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CDE Diabetes

Flashcards: Diabetes and Pregnancy (Chapter 36)

Pregnancy acts as a metabolic stress test, and hyperglycemia during this critical period carries significant risks for both the mother and the developing fetus. The 2018 Clinical Practice Guidelines provide rigorous standards for pre-conception counseling, screening protocols, and tight glycemic targets to ensure the best possible start for the next generation.

This practice exam tests your ability to navigate the specific diagnostic algorithms for Gestational Diabetes Mellitus (GDM), manage complex insulin regimens during changing physiology, and ensure appropriate postpartum follow-up.

Key Concepts Covered in This Exam:

  • Pre-conception Care: Mastering the checklist for women with pre-existing diabetes, including the recommendation for 1 mg of folic acid daily and achieving an A1C target of 7.0% (optimally 6.5%) prior to conception.

  • Screening & Diagnosis: Differentiating between the “Preferred” Two-Step Approach (50g screening followed by 75g diagnostic OGTT) and the “Alternative” One-Step Approach.

  • Glycemic Targets: Memorizing the strict targets during pregnancy: Fasting/preprandial <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L, and 2-hour postprandial <6.7 mmol/L.

  • Pharmacotherapy: Identifying insulin as the first-line therapy for GDM and understanding the specific limitations and placental transfer of oral agents like metformin and glyburide.

  • Postpartum Follow-up: Recognizing that women with GDM are at high risk for developing Type 2 diabetes and require screening with a 75g OGTT between 6 weeks and 6 months postpartum.

Categories
CDE Diabetes

Practice Exam: Diabetes and Pregnancy (Chapter 36)

Pregnancy acts as a metabolic stress test, and hyperglycemia during this critical period carries significant risks for both the mother and the developing fetus. The 2018 Clinical Practice Guidelines provide rigorous standards for pre-conception counseling, screening protocols, and tight glycemic targets to ensure the best possible start for the next generation.

This practice exam tests your ability to navigate the specific diagnostic algorithms for Gestational Diabetes Mellitus (GDM), manage complex insulin regimens during changing physiology, and ensure appropriate postpartum follow-up.

Key Concepts Covered in This Exam:

  • Pre-conception Care: Mastering the checklist for women with pre-existing diabetes, including the recommendation for 1 mg of folic acid daily and achieving an A1C target of 7.0% (optimally 6.5%) prior to conception.

  • Screening & Diagnosis: Differentiating between the “Preferred” Two-Step Approach (50g screening followed by 75g diagnostic OGTT) and the “Alternative” One-Step Approach.

  • Glycemic Targets: Memorizing the strict targets during pregnancy: Fasting/preprandial <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L, and 2-hour postprandial <6.7 mmol/L.

  • Pharmacotherapy: Identifying insulin as the first-line therapy for GDM and understanding the specific limitations and placental transfer of oral agents like metformin and glyburide.

  • Postpartum Follow-up: Recognizing that women with GDM are at high risk for developing Type 2 diabetes and require screening with a 75g OGTT between 6 weeks and 6 months postpartum.

1. Case: A woman with pre-existing diabetes at 34 weeks gestation requires betamethasone for fetal lung maturation. According to the recommended protocol, how should insulin doses be adjusted on Days 2 and 3 after the first dose?

2. Why is glyburide NOT recommended as first- or second-line treatment for GDM according to current guidelines?

3. What is the most common form of monogenic diabetes identified during pregnancy in Canada?

4. What minimum duration of breastfeeding is recommended for women with gestational diabetes to help prevent childhood obesity and diabetes?

5. According to the preferred screening approach for gestational diabetes, what glucose challenge test (GCT) value is diagnostic for GDM without requiring further testing?

6. Case: A woman with type 1 diabetes on CSII (insulin pump) is in active labour. She and her partner are comfortable managing her pump. What is the most appropriate recommendation regarding insulin delivery during labour?

7. Which rapid-acting insulin analogue has been studied in a randomized trial of 322 pregnant women with type 1 diabetes and shown to reduce episodes of major hypoglycemia?

8. What is the incidence of hypertension complicating pregnancy in women with type 1 and type 2 diabetes?

9. A woman with type 1 diabetes has just delivered. How should her insulin doses be adjusted in the immediate postpartum period?

