1. Diabetes in the Schools: The Challenge of Managing a Bunch of Sweet Kids in the School Environment Bruce Boston, MD Professor, Pediatric Endocrinology Oregon Health & Science University

2. Commercial Disclosure I have nothing to disclose.I have nothing to disclose.

3. The Many Faces of Diabetes

4. The Physician Perspective Glucose Insulin Carbohydrate Blood Vessel Pancreas Cell

5. The School Nurse Perspective

6. The Start of Each School Year…

7. It takes a village…. Diabetes Care Providers School Nurse Teachers Family

8. Objectives Understand evidence behind reasons to achieve good blood sugar control in the school setting.Understand evidence behind reasons to achieve good blood sugar control in the school setting. Appreciate the challenges raised by psychosocial diabetes and acquire some new tools in the care of these students.Appreciate the challenges raised by psychosocial diabetes and acquire some new tools in the care of these students. Describe new advances in Type 1 diabetes care.Describe new advances in Type 1 diabetes care.

9. The Complexity of Diabetes Care 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? When is it too often?How often should I check blood sugar? When is it too often? Shots before vs. after eating?Shots before vs. after eating? School breakfast and snacks. Some kids in 2013 seem to eat like “Hobbits”!School breakfast and snacks. Some kids in 2013 seem to eat like “Hobbits”! Testing in the classroom.Testing in the classroom.

10. The Goal Provide a safe environment for a child/adolescent to learn.Provide a safe environment for a child/adolescent to learn. Improve their educational experience despite their chronic condition.Improve their educational experience despite their chronic condition. Provide a window into the social factors preventing good diabetes care.Provide a window into the social factors preventing good diabetes care.

11. The Goal We can all agree that achieving the best blood sugars we can is always the goal.We can all agree that achieving the best blood sugars we can is always the goal. But the “best blood sugar goal” is going to be different in each kid.But the “best blood sugar goal” is going to be different in each kid. And we need to weigh the cost (i.e. interference with social development?) with the benefit (better A1c and better school performance?)And we need to weigh the cost (i.e. interference with social development?) with the benefit (better A1c and better school performance?)

12. Factors Associated With Academic Achievement in Children With Type 1 Diabetes 244 subjects in a rural Midwestern State.244 subjects in a rural Midwestern 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 and Tests of Educational development in the state was 106.Average Test of Basic Skills score and Tests of Educational development in the state was 106. McCarthy, et. al. Diabetes Care Volume 26(1), January 2003, pp 112-117

13. ITBS/ITED Achievement Scores and School Performance Based on Metabolic Control

14. Mean Achievement Scores for Children Based on Level of Metabolic Control and History of Hospitalizations

15. Effects of Prior Hypoglycemia and Hyperglycemia on Cognition in Children with Type 1 Diabetes Mellitus Tested youth with T1DM ages 5-16 (n=117) and non-diabetic sibling controls.Tested youth with T1DM ages 5-16 (n=117) and non-diabetic sibling controls. Tested verbal and spacial intelligence, verbal and spacial memory, and processing speed.Tested verbal and spacial intelligence, verbal and spacial memory, and processing speed. Perantie, et.al. Pediatric Diabetes vol. 9, p 87

16. Effects of Prior Hypoglycemia and Hyperglycemia on Cognition in Children with Type 1 Diabetes Mellitus Results:Results: –T1DM group had lower verbal intelligence scores than siblings. –Within T1DM group: Chronic hyperglycemic exposure (i.e. higher age adjusted A1c values) led to decreased verbal intelligenceChronic hyperglycemic exposure (i.e. higher age adjusted A1c values) led to decreased verbal intelligence Severe acute hypoglycemic episodes (especially before age 5 years) led to spatial intelligence and delayed recall.Severe acute hypoglycemic episodes (especially before age 5 years) led to spatial intelligence and delayed recall.

17. Acute Hyperglycaemia Impairs Cognitive Function in Children with IDDM 12 subjects with Type 1 DM in the Paediatric Clinic at Princess Margaret Hospital.12 subjects with Type 1 DM in the Paediatric Clinic at Princess Margaret Hospital. Ages 10 to 16 years with diabetes approximately 5 yearsAges 10 to 16 years with diabetes approximately 5 years Average A1c 9.6 +/- 0.4%Average A1c 9.6 +/- 0.4% Two testing periods with blood sugars “clamped”:Two testing periods with blood sugars “clamped”: –Euglycaemia 10 mmol/liter (180 mg/dl) –Hyperglycaemia 25 mmol/liter (400 mg/dl) Davis, et.al. JPEM, Vol 9. p 455

18. Acute Hyperglycaemia Impairs Cognitive Function in Children with IDDM Results:Results: –Performance IQ percentile Hyperglycaemia 62.3Hyperglycaemia 62.3 Euglycaemia71.8Euglycaemia71.8 –Average decline in IQ 9.5* *p<0.05

19. Effect of Acute Hypoglycemic Episode 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”!!!

20. Physiology Based Approach to Common Questions from Students, Parents and Nurses Do I have to drink water when my blood sugar is high?Do I have to drink water when my blood sugar is high? How do I know if a high blood sugar is “okay” or is “urgent”?How do I know if a high blood sugar is “okay” or is “urgent”? Does exercise help bring a high blood sugar down?Does exercise help bring a high blood sugar down?

21. Do I have to drink water when my blood sugar is high? High glucose concentration in urine is 0.5 to 1.0 gram/dl.High glucose concentration in urine is 0.5 to 1.0 gram/dl. 500 ml of urine would contain only 2.5 to 5 grams of glucose.500 ml of urine would contain only 2.5 to 5 grams of glucose. Would take a long time for blood sugar to drop from water drinking alone.Would take a long time for blood sugar to drop from water drinking alone. However, important to offer water if thirsty to allow student to stay hydrated.However, important to offer water if thirsty to allow student to stay hydrated.

