The purpose of Practical Pediatrics is to offer providers current information relevant to the care of infants, children and adolescents in the outpatient setting. Following the presentations, attendees should be better able to:
Review factors associated with teen driver crashes.
Describe the evidence for improved outcomes with the patient-centered medical home model.
Interpret commonly ordered rheumatologic laboratory tests.
Recognize and manage dermatologic disorders.
Review the epidemiology of pertussis in the United States and North Carolina.
Review current U.S. Medical Eligibility Criteria for contraception for pediatric and adolescent populations.
Review the importance of motor vehicle crashes as a leading cause of child injury and death.
Discuss MOC Part 4 requirements for quality improvement.
Discuss managing a patient with an acute illness and type 1 diabetes.
Review the common clinical manifestations of spina bifi da in children.
Describe the trends in designer drugs of abuse nationally and regionally.
Review criteria for autism spectrum disorders from the DSM-V.
Review the evaluation for microcytic anemia.
Submit a question SPEAKER 1: So I'm starting with just a quick case here. This is an 8-year-old with known type 1 diabetes who comes to your office sick. She has been throwing up for the past 24 hours, and her parents are worried. And you are kind of worried too. So with that, we'll actually stop for one second and actually look at our objectives. And I have a confession to make. I made objectives for this back six months or so ago when it was asked, promptly forgot about them, and then about a month ago, I asked some friends who are pediatricians, what do you want to learn about type 1 diabetes? What do you want to know? And then I made this presentation based on the feedback I got from them. So I hope that this is really useful to you and really helpful. But the objectives here may not match what's in your syllabus from prior, at least for the evaluation. So we're going to talk about sick days in diabetes. We're going to talk about preventative care in type 1 diabetes. Co-morbidities. And then those teenager things-- sex, drugs, alcohol-- you know, all that kind of good stuff. And just in case I need it, I don't have any conflicts of interest to disclose that I know of. I kind of wish I did. But not really, so-- if you have opportunities for me, let me know. Anna, that's my pager. I'm on call. I have somebody covering, but if you have it, just in case, that would be great. Thank you. So back to our first case. This is an 8-year-old, we said, who's been sick. She's been throwing up for 24 hours, and her parents are worried. What are some key questions to ask? This is open time for you guys to talk, and hopefully keep your brains moving at the end of the day. SPEAKER 2: Do you know your sick day planner [INAUDIBLE]. SPEAKER 1: Great. Do you have a sick day planned? And do you know what you're supposed to do, what else? SPEAKER 2: [INAUDIBLE] SPEAKER 1: Do you have ketones? Yeah, what are your blood sugars? What other general [INAUDIBLE] questions would you want to know? SPEAKER 2: [INAUDIBLE] SPEAKER 1: Yeah, is she keeping anything down? How are things going? Exactly. So these are the questions I came up with. You probably also have additional ones. But my thoughts are is she peeing, right? You know how dehydrated is she? Is she keeping anything down? How is it going? Is it getting better, worse, about the same? And then from a diabetes standpoint, what have her blood sugars been? Are they low, are they high? Have they been OK? Does she have ketones? And has the family contacted the diabetes team, or do they have a sick day plan that they're following? So to start we'll talk about the ketones. Ketones are produced by all of us. When you use up your glycogen stores, you break down fat as an energy source and we make ketones. We all make ketones. And this is common in the setting of an illness where you've been throwing up for 24 hours and things like that. Of course, with kids with diabetes though, they make ketones when they don't have enough insulin around, right? So if they don't have enough insulin, then they're going to break down ketones as an energy source as well. So when you have a child with Type 1 diabetes who's been sick and throwing up, they have two potential reasons to develop ketones. And it doesn't matter why they developed them, but ketones makes you insulin-resistant and that can then increase your risk for DKA. And so ketones are really key for our kids with diabetes, knowing what they are and then what to do for them. So we take those ketones. We put them in context of the blood sugar. What has the blood sugar been? Has their blood sugar been high? Is it over 200? Is it really high? Is it just reading high on their meter? And do they have ketones with that? And if their blood sugar is high then that means, of course, that they need more insulin around. And if they have ketones, then they need even more insulin. And so there's a little formula that we use for ketone dosing and somebody with diabetes who has high blood sugars. And it's 0.1 for kilo. And so if I don't know their kilos, I just ask the family what is their weight in pounds. Divide that by 2, because that's going to get you pretty close, and take a tenth of that. And that gives me a pretty good dose for them to know, OK, how much extra insulin should you need above and beyond what you should do for your blood sugar. If they have normal blood sugars that can be really challenging, particularly if they have