10. Case: A woman with pre-existing diabetes has severe nonproliferative retinopathy. She is planning pregnancy. What preconception intervention reduces the risk of visual impairment during pregnancy?

11. Case: A woman with GDM has been on nutritional therapy for 2 weeks. Her fasting blood glucose levels remain at 5.8-6.2 mmol/L and 1-hour postprandial values are 8.5-9.0 mmol/L. What is the most appropriate next step?

12. Case: A 28-year-old woman with a BMI of 23 kg/m² is diagnosed with diabetes at 26 weeks gestation. She has no risk factors for GDM, negative autoantibodies, and her mother and maternal grandmother were both diagnosed with diabetes before age 30. What is the most appropriate clinical reasoning?

13. What is the target blood glucose range during labour and delivery in women with diabetes to minimize neonatal hypoglycemia?

14. According to the guidelines, what is the recurrence rate of gestational diabetes in subsequent pregnancies?

15. A diabetes educator is counselling a woman with newly diagnosed GDM about evidence-based dietary approaches. Based on current meta-analyses, which dietary intervention has demonstrated reduced insulin use and lower newborn weight without increasing SGA?

16. A woman at 25 weeks gestation has a 50g glucose challenge test result of 8.5 mmol/L. What is the next appropriate step?

17. Using the preferred 2-step screening approach, what fasting plasma glucose value on a 75g OGTT would diagnose gestational diabetes?

18. After 16 years of follow-up, what percentage of women with prior gestational diabetes will develop type 2 diabetes?

19. Case: A woman with type 2 diabetes becomes pregnant while taking glyburide and metformin. What is the most appropriate management of her diabetes medications?

20. A clinical team is debating the preferred vs. alternative GDM screening approaches. Which statement best reflects the key difference between these approaches?

21. Case: A woman with GDM at 36 weeks gestation asks about timing of delivery. Her blood glucose is well-controlled on diet alone with no comorbidities. What is the recommended timing of delivery?

22. Case: A 32-year-old woman with type 1 diabetes is planning pregnancy. Her current A1C is 8.2%. She is taking lisinopril for mild hypertension and atorvastatin for dyslipidemia. What is the most appropriate preconception recommendation?

23. What percentage of women who conceive on metformin will ultimately require add-on insulin therapy to achieve adequate glycemic control during pregnancy?

24. Case: A 38-year-old woman with a BMI of 34 kg/m², prior GDM, and a mother with type 2 diabetes is at 10 weeks gestation. What early screening approach is recommended?

25. Case: A woman with type 1 diabetes at 8 weeks gestation has experienced two severe hypoglycemic episodes. Which factors are predictive of severe hypoglycemia during pregnancy?

26. Case: A pregnant woman with type 1 diabetes at 28 weeks gestation has a sudden 20% decrease in insulin requirements over 2 weeks. What is the most appropriate clinical consideration?

27. Case: A woman with type 1 diabetes asks about retinopathy monitoring during pregnancy. What ophthalmological assessment schedule is recommended?

28. What is the recommended postpartum screening test and timeframe for women who had gestational diabetes?

29. What is the fasting plasma glucose target for pregnant women with gestational diabetes?

30. What is the target A1C recommended by Diabetes Canada for women with pre-existing diabetes during pregnancy, if it can be safely achieved?

31. Case: A woman with type 1 diabetes is considering pregnancy but has an eGFR of 55 mL/min/1.73 m² and significant proteinuria. Based on current evidence, what counselling about pregnancy and renal function is most accurate?

32. What is the first-line therapy for gestational diabetes according to Diabetes Canada guidelines?

33. A diabetes educator is developing patient education materials about breastfeeding for women with type 1 diabetes. Which statement about breastfeeding and diabetes medication is most accurate?

34. What folic acid supplementation dose is recommended for women with pre-existing diabetes planning pregnancy?

35. A healthcare team is reviewing evidence on GDM prevention. Which intervention has demonstrated a significant 60% reduction in GDM development in one randomized controlled trial?

36. At what gestational age should ASA 81 mg daily be started in women with pre-existing diabetes to reduce the risk of preeclampsia?

