Peds Ch 48 - ENDO: Pancreas (DIABETES)

Pancreas

Dual-function organ:

• Endocrine (ductless)

• Exocrine (with ducts)

Pancreas - Endocrine Portion (Islets of Langerhans)

• Alpha cells → secrete glucagon

• Beta cells → secrete insulin

Insulin

• Essential for:

  • Carbohydrate metabolism

  • Also affects fat and protein metabolism

• Produced from amino acids

• Normal production:

  • 35–50 units/day in adults (less in children)

Stimulates Insulin Release

• ↑ Blood glucose (>100 mg/dL)

• Hormones:

  • Gastrin (after eating)

  • Glucagon

  • Cortisol

  • Growth hormone (GH)

  • Progesterone

  • Estrogen

Inhibits Insulin Release

• Epinephrine

• Norepinephrine

  • Preserve glucose for fight-or-flight response

Key Concept - Insulin

• Insulin is released when blood glucose is high and decreases when glucose is low, helping maintain glucose balance (homeostasis)

Common Childhood Disorders

• Type 1 Diabetes (T1D)

• Type 2 Diabetes (T2D)

Type 1 Diabetes Mellitus (T1D)

• Absolute (or near absolute) insulin deficiency

• Caused by autoimmune destruction of pancreatic beta cells

• Incidence:

  • ~1 in 500 children/adolescents in the U.S.

• Affects males and females equally

• Common onset:

  • 5–7 years old or puberty

• Abrupt onset

Type 1 Diabetes Mellitus (T1D) - Etiology

• Autoimmune process destroys islet (beta) cells

• Associated with genetic markers:

  • HLA-DR3 and HLA-DR4

• Increased risk:

  • Family history (siblings)

T1D - Pathophysiology

1. ↓/No insulin

2. Glucose cannot enter cells

3. → Hyperglycemia (↑ blood glucose)

4. Kidneys respond:

   • Glucose spills into urine (glycosuria) when > ~160 mg/dL

   • → Polyuria (↑ urination)

5. Fluid loss → Dehydration

   • → Polydipsia (↑ thirst)

6. Cells starved of glucose:

   • Body breaks down fat & protein

7. Fat breakdown → Ketones

   • → Ketoacidosis (DKA)

8. Electrolyte shifts:

   • Loss of potassium & phosphate

T1D - CM

• Polyuria (frequent urination; may present as bed-wetting)

• Polydipsia (excessive thirst)

• Polyphagia (increased hunger)

• Weight loss (despite eating)

• Fatigue

• Blurred vision

• Mood/behavior changes

• Dehydration

• Signs of ketoacidosis (severe cases)

T1D - Complications (Untreated)

• Diabetic ketoacidosis (DKA)

• Electrolyte imbalance

• Severe dehydration

• Growth failure (short stature, underweight)

T1D - Management Overview

• Insulin therapy (lifelong)

• Carbohydrate counting

• Blood glucose monitoring

• General foot care

Key Features vs Type 2

• Requires insulin (oral meds ineffective)

• Abrupt onset

• Weight loss (not obesity)

• Possible “honeymoon period”

  • Temporary remission (1–12 months after diagnosis)

Type 1 vs Type 2

Category	Type 1 Diabetes	Type 2 Diabetes
Age at Onset	5–7 years or puberty	40–65 years (can occur in adolescents—MODY)
Onset	Abrupt	Gradual
Weight Changes	Marked weight loss (early sign)	Associated with obesity
Polydipsia	Present	Present
Polyphagia	Present	Not typical
Polyuria	Present (may begin as bed-wetting)	Present
Fatigue	Present (↓ school performance)	Present
Blurred Vision	Present	Present
Mood Changes	Present (behavior issues possible)	Present
Therapy	Insulin required (oral meds ineffective)	Diet, oral meds, or insulin
Nutrition	Carb counting + glucose monitoring	Weight control + balanced diet
Skin/Foot Care	Basic care	Meticulous care required
Remission	Honeymoon period (1–12 months)	None

T1D - Assessment (Clinical Signs)

