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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine:

  

The Treatment of Diabetes: The Rule of “1’s”

Introduction: There are 3 phases of treatment: ketoacidosis, postacidotic, and continuing phases

1. Ketoacidosis:

a. Fluid Replacement: Once high blood sugar and ketonemia diagnosed, fluids should be started - if acidosis present, assume 10% dehydration.  Also 10cc-20cc/kg bolus.  In a 30 kg child, then replace 3000 cc by first method; 300-600 cc in second and keep giving until not dry.

  • Use isotonic saline; add K+ early - when correcting acidosis, K+ moves intracellularly.

  • Things to follow: blood gases, lytes, serum calcium (tends to be low). If pH less than 7.2, consider alkali treatment with NaHCO3: not often done.

Side Effects: hyperkalemia, hypokalemia, hypocalcemia, hypoglycemia, arrythmias and most Severe - cerebral edema: Must be treated promptly with hyperventilation and mannitol. (Sx: headache, delirious, bradycardia, vomiting, decreased responsiveness)

b. Insulin Treatment:

                       

Bolus   

Maintenance

Serum glucose: > 700 mg/dL:   

0.1 units/kg IV

0.1 units/kg/hour IV

Serum glucose >300 < 700 mg/dl

no bolus

0.1 units/kg/hour IV     

Serum glucose < 300 mg/dL:                                       

no bolus

0.05 units/kg/hour
add 5% dextrose to IV

Goal: Have serum glucose fall no faster than 50-100 mg/dL/hour

When sugar approaches 300 mg/dL: start IV fluids with 5% dextrose to maintain sugar in 150-250 mg/dL; may require 7.5% or 10% dextrose in some patients

2. Postacidotic or Transition Period.  There are many methods to go about this phase; often used are sliding scales.  For those that present without acidosis, or after treatment of DKA:

  • 0.1 to 0.25 units/kg to start subcutaneously, then base on the blood sugars every 6-8 hrs a.c.

  • After two days, determine the amount of insulin needed for that child and divide dose into:

  • Total daily dose usually ends up being 0.5 units/kg to 1 unit per kg.

  • 2/3 in AM and 1/3 in PM.  Divide each dose into 2/3 long-acting and 1/3 short acting.

  • If need to make changes, do so by changing no more than 10% at a time.

Ultimate goal of diabetic treatment: have sugars be as normal as possible, no ketones in urine.

3. Continuing Period. During the transition period, nutrition is important: 1000 cals plus 100 per year of age.  (e.g. 10 yo: 2000 calorie diet).  Nutritionist important in explaining exchanges, dietary needs to parents.  A team approach for the entire educational process can be key.

Followup: see Outpatient Management of Diabetes on the next page: 1 month, 3 months, every 6 months, anytime there is an illness.  More if psychological problems, hypoglycemia or hyperglycemia; on PE: check fundi, weight, height, BP.  Laboratory: check books and correlate against machine in your office; Hgb A1C: goal:<7%

Refer: routinely to ophthalmologist, possibly diabetologist.

Conclusion: Despite improved care and techniques for following children, this is still a bad disease and parents/child have trouble adjusting to it.  Many support services may be needed.

Reviewed 4/01

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004