37. Case: A woman with prior GDM has a postpartum 75g OGTT showing impaired glucose tolerance. She asks about strategies to prevent progression to type 2 diabetes. Based on evidence, what interventions have demonstrated benefit in this population?

38. At what gestational age should all pregnant women without known pre-existing diabetes be screened for gestational diabetes?


 

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CDE Diabetes

Study Guide: Diabetes and Pregnancy (Chapter 36)

1. Overview & Classification

Pregnancy is a state of increased insulin resistance. Hyperglycemia during pregnancy increases risks for both mother (preeclampsia, C-section) and baby (macrosomia, shoulder dystocia, neonatal hypoglycemia).

Classification:

  1. Pre-existing Diabetes: Type 1 or Type 2 diabetes diagnosed before pregnancy.

  2. Gestational Diabetes Mellitus (GDM): Glucose intolerance first recognized during pregnancy.

2. Pre-Conception Care (Pre-Existing Diabetes)

For women with Type 1 or Type 2 diabetes, care begins before conception to minimize congenital malformations (which occur in the first few weeks).

  • A1C Target: Aim for 7.0% (ideally 6.5%) prior to conception.

  • Supplements: Start Folic Acid (1 mg/day) 3 months pre-conception to prevent neural tube defects.

  • Medication Review: Stop potentially teratogenic drugs:

    • ACE Inhibitors / ARBs.

    • Statins.

  • Screening: Assess for complications (retinopathy, nephropathy) as pregnancy can worsen them.

3. Diagnosis of GDM (The "Preferred" vs. "Alternative" Approach)

This is a high-yield exam topic. Canada suggests a “Preferred” 2-step approach but allows an “Alternative” 1-step approach. Screening typically occurs at 24–28 weeks gestation.

A. Preferred Approach (Sequential 2-Step)

  1. Step 1 (Screen): 50g Oral Glucose Challenge Test (non-fasting).

    • < 7.8 mmol/L: Normal.

    • 7.8 – 11.0 mmol/L: Indeterminate Go to Step 2.

    • 11.1 mmol/L: GDM Diagnosed (No further testing needed).

  2. Step 2 (Diagnostic): 75g Oral Glucose Tolerance Test (fasting).

    • Diagnosis of GDM is made if ONE value is met or exceeded:

      • Fasting 5.3 mmol/L

      • 1 hour 10.6 mmol/L

      • 2 hour 9.0 mmol/L

B. Alternative Approach (1-Step)

  • Test: 75g Oral Glucose Tolerance Test (fasting).

  • Diagnosis of GDM is made if ONE value is met or exceeded:

    • Fasting 5.1 mmol/L

    • 1 hour 10.0 mmol/L

    • 2 hour 8.5 mmol/L

4. Management Targets During Pregnancy

Targets are tighter during pregnancy to prevent macrosomia.

ParameterTarget (mmol/L)
Fasting / Pre-prandial< 5.3
1-hour Post-prandial< 7.8
2-hour Post-prandial< 6.7
A1C 6.5% (ideally  6.1% if safe)

5. Management Strategies

A. Lifestyle (First Line)

  • Nutritional therapy is the primary intervention for GDM.

  • Weight Gain: Monitor gestational weight gain based on pre-pregnancy BMI (e.g., Normal BMI 18.5–24.9 should gain 11.5–16 kg).

  • Ketones: Avoid ketosis (starvation ketones) as it may harm the fetus.

B. Pharmacotherapy

  • Insulin: The Gold Standard and first-line pharmacotherapy if lifestyle fails to reach targets within 2 weeks.

    • Safe Insulins: Aspart, Lispro, Glargine, Detemir, NPH, Regular. (Glulisine and Degludec were not standard at time of 2018 guidelines for pregnancy).

    • Dosing: Needs increase dramatically in the 2nd and 3rd trimesters due to placental hormones causing insulin resistance.

  • Metformin: Can be used as an alternative or adjunct. It crosses the placenta.

  • Glyburide: Generally not recommended as first-line due to higher rates of neonatal hypoglycemia and macrosomia compared to insulin or metformin.

6. Intrapartum & Postpartum Care

  • Labor: Maintain maternal glucose between 4.0 – 7.0 mmol/L to prevent neonatal hypoglycemia.