ketones. Because the ketones mean you need more insulin, right? But if your blood sugar is 120, how can you give somebody more insulin if they can't keep food down, and you can't give them carbs to go with that extra insulin? And so that can be really challenging to be able to give them the insulin that they need when their blood sugars are actually normal. Now if they're starting to get better, and you think they're turning the course, then that's something that we may be able to work with. That doesn't necessarily mean that they have to go to the hospital. But certainly it can make it a little bit more challenging. And then the scenario that's probably the most challenging is the low blood sugars. So if a child is throwing up, they can't keep anything down, and their blood sugar's low, then that actually really can be quite dangerous, right? So we try using things that you guys use as well to try to get fluids into somebody when they're throwing up, and they can't keep something down. So you might try popsicles or maybe icing, just on the tongue, to see if they can absorb. Then what we'll sometimes do is use mini-dose glucagon. And that's what I have up there for you. And so you know that we use glucagon in the setting of severe low blood sugar. And that's typically used in such a way that we give a big dose one time intramuscularly, and it raises the blood sugar up significantly. In this setting, we don't want to give them a big whopping dose and we don't want to get them an IM shot. And so we have them reconstitute the glucagon as it says in their kit, and then they use an insulin syringe. And they drop the glucagon with the insulin syringe. And the dosing is from two to 15 units, and it's based on their age. So two and under use two units. And then it's one unit per age up to 15 years, and 15 and beyond is 15 units. And that's something that you can do to give them a small dose of glucagon to help bring that blood sugar up, which may then give you enough time to turn the vomiting around, to prevent them from having to come into the hospital. And families can do that at home, which is nice, too. We generally say if they're thinking about doing that, that they should be talking to us about that, so that we know what's going on and can help them as well. It can also be given an additional time. So they can do it once, bring the blood sugar up as it comes back down again. They can do it again, too. So a couple of things that we can do to try to keep them from having to be admitted, if possible. So what can you do in the office? You've got the information now. What are the things that you guys can do? SPEAKER 2: Check your ketones. SPEAKER 1: Check for ketones. Yeah. Check the blood sugar. And the big thing that I actually want you to do is assess. So I want you to you use your clinical judgment. Look at the child. How do they look? Is this a sick kid, a not sick kid? Do they look like they might have DKA? Are they Kussmauling? How dehydrated do they look? You know that assessment is so important to be able to get a sense of where do they need to go. And it really helps that with the next slide, which is the communication part of things. Have they talked with us or not. So if they've talked with us, they should be able to come to you with a plan and say, this is what I've talked to our diabetes provider and this is what they recommend and this is what we're doing. And it should make sense. It shouldn't be something completely weird or unusual to you. But if they haven't, then contacting us is greatly appreciated. We want to know what's going on, and we want to be able to help you triage them and know what's best to do for them, too. And so from my standpoint, if I'm talking to you, it's great for me to have your assessment and know how you think they look, how sick they look. And that helps us know can we send them home with some really good instructions and follow up, or really should they go to the ER or not. And so letting us know and letting us hopefully work with you guys to get a good plan for the family is really key. And we really appreciate that. So we're hoping it's spring, right? I like to use some pictures to interject throughout my talks, just to give it a little break. And when I was thinking about pictures, I first was looking at some pictures from Lake Tahoe. And I was like, no, we cannot look at any more snow. So these are dahlias that were taken a few years ago at a dahlia farm in Oregon, between Portland and Salem. And I was going to write down the names of them for you in case you're interested, and I forgot. And so if you really want to know what they are, let me know later and I can get you what they are. So this is one of the dahlias. And hopefully we'll all see these in the near future. I haven't looked at the 10 day forecast, I'm afraid to. So, I don't know. So Case 2-- a 12-year-old comes in with well-controlled diabetes, and for a quote "sinus infection". Parents are concerned about a sinus infection. He's had congestion for a week with no significant fevers. And the parents, of course, they think he needs antibiotics because he has diabetes. What do you guys think? Does he need antibiotics because he has diabetes? No, no, of course, not. So I would say, no, treat him as you would any other child. This to me sounds more like just upper respiratory infection, a cold. Course I made the case-- so it's whatever I want it, right? But we're going to say it's a cold. And we know that being sick and colds and things like that can cause some higher blood sugar. So that's certainly