• Abrupt onset of symptoms

• Polydipsia (increased thirst)

• Polyuria (increased urination)

  • May present as enuresis (bed-wetting) in toilet-trained child

• Dehydration

  • May lead to constipation

• In severe cases:

  • Child may present in coma due to:

    • Hyperglycemia

    • Ketoacidosis

T1D - Laboratory Findings

• Random plasma glucose > 200 mg/dL

• Glycosuria (glucose in urine)

Normal Blood Glucose Ranges (Children with T1D)

Timing	Glucose Level (mg/dL)
Before meals	70–110
1 hour after meals	90–180
2 hours after meals	80–150
2 a.m. – 4 a.m.	70–120

T1D - Diagnostic Criteria (Confirm on 2 Occasions)

• Symptoms + random glucose > 200 mg/dL

• Fasting glucose > 126 mg/dL

• 2-hour GTT glucose > 200 mg/dL

Glucose Tolerance Test (GTT)

Procedure:

• 8-hour fasting

• Drink glucose solution

• Blood drawn:

  • Baseline (fasting)

  • 1 hour

  • 2 hours

GTT - Important Nursing Considerations

• GTT can be difficult for children:

  • Fasting

  • Sweet solution

  • Multiple blood draws

• Use:

  • Topical anesthetic (EMLA) to reduce pain

• Do NOT draw blood from IV line

  • IV fluids containing glucose → false high results

T1D - Blood Tests

Acid–Base & Respiratory Status

• pH

• PCO₂ (partial pressure of carbon dioxide)

  • Helps assess acidosis (DKA)

Electrolytes

• Sodium (Na⁺)

• Potassium (K⁺)

  • Imbalances common in diabetic ketoacidosis

Glycosylated Hemoglobin (HbA1c)

• Measures average blood glucose over past 3–4 months

  • Based on RBC lifespan (~120 days)

• Normal (nondiabetic):

  • 1.8–4.0

• > 6.0 = chronic hyperglycemia

White Blood Cell (WBC) Count

• May be elevated

  • Even without infection

  • Due to stress response (DKA)

• Still must assess for infection

  • Common trigger of diabetic crisis

Infection Workup

• Nose and throat cultures

  • To identify possible infection trigger

Electrocardiogram (ECG)

• Done if low potassium

• Looks for:

  • T-wave abnormalities

  • Signs of potassium imbalance

T1D - Overall Treatment Components (5)

• Insulin administration

• Nutrition regulation

• Exercise regulation

• Stress management

• Blood glucose & urine ketone monitoring

Initial Management (Hospitalization)

• ~3-day hospital stay

• Focus:

  • Stabilization

  • Extensive education (child + caregivers)

Initial Insulin Therapy (Emergency Phase)

• Child usually presents with:

  • Hyperglycemia

  • Ketoacidosis (DKA)

Initial Regulation of Insulin - IV Insulin

• Dose:

  • 0.1–0.2 units/kg/hour

• Type:

  • Regular (short-acting) insulin (e.g., Humulin-R)

• Reason:

  • Rapid onset of action

Initial Regulation of Insulin - Response to Treatment

• When glucose < 200 mg/dL:

  • Reduce insulin infusion

• Within ~12 hours:

  • Acidosis improves

  • Glucose approaches normal range

Initial Regulation of Insulin - Glucose Administration

• Even with hyperglycemia:

  • Glucose may be added to IV fluids

• Reason:

  • Insulin allows cells to use glucose

  • Without glucose:

    • Body continues fat/protein breakdown

    • Acidosis worsens

Transition Phase (After Stabilization)

After ~24 Hours

• Switch from:

  • IV → Oral feeding

• Continue insulin therapy

Transition Phase - Short-Term Insulin Plan

Regular insulin (SC):

• Given 3–4 times/day initially

Transition Phase - Next Step

• Add:

  • Intermediate-acting insulin

• Timing:

  • Usually day 2, once oral intake begins

T1D - Daily Insulin Requirements

• Children:

  • 0.4–0.7 units/kg/day

• Adolescents:

