Childhood diabetes

Dr. Faten BenRajab

2016

By the end U will know:

Definition & classification of DM.
Etiology.
Diagnosis & presentation of DM.
Management of DM include:
Education to family& the patient .
Insulin treatment ,Guidelines of insulin dosage &regimens.
Glycemic control in diabetic patients.
Meal planning & Exercises.
Hypoglycemia in diabetics
Diabetic follow up & Annual follow up.

Definition
The term diabetes mellitus describes a metabolic disorder of multiple

etiologies characterized by chronic hyperglycemia with disturbances

of carbohydrate, fat and protein metabolism resulting from defects of
insulin secretion, insulin action or both.

Diabetes Epidemiology

Diabetes is the most common endocrine problem & is a major health hazard worldwide.
Incidence of diabetes is alarmingly increasing all over the globe; over the last 20 yrs.
It affects around 2 per 1000 children by 16 years of age.

Types of Diabetes in Children

Type 1 diabetes mellitus accounts for >90% of cases.
Type 2 diabetes is increasingly recognized in children.
Permanent neonatal diabetes & Transient neonatal diabetes.
Maturity-onset diabetes of the young.

Secondary diabetes e.g. in cystic fibrosis or Cushing syndrome.

Type 1 Diabetes: Etiology

Type 1 diabetes mellitus is an autoimmune disease.
It is triggered by environmental factors in genetically susceptible
individuals.
Both humoral & cell-mediated immunity are stimulated.

Genetic Factors
Evidence of genetics is shown in: Ethnic differences.
Familial clustering.
High concordance rate in twins.
Specific genetic markers. ( in HLA- DR3 or DR4 & DR 2 ,5)
Higher incidence with genetic syndromes or chromosomal defects.

Autoimmunity / Environmental Influence

Circulating antibodies against B-cells, GAD & insulin.
Immuno-fluorescent antibodies & lymphocyte infiltration around
pancreatic islet cells.
Evidence of immune system activation. Circulating immune complexes
with high IgA & low interferon levels.

Association with other autoimmune diseases.

Seasonal (Spring /Autumn) & geographical variation.

Migrants take on risk of new home.

Viruses:- Coxaschie B ,Mumps &Rubella

Other Modifying Factors

The counter-regulatory hormones:
Glucagon.
Cortisol.
catechol amines.
Thyroxin.
GH & somatostatin.
sex hormones.
Emotional stress

Criteria of diagnosis
FBG is 126 mg /dl
The post challenge plasma glucose ( RBG ) is 200 mg /dl in OGTT.

OR
Symptoms of diabetes with high BG ( RBG is 200 mg /dl).

If there are no symptoms two elevated results must be obtained.

After diagnosis , We do C- peptide & T1DM associated auto antibodies &HbA1c.

Clinical Presentations
Classical symptom triad:
polyuria, polydipsia and weight loss

Secondary nocturnal enuresis & frequent Candida infection.

DKA.
Accidental diagnosis.

Anorexia nervosa like illness.

Remember: acute infections in young non-diabetic children can cause hyperglycemia without
ketoacidosis.

Natural History
Diagnosis & initiation of insulin.

Period of metabolic recovery.

Metabolic Recovery
During metabolic recovery the
patient may
develop one or more of the
following:
Hepatomegaly
Peripheral edema

Honeymoon phase.

Loss of hair
Problem with visual acuity
State of total insulin dependency

These are caused by deposition of

glycogen & metabolic re-balance.

Honeymoon Period
Due to B-cell reserve optimal function & initiation of insulin therapy.
Leads to normal blood glucose level without exogenous insulin.
Observed in 50-60% of newly diagnosed patients & it can last up to
1-3 year but it always ends.

Can confuse patients & parents if not educated about it early.

Smogyi &Dawn phenomena.

Complications of Diabetes
Acute:

DKA.
Hypoglycemia.
Late-onset:

Retinopathy.
Neuropathy.
Nephropathy.
Ischemic heart disease & stroke.

Diabetes Management
When a problem is
too large and seems
unsolvable?????!
dont forget that you
can eat an elephant
assuming it is cut it
Into enough small pieces

Management of DM
Newly diagnosed diabetics need hospital management.
Provide treatment to achieve good control, maintain good general
health ,normal growth &development.
Education about DM.

Management of associated diseases & prevention of long term complications.

Education

Teach the family about the disease , its treatment & complications.
Training them how to give insulin.
Home monitoring.
Diet (meal planning) & Exercises.
How to manage the patients during hypoglycemia & sick days.

Insulin treatment
Different types of insulin.
Dose regimen.

Insulin used as basal &meal time insulin

Basal insulin :

Slow onset & prolonged duration.

Used to restrain hepatic glucose production to keep
balance between hepatic glucose & glucose release to
supply tissue like brain during non-feeding state.

Types of basal insulin

NPH:
Twice daily injection.
Ultra lente:
Once at bed time or twice daily injection.

Glargine / Detemir:
Given once daily at dinner , bed time or any time, and can
be given twice daily.
(Morning dose lower than the night dose)

Meal time insulin

Rapid onset & short duration.

stimulate peripheral uptake, utilization of glucose &

inhibit glucose release.
Regular
Lispro ,Aspart &Glulisine
Cocktail

Storage of insulin
Insulin must never be frozen.

Unused insulin should be stored in a refrigerator (4 8C).

After first usage, an insulin vial should be discarded after 3 months if kept
at 2 8C or 4 weeks if kept at room temperature.
Insulin pens which in use should keep it in room temperature for 28 D.

Daily insulin dosage

Dosage depends on many factors such as: Age.
Weight.
Stage of puberty.
Duration and phase of diabetes.
State of injection sites.
Nutritional intake and distribution.
Exercise patterns.
Daily routine.
Results of blood glucose monitoring (and HbA1c).
Intercurrent illness.

Guidelines of dosage
During the partial remission phase, the total daily insulin dose is often <0.5 IU/kg/day.
Pre-pubertal children usually require 0.71.0 IU/kg/day.
During puberty, requirements may rise above 1 and even up to 2 U/kg/day.
The correct dose of insulin is that which achieves the best attainable glycemic
control for an individual child or adolescent
without causing obvious hypoglycemia problems, and the harmonious growth
according to weight and height childrens charts.

Insulin doses according to age

Age (year)

Target glucose (mg/dl)

Total daily insulin

(u /kg/d)

Basal insulin
(% of total daily dose)

0-5
5-12
12-18

100-200
80-150
80-150

0.6-0.7
0.7-1
1-1.2

25-30
40-50
40-50

Dont manage diabetes with insulin that

you have in your pockets?
But you have to know how to choose according to your patient need..

Insulin regimens

Insulin Regimens
Twice daily: either NPH alone or NPH+Reg.

Thrice daily: Reg. before each meal and NPH only before dinner.
Intensive 4 times/day (MDI): Reg. before meals + NPH or Glargine a
bed time.
Flexible insulin regimen.
Continuous s/c infusion using pumps loaded with Rapid acting insulin.

Injection sites
The usual injection sites are:
Abdomen (the preferred site when faster absorption is required and it may be
less affected by muscle activity or exercise).
Front of thigh/lateral thigh; the preferred site for slower