something to think about in this child is how their blood sugar has been affected by their illness. And you can make insulin doses for that. Typically we think of increasing their basal insulin either the Lantus or the basal rates on their pump by about 10%. And that's kind of a good rule of thumb that can be used to make an adjustment to help out with that. And when it comes to the pump, it can actually be done for a temporary period of time. So the pumps all have settings whereby the parents can tell the pump to give them a little extra insulin, the initial 10% for x number of hours, and then that's a way that they can get some extra insulin help with those blood sugars during that time period. The other thing of interest is that some antibiotics will actually seem to increase blood sugars in kids. And amoxycillin seems to be one of the classic ones that I've seen in some of my patients. They would say, their blood sugar has been doing pretty good. Things have been going OK. They got an ear infection and it was fine. And they got amox and now their blood sugars are high. I'm like, well, take your amoxycillin. Take the full course. And they'll come back down once you come off that. And here's an insulin adjustment to try to help with those blood sugars in the meantime. So antibiotics are not needed unless she would treat them with antibiotics if they didn't have diabetes as well. Case 3 is a 10-year-old who comes to your office for redness and swelling at the last pump site. She thinks she wore her set an extra day-- four days instead of three, oops. So should you do anything special for this child because she has diabetes? And just to make sure you guys know-- so the pump site is where the pump is connected to the patient. It's a really small catheter, basic little IV tubing, but really tiny, that just goes in the sub-cu tissue. And they typically stay there for three days. And we have found if the kids wear them a little bit longer, then they can sometimes have little infections at the site. So you do sometimes see that. And I will tell patients-- wash it. Use an over-the-counter, anti-bacterial ointment on it if it's red. And we'll follow it, and if it's getting worse, then see your primary care provider to have them evaluate it. And so I am really using you guys in that manner to assess and decide what do they need. So for her, I wouldn't necessarily automatically give her antibiotics again in this case. We think about, in older people, having increased risk for infections and problems with their skin with diabetes. But in our kids who have diabetes, I don't find that they have more problems with infections or clearing infections of the skin at all. They tend to do just fine. Every once in a while the older adolescents who've had diabetes for a long time and maybe not very well-controlled will have some skin issues. But a typical kind of standard kid with diabetes shouldn't have any problems. So I would treat them as you would anybody else. If this was a child without diabetes who had this looking skin infection, what would you do? Would you do antibiotics or not? And you sure use your judgment for that. And then just cover typical skin flora. You don't need to cover anything special for them as well. And thank you so much for seeing these patients as well for us, so helpful. So another flower to cheer us up. So our fourth case is a 13-year-old with Type 1 diabetes as well, who comes for his well adolescent check. He's had diabetes for just a couple of years. He's done really well. He's accepted the diagnosis. He's taken it on. He's just really doing awesome and his family is supportive and they're just doing a great job. And I can think of actually a number of kids who really fit into this scenario and they're just doing awesome. So he comes to you for his well adolescent check. And so you're getting ready to see him. Is there anything different that you should do for this patient that you wouldn't do for somebody else, one of your other adolescents just because they have diabetes? And this is thinking about kind of preventative care, so kind of going through those steps. So this-- clearly you don't need to memorize this table. Well, maybe you do. I guess you guys have to do this all the time. Sorry. You're good? Excellent. These are brand new. I mean these came out within the past month, from the AP. And so he's 13. So you can see along there, possibly you can see along there, the 13 year old column. All the things you're supposed to do for a 13-year-old-- there's a lot going on there. And so we're just going to step through with the things that are recommended for diabetes as well and what the additional things are. So for a child with diabetes you want to think about the blood sugar control. So do you have a sense of-- do they have good blood sugar control or not? And hopefully the family should be able to tell you this. The family should be to say, oh, yeah, he's been well-controlled . Or oh, no, things have slipped recently, or gosh, no, things really haven't been going well. And as well, the notes that you receive from us should tell you exactly what we think of their diabetes control. We all use pretty standard templates for our diabetes notes. And they say right in them this child has well-controlled or poorly controlled diabetes, and what their A1C targets are. But I also gave this to you so you can see that the A1C targets go down with age. So the younger kids have a higher target because of the risk for low blood sugar. And then that those targets go down as they get older. In some