  • Up to 1.2 units/kg/day

• Given in 2 divided doses:

  • Morning (before breakfast): 2/3 total dose

  • Evening (before dinner): 1/3 total dose

Common Insulin Regimen

• Combination of:

  • Intermediate-acting insulin + Regular (short-acting) insulin

• Typical ratio:

  • 2:1 ratio

  • Example: 0.75 intermediate : 0.33 regular

• Often mixed in same syringe (varies per child)

Rapid-acting Insulin

• Lispro (Humalog)

• Aspart

Lispro (Humalog) - Onset

Immediate

Lispro (Humalog) - Peak

30 min–1 hr

Lispro (Humalog) - Duration

3–4 hr

Aspart - Onset

~15 min

Aspart - Peak

30–40 min

Aspart - Duration

3–5 hr

Short-acting Insulin

Regular (Humulin-R)

Regular (Humulin-R) - Onset

0.5–1 hr

Regular (Humulin-R) - Peak

2–4 hr

Regular (Humulin-R) - Duration

5–7 hr

Long-acting Insulin

• Lantus (glargine)

• Humulin-U

Lantus (glargine) - Onset

~1 hr

Lantus (glargine) - Peak

Minimal (~5 hr)

Lantus (glargine) - Duration

~24 hr

Humulin-U - Onset

~6 hr

Humulin-U - Peak

16–18 hr

Humulin-U - Duration

36+ hr

Intermediate-acting Insulin

• Humulin-N

• Humulin-L

Humulin-N - Onset

1–2 hr

Humulin-N - Peak

4–12 hr

Humulin-N - Duration

24+ hr

Humulin-L - Onset

1–3 hr

Humulin-L - Peak

6–14 hr

Humulin-L - Duration

24+ hr

Types of Insulin

Type	Example	Onset	Peak	Duration
Rapid-acting	Lispro (Humalog)	Immediate	30 min–1 hr	3–4 hr
Rapid-acting	Aspart	~15 min	30–40 min	3–5 hr
Short-acting	Regular (Humulin-R)	0.5–1 hr	2–4 hr	5–7 hr
Long-acting	Lantus (glargine)	~1 hr	Minimal (~5 hr)	~24 hr
Intermediate-acting	Humulin-N	1–2 hr	4–12 hr	24+ hr
Intermediate-acting	Humulin-L	1–3 hr	6–14 hr	24+ hr
Long-acting	Humulin-U	~6 hr	16–18 hr	36+ hr

Why Combine Insulins

• Different peak times → better glucose control

• Covers:

  • Meals (short-acting)

  • Baseline needs (intermediate/long-acting)

Peak Times & Hypoglycemia Risk

• Short-acting peak (2–4 hr):

  • ~10 a.m.–12 p.m. (after breakfast dose)

• Intermediate peak (8–14 hr):

  • Late afternoon (before dinner)

• ⚠ These are high-risk times for hypoglycemia

Alternative Regimens

• Some children require:

  • 3–4 injections/day

• Benefit:

  • More flexibility with:

    • Meals

    • Activity

Dose Adjustment (“Thinking Scales”)

Lag Time (Injection → Meal)

• High premeal glucose:

  • ↑ lag time (delay eating)

• Low premeal glucose:

  • ↓ lag time (eat sooner)

Adjustments Based on Lifestyle

• Large meal:

  • ↑ insulin dose

• Increased activity (e.g., sports):

  • ↓ insulin dose

Insulin Glargine (Lantus)

• Long-acting (24 hr)

• Given via pen injection

• Cannot be mixed with other insulins (low pH)

• May be used with:

  • 3 doses of short-acting insulin before meals

Mixing Insulin

• Draw short-acting (regular) insulin FIRST, then intermediate-acting.

• Rationale:

  • Prevents contamination of short-acting insulin.

  • Maintains its rapid onset, which is critical for emergency use.

Route of Administration

• Subcutaneous (SC) is the standard route.

• IV administration: REGULAR INSULIN ONLY

  • Used only in emergencies.

  • May give ½ of the required dose IV.

