Children and Diabetes Management
Type II diabetes is an evolving prevalence globally implicating not only predominately-obese middle age adults but also now adolescents and children ranging from 6-15 years of age relatively among the ethnic descent population presenting with other comorbid implications. Diabetes main relationship corresponds with the rising incidence of obesity from repeated exposure to diminished recreational activity, genetics and insulin resistance combines to create high-risk individuals presenting with advanced, uncontrolled diagnosis needing long-term modifications (Copeland, Becker, Gottschalk & Hale, 2005). Children and adolescents fitting into this accelerated category represent 20-25% of new diagnosis needing both psychologically and physical monitoring for compliance and treatment effectiveness although, type II diabetes is relatively new territory for children, available preventative strategies are still in their infancy (Alberti et al, 2004). Multidisciplinary healthcare specialized teams are uniquely qualified to organize treatment regimens for maximal effectiveness and efficiency in patient outcomes especially with initial new cases presenting in advanced hyperglycemic states needing immediate lifestyle changes.
Estimated costs alone in 2007 were $174 billion and climbing to affect over 20.8 million people, or 7% of the population which, 176, 500 are people under the age of 20 and slowly progressing alongside adults. This paper discusses diabetes in children with multiple risk factors and the need for multidisciplinary case management initiation (Von & Hewett, 2007). Diabetes is a chronic illness requiring lifelong commitments to development of overall medical treatment plan requiring supportive care of children and adolescents moving away from just controlling blood glucose and towards comprehensive approaches to reduce risks of severe complications including cardiovascular disease and mortality leaving a great deal at stake clinically. Engaging patients in education development strategies based on evidenced based practice implement recommended factors meant to individually reflect components of patient preferences and management options gives them the opportunity to work toward target goals and initiatives needed for self-containment. Diabetes is classified into four subgroups, this paper discusses Diabetes II, which results from insulin resistance defect that progressive gets worse until the need for insulin is required. Although some patients cannot be classified between types, I or type II, clinical presentation of both diseases are similar and may vary in adolescents and children making diagnosis difficult and delayed (American Diabetes Association. (2012). Long-term outlook for youth afflicted with diabetes is using various quality interventional procedures collaboratively approached by multidisciplinary efforts demonstrating increased comprehensive improvements in cost and clinical effectiveness for patients and healthcare support.
The revealing picture seen is major challenges facing society now and in the near future, if the prevalence of this disease is not reversed creating excessive burdens straining our economic resources without improving health outcomes of the escalating complexities occurring in high-risk young individuals (Government of New Brunswick, 2011). (3) Diabetes type II is now one of the most common types of childhood diseases once afflicting only adults now has coincided with obesity to account for almost one third of new diagnosed cases in the United States particularly in minority and ethnic groups (Pozzo & Rosenbloom, 2012). Diabetes II is now the sixth leading cause of death in American youth adding extreme risk of cardiovascular, eye, lower extremity, and renal disease as the number one reason 50% are hospitalized at onset and that 1 in 4 newly diagnosed suffer from DKA. Managing this crippling disease and altering lifestyle amongst a new generation of non-compliance and uncertainty comes a hope for a new beginning that acceptance rather than conclusion takes hold for those remaining in their productive years (Lord, 2009). Children with Diabetes
Nearly 366 million people worldwide have diabetes and if predictions hold true by 2030, an estimated 552 million individuals will be affected by diabetes including one in five obese children diagnosed with a once thought of adult-onset form of diabetes (non-immune mediated form). Eighty-five percent of children affected are between the ages of 6 to 19 from African-American, Mexican-American, and Pacific Islander backgrounds whose body mass index considers them obese from diverse, socioeconomic challenged backgrounds requiring familial, educational and medical interventions to be successful. Accommodating cognitive and learning abilities and engaging in interactive learning makes all the difference between positive reinforcement and negative behavioral summaries (Copeland, Becker, Gottschalk & Hale, 2005). Although not completely understood, signs and symptoms vary and can resemble adult onset type-II diabetes from mild asymptomatic hyperglycemia to sever ketoacidosis in up to 40% of patients presented to the emergency room, especially among African Americans adolescents early on. Other varying signs and symptoms include acanthosis nigricans, polydipsia, amenorrhea, polyuria, and signs of metabolic syndrome such as hypertension, steatohepatitits, dyslipidemia, and microalbuminuria (Zeitler, 2010). Initial treatment should focus on clinical presentation of symptoms and eventual diagnosis whether that is type I or type II diabetes and intense education on life style changes to address possible obesity and cardiovascular issue that could arise in the future.