ways, it seems counterintuitive. Because as you know, you go from the younger, typically pretty compliant child, to the older adolescent who may not have as much compliance. We're actually asking them to do more, right? So there is a little of a disconnect there it seems. But we have a good number of adolescents who also do really well and are able to meet their targets. From a blood sugar standpoint and overall safety standpoint-- for their overall health, this is the best recommendation. So for him, he's 13, so his target is technically less than 7.5%. He's actually at an age where it could probably go either way. I could use either less than eight or less than 7.5. He's kind of in a transition time. But he's had well-controlled diabetes. That's what I told you at least. So additional preventative care for Type 1 diabetes is blood pressure. This, of course, is something that you're going to be checking anyways. And the recommendations for our kids with diabetes state that if it's elevated over the 90th percentile, then it should be repeated. And if on three different occasions it's elevated, then treatment should be considered. And if it's between the 90 and 95th percentile, then using lifestyle interventions, diet and exercise are the recommendations. And if it's over the 95 percentile, then starting with actually an ACE inhibitor for that. And I can tell you blood pressure is one of those things-- I don't know if this happens in your clinic. But it's something that I think-- at least in our clinic-- frequently gets missed. You know you're looking at everything. You're looking at all these blood sugars. Then you just overlook that blood pressure. And the patient's gone home. And you look, you say, oh, my goodness, look at that blood pressure. Oh, I missed it was elevated. And so we're trying to check and see, and hopefully you guys are helping us out, too, and looking at those blood pressures and seeing how are those looking. And do we need to be thinking about the blood pressure for this child? The next step is of the next one is lipids which, of course, are also something that you'd be thinking about screening depending on the age of the child. The recommendations depend on when the child is diagnosed. So if they're diagnosed in the prepubertal time period and they have a strong family history of heart disease or younger heart disease, then you're supposed to obtain a lipid panel after their blood sugars are controlled, so after things have gotten under control. If they don't have any additional risk for heart disease, then the screening is what's recommended for all other kids, which is between 9 and 11 getting your first lipid panel, and then screening thereafter based on the results. If they were pubertal at the time of diagnosis, then you want to let them, again, get their blood sugars under control. And then get a lipid level at that time and screen and see where they're at. And then if it's abnormal, you're going to monitor annually and of course, making adjustments for that, right? We'll get to that on the next slide. And if it's normal, then you're going to repeat that every five years. If they have normal lipids, you don't have to screen them all the time. It's really quite actually intermittently. And if they're abnormal, we're really looking at the recommendations, at least from the American Diabetes Association, are based on the LDL. And so if the LDL is greater than 160, then you can think about initiating therapy if they don't have any other cardiovascular risk factors. If the LDL is greater than 130 and they have another cardiovascular risk factor, besides that they have the diabetes, which they all have, then you'd initiate therapy at that time with the goal of trying to get the LDL to less than 100. The first step for trying to treat is improving glucose control. That's an issue. MNT is medical nutrition therapy. I'm sorry I didn't write that out for you guys. I just realized I just used that abbreviation that I'm used to. And then part of that is a Step 2 American Heart Association diet. And this sounds kind of easy. But when you think about it, these kids are already on medical nutrition therapy. They're already thinking about their carbs and what they're eating and things like that. And so adding in thinking about the fat can be a big step, particularly in our teenagers. So this can be challenging if we're thinking about really trying to ramp up some of the dietary recommendations. If that is not sufficient and you've checked again in a year and their LDL is still high, then we go to statins. And statins do carry a pregnancy risk, and so there is a caution in post-pubertal girls. Statins-- they don't have a specific risk in humans. It's really been shown in animal controls or in animal studies. But of course, they are important in cholesterol metabolism, which is really important in the developing fetus. And so it makes sense that that could cause problems. And so the recommendation is not to use statins during pregnancy. So preventative care in our Type 1 diabetics that is specific for the diabetes part of things and that you're not going to find in that big table that you all know by heart-- so the nephropathy screening begins annually after they've had diabetes for five years and they're at least at pubertal age. So if you have a two-year-old who's had diabetes for five years and they're seven, they're not yet pubertal. You would wait until they hit 10 or start having signs of puberty. But if you had say a 10-year-old who was diagnosed with diabetes, then you would wait