  • Breastfeeding: Strongly encouraged. It reduces the risk of the child developing obesity/diabetes and helps maternal weight loss.

    • Metformin & Glyburide: Considered safe during breastfeeding.

  • Postpartum Screening (GDM):

    • Women with GDM are at high risk for Type 2 diabetes.

    • Test: 75g OGTT between 6 weeks and 6 months postpartum.

7. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S277).

  1. Pre-conception: Women with diabetes should receive pre-conception care (A1C 7.0%, Folic Acid 1 mg) [Grade D, Consensus].

  2. Screening GDM: Screen all pregnant women at 24–28 weeks [Grade C, Level 3].

  3. Diagnosis: Use the Preferred 2-step approach (50g screen 75g diagnostic) OR the Alternative 1-step approach (75g diagnostic) [Grade B, Level 2].

  4. Glycemic Targets: Fasting < 5.3 mmol/L, 1h < 7.8 mmol/L, 2h < 6.7 mmol/L [Grade D, Consensus].

  5. Treatment:

    • Insulin is first-line [Grade A, Level 1].

    • Metformin may be used as an alternative [Grade A, Level 1A].

  6. Postpartum: Screen women with GDM for diabetes between 6 weeks and 6 months postpartum using a 75g OGTT [Grade D, Consensus].

Reference:

Feig DS, Berger H, Donovan L, et al. Diabetes and Pregnancy. Canadian Journal of Diabetes. 2018;42:S255-S282. doi:10.1016/j.jcjd.2017.10.038
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CDE Diabetes

Flashcards: Type 2 Diabetes in Children and Adolescents (Chapter 35)

Type 2 diabetes in children and adolescents is distinct from the adult-onset form, characterized by a rapid decline in beta-cell function and the early appearance of complications. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding targeted screening criteria, diagnostic differentiation, and the specific pharmacologic limitations in the pediatric population.

Key Topics Covered:

  • Screening Criteria: Memorizing the indications for screening: every 2 years starting at age 8 (or puberty) in children with multiple risk factors.

  • Disease Trajectory: Understanding that Type 2 diabetes in youth is more aggressive than in adults, often presenting with hypertension, dyslipidemia, or MASLD at diagnosis.

  • Pharmacotherapy: Identifying metformin as the preferred oral agent for youth in Canada and knowing when to initiate insulin (e.g., for ketosis or severe hyperglycemia).

  • Differential Diagnosis: Recalling when to test for diabetes autoantibodies to distinguish between Type 1, Type 2, and monogenic diabetes.

  • Prevention: Reviewing anticipatory guidance strategies regarding sleep, screen time, and activity to reduce risk.

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CDE Diabetes

Practice Exam: Type 2 Diabetes in Children and Adolescents (Chapter 35)

The incidence of Type 2 diabetes in youth is rising at an alarming rate, presenting a distinct and aggressive clinical challenge compared to the adult-onset form. The 2018 Clinical Practice Guidelines highlight that adolescents with Type 2 diabetes face a more rapid decline in beta-cell function and a higher risk of early complications, necessitating prompt diagnosis and intensive management.

This practice exam tests your ability to identify at-risk youth, apply specific screening algorithms, and implement appropriate pharmacologic and lifestyle interventions.

Key Concepts Covered in This Exam:

  • Targeted Screening: Identifying the specific criteria for screening (e.g., age 8 with 3 risk factors or post-puberty with 2 risk factors) and the recommended interval of every 2 years.

  • Diagnostic Differentiation: Understanding how to distinguish Type 2 diabetes from Type 1 diabetes and monogenic diabetes in the pediatric population.

  • Pharmacotherapy: Identifying metformin as the first-line medication in combination with lifestyle intervention, and knowing when the addition of insulin is mandatory (e.g., severe metabolic decompensation or ketosis).

  • Comorbidity Management: Recognizing the high prevalence of associated conditions such as Polycystic Ovary Syndrome (PCOS), Nonalcoholic Fatty Liver Disease (NAFLD), and dyslipidemia.

  • Psychosocial Care: Acknowledging the critical need for mental health support, as youth with Type 2 diabetes have higher rates of depression and distress compared to their peers.