Target therapy is to maintain glycohemoglobin below 6.5% with correct medication, diet and activity regulation although studies on children and adolescents Glycohemoglobin (A1C) have not been studied systematically this is only an assumption with adding possibly insulin as a backup source (Zeitler, 2010). Care must be coordinated to identify risk factors before diabetes occurs and establish an action plan to provide high quality of care initially to prevent health disparity challenges and undo consequences to measure outcome performance. Although DPP strategies are an effective means for adults, behavioral strategies for high-rick individuals in Random Control Trials (RCT) seem promising to use in a community setting for adolescents and are now being evaluated by the CDC for population use and funding (Green, Brancati & Albright, 2012). Medical History and Chief Complaints of Diabetic Children
Most Children presenting with type II diabetes are typically not ill compared to children with type I diabetes, disease progression is slower and parents often rarely seek medical attention unless children or adolescents gain excessive weight or are extremely fatigued because of insulin resistance. A history of polyuria and polydipsia is relatively uncommon however; symptoms such as blurred vision, yeast infections, or lower extremity paresthesias may signal long-term hyperglycemia and advanced diabetes needing immediate attention (Khadduri and Griffing, 2012). Diagnosis according to the American Diabetes Association (ADA) involves assessment of height, weight, race gender, BMI, recent signs and symptoms, positive family or maternal gestational diabetes, age range of 12-16 years of age coinciding with the relative insulin resistance that occurs during pubertal development. Classifying diabetes is generally more difficult than establishing a diagnosis and is based on presenting signs, symptoms, laboratory testing and clinical data although children may present with both features of type I and II diabetes initially (Copeland, Becker, Gottschalk, and Hale, 2005) In some patients, androgen-mediated problems such as acne, hirsutism, and menstrual disturbances may be the chief complaints in females but not for male children for observation is consistent with the need for fewer calories to maintain weight in the face of decreased lean body mass.
Most Glyco- hemoglobin’s were at or below 9.5% reflecting poor blood glucose control in individuals of African American, American Indian, Hispanic, and Asian/Pacific Islander youth (Pillock, 2010, p. 28). Case managers are extremely important to provide continuity of care by using their relationship with the family and child to titrate structural adherence with flexible interventions facilitating strengths and weaknesses of child in order to enhance a better individual strategic regime. Clinical components involve assessment, planning, connection, evaluation and monitoring high-risk individuals through collective, cost effective interventions decreasing excessive health resource use, monitoring and coordinated services due to multiple admissions due to negative outcomes (Kanter, 2010). Early on children may present without symptoms at all acanthosis nigricans at the base of the neck, the axillae, anogenital area, and skin folds appearing as a velvety brown-black color because of their association with insulin resistance looks like dirty skin by some but is a manifestation of hyperinsulinism and insulin resistance. Other physical complaints include again fatigue, slow healing wounds, frequent infections, pain and numbness in hands and feet, which can become very dangerous if wounds are present and not noticed, erectile dysfunction in young adolescent males, and frequent bladder and kidney infections due to hyperglycemia (Casey & Rose, 2012). DKA is a life threatening alteration requiring immediate treatment of complications including cerebral edema to prevent mortality with slow rehydration, without sodium bicarbonate or insulin with adequate potassium replacement alongside intensive metabolic and neurologic monitoring under the care of Endocrinology always (Dean & Sellers, Case Management
Involving case management as a permanent solution to children and adolescent environments is needed for most chronic illnesses especially diabetes II where compliance in young, rebellious populations are dividedly complex, irrational, emotional, and hard to evaluate. Self-care deficits are not only common but expected approximately in 50% of newly diagnosed cases with children being more complacent than their older counterparts when life and friends are more important than health. Connecting social acceptance to internal attitudes in achieving medical independence is far from perfect in the world of adolescents but more a reality in children ages 6-12 that are more likely to become compliantly responsible without parental or medical conflict. Case managers are perfectly positioned to transition children and teens through challenges in response to unmotivated success in illness regimes even though they may indicate unsuitable, for approaching young patients and their perspective phases systematically as individuals coincides to improved interactions and increased self-esteem (Kyngas, 1999).
Educational objectives must look at overall lifespan of the children, cultural background, and character to relate materials to cognitive abilities and experiences focusing on multiple relevant formats preferable to self-direct encouraging independence yet manageable, appropriate health content (Zeitler, 2010). In 2008, African-American and Hispanic were among the poorest, uneducated, at risk children (140% poverty level) needing individualized and multidisciplinary care to control diabetes and obesity to decrease body mass index then white American children who had health insurance and educated (Katzmarzyk & Staiano, 2012). Initially misdiagnosed as Type I diabetes in children, type II is more prevalent throughout the world presenting in more obese, ethnic populations due in part to a sedentary life styles creating increased specialized care associated with risk factors combined with insulin resistance early in the disease leading to increased mortality (Rosenbloom, Silverstein, Amemiya, Zeitler & Klingensmith, 2008). Puberty appears to be a contributing factor in the increase in type II causing a increased resistance to insulin causing hyperinsulinaeimia confusing type I and type II possibly in relation to increased hormone release in combination with obesity making the link environmental in nature. Standards of care are individualized treatment modalities recommended by the American Diabetes Association intended to diagnosis, treat, and support cost effective interventions for type I, II, other, and gestational diabetes.
