Diabetes in children pptx - D. Razzaq

L5 Diabetes in children

Diabetes mellitus in children (type 1 DM ): L5
Definition :Common chronic metabolic disease characterized by hyperglycemia as a cardinal biochemical features .

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Etiological classification of DM

1-Type 1 DM (beta cell destruction )
• Immune mediate
• Idiopathic
2-type 2DM (insulin resistance &deficiency )
• Typical
• Atypical )
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3-enetic defect of beta cell
• Mody (maturity onset diabetes of young )
• Wolfram syndrome (DDMOD diabetes mellitus ,diabetes insipidus optic atrophy &deafness)
• Mitochondrial DNA mutation

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• Thiamine responsiveness megaloplastic anemia with diabetes

4-drug or chemical induced
• L-asparginase
• Anti rejection .cyclosporine …..
• Phenytoin
• Diazoxide
• Beta blockers
• α interferone
5- disease of exocrine pancreas
• Cystic fibrosis
• Trauma to pancreas
• Pancreatitis
6-infection (CMV ,Rubella .HUS)
7-genetic syndromes
• Prader willi syndrome
• Downs syndrome
• Turner syndrome
• Klinefelter syndrome
8-Gestational diabetes
9-Neonatal diabetes
• Transient
• Permanent
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• Type 1 diabetes mellitus :
Insulin dependent or juvenile diabetes characterized by low or absent level of endogenously produced insulin & by dependence on exogenous insulin ; insulin act on movement of glucose into cells to subdue hepatic glucose production & halt movement of fatty acid from periphery to liver

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the natural history include 4 stages :

• Preclinical Beta cell autoimmunity with progressive defect of insulin production
• Clinical diabetes
• Transient remission ,honeymoon period
• Established diabetes

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Its account about 10 % of cases of diabetes affecting >10 million people in the world ,over all incidence of type 1 DM varies from 0.7/100 000 /year [in Pakistan to 40/100 000/year In Finland. Girls and boys are equally effected ,no apparent correlation with socioeconomic status .

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Age incidence ,2 peak group 5-7 yrs and time of puberty .there is a familial clustering inT1DM with prevalence in sibling approaching 6% but in general population is 0.4%in US .
HLA system mostly associated with DR3/4-DQ2/8

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Natural history of diabetes involve some or all of the following stages :

• Initiation of autoimmunity
• Preclinical of autoimmunity with progressive loss of beta cell function
• Onset of clinical disease
• Transient remission
• Established disease
• Development of complications

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Influence of high insulin vs low insulin on some metabolic processes in liver, muscle &adipose tissues :

High plasma insulin(postprandial state )
Low plasma insulin (fast state )
Liver
Glucose uptake
Glycogen synthesis .lipogenesis
Absence of ketognesis
Glucose production
Glycogenolysis
Gluconeogenesis
Muscles
Glucose uptake
Glucose oxidation

Glycogen synthesis
Protein synthesis
Absence of glucose uptake
Fatty acid &ketone oxidation

Glycogenlysis

Proteolysis
Adipose tissues
Glucose uptake
Lipid synthesis
Absence of glucose uptake
Lipolysis & fatty acid release
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Diagnosis

Impaired glucose tolerance
Diabetes mellitus
Fasting glucose 100-125mg/dl

Or

2hrs plasma glucose during OGTT more or equal 140mg/dl but <200mg/dl
Symptoms of diabetes +random plasma glucose more or equal to 200mg/dl
Or
Fasting (at least 8 hr )plasma glucose more or equal to 126mg/dl
or
2hrs plasma glucose during OGTT more or equal to 200mg/dl
Or HA1c >or equal to 6.5%

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DM should suspected in any child with polyuria & dehydration ,poor weight gain ,hyperglycemia ,glucosuria & ketonuria
Random serum sugar >200mg/dl with typical symptoms with or without ketonuria is diagnostic
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• Initial management of type1 DM

Most newly cases of DM are alert and able to eat and drink and can manage with subcutaneous insulin alone
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iv fluid required if the child vomiting or dehydrated . intensive educational programme is needed for the parents and child to cover
• Basic understanding of pathophysiology ofDM
• Insulin injection technique &sites
• Diet , regular meal & snacks ,reduced refined CHO .healthy diet no >than 30% fat intake

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• 4-match food intake with insulin &exercise
• 5-blood glucose monitoring
• 6-recognition and treatment of hypoglycemia
• 7-the psychological impact of lifelong condition with serious short & long term complications

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• INSULIN THERAPY

• Most insulin used in Iraq for children is humen with concentration 100U/ml with different types includes
• human insulin analogues . rapid acting like lispro &aspart within few minutes
• short acting soluble insulin onset 30-60 min. peak 2-4 hrs. duration up to 8 hrs. given 15-30 min.before meal