Please go to Practice Exam: Type 2 Diabetes in Children and Adolescents (Chapter 35) to view this quiz

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Study Guide: Type 2 Diabetes in Children and Adolescents (Chapter 35)

1. Overview & Epidemiology

Type 2 diabetes (T2D) in youth is a growing epidemic, disproportionately affecting specific ethnic groups. It is an aggressive disease with early onset of complications.

  • High-Risk Populations: Incidence is highest among children of Indigenous, African, Arab, Asian, Hispanic, and South Asian descent.

  • Pathophysiology: Characterized by insulin resistance (usually obesity-related) combined with rapid beta-cell failure.

  • Complications: Microvascular and macrovascular complications (nephropathy, hypertension, dyslipidemia) appear earlier and progress faster in youth-onset T2D compared to type 1 diabetes or adult-onset T2D.

2. Screening & Diagnosis

Screening is targeted at high-risk individuals rather than universal screening.

Who to Screen? Screening should be considered every 2 years using A1C (or FPG) in children who have:

  1. 3 risk factors in prepubertal children.

  2. 2 risk factors in pubertal children.

The Risk Factors:

  • Obesity (BMI 95th percentile).

  • High-risk ethnic group (Indigenous, African, Arab, Asian, Hispanic, South Asian).

  • Family history of type 2 diabetes (first or second degree) or exposure to diabetes in utero.

  • Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, NAFLD, PCOS).

  • Note: Screening typically begins at onset of puberty or age 10 years, whichever is earlier.

3. Management Strategies

Management requires an interprofessional approach involving lifestyle and pharmacotherapy.

A. Lifestyle Intervention

  • Goal: Healthy behaviour changes for the entire family, not just the child.

  • Activity: Aim for 60 minutes of moderate-to-vigorous activity daily.

  • Diet: Limit sugar-sweetened beverages, increase fiber, regular meals.

  • Screen Time: Limit recreational screen time to < 2 hours/day.

B. Pharmacotherapy

  • First Line: Metformin is the drug of choice.

  • Insulin:

    • Start insulin immediately with metformin if there is metabolic decompensation (DKA, severe hyperglycemia, unexpected weight loss) or if the diagnosis (T1D vs T2D) is unclear.

    • Once metabolic stability is achieved, wean insulin while introducing metformin.

  • Targets: A1C target is 7.0% for most adolescents.

4. Comorbidities Surveillance

Youth with T2D are at very high risk for comorbidities. Screening should occur at diagnosis and regularly thereafter.

ComorbidityScreening ToolFrequency
HypertensionBP MeasurementEvery visit
DyslipidemiaLipid Profile (Fasting)At diagnosis, then annually
NephropathyUrine ACRAt diagnosis, then annually
RetinopathyDilated Eye ExamAt diagnosis, then annually
NeuropathyFoot ExamAt diagnosis, then annually
Fatty Liver (NAFLD)ALT (Enzymes)At diagnosis, then annually
PCOSMenstrual HistoryEvery visit
OSASleep History

Every visit

Note: This differs from T1D (where screening often starts 5 years post-diagnosis). In T2D, you screen at diagnosis.

5. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S253).

  1. Screening: Targeted screening (A1C/FPG) every 2 years for children with risk factors (pubertal + 2 factors, or prepubertal + 3 factors) [Grade D, Consensus].

  2. Management:

    • Metformin is the first-line oral agent [Grade A, Level 1A].

    • Insulin should be used for severe metabolic decompensation (DKA, A1C 9.0%) [Grade D, Consensus].

  3. Complications: Screen for nephropathy, retinopathy, neuropathy, dyslipidemia, and hypertension at diagnosis and annually thereafter [Grade D, Consensus].

  4. Mental Health: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].

  5. PCOS: Adolescent females with T2D should be assessed for menstrual irregularities and hyperandrogenism [Grade D, Consensus].

Reference:

Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes. 2018;42 Suppl 1:S234-S246. doi:10.1016/j.jcjd.2017.10.036
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CDE Diabetes

Flashcards: Type 1 Diabetes in Children and Adolescents (Chapter 34)

Type 1 diabetes is the most common endocrine disease in childhood and adolescence, presenting unique challenges that evolve as the child grows. These flashcards are designed to help pharmacists and healthcare professionals memorize the 2018 Clinical Practice Guidelines regarding pediatric-specific A1C targets, the prevention of diabetic ketoacidosis (DKA) complications, and the screening schedules for associated autoimmune conditions.