As of 2009, classification of disease is now determined by glycohemoglobin (A1C) at or < 6.5% (American Diabetes Association, 2012). Type II diabetes develops when the body is resistant to insulin, meaning the insulin is not used properly and the pancreas slowly loses the ability to adequately control blood glucose. In relation to children, this is hard to diagnose because of minimal symptoms to none requiring blood tests to differentiate diagnosis or discovered when brought to the emergency room with severe ketoacidosis especially in about 40% of pediatric, African-Americans patients (Zeitler, 2010). Theories behind type II diabetes epidemic is the vast growth of today’s youth inactivity creating obesity in some, poor nutrition, and exposure to environmental contributors, low birth weight and gestational diabetes all correlate to the sizable awareness urgently needing individual funding management from the federal government (Center for disease control and prevention, 2012). School Nurse and Diabetes
Healthcare for a child with diabetes is a major family adjustment concerning daily survival management of care following diagnosis and responsibilities with treatment to correctly balance activity, medications, schedules, and nutrition. Diabetes in itself is complex, creating a stressful condition for adolescents already struggling with self-identity and acceptance add pressure to manage a chronic condition with medication in multiple environments may destroy self-esteem and independent development leading to rebellious activities. Successful coping begins with daily management strategies to develop a normalcy collaborative partnership with family, student, peers, and teachers for effective coping to prevent noncompliance. According to Federal and some state guidelines, children with disabilities are protected from discrimination and must be provided effectively management, affordable accommodations, and individualized healthcare plan documented by qualified personnel with minimal academic disruption (American Diabetes Association, 2012).
Nurses as part of the multi-disciplinary team approach should lead in coordinating adequate training to guide others on checking blood glucose levels, signs and symptoms of hyper/hypoglycemia, give insulin injections and glucagon in emergencies, and work with student/family on routines, schedule changes and meals. Nurses work with a variety of school age children and it is important to gauge their cognitive and competence in performing diabetes monitoring and the ability to complete during school hours with or without help. Younger children may require more assistance and should be monitored until condition returns to normal to avoid further complications and continue to participate in academic activities and manage diabetes effectively without complications later in life. Sometimes laymen are unable to understand symptoms presented putting children at high risk for emergency situations should Diabetic Ketoacidosis occur or Hypoglycemia arise and not treated developing into serious medical complications (National Association of School Nurses, 2012). Best Practices for Children and Adolescents
Standards of care in chronic illness adaption and self-management require extensive patient education and support from a variety of sources to prevent long-term complications resulting from complications beyond glycemic interventions. The intended purpose here is to provide component information directed toward multidisciplinary treatment goals and individualistic aspects of the disease process including comorbidities to evaluate intended outcomes of care. Children and adolescents who fit into this category require extensive screening, diagnostics and therapies addressing those that best fit favorable outcomes, are cost effective, evidenced based, and can be easily utilized by young participants (American Diabetes Association, 2012). Evaluation on Published Guidelines on Diabetes
For children born in 2000 and beyond, the risk of diabetes type two is a rapidly progressing public epidemic more among obese female adolescents than males according to La Pierre, 2010 of what is now called “diabesity.” Such an affluent name for a devastating disease accounting for 11.6% of the global healthcare expenditures that varies between races and ethnicity particularly African American population and immune and nonimmune related types (La Pierre, 2010). The is no comparison among the two classifications when presenting symptoms to a physician and extremely relevant considering diabetes type II used to be considered only for adults and now is found in children of all ages and must be correctly diagnosed for appropriate therapy. Type II Diabetes in youth is often associated with comorbidities such as cardiovascular disease, hypertension, and dyslipidemia that may present at a young age making treatment more a difficult process depending on insulin resistance syndrome status. Immune mediated type II diabetes is vastly unknown presenting with children usually underweight with polydipsia and polyuria, ketosis, ketoacidosis, then no symptoms and a decrease for insulin (honeymoon period) then spiking demanding high doses for survival -confusing even the most trained professionals.
