic, Asian, or Native Indian descent;

- Those who eat a diet high in fats and carbohydrates; and those
who do not exercise regularly.
 - Development of polycystic ovary syndrome (PCOS) (see Chapter
8) is also strongly associated with the disorder.

D. Clinical Manifestations

a. Type 1 Diabetes Mellitus

- Although children may be prediabetic for some time, the onset of symptoms in
childhood is usually abrupt.

- Parents notice increased thirst and increased urination (which may be recognized
first as bed-wetting [enuresis] in a previously toilet-trained child). The dehydration
may cause constipation.

b. Type II Diabetes Mellitus

- Symptoms often become apparent for the first time at puberty because increasing
sex hormones naturally increase insulin resistance, creating a need for more insulin
production.

- Children’s urine will show glucose but few ketones.

- Children experience lessened amounts of thirst or increased urination.

- About 90% of children with T2D have dark shiny patches on the skin (acanthosis
nigricans), which are most often found between the fingers and between the toes, on
the back of the neck (“dirty neck”), and in axillary creases (Stephen, Gungor, &
Douty, 2012).

-Children whose family has a history of T2D, are from susceptible genetic groups,
 or have symptoms such as acanthosis nigricans or high blood pressure should be
screened by a fasting blood sugar test at puberty and again every 2 years.

E. Complications

a. Type 1 Diabetes Mellitus

i. Arteriosclerosis

- Many long-term body changes such as arteriosclerosis (hardening

of artery walls), which can lead to general poor circulation and
kidney disease, and thickening of retinal capillaries and cataract
formation, which ultimately can result in blindness, occurring
because of chronic hyperglycemia, are not a major part of disease
management in childhood because their onset does not begin until
adulthood. It is not too early, however, when discussing
hyperglycemia to mention that it does have long-term effects if
not regulated beginning in childhood.

ii. Severe Kidney Disease

- Diabetic nephropathy is a serious kidney-related complication of

5. Distinguish the type 1 diabetes and type 2 diabetes. It is also called diabetic
kidney disease. About 25% of people with diabetes eventually
different diagnostic
develop kidney disease.
studies done. - Diabetic nephropathy affects your kidneys' ability to do their
usual work of removing waste products and extra fluid from your
body. The best way to prevent or delay diabetic nephropathy is
by maintaining a healthy lifestyle and treating your diabetes and
 high blood pressure.
- Over many years, the condition slowly damages your kidneys'
delicate filtering system. Early treatment may prevent or slow the
disease's progress and reduce the chance of complications.
- Your kidney disease may progress to kidney failure, also called
end-stage kidney disease. Kidney failure is a life-threatening
condition. At this stage your treatment options are dialysis or a
kidney transplant.

iii. Chronic Hyperglycemia

- High blood sugar (hyperglycemia) affects people who have
diabetes. Several factors can contribute to hyperglycemia in
people with diabetes, including food and physical activity
choices, illness, nondiabetes medications, or skipping or not
taking enough glucose-lowering medication.

b. Type 2 Diabetes Mellitus

i. Atherosclerosis

6. Identify the ii. Kidney Disease

collaborative care iv. Poor hearing ability
concerning the - Diabetes may contribute to hearing loss by damaging nerves and
surgical, medical, and blood vessels. Similar studies have shown a possible link
rehabilitation. between hearing loss and nerve damage. 
v. Blindness
- Diabetic retinopathy is an eye condition that can cause vision loss
and blindness in people who have diabetes. It affects blood
vessels in the retina (the light-sensitive layer of tissue in the back
of your eye).

F. Diagnostic Evaluation

Laboratory Studies

Fasting blood glucose test and the random blood glucose

* Laboratory studies usually show a random plasma glucose level greater than 200
mg/dl (normal range, 70 to 110 mg/dl fasting; 90 to 180 mg/dl not fasting) and
significant glycosuria.

* A diagnosis of diabetes is established if one of the following three criteria is

present on two separate occasions: • Symptoms of diabetes plus a random blood
glucose level greater than 200 mg/dl • A fasting blood glucose level greater than 126
mg/dl • A 2-hour plasma glucose level greater than 200 mg/dl during a 75-g oral
glucose tolerance test (GTT)

Oral Glucose Tolerance Test ( GTT)

* Involves the oral ingestion of a concentrated glucose solution followed by blood

glucose levels drawn at fasting (baseline), after 1 hour, and after 2 hours.

