Type I Diabetes Mellitus MR 8/14/09 J.Chen

Management Insulin Monitoring Nutrition Exercise Education

Insulin

Insulin Requirements Preadolescent-0.5-1 unit/kg/day Adolescents-0.8-1.2 units/kg/day During honeymoon period-<0.5 units/kg/day

Starting an Insulin Regimen Split mixed Regimen vs. Basal/Bolus Regimen

Split/Mixed Regimen 2-3 injections based on NPH 2/3 in AM, 1/3 in PM 2/3 NPH, 1/3 Regular/Rapid More rapid/regular may be required in AM because of dawn phenomenon (nocturnal release of counter regulatory hormones-less insulin sensitivity in AM) May require less during Honeymoon period

Split/Mixed Regimen

Monitoring Traditionally before meals, at bedtime, overnight More often when ill or active Acceptable range Fasting/preprandial: preschool: 100-180mg/dL School age: 90-180mg/dL Teenagers: 90-130mg/dL Bedtime/overnight Preschool: 110-200mg/dL School age:100-180mg/dL Teenagers: 90-150mg/dL

Basal Bolus Regimen Aims to achieve more physiologic insulin concentrations Basal provides baseline or fasting insulin Bolus provides coverage for food and correct for hyperglycemia Basal rate given either through injection or via insulin pump

Basal/Bolus Regimen Basal requirement ~50% daily insulin need Either long acting insulin or Rapid acting insulin via pump Bolus dose has 2 parts: 1. coverage for carbohydrates in meal 2. correction for blood glucose concentration outside of target range.

Monitoring HbA1c Urine or blood ketones should be monitored: <6yr: 7.5-8.5% 6-12yr:<8% 13-19yr: <7.5% Urine or blood ketones should be monitored: Blood glucose elevated Nausea Vomiting Feeling ill

Nutritional Management Balanced Diet with adequate calories and nutrients for normal growth 50-55% carbohydrate calories, 20% protein calories, 30% fat calories Most carb calories should be complex carbohydrates Fat portion should be low in cholesterol and saturated fats

Nutritional Management Split/Mixed- timing important Snacks Treats should be allowed Basal/Bolus Flexibility in timing, amount, and content Accurate carb counting and insulin dose calculation

Next TIME: DKA