until 15 before starting the screening. And it's an annual microalbumin that you can just get randomly. You don't have to do anything special. Doesn't have to be 24 hour, first thing in the morning, just a random one is fine. If it's abnormal, then we repeat it in three months. And we tell them to come well-hydrated, because that does seem to make a difference. So say, make sure you drink lots of water before your next visit. We're going to get another urine then. They can repeat it then. And if it's been high on three occasions over at least a six month period of time, and you've been trying to improve blood sugars, of course, then they recommend treatment with an ACE inhibitor. And our ACE inhibitors also have potential reproductive issues with the girls and so we want to be careful along those lines, too. The ACE inhibitors cause problems with kidney development, which leads to oligohydramnios and all the problems associated with that. It can cause skeletal abnormalities, too. So they're really strongly recommended to not be taken during pregnancy. Retinopathy has very similar screenings to nephropathy-- having had diabetes for 3-5 years and being pubertal. What I typically tell all my patients is start getting your eyes examined on a yearly basis. I want them to think about taking good care of their eyes. They don't necessarily need the big retina exam, but they should be seen by an optometrist or an ophthalmologist on a yearly basis and have their eyes examined. And once they've had diabetes for a little while, then they have the more specific testing and evaluation. And then the follow up after that is really based on the eye care professional. Typically annually, but it can be longer if their ophthalmologist said that it can go longer. And then autoimmunity-- so of course these kids are at risk for other autoimmune conditions. So we're looking at thyroid disease. There's variable rates that anywhere from 17 to 30% is what I found of thyroid disease in the context of Type 1 diabetes. So we get a screening TSH, free T4 thyroid antibodies at diagnosis. And then the recommendation is to screen every one to two years. And the thyroid antibodies are really helpful because they're predictable of future thyroid disease. And so if the antibodies are positive, we'll actually follow the thyroid levels every six months instead of every one to two years. And there are some people who have thyroid antibodies and never develop the disease. But it gets us following them and making sure that they're not going to develop something, because I would put them in a high risk category for that. And celiac disease you also screen at diagnosis. I would say probably about 1% of our kids at diagnosis also have celiac disease. I would say-- because it's about one a year and we see about 100 new onsets a year. So we screen at diagnosis. And then there isn't a recommendation how frequently to screen thereafter. So it's really based on symptoms. Are they having symptoms of celiac disease? Are they growing poorly? Any GI complaints, problems with their blood sugars that are unexplained? And these are all kind of typical symptoms that we would then rescreen for. And then they're at risk for other autoimmunity-- adrenal insufficiency, pernicious anemia, others. And those are just screen based on if they develop symptoms or not. There's any not any specific recommendations on frequency for that. So another flower to break things up. OK, I think that one's called firecracker or something like that. So our last case-- you have a 16-year-old with Type 1 diabetes who has had it for eight years. And you can tell from the notes that her diabetes has slipped over the past few years. It's just not as good as it's been. And so there's been some concern about that clearly. So how does the diabetes affect the things that you would normally talk to her and her family about? What additional things might you think about in light of her poorly controlled diabetes? This is where we get to talk about the co-morbidities and those adolescent type things. We're going to start with the sex and alcohol just to keep things interesting, right? So sexual activity-- this doesn't have to be the full-blown thing, making out works out, too. It tends to cause low blood sugar. Everyone thinks, oh, no, it's a stress-- it's going to raise the blood sugar. For whatever reason, it doesn't. It typically causes lows. So I do try to warn the teens that make sure you have low blood sugar treatment with you, things like that. The important thing really from this standpoint is the pregnancy. We really want to avoid unplanned pregnancies if possible because of the risk to the fetus. You really need to have well-controlled diabetes before you get pregnant to decrease the risk to the fetus over time. And so that you really, really try to minimize unplanned pregnancies. And interestingly, for whatever reason, the rates of contraception use are lower in girls with Type 1 diabetes. But they're as sexually active as their peers. So this is a place where we can actually probably have some improvement if we think about being really on top of the contraception, which you guys heard about earlier today. And then alcohol has all kinds of issues for our teens, right? But then when you add in diabetes, it just adds a whole other level of complexity. I knew someone from camp, one of the counselors from camp says, you know, drinking beer is like drinking a bagel, because it has so many carbs in it. And so there's a lot of carbs in it, which can cause high blood sugar. But also the