22. How do I know if a high blood sugar is “okay” or is “urgent”? “It’s all about the ketones”.“It’s all about the ketones”.

23. Normal Glucose Homeostasis Glucose Insulin Glucose

24. Evolution of Ketosis Glucose Lipids Ketones Glucose “Counter regulatory hormones”

25. Evolution of DKA Glucose Lipids Ketones Glucose Acids

26. Too many carbs? Glucose Insulin Glucose

27. Does exercise help bring a high blood sugar down? Maybe.Maybe. Maybe not.Maybe not. Might even be harmful.Might even be harmful.

28. Maybe Glucose Insulin Glucose

29. Maybe Insulin Glucose

30. Maybe Not Glucose Insulin Glucose Adrenalin from stress, anger or excitement promotes hepatic gluconeogenesis, glycogenolysis and insulin resistance.

31. Might Even be Harmful Glucose Lipids Ketones Glucose “Counter regulatory hormones”

32. Might Even be Harmful Glucose Lipids 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.

33. Summary Good blood sugar control is always the goal.Good blood sugar control is always the goal. But the “best blood sugar goal” is going to be different in each kid.But the “best blood sugar goal” is going to be different in each kid. Care plans and goals need to be individualized to each student.Care plans and goals need to be individualized to each student.

34. Psychosocial Diabetes

35. Diabetes in Balance Insulin Carbohydrate Exercise Stress Low Blood Sugar High Blood Sugar

36. Diabetes out of Balance +/- Insulin C a rb o hy dr at e Exercise Stress Low Blood Sugar High Blood Sugar

37. The Effect of Stress on Blood Sugars Stress

38. Goals for Management of Psychosocial Diabetes Support the adolescent with diabetes until they mature enough to take on the challenges of diabetes care on their own.Support the adolescent with diabetes until they mature enough to take on the challenges of diabetes care on their own.

39. Goals for Management of Psychosocial Diabetes Simplify management!Simplify management! Set small goals that may not reflect optimal diabetes care.Set small goals that may not reflect optimal diabetes care. Insulin administration is the first, second and third goal.Insulin administration is the first, second and third goal. Strongly encourage counseling!!!Strongly encourage counseling!!! Monitor and treat complications.Monitor and treat complications. Be Patient!!!Be Patient!!!

40. Outpatient Psychosocial DM Insulin Approach Lantus Short Acting Breakfast LunchDinner NPH

41. NICH Novel Interventions in Children’s Health Care.Novel Interventions in Children’s Health Care. Program Developed by Dr. Michael Harris and team.Program Developed by Dr. Michael Harris and team.

42. The 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+ hospitalizations –27% of hospital charges or $67,000,000 –20% of admissions –Most NICU grads –3rd most common is DKA

43. Demographic Profile 46% - Single parent household46% - Single parent household 48% - Unemployment / employment insecurity48% - Unemployment / employment insecurity 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

44. WHAT (Knowledge & Resources) HOW (Behavioral Interventions) WHY (Social Ecology)

45. WHY (Social Ecology) HOW (Behavioral Interventions) WHAT (Knowledge & Resources)

46. Care Coordination Case Management Behavioral Family Systems Therapy NICH Novel Interventions in Children’s Healthcare T1DM © Michael A. Harris, PhD - 2012

47. Financial Outcomes of NICH

48. What’s “New” in Diabetes?

49. Mini Glucagon Protocol Low dose glucagon can help to prevent hypoglycemia:Low dose glucagon can help to prevent hypoglycemia: –Gastrointestinal illness –Repeated hypoglycemia –NOT FOR USE IF EXPERIENCING SEVERE HYPOGLYCEMIA!

50. Mini Glucagon Protocol Recommended dose:Recommended dose: –20 µg for kids ages 2 or under, and –10 µg per year of age for kids from 2 to 15 (20 µg at age 2, 30 µg at age 3, etc.) –150 µg for kids 15 or older Reconstitute glucagon kit: 1 unit=10 ugReconstitute glucagon kit: 1 unit=10 ug

51. What’s new-Technology Continuous Glucose monitoringContinuous Glucose monitoring –Monitors designed to provide integrated information to provider (i.e. iPRO) –Monitors used by patient to provide “real time” glucose data.

52. CGM Examples

53. Using Continuous Glucose Monitors

54. Challenges using CGM in Pediatrics

55. Paired blood sugar sensor readings increases accuracy

56. Type 1 Diabetes- Where We Are Going. –Islet cell transplants Limited to adultsLimited to adults Limited by lack of islet cellsLimited by lack of islet cells Limited by need for immunosuppressionLimited by need for immunosuppression –“Closed loop” artificial pancreas Only as accurate as the glucose sensor.Only as accurate as the glucose sensor. –New sub Q insulin delivery methods.

57. Closed Loop Pump

58. What we have now…. Basal Rate 210210

59. Closed Loop Pump Basal Rate 210210

60. Dual Hormone Closed Loop Pump Basal Rate 210210 Insulin Glucagon

61. Microneedles

62. Conclusions Managing students with diabetes, and their families, can be challenging (and rewarding!!!).Managing students with diabetes, and their families, can be challenging (and rewarding!!!). Social issues as well as new technologies will create even more challenges for managing these kids in the near future.Social issues as well as new technologies will create even more challenges for managing these kids in the near future. It takes a coordinated team (a village?) to do this successfully.It takes a coordinated team (a village?) to do this successfully.