Key Topics Covered:

  • Therapeutic Targets: Recalling the unified A1C target of <7.5% for all pediatric age groups to balance long-term complications with the risk of severe hypoglycemia.

  • Insulin Regimens: Identifying basal-bolus therapy (MDI) and continuous subcutaneous insulin infusion (CSII/pumps) as the standards of care for matching insulin to physiological needs.

  • DKA Management: Understanding the critical protocols to prevent cerebral edema, the leading cause of mortality in pediatric DKA, particularly avoiding aggressive fluid resuscitation.

  • Comorbidity Screening: Memorizing the screening schedule for hypothyroidism (at diagnosis and every 2 years) and celiac disease (at diagnosis and if symptomatic).

  • Monitoring Protocols: Reviewing the recommendation for frequent glucose monitoring (6 to 10 times daily) or the use of Continuous Glucose Monitoring (CGM) to manage glycemic variability.

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CDE Diabetes

Practice Exam: Type 1 Diabetes in Children and Adolescents (Chapter 34)

Type 1 diabetes remains the most common endocrine disease in childhood, with incidence rates rising globally. The 2018 Clinical Practice Guidelines stress that management in this population is uniquely complex, requiring a delicate balance between achieving strict glycemic targets to prevent long-term complications and minimizing the immediate risks of hypoglycemia and diabetic ketoacidosis (DKA).

This practice exam tests your ability to navigate these challenges, from selecting appropriate insulin regimens to managing acute complications and screening for associated autoimmune conditions.

Key Concepts Covered in This Exam:

  • Therapeutic Targets: Mastering the recommendation to aim for an A1C <7.5% across all pediatric age groups, while acknowledging that targets must be individualized based on hypoglycemia risk.

  • Insulin Regimens: Identifying basal-bolus therapy (MDI) or continuous subcutaneous insulin infusion (CSII/pumps) as the gold standard treatments for optimizing control and flexibility.

  • DKA Management: Understanding the critical protocols for treating diabetic ketoacidosis, including the cautious use of fluids and insulin to prevent cerebral edema, the leading cause of mortality in pediatric DKA.

  • Monitoring: Recognizing the need for frequent glucose monitoring (6 to 10 times daily) or the use of Continuous Glucose Monitoring (CGM) to safely manage variability.

  • Comorbidity Screening: Recalling the schedule for screening associated autoimmune diseases, specifically hypothyroidism (at diagnosis and every 2 years) and celiac disease (at diagnosis and symptomatic intervals).

Please go to Practice Exam: Type 1 Diabetes in Children and Adolescents (Chapter 34) to view this quiz

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CDE Diabetes

Study Guide: Type 1 Diabetes in Children and Adolescents (Chapter 34)

1. Overview & Diagnosis

Type 1 diabetes (T1D) is the most common endocrine disease in children.

  • Presentation: Classic symptoms (polyuria, polydipsia, weight loss) are common. However, DKA is the initial presentation in 15-67% of cases.

  • Urgency: Suspicion of diabetes in a child is a medical emergency. Immediate referral and confirmation are required to prevent DKA.

  • Differentiation: While T1D is autoimmune (positive antibodies: GAD, IA-2, ZnT8), Type 2 diabetes is rising in youth.

    • Type 1: Leaner, younger, autoimmune markers, insulin deficient.

    • Type 2: Obesity, acanthosis nigricans, family history of T2D, insulin resistant.

    • Monogenic (MODY): Strong multi-generational family history, negative antibodies.

2. Management Targets

Glycemic targets in pediatrics balance the need to prevent long-term complications with the risk of severe hypoglycemia and the developmental burden of care.

  • A1C Target: 7.5% for all children and adolescents (age < 18).

    • Note: This differs from the adult target of 7.0%.

    • Rationale: To minimize neurocognitive impairment from severe hypoglycemia in young brains while protecting against vascular complications.

  • Intensive Therapy: Basal-bolus regimens (MDI) or Insulin Pumps (CSII) are the standard of care to achieve these targets.