Type II diabetes on the other hand, usually are obese with ketones present in the urine, glycosuria, absent or mild polyuria, polydipsia, and possible weight loss with or without ketoacidosis associated with some illness, stress, or infection 5-25% of the time (American Diabetes Association, 2000). Obesity is the classic symptom of type II in 85% of children diagnosed although it can be unrecognizable in children with significant weight loss month noticed several months to a year before clinical diagnosis starting at the age of ten. Curtailing diabetes from reaching epidemic proportions globally involves great attempts to de-westernize areas implicated to sedentary lifestyles and poor eating habits and decrease risk factors affecting the young (Bloomgarden, 2004). Understanding individual diabetes treatment etiology begins with patient’s current insulin states, pancreatic cell antibodies, and probabilistic clinical parameters such as age at time of onset to manage physiological deficiencies according to the American Diabetes Association onset (Bogen, 2008).
Knowing puberty may play a huge role in affecting blood sugar levels resulting in hyperinsulinaeimia and slowly decrease as the child ages making insulin resistance a greater risk and education a necessity since growth hormone production is transient in this period. Children and adolescents should all receive comprehensive education regarding self-management following National Standards for Diabetes Treatment including correct blood glucose monitoring during illness and good health, treating hyper and hypoglycemia, HA1c and family shared responsibility for medications. Daily activity is a necessary combined component with nutrition management culturally sensitive to healthy eating and positive behavior modification choices to effective weight management that excludes sedentary living. Since diabetes II is a progressive disease, success comes from resulting combinations of diet, activity, and ultimately insulin – oral medication adherence. Concerns for adolescence safety is reasonably minimal as compared to adults however, children medications for children have not been approved and are vastly dangerous since mechanisms of action are unknown and have known to be fatal if routinely used. At this time, recommended treatment for children include educative resources, blood work with glycohemoglobin, frequent glucose monitoring, activity, and insulin regimes if necessary (American Diabetes Association, 2000). Evaluates Clinical Pathway Effectiveness
Length of stay for children and adolescents in hospital environments is a serious concern varying according to consistent quality of care and pathway management for optimal efficiency implementing successful multidisciplinary approaches directing standards of care to educate this vulnerable, high-risk population. Institution of clinical pathways in children and adolescents can decrease length of stay with a low rate of readmission after discharge with proper medical management to decrease variations of care and resources to improve healthcare quality. The American Diabetes Association (ADA) recognizes clinical pathways as vitally pertinent to improving life and controlling cost of care consistently in patients for long periods of time strategically involving nurse educators, dieticians, social workers, and psychologist (Cogen, Johnson, Pastor & Kaplowitz 2008). Patients admitted to the hospital having pathways instituted immediately show that if routines are utilized with a diabetes diagnosis, illness rates, and age based on evidenced based practice guidelines from multiple sources, patients overall survival skills and psychological dealing to their chronic condition was more responsibly focused.
However, if not completed, children and adolescents faired far worse and were unable to be discharged safety for two continued weeks to receive further instruction and monitoring to prevent noncompliance and psychological nonadherence that included family. Some resistance to pathways were noted from patients and physicians new to the program practicing new methods of regimes but with continued educational exposure embraced techniques eloquently. Frequent correspondence through team collaboration is completed to determine variances in utilization of standards, quality and effectiveness, patient satisfaction, and adverse event occurrences before and after discharge. This has found its way to becoming a most effective pathway in controlling blood sugar variations which maintains symptoms letting patients manage condition at home rather in the hospital setting containing cost and compliancy (Cogen, Johnson, Pastor, and Kaplowitz, 2008). Conclusion
Simply treating a child or adolescent with type II diabetes, as an adult will not suffice for special considerations must be completed to address physical, emotional, developmental, and socioeconomic status to establish an ideal relationship and adherence to therapy. Diabetes is a serious, chronic condition challenging more than 20 million adults and children requiring life-long commitments to healthy regimes and medications currently unregulated but showing promise in trials for use on children and adolescents. Multidisciplinary resource approaches to care are best suited for case managers experienced in this new phenomenon engulfing early childhood with obesity at an alarming rate (Copeland, Becker, Gottschalk & Hale, 2005). Diabetes effects on children and adolescents is still vastly unknown territory concerning presentation and characteristics creating consequences that for some have unmanageable terms significantly impeding on independence and reducing life span potential (Green, Brancati & Albright, 2012).
Diabetes monitoring and efficiency begins with medical management teaching children and adolescents safe interventional standards to decrease hospitalization, length of stays, compromised care and noncompliance through collaborative efficiency in this vulnerable, high-risk population (Cogen, Johnson, Pastor and Kaplowitz, 2008). Individualized, evidenced based initiatives are a significant objective in creating healthy self-management commitments leading to successful behavior transformation integration of medications, activities, nutrition, weight reduction, and diabetes complications improvements offering better quality of care and hopes for the future (American Diabetes Association, 2012). Although potentials barriers to care exists among various demographic areas and socioeconomic populations, treatment aims to correct deficiencies to substantially improve regression and reduce or eliminate risks providing systemic life care in diabetes management (Jovanovic,, 2004)
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