alcohol affects how you respond to low blood sugar and can mask the symptoms of low blood sugar. And people can just think you're drunk and not low. And so that puts you at risk for severe low blood sugar as well. So there's a lot of risk with drinking that I try to talk to our teens about to let them know that they really do need to be careful. And I, of course, tell them not to drink before they're 21. But we know that some do. And so try to increase awareness and hopefully also help the parents be aware too, which I think can be helpful. We all know that tobacco is not good for us, for lots of reasons. But with the Type 1 diabetes, you have another cardiovascular risk factor, you add tobacco on that makes things all the more worse. And as well, tobacco seems to increase the risk for microalbuminuria, which increases your risk for nephropathy and that's never a good thing. Marijuana is actually interesting. If you Google marijuana and Type 1 diabetes, you will see all kinds of links for how marijuana is good for your blood sugar. I didn't look into the scientific part of that, if there's any scientific basis behind that. What I can tell you is that my patients who smoke pot don't have well-controlled diabetes. You know I just think it probably applies along a lot of levels, they probably don't have as good grades either in general and things like that. So it just, as I said, someone who's smoking pot probably doesn't care a lot about their diabetes, if they're a frequent or regular pot smoker. So is it better or does it help your blood sugars? I don't know. But does it help your diabetes? Not really, not so much. There are co-morbidities that are associated with diabetes. And one of them that we don't talk about much is actually just diabetes-related stress. And so up to half of patients report that their diabetes is a stress in their life. And you can think of why. You're a teenager. You've got a lot of stuff going on and then you add on all the complexities and all the different stuff you've got to do for diabetes. And it's a lot, and I don't want to downplay that at all. We're really asking these kids to do a lot. And so it can cause stress in even the ones who seem like they just don't care at all. And they just don't give a rip. A lot of them will have stress about their diabetes. They may be worried about what they're doing to themselves, worried about their control. They might not like the interactions they're having with their family or their friends about diabetes. Or they've had their co-workers say, you know, oh, you can't do this or that because you have diabetes. They may be worried about complications. It's not a good motivator for change for adolescents, but they may worry about what are they doing to themselves in the future. And even though we try to give them goals or help them come up with goals for their diabetes care, they may not have a good sense of what they should be doing and that can lead to stress as well. And all these reasons for stress are linked to poor diabetes control and compliance, which then, of course, worsens outcomes in the long run. And so thinking about asking the adolescent with diabetes, how is it going for you? How are you thinking about diabetes? How are you dealing with it? Just a really general question along those lines can give them a chance to hopefully express a little bit of this if this is what's going on. Anxiety is a common psychiatric disorder in the general population, as well on diabetes. And with diabetes, a lot of times anxiety is related to low blood sugar. And so if somebody is really anxious about having lows, or they've had a severe low and they don't want to repeat that again, then you find that they start doing things to prevent themselves from having lows and that can certainly lead to poor diabetes control. As well-- some people even though they take shots lots and lots and lots-- can have quite a fear of shots. And then really try to kind of avoid them, of course, then. Or that leads to panic attacks and this can be something that really prevents good control as well. So recognizing and treating anxiety is, of course, important for a diabetes management, but also I think typically for their overall health. Because if they're anxious about diabetes, they probably have anxiety about other things, too. Depression is another co-morbidity that comes more frequently with our patients with diabetes. Up to a third of our adolescents will report some symptoms, at least. And it really affects their overall care. All the studies show that when you have depression in diabetes that you just don't take as good a care of yourself. And that makes sense when you think about it. And so screening for diabetes and treating it is really key to trying to help out, particularly in the setting of compliance and trying to improve compliance with our teenagers. Sometimes I find that families are not as open to it, to treating depression or looking for it. They want to say, oh, they just have diabetes and it's hard and you know. There isn't anything else going on. But if their depression scores are coming up high and stuff, you don't really want to ignore it. You don't want to say, oh, this is just diabetes. Go ahead and really work with the family to try to get them to get the child help. And diabulemia-- which is a term for eating disorder in kids with diabetes-- this is much more common in our kids with diabetes, eating disorders are, and can cause a lot of problems. You can see a third of females struggle with some of the subclinical symptoms of it. They