3. Acute Complications: Pediatric DKA

Management of DKA in children differs significantly from adults due to the risk of Cerebral Edema.

  • Cerebral Edema: The leading cause of diabetes-related death in children.

    • Risk Factors: Younger age, new onset, severe acidosis, rapid fluid administration, rapid drop in osmolality.

  • Fluid Management:

    • Do NOT bolus fluids aggressively unless in shock.

    • Rehydrate gradually over 48 hours.

    • Use isotonic fluids (0.9% NaCl) initially.

  • Insulin: Start IV insulin infusion (0.05–0.1 units/kg/h) only 1–2 hours AFTER starting fluid replacement. Do not give an IV insulin bolus.

4. Routine Screening & Autoimmune Comorbidities

Children with T1D are at higher risk for other autoimmune conditions.

  • Thyroid Disease: Screen at diagnosis and then every 2 years. (Hypothyroidism affects growth).

  • Celiac Disease: Screen at diagnosis and then every 1–2 years. (Symptoms: poor growth, anemia, unpredictable hypoglycemia).

  • Complication Screening (Retinopathy, Nephropathy, Neuropathy):

    • Neuropathy and Retinopathy Start Screening: At 15 years of age, provided diabetes duration is 5 years.

    • Nephropathy Start Screening: At 12 years of age in those with duration of type 1 diabetes >5 years

5. Psychosocial & Developmental Stages

Diabetes management must be adapted to the child’s developmental stage.

  • Infants/Toddlers: Parents manage all care. Risk of severe hypoglycemia affecting brain development is high.

  • Preschoolers: Can help pick injection sites but cannot manage tasks. Picky eating makes dosing difficult.

  • School Age: Can perform tasks (testing, bolusing) but require supervision. They cannot be solely responsible.

  • Adolescents: Transition to autonomy but high risk of rebellion, burnout, and eating disorders (insulin omission for weight loss).

  • Transition Care: Structured transition to adult care should begin in early adolescence and occur gradually.

6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S244).

  1. DKA Protocol: Management of DKA should follow pediatric-specific protocols (gradual rehydration, no insulin bolus) to avoid cerebral edema [Grade D, Consensus].

  2. Targets: Target A1C is 7.5% for all children/adolescents [Grade D, Consensus].

  3. Regimens: Children should be treated with intensive insulin therapy (MDI or Pump) matched to food and activity [Grade A, Level 1].

  4. Autoimmune Screening: Screen for Thyroid and Celiac disease at diagnosis and regularly thereafter [Grade D, Consensus].

  5. Complication Screening: Screen for retinopathy, and neuropathy starting at 15 years of age with a duration of diabetes of 5 years. Screen for nephropathy starting at 12 years of age with diabetes duration of 5 years. [Grade D, Consensus].

  6. Psychosocial: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].

  7. Dyslipidemia: Screen at 12 and 17 years of age.
  8. Hypertension: Screen all children with type 1 diabetes at least twice a year

Reference:

Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes. 2018;42 Suppl 1:S234-S246. doi:10.1016/j.jcjd.2017.10.036
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CDE Diabetes

Flashcards: Sexual Dysfunction and Hypogonadism in Men with Diabetes (Chapter 33)

Erectile dysfunction (ED) affects a staggering 35% to 90% of men with diabetes and often serves as a “canary in the coal mine” for silent coronary artery disease. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding screening protocols, the cardiovascular implications of ED, and the safe management of hypogonadism.

Key Topics Covered:

  • Vascular Warning Signs: Understanding the evidence that ED may precede the onset of coronary artery disease, serving as a critical marker for vascular health.

  • Screening Protocols: Memorizing the recommendation to screen all men with diabetes for ED using a sexual function history or the IIEF-5 questionnaire.

  • First-Line Therapy: Identifying PDE5 inhibitors as the first-line treatment and recalling the absolute contraindication for their use with nitrates.

  • Hypogonadism Diagnosis: Recalling the specific requirement for morning total testosterone measurement to accurately diagnose biochemical hypogonadism.

  • Testosterone Replacement: Understanding the indications for replacement therapy—specifically for symptomatic men with confirmed low testosterone—and its potential to improve insulin sensitivity.