Diabetes in the Schools: The Challenge Diabetes in the Schools: The Challenge of Managing a Bunch of Sweet Kids in of Managing a Bunch of Sweet Kids in

the School Environmentthe School Environment

Bruce Boston, MDBruce Boston, MD

Professor, Pediatric EndocrinologyProfessor, Pediatric Endocrinology

Oregon Health & Science UniversityOregon Health & Science University

Commercial Disclosure Commercial Disclosure

• I have nothing to I have nothing to disclose.disclose.

The Many Faces of DiabetesThe Many Faces of Diabetes

The Physician PerspectiveThe Physician Perspective

Glucose Glucose

Glucose

Glucose

Insulin

Carbohydrate

Blood Vessel Pancreas

Cell

The School Nurse PerspectiveThe School Nurse Perspective

The Start of Each School Year…The Start of Each School Year…

It takes a village….It takes a village….

Diabetes Care Providers

School NurseTeachers

Family

ObjectivesObjectives

• Understand evidence behind reasons to Understand evidence behind reasons to achieve good blood sugar control in the achieve good blood sugar control in the school setting.school setting.

• Appreciate the challenges raised by Appreciate the challenges raised by psychosocial diabetes and acquire some psychosocial diabetes and acquire some new tools in the care of these students.new tools in the care of these students.

• Describe new advances in Type 1 Describe new advances in Type 1 diabetes care.diabetes care.

The Complexity of DiabetesThe Complexity of Diabetes Care in 2013Care in 2013

• Shots vs. Pumps vs. PensShots vs. Pumps vs. Pens

• Continuous Glucose Monitors and Sensors?Continuous Glucose Monitors and Sensors?

• How often should I check blood sugar? How often should I check blood sugar? When is it too often?When is it too often?

• Shots before vs. after eating?Shots before vs. after eating?

• School breakfast and snacks. Some kids in School breakfast and snacks. Some kids in 2013 seem to eat like “Hobbits”!2013 seem to eat like “Hobbits”!

• Testing in the classroom.Testing in the classroom.

The GoalThe Goal

• Provide a safe environment for a Provide a safe environment for a child/adolescent to learn.child/adolescent to learn.

• Improve their educational Improve their educational experience despite their chronic experience despite their chronic condition.condition.

• Provide a window into the social Provide a window into the social factors preventing good diabetes factors preventing good diabetes care.care.

The GoalThe Goal

• We can all agree that achieving the We can all agree that achieving the best blood sugars we can is always best blood sugars we can is always the goal.the goal.

• But the “best blood sugar goal” is But the “best blood sugar goal” is going to be different in each kid.going to be different in each kid.

• And we need to weigh the cost (i.e. And we need to weigh the cost (i.e. interference with social development?) interference with social development?) with the benefit (better A1c and better with the benefit (better A1c and better school performance?)school performance?)

Factors Associated With Factors Associated With Academic Achievement in Academic Achievement in

Children With Type 1 DiabetesChildren With Type 1 Diabetes

• 244 subjects in a rural Midwestern 244 subjects in a rural Midwestern State.State.

• Ages 8 to 18.Ages 8 to 18.

• Diabetes for at least 1 year.Diabetes for at least 1 year.

• Average Test of Basic Skills score Average Test of Basic Skills score and Tests of Educational and Tests of Educational development in the state was 106.development in the state was 106.

McCarthy, et. al. Diabetes Care Volume 26(1), January 2003, pp 112-117

ITBS/ITED Achievement Scores ITBS/ITED Achievement Scores and School Performance Based and School Performance Based

on Metabolic Controlon Metabolic Control

Mean Achievement Scores for Children Mean Achievement Scores for Children Based on Level of Metabolic Control Based on Level of Metabolic Control

and History of Hospitalizationsand History of Hospitalizations

Effects of Prior Hypoglycemia and Effects of Prior Hypoglycemia and Hyperglycemia on Cognition in Hyperglycemia on Cognition in

Children with Type 1 Diabetes MellitusChildren with Type 1 Diabetes Mellitus

• Tested youth with T1DM ages 5-16 Tested youth with T1DM ages 5-16 (n=117) and non-diabetic sibling (n=117) and non-diabetic sibling controls.controls.