may restrict what they eat. They may have preoccupations with weight and their shape, guilt after eating. And the one that we think about, which is where the term diabulemia comes from, is skipping insulin for weight control. So it's a way of binging, right? So you eat a bunch, you don't take insulin. That means you don't absorb those calories, you don't have to put that weight on. So it's a way of binging, and that's where that term comes from. And up to 60% of girls will try to lose weight with unhealthy weight control habits and behaviors. And the eating disorders have a vicious cycle. So it starts off with negative feelings about weight, shape, and body that lead to depression and anxiety, which causes higher blood sugars. So you don't take as good a control of you diabetes, which leads to poorer control, insulin restriction, then you have more negative feelings. And you can see the cycle continues. And as I alluded to at least, eating disorders are associated with worse control, reduced compliance. And it's also associated with depression. And then you can have increased risk of DKA and of microvascular complications from the poorer control. And of course, skipping insulin or anorexia in the setting of diabetes really can be a life-threatening complication. So this is really something that we want to screen for. So I have some warning signs that we can all try to look for so that we can pick up these girls. So unexplained elevations in A1C levels, repeated occurrences of DKA, extreme concerns about their weight and body shape or changes in their eating patterns that are concerning to you, unusual periods of intense exercise, and amenorrhea. So they start skipping their periods. So these are all the warning signs. A lot of them overlap with our other girls, but they're some of the diabetes-specific ones, too. And then driving-- I made this slide before I noticed in your schedule that you had a couple of lectures on driving. So I hope what I say here doesn't conflict with anything that you have already been told. So I think of driving as a privilege, not a right. And I tell our teens that, when they think that they should just be able to get their driver's license. And that there are inherent risks associated with driving that they don't always seem to understand or comprehend. Some of them do. Some of the adolescents, right, are really responsible and really worried about causing any harm with the car and some clearly are not. And unfortunately, diabetes and driving can be a lethal combination. And so we really want to be careful with our kids when it comes to driving and making sure that they're going to be as safe as possible. So the DMV requires that a medical form be filled out if you have diabetes that states whether you're compliant with your regimen, and if you have hypoglycemia awareness or not. And we use an A1C cut off of less than 10% as a way to indicate compliance. Now if you think back, if you're a teenager who's old enough to drive your A1C should be less than 7.5. So we're not saying that they have to be at goal, we want something to show that they're at least on a regular basis getting their insulin. And I've had a number of teens who are trying pretty well, they just aren't getting their A1Cs down. They're in the 8% or 9% range. So we figure that that shows sufficient compliance that they should be allowed to drive. But we also want to make sure that they also know what it feels like to be low. And they need to check a blood sugar before they drive. And I tell them this, and I document it-- that they have been told that they must check their blood sugar before they drive their car to make sure their blood sugar is safe before driving. If they've checked a blood sugar in the past hour, I tell them that's sufficient. But if it's been longer than that, they need to check a blood sugar. They have to carry a low blood sugar treatment with them in the car. If they feel low, they should stop. You know, pull over of course first, pull over and stop if it's at all safe. And treat their low blood sugar. Get their blood sugar up before they continue driving. And if they're at a place where they can't pull over, which happens-- then treat and pull over as soon as possible and check and see where they're at. I liken driving low as driving drunk and most kids have been told enough that driving drunk is a bad thing that they understand that analogy. And I tell this in front of the parents so that the parents know that as well, too. I also tell the parents what does your child need to do, what does your teen need to do to be allowed to drive. Do they have to maintain certain grades, are there things that you want them to do to have the privilege of driving? And one of those things can be diabetes. You can have them have a lower A1C goal for your family to drive. That's OK. So most parents will use the ten. But I've had some who have chosen have a lower A1C requirement for their child to drive. I think diabetes is like an extra class in school. And so if someone's really doing poorly, I ask the parents, well, if they were failing their math class in school, what would you do? What would you do to try to help them? Would they not be able to do certain things? What are you going to do to get that grade up? And then apply that to diabetes as well. And so that's where I think this kind of overlaps that. So you can see my references are nice and up to date-- 2014 from the American Diabetes Association, and one from the Joslin. And thank you. And I will certainly take any questions that you have.