Parents of children with Type 1 DM are not often aware of the danger symptoms of an imminent DKA episode, and hence children end up getting hospitalized. It can be prevented by proper education of the parents and the child. How much time do you spend on this?. What would you all advise?
We do this very regularly, at almost every visit. I have even designed a card to reflect the principles of sick day management that we give to patients each year. We particularly try to focus extra re-education around the winter season when DKA episodes seem to spike (though they can occur at any time). If you go to this website: http://www.childrenshospital.vanderbilt.org/services.php?mid=10248
you can see some comprehensive sick day guidelines. If you click on the link "Coping with Flu Season" you can also obtain the post-card i mentioned above. You are welcome to use it to create your own teaching tool. I think a reference card is valuable.
Dear Daniel, yes- I feel it is a very good approach you are taking towards this problem. A card would indeed be a most valuable tool.
It was interesting about your statement on DKA peaking during winter season- Here in my district too, we have observed cases coming in mostly during the months of August- October. What would you think are probable factors affecting this?
In the winter, i think infectious illness compounds the insulin insufficiency (many DKA patients are not fully compliant). Depending on your viral seasons, you may see a similar affect. Sometimes we also see a blip in summer when school is out leading to less supervision and structure; the decrease in structure may further impair adherance.
That's a reasonable deduction- yes, the higher incidence of viral illnesses do seem to correlate with the DKA spikes.
A few patients whom I know come from families with severe financial constraints who do not have the luxury of purchasing a pen delivery device, and instead have to rely on the traditional insulin syringe- which they hate, and do not allow parents to administer the doses.
What is the frequency of follow up you advise for children?.
We generally see our patients every three months. Patients that miss many follow-ups also tend to have more DKA episodes. Likely, this relates to lower socioeconomic status. This may be what you see with your users of pen needles--that they are of higher SES than those using vials/syringes and possibly have better insurance. To try to improve access to medical guidance, we also answer phone calls from patients 24 hrs a day, 7 days a week. A nurse responds Monday through Friday during the day and a physician at night and on weekends. We encourage patients to call with concerns about diabetes and if they are sick with high ketones. Sometimes we can take corrective actions that prevent DKA admissions when families call during early signs of illness.
As a dentist, I spend five to ten minutes discussing nutrition and home dental care for parents of these children each visit. Each education setting should be documented. Follow up of outcome is also recorded on next visits.
Yes, nutritional counselling is of extreme importance indeed. Not many physicians take the time to counsel the parents about the diet of the child.
It also helps if a proper 'Insulin Diary' is maintained. I have started applying this practice and one can reasonably track the developments of the child. The parents are taught to track monthly weight, Insulin dosage, hospitalization details, Fortnightly blood sugar levels.
it also serves as a ready reference for any physician who would be involved in future care of the child.
A good dietitian can also prepare a customized diet chart for the children based on their liked foods- which is very important since available dietary components vary a lot depending on where one comes from. It does take some time, but in the end it is really worth it.
It was indeed very heartening to find that the time invested in counselling and educating the parents of a child with T1DM helped in saving the child's life.
During one of the earlier sessions, I had provided the ready reckoner for T1DM patients to the parents of a 9 year old girl, and they were very quick in picking up the warning signs in their child during a subsequent episode- and in turn brought the child to the hospital for prompt treatment.
My profound thanks to Daniel Moore for providing the link to the excellent Q&A page.
I would suggest everyone handling such patients to provide them with ample literature on the condition- it helps a great deal in identification of a potentially serious condition, and early treatment initiation.
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