• Tested verbal and spacial Tested verbal and spacial intelligence, verbal and spacial intelligence, verbal and spacial memory, and processing speed.memory, and processing speed.

Perantie, et.al. Pediatric Diabetes vol. 9, p 87

Effects of Prior Hypoglycemia and Effects of Prior Hypoglycemia and Hyperglycemia on Cognition in Hyperglycemia on Cognition in

Children with Type 1 Diabetes Mellitus Children with Type 1 Diabetes Mellitus

• Results:Results:–T1DM group had lower verbal intelligence scores T1DM group had lower verbal intelligence scores

than siblings.than siblings.

–Within T1DM group:Within T1DM group:

• Chronic hyperglycemic exposure (i.e. higher Chronic hyperglycemic exposure (i.e. higher age adjusted A1c values) led to decreased age adjusted A1c values) led to decreased verbal intelligenceverbal intelligence

• Severe acute hypoglycemic episodes Severe acute hypoglycemic episodes (especially before age 5 years) led to spatial (especially before age 5 years) led to spatial intelligence and delayed recall.intelligence and delayed recall.

Acute Hyperglycaemia Impairs Acute Hyperglycaemia Impairs Cognitive Function in Children Cognitive Function in Children

with IDDMwith IDDM• 12 subjects with Type 1 DM in the 12 subjects with Type 1 DM in the

Paediatric Clinic at Princess Margaret Paediatric Clinic at Princess Margaret Hospital.Hospital.

• Ages 10 to 16 years with diabetes Ages 10 to 16 years with diabetes approximately 5 yearsapproximately 5 years

• Average A1c 9.6 +/- 0.4%Average A1c 9.6 +/- 0.4%

• Two testing periods with blood sugars Two testing periods with blood sugars “clamped”:“clamped”:– Euglycaemia 10 mmol/liter (180 mg/dl)Euglycaemia 10 mmol/liter (180 mg/dl)

– Hyperglycaemia 25 mmol/liter (400 mg/dl)Hyperglycaemia 25 mmol/liter (400 mg/dl)

Davis, et.al. JPEM, Vol 9. p 455

Acute Hyperglycaemia Impairs Acute Hyperglycaemia Impairs Cognitive Function in Children Cognitive Function in Children

with IDDMwith IDDM• Results:Results:

–Performance IQ percentilePerformance IQ percentile

• Hyperglycaemia Hyperglycaemia 62.362.3

• EuglycaemiaEuglycaemia 71.871.8

–Average decline in IQAverage decline in IQ 9.5* 9.5* *p<0.05

Effect of Acute Hypoglycemic Effect of Acute Hypoglycemic Episode on Cognitive FunctionEpisode on Cognitive Function

• No studies available to quoteNo studies available to quote

• But, this is literally a “No Brainer”!!!But, this is literally a “No Brainer”!!!

Physiology Based Approach to Physiology Based Approach to Common Questions from Common Questions from

Students, Parents and NursesStudents, Parents and Nurses

• Do I have to drink water when my Do I have to drink water when my blood sugar is high?blood sugar is high?

• How do I know if a high blood How do I know if a high blood sugar is “okay” or is “urgent”?sugar is “okay” or is “urgent”?

• Does exercise help bring a high Does exercise help bring a high blood sugar down?blood sugar down?

Do I have to drink water when Do I have to drink water when my blood sugar is high?my blood sugar is high?

• High glucose concentration in urine is High glucose concentration in urine is 0.5 to 1.0 gram/dl.0.5 to 1.0 gram/dl.

• 500 ml of urine would contain only 2.5 500 ml of urine would contain only 2.5 to 5 grams of glucose.to 5 grams of glucose.

• Would take a long time for blood sugar Would take a long time for blood sugar to drop from water drinking alone.to drop from water drinking alone.

• However, important to offer water if However, important to offer water if thirsty to allow student to stay thirsty to allow student to stay hydrated.hydrated.

How do I know if a high blood How do I know if a high blood sugar is “okay” or is “urgent”?sugar is “okay” or is “urgent”?