* The test is difficult for children to undergo because it requires them to fast for 8
hours, drink an overly sweet solution, and submit to painful, intrusive procedures
(routine application of lidocaine/prilocaine [EMLA] cream to fingerstick or
venipuncture sites and use of intermittent infusion devices greatly reduces this
problem). Do not take blood for glucose analysis from functioning IV tubing to try
to help with pain because the glucose in the IV solution will cause the serum reading
to be abnormally high.

Other Diagnostic Tests

- If diabetes is detected, the diagnostic workup also usually

includes an analysis of blood samples for pH, partial pressure of
carbon dioxide (PCO2), sodium, and potassium levels; a white
blood cell count; and a glycosylated hemoglobin (HbA1c)
evaluation.
- In nondiabetic children, the usual HbA1c value is 1.8 to 4.0. A
value greater than 6.0 reflects an excessive level of serum
glucose. Measuring HbA1c has advantages because it not only
provides information on what is the child’s present serum glucose
 level but what the serum glucose levels have been during the
preceding 3 to 4 months (red blood cells have a life span of 120
days).
- If the potassium level of the blood is low, a child may need an
electrocardiogram to observe for T-wave abnormalities, the mark
of potassium deficiency. The white blood cell count of a child
with diabetes may be elevated even though no infection is
present, apparently as a response to the ketoacidosis.
- The presence of infection must always be suspected, however,
because it is often a precipitant to a diabetic crisis. For this
reason, nose and throat cultures may be obtained as well.

G. Medical Management

Pancreas Transplantation

* For children who develop severe kidney disease or arteriosclerosis, pancreas

transplantation may be considered to prevent further damage. In contrast to other
organ transplantation procedures, the child’s pancreas is not removed entirely prior
to transplant. This is because the portion that supplies digestive enzymes is still
functioning and so is left in place. The digestive enzymes of the new pancreas are
diverted into the intestine or bladder, or the pancreatic ducts can be sclerosed, so the
digestive enzymes do not leave the transplanted organ. Grafts may be taken from
cadavers or from live donors, who can donate up to 45% of their pancreas and still
maintain a functioning organ for themselves.

H. Pharmacologic Management

a. Type 1 Diabetes Mellitus

i. Insulin administration

- Children can be regulated on a variety of insulin programs, but typically receive a

combined insulin dose of 0.4 to 0.7 units per kilogram of body weight daily in two
divided doses (one before breakfast and one before dinner); adolescents may need as
much as 1.2 units per kilogram daily divided into the two doses.

- The most common mixture of insulin used with children is a combination of an

intermediate-acting insulin and a regular insulin, usually in a 2:1 ratio or 0.75 units
of the intermediate-acting insulin to 0.33 units regular insulin, and given in the same
syringe, although this prescription varies for individual children.

- The morning dose is two thirds of the total daily dose; the evening dose is the
remaining one third.
Injection sites

* According to the American Diabetes Association, insulin injection sites in

children and adults are the upper outer portions of the arms; the thighs, 4 in. below
the hip and 4 in. above the knee (adjusted proportionally for children); and the
abdominal area just above and just below the waist. The navel and a circular area
just around it are excluded as injection sites. In some children, the abdominal area
may not be an appropriate injection site

Insulin Pumps

* An insulin pump is an automatic device approximately the size of an iPhone. It

delivers insulin at a constant rate, so it regulates serum glucose levels better than
periodic injections (Buchko, Artz, Dayhoff, et al., 2012). A syringe of regular
insulin is placed in the pump chamber; a length of thin polyethylene tubing leads to
the child’s abdomen, where it is implanted into the subcutaneous tissue of the
abdomen by a small-gauge needle

Inhalation Insulin

* Inhalation insulin is not available as yet but may be in the future; production of it
is in experimental trials. Difficulties with development are constructing an accurate
delivery system and determining how the development of a cold or allergies that
cause edem
b. Type 2 Diabetes Mellitus

i. antiglycemics- antiglycemic agents such as a biguanide (metformin), which

decreases the amount of glucose produced by the liver and increases insulin
sensitivity in both the liver and muscle cells.