Injection Sites

Common sites in children:

• Upper outer arms

• Outer thighs

Other possible site:

• Abdomen (more common in adults)

  • Often avoided in children due to tenderness

Guidelines:

• Avoid:

  • Area around the navel

• Use:

  • Thigh: 4 inches below hip to 4 inches above knee (adjust for child size)

Site Rotation

• Rotate injection sites systematically.

• Document site use (especially in hospital settings).

• Prevents:

  • Lipodystrophy (atrophy) → pockmarks

  • Lipohypertrophy (fat buildup/scar tissue)

Effects of Repeated Use of Same Site

• Leads to:

  • Lipohypertrophy (scar tissue buildup)

  • Reduced pain → encourages repeated use

• Problem:

  • Poor insulin absorption

  • Insulin becomes “trapped” in tissue

• Risk:

  • Increased dose required → later injection at new site can cause hypoglycemia (overdose)

Activity Considerations - Insulin

• Exercise increases insulin absorption.

• Avoid injecting into areas that will be exercised soon:

  • Example:

    • Jogging → avoid thigh

    • Tennis → avoid dominant arm

Insulin Storage & Temperature

• Store extra insulin in refrigerator.

• Inject at room temperature:

  • Reduces tissue damage (atrophy)

  • Improves effectiveness

Injection Technique

• Use short needle (< 0.4 inches).

• Inject at 90-degree angle:

  • Still reaches subcutaneous tissue

  • Easier for children than 45-degree angle

Devices

• Options include:

  • Insulin pens

  • Jet injectors

• Benefits:

  • Pre-measured doses

  • Easier to use

  • Promote independence

  • Compatible with 90-degree technique

Insulin Pumps (CSII – Continuous Subcutaneous Insulin Infusion)

• Small automatic device (≈ size of an iPhone).

• Delivers continuous insulin at a constant rate.

• Uses:

  • Regular insulin in a syringe inside the pump.

  • Thin tubing connected to a subcutaneous needle in the abdomen.

Insulin Pumps - Effectiveness

• Provides better glucose regulation than periodic injections.

• Improves management of Type 1 Diabetes (T1D).

Insulin Pumps - Benefits

• Most children:

  • Adjust well

  • Prefer over injections

Psychosocial & Quality of Life Improvements:

• Increased self-efficacy in diabetes management

• Greater independence (especially adolescents)

• Improved quality of life (all age groups)

• Reduced:

  • Parenting stress

  • Worry about hypoglycemia

  • Overall disease burden

Inhalation Insulin

• Not currently available.

• Still in experimental trials.

Challenges

• Developing:

  • Accurate delivery system

• Concerns:

  • Effects of colds/allergies

  • Nasal membrane swelling (edema) may alter absorption

Insulin-to-Carbohydrate Ratio

• Individualized based on:

  • Age

  • Activity level

Example (from text):

• Ratio: 1 unit insulin : 10 g carbs

• Meal: 50 g carbs

• Calculation:

  • 50 ÷ 10 = 5 units insulin before meal

Meal Planning

• Daily pattern:

  • 3 meals (spaced, high in fiber)

  • 3 snacks:

    • Midmorning

    • Midafternoon

    • Evening

Purpose

• Maintain stable carbohydrate levels throughout the day

Self-Monitoring of Blood Glucose (SMBG)

• Children (early school age) can learn:

  • Finger puncture technique

  • Use of computerized glucose monitors

• Tools:

  • Spring-loaded lancet → minimizes pain

  • Automatic glucometer → simplifies reading

• Adolescents:

  • Usually able to monitor glucose independently daily

Urine Testing

• Not routine

• Used when child:

  • Has acute illness (e.g., nausea, vomiting, diarrhea)

  • Cannot eat

Purpose

• Detect ketonuria

Key Finding

• Presence of acetone:

  • Indicates fat breakdown for energy

  • May signal developing acidosis

“Honeymoon” Period

• Occurs after initial diagnosis and insulin regulation

Characteristics

• Temporary phase where:

  • Little or no insulin is required

Cause

• Exogenous insulin stimulates pancreas to produce small amounts of natural insulin