• ““It’s all about the ketones”.It’s all about the ketones”.

Normal Glucose HomeostasisNormal Glucose Homeostasis

Glucose Glucose

Insulin

Glucose

Evolution of KetosisEvolution of Ketosis

Glucose Glucose

LipidsKetones

Ketones

Ketones

Glucose

“Counter regulatory hormones”

Evolution of DKAEvolution of DKA

Glucose Glucose

LipidsKetones

Ketones

Ketones

Glucose

Acids

Too many carbs?Too many carbs?

GlucoseGlucose

Insulin

Glucose

Does exercise help bring a high Does exercise help bring a high blood sugar down?blood sugar down?

• Maybe.Maybe.

• Maybe not.Maybe not.

• Might even be harmful.Might even be harmful.

MaybeMaybe

Glucose Glucose

Insulin

Glucose

MaybeMaybe

Glucose

Insulin

Glucose

Glucose

Maybe NotMaybe Not

Glucose

Insulin

GlucoseGlucose

Adrenalin from stress, anger or excitement promotes hepatic gluconeogenesis, glycogenolysis and insulin resistance.

Might Even be HarmfulMight Even be Harmful

Glucose Glucose

LipidsKetones

Ketones

Ketones

Glucose

“Counter regulatory hormones”

Might Even be HarmfulMight Even be Harmful

Glucose Glucose

LipidsKetones

Ketones

Ketones

Glucose

“Counter regulatory hormones”

If already ketotic, exercise causes intracellular sugar to drop even lower which leads to increased counter regulatory hormone response, more ketosis and possibly even higher blood sugar.

Summary Summary

• Good blood sugar control is Good blood sugar control is always the goal.always the goal.

• But the “best blood sugar goal” is But the “best blood sugar goal” is going to be different in each kid.going to be different in each kid.

• Care plans and goals need to be Care plans and goals need to be individualized to each student.individualized to each student.

Psychosocial DiabetesPsychosocial Diabetes

Diabetes in BalanceDiabetes in Balance

Insulin Carbohydrate

Exercise

Stress

Low BloodSugar

High BloodSugar

Diabetes out of BalanceDiabetes out of Balance

+/- Insulin CarbohydrateExercise

Stress

Low BloodSugar

High BloodSugar

The Effect of Stress on Blood The Effect of Stress on Blood SugarsSugars

Stress

Goals for Management ofGoals for Management of Psychosocial DiabetesPsychosocial Diabetes

• Support the adolescent with Support the adolescent with diabetes until they mature enough diabetes until they mature enough to take on the challenges of to take on the challenges of diabetes care on their own.diabetes care on their own.

Goals for Management ofGoals for Management of Psychosocial DiabetesPsychosocial Diabetes

• Simplify management!Simplify management!

• Set small goals that may not reflect Set small goals that may not reflect optimal diabetes care.optimal diabetes care.

• Insulin administration is the first, Insulin administration is the first, second and third goal.second and third goal.

• Strongly encourage counseling!!!Strongly encourage counseling!!!

• Monitor and treat complications.Monitor and treat complications.

• Be Patient!!!Be Patient!!!

Outpatient Psychosocial DM Outpatient Psychosocial DM Insulin ApproachInsulin Approach

Lantus

Short Acting

Breakfast Lunch Dinner

NPH

NICHNICH

• Novel Interventions in Children’s Novel Interventions in Children’s Health Care.Health Care.

• Program Developed by Dr. Program Developed by Dr. Michael Harris and team.Michael Harris and team.

The ProblemThe Problem• 279 youth were hospitalized 2x279 youth were hospitalized 2x

• 82 youth were hospitalized 3x82 youth were hospitalized 3x

• 148 youth were hospitalized 4x148 youth were hospitalized 4x

• 230 youth (4.5% of all patients)230 youth (4.5% of all patients)– 3+ hospitalizations3+ hospitalizations