I. Special Considerations
a. Partial Remission or Honeymoon Phase in
Type 1 Diabetes
- Insulin requirements can decrease transiently following initiation
of insulin treatment.
- This has been defined as insulin requirements of less than 0.5
units per kg of body weight per day with an HbA1c < 7%
- Ketoacidosis at presentation and at a young age reduce the
likelihood of a remission phase
- It is important to advise the family of the transient nature of the
honeymoon phase to avoid the false hope that the diabetes is
spontaneously disappearing
- Treatment by reduce the dose of Insulin accordingly.
b. Somogi Phenomena
- In children with High dose of Insulin at Night (Long acting)
develop late night(3-4 a.m) Hypoglycemia Counter regulatory
hormone will increase Early morning Hyperglycemia
- Treatment: Reduce the dose of Long-acting Insulin at Night

c. Dawn Phenomena
- In children with Normal dose of Insulin at Night & Normal
midnight glucose (Normoglycemia), Counter regulatory hormone
may normally increase Early morning Hyperglycemia. •
Treatment: Increase the dose of Long-acting Insulin at Night

d. Management of DM during Infection

- Infection may precipitate hyperglycemia or DKA. • Mild
infection should be treated + increase the dose of Insulin by 10 –
15%. • Sever infection necessitate hospitalization. Management
during Infection
J. Nursing Interventions

 Ensure adequate and appropriate nutrition. The child with diabetes

needs a sound nutritional program that provides adequate nutrition for
normal growth while it maintains the blood glucose at near normal levels;
the food plan should be well balanced with foods that take into
consideration the child’s food preferences, cultural customs, and lifestyle;
if a particular meal is going to be late, the child should have a complex
carbohydrate and protein snack.

 Prevent skin breakdown. Teach the caregiver and child to inspect the

skin daily and promptly treat even small breaks in the skin; encourage
daily bathing; teach the child and caregiver to dry the skin well after
bathing, and give careful attention to any area where skin touches skin,
such as the groin, axilla, or other skin folds; emphasize good foot care.

 Prevent skin infection. Diabetic children may be more susceptible to

urinary tract and upper respiratory infections; teach the child and
caregiver to be alert for signs of urinary tract infection; instruct them to
report signs of urinary tract or upper respiratory tract infections to the
care provider; insulin should never be skipped during illness; fluids need
to be increased.

 Regulate glucose levels. The child’s blood glucose levels must be

monitored to maintain it within normal limits; determine the blood
glucose level at least twice a day, before breakfast and before the evening
meal; offer encouragement and support, helping the child to express fears
and acknowledging that the fingerstick does hurt and it is acceptable to
dislike it.

 Provide child and family teaching in the management of

hypoglycemia and hyperglycemia. If the blood glucose is higher than
240mg/dl, the urine may be tested for ketones; be aware of the most
likeley times for an increase or decrease in the blood glucose level in
relation to the insulin the child is receiving; and teach the child and
family to recognize the signs of both hypoglycemia and hyperglycemia.

IMPORTANT CONSIDERATIONS:
1. Do not shake the insulin as this damages the insulin
2. After first usage, an insulin vial should be discarded after 3 months if
kept at 2-8 C or 4 weeks if kept at room temperature
3. Intermediate-acting and short-acting/rapid- acting insulin, can be
combined in one syringe
4. Use 4mm needle for injection of Insulin SC
 7. Enumerate the
different nursing
diagnosis and
interventions for the
following care of
children with diabetes
mellitus

References:

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https://nurseslabs.com/diabetes-mellitus-type-1-juvenile-diabetes/
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47676346

Mayo Clinic. (2019, September 19). Diabetic nephropathy. Retrieved April 15, 2021, from https://www.mayoclinic.org/diseases-conditions/diabetic-

nephropathy/symptoms-causes/syc-20354556

National Eye Institute. (2019, August 03). Diabetic Retinopathy. Retrieved April 15, 2021, from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-

and-diseases/diabetic-retinopathy#:~:text=Diabetic%20retinopathy%20is%20an%20eye,at%20least%20once%20a%20year.

Pietrangelo, A. (2018, August 20). The Connection Between Type 2 Diabetes and Hearing Loss. Retrieved April 14, 2021, from

https://www.healthline.com/health/type-2-diabetes/hearing-loss

Silbert-Flagg, J., &amp; Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Philadelphia: Wolters Kluwer.