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• intermediate acting insulin onset 1-2 hrs . peak 4-12 hrs( insulin with protamine )

• mixed short & intermediate 30/70 mixtard
• very long acting insulin analogues e.g glargine (lantus)
teenager preferable to use bolus & basal (basal .lantus at night and short acting before each meal )

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Factors affecting blood glucose

Increase blood glucose
Decrease blood glucose
• omission of insulin
• refined food
• illness
• menstruation
• growth hormone
• corticosteroids
• sex hormones at puberty
• stress of an operation
• insulin
• exercise
• anxiety (marked )
• some drugs
•
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DIET : healthy diet recommended with high complex CHO &relatively low fat content ,diet should be high in fiber

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• Diabetic ketoacidosis DKA :

End result of metabolic abnormalities result from sever deficiency of insulin or insulin ineffectiveness. It is occur in 20-40 % of children with newly diagnosed diabetes & DKA consider when serum sugar >300 mg .acidosis .+S/S of DM with ketosis .

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Classification of DKA

Normal
Mild
Moderate
Sever
Co2)meq/l venus
20-30
16-20
10-15
<10
pH venous
7.35-7.45
7.25-7.35
7.15-7.25
<7.15
Clinical
No changes
Only fatigue
Kussmaul ,oriented but sleepy
Kussmaul or depress respiration ,sleepy to coma
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Treatment
Time
Therapy
Comment
1st hr.
10-20ml/kg IV bolus 0.9%NaClor LR
Insulin drip at 0.05-0.1unit/lg/hr
Volume expansion ,NPO monitor I/O,use flow sheet prepare manitol 1g/kg at bed side if cerebral edema developed
2nd hr. until DKA resolution
0.45% Nacl plus continue insulin drip
20meq/l KPhos &20 meq/l K Ac….5%glucose if blood >250mg/dl
85ml/kg +maintenance -bolus
IV rate =
23 hr
If K <3meq give 0.5-1 meq as oral solution or increase iv K to 80meq/l
Maintenance =100ml/kg for 1st 10 kg+50ml/kg for 2nd 10 kg +25 ml/kg for remaining kg
Initial bolus fluid consider part of total fluid allowed & subtracted before calculating iv rate

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Sample calculating for 30 kg child
1st hr 300 ml iv bolus 0.9% NaCl or LR
2nd & subsequent hrs= (85ml × 30)+1750ml -300ml =
23hr

= 175 ml

hr
I/O input output, NPO nothing by mouth ,KAc potasium acetate ,kphos=potasium phosphate ….LR lactated Ringer..NaCl sodium chlodide

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• Long term management of DM

Aim of long term management :
• normal growth & development
• normal home & school life as possible
• good diabetic control through knowledge & technique
• encourage children to be self- reliant
• avoidance of hypoglycemia

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Assesment of a child with DM summary
Assessment of diabetic control :
• any episode of hypoglycemia
• school absence
• interference with normal life
• HbA1C result
• Insulin regimen ---appropriate
• Diet –healthy diet
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General overview :

• Normal growth and pubertal development , ovoid obesity
• Blood pressure checking
• Renal for microalbuminuria
• Eye ---cataract
• Feet –care
• Screening for celiac and thyroid disease
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Knowledge &psychological aspects
• Good understanding of diabetes
• Becoming self-reliant but appropriate supervision at home
• Taking exercise ,sport?
• Smoking ???
• Is hypo treatment readily available ?
•
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Ddiabetic lipohypertrophy

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What shall I eat?
Breakfast
• a bowl of cereal with semi-skimmed milk
• wholegrain toast with spread and/or jam
• yogurt and fruit
• a cereal bar and a glass of milk.

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Lunch

• a chicken or ham salad sandwich...
• a small pasta salad...
• soup and a roll...
...with a piece of fruit and a yogurt.

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Dinner

• salad
• roast chicken with potatoes and
• vegetables
• beef stir fry, vegetables and rice
• chicken tortillas and salad
• salmon and noodles
• curry and rice

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• What sort of snacks do I need to eat?

.
The healthiest snack choice is definitely a piece of fruit, but rice cakes, crackers, a couple of biscuits, a small bag of crisps, a cereal bar, or a yogurt are good snack choices too.
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• Foods to avoid for a type 1 diabetes diet include

sodas (both diet and regular),
simple carbohydrates - processed/refined sugars (white bread, pastries, chips, cookies, pastas),

trans fats (anything with the word hydrogenated on the label), and high-fat animal products.