– 27% of hospital charges or $67,000,00027% of hospital charges or $67,000,000

– 20% of admissions 20% of admissions

– Most NICU gradsMost NICU grads

– 3rd most common is DKA3rd most common is DKA

Demographic ProfileDemographic Profile

• 46% - Single parent household46% - Single parent household• 48% - Unemployment / employment 48% - Unemployment / employment

insecurityinsecurity• 11% - Not residing with immediate family11% - Not residing with immediate family• 46% - Not in school46% - Not in school• 38% - Housing insecurity / homelessness38% - Housing insecurity / homelessness• 59% - Family isolated; no support59% - Family isolated; no support• 24% - Youth involved in substance abuse24% - Youth involved in substance abuse• 76% - Youth w psych/behavior problems76% - Youth w psych/behavior problems• 27% - Family has open DHS case27% - Family has open DHS case

NICHNovel Interventions in Children’s Healthcare

T1DM

© Michael A. Harris, PhD - 2012

Financial Outcomes of NICHFinancial Outcomes of NICH

What’s “New” in What’s “New” in Diabetes?Diabetes?

Mini Glucagon ProtocolMini Glucagon Protocol

• Low dose glucagon Low dose glucagon can help to prevent can help to prevent hypoglycemia:hypoglycemia:– Gastrointestinal illnessGastrointestinal illness

– Repeated hypoglycemiaRepeated hypoglycemia

– NOT FOR USE IF NOT FOR USE IF EXPERIENCING SEVERE EXPERIENCING SEVERE HYPOGLYCEMIA!HYPOGLYCEMIA!

Mini Glucagon ProtocolMini Glucagon Protocol

• Recommended dose:Recommended dose:– 20 µg for kids ages 2 or under, and 20 µg for kids ages 2 or under, and

– 10 µg per year of age for kids from 2 to 15 (20 µg at 10 µg per year of age for kids from 2 to 15 (20 µg at age 2, 30 µg at age 3, etc.) age 2, 30 µg at age 3, etc.)

– 150 µg for kids 15 or older 150 µg for kids 15 or older

• Reconstitute glucagon kit: 1 unit=10 ugReconstitute glucagon kit: 1 unit=10 ug

What’s new-TechnologyWhat’s new-Technology• Continuous Glucose monitoringContinuous Glucose monitoring

– Monitors designed to provide integrated information Monitors designed to provide integrated information to provider (i.e. iPRO)to provider (i.e. iPRO)

– Monitors used by patient to provide “real time” Monitors used by patient to provide “real time” glucose data.glucose data.

CGM ExamplesCGM Examples

Using Continuous Glucose Using Continuous Glucose MonitorsMonitors

Challenges using CGM in Challenges using CGM in PediatricsPediatrics

0 100 200 300 4000

1

2

3

4

Blood sugar

Sen

sor

"sig

nal

"

0 100 200 300 4000

1

2

3

4

Blood sugar

Sen

sor

"sig

nal

"Paired blood sugar sensor Paired blood sugar sensor

readings increases accuracyreadings increases accuracy

Type 1 Diabetes- Where We Are Type 1 Diabetes- Where We Are Going.Going.

– Islet cell transplantsIslet cell transplants

• Limited to adultsLimited to adults

• Limited by lack of islet cellsLimited by lack of islet cells

• Limited by need for Limited by need for immunosuppressionimmunosuppression

– ““Closed loop” artificial pancreas Closed loop” artificial pancreas

• Only as accurate as the glucose sensor.Only as accurate as the glucose sensor.

– New sub Q insulin delivery methods.New sub Q insulin delivery methods.

Closed Loop PumpClosed Loop Pump

What we have now….What we have now….B

asal

Rat

e 2

1

0

Closed Loop PumpClosed Loop PumpB

asal

Rat

e 2

1

0

Dual Hormone Closed Loop PumpDual Hormone Closed Loop PumpB

asal

Rat

e 2

1

0

InsulinGlucagon

MicroneedlesMicroneedles

ConclusionsConclusions

• Managing students with diabetes, Managing students with diabetes, and their families, can be and their families, can be challenging (and rewarding!!!).challenging (and rewarding!!!).

• Social issues as well as new Social issues as well as new technologies will create even more technologies will create even more challenges for managing these challenges for managing these kids in the near future.kids in the near future.

• It takes a coordinated team (a It takes a coordinated team (a village?) to do this successfully.village?) to do this successfully.