Duration

• Can last:

  • 1 month up to 1 year

Important Teaching

• Not a cure

• Symptoms will return as pancreatic function declines

• Parents should be prepared for recurrence

Stress Adjustment

Effect of Stress

• Physical or emotional stress → increased insulin needs

Nursing/Assessment Points

• Assess:

  • Blood glucose monitoring difficulties

  • Injection challenges

  • Home and school stress

Communication

• Interview child separately from parents when possible

School Considerations

• May need:

  • Parent–school collaboration

  • Support for participation in activities/sports

• Privacy:

  • Some children prefer testing in nurse’s office

Complications

Short-Term

• Infection/fever:

  • Causes insulin resistance

  • Requires increased insulin

Parental Teaching

• Notify provider if child:

  • Is ill

  • Has nausea/vomiting

Surgery

• Requires:

  • Careful glucose regulation

  • Monitoring if oral intake is restricted

Long-Term (Chronic Hyperglycemia Effects)

• Arteriosclerosis → poor circulation, kidney disease

• Retinal damage → vision problems, blindness

• Cataracts

Key Point

• Prevention starts in childhood with good glucose control

Pancreas Transplantation

Indication

• Severe complications:

  • Kidney disease

  • Arteriosclerosis

Procedure

• Original pancreas:

  • Not fully removed (digestive function preserved)

• New pancreas:

  • Enzymes diverted to:

    • Intestine or bladder

    • OR ducts blocked (sclerosed)

Donors

• Cadaver donors

• Living donors:

  • Can donate up to 45% of pancreas

Post-Transplant Care

• Lifelong immunosuppressive therapy:

  • Antilymphocyte globulin

  • Cyclosporine

  • Prednisone

  • Azathioprine

• Rejection treatment:

  • Monoclonal T-cell antibodies (OKT3)

Limitations

• Considered last resort because:

  • Major surgery

  • ~50% rejection rate

  • Lifelong immunosuppression required

  • Possible recurrence of diabetes

HYPOGLYCEMIA vs HYPERGLYCEMIA

Type 2 Diabetes Mellitus (T2D)

• Characterized by diminished insulin secretion

• Not autoimmune (unlike T1D)

• Pancreas:

  • Still produces small amounts of insulin

T2D - Management

• Most children:

  • Do NOT require daily insulin

• Treatment includes:

  • Diet (nutrition therapy)

  • Exercise

  • Oral hypoglycemic agents

T2D - Medication

Metformin (biguanide)

• Decreases glucose production in liver

• Increases insulin sensitivity in liver and muscles

T2D - Risk Factors

• Obesity (major predisposing factor)

• Family history of diabetes

• Higher prevalence in:

  • African, Hispanic, Asian, Native American populations

• Lifestyle factors:

  • High fat and carbohydrate diet

  • Physical inactivity

• Associated condition:

  • Polycystic Ovary Syndrome (PCOS)

T2D - Onset & Diagnosis

• Often appears during puberty

  • Due to increased insulin resistance from sex hormones

• Diagnosis may be difficult initially:

  • Symptoms overlap with T1D

T2D - CM

• Urine findings:

  • Glucose present

  • Few or no ketones

• Symptoms (often mild):

  • Less pronounced polyuria (urination)

  • Less pronounced polydipsia (thirst)

T2D - Key Physical Sign

• Acanthosis Nigricans

  • Present in ~90% of children with T2D

  • Appearance:

    • Dark, shiny, thickened skin

Common locations:

• Neck (“dirty neck”)

• Axilla (armpits)

• Between fingers and toes

T2D - Screening Recommendations

• Screen children who have:

  • Family history of T2D

  • High-risk ethnicity

  • Signs like acanthosis nigricans or hypertension

Method

• Fasting blood glucose test

Timing

• At puberty

• Every 2 years thereafter

T2D - Complications (Long-Term)

• Atherosclerosis → poor circulation

• Kidney disease

• Poor wound healing

• Vision problems/blindness

Cause

• Chronic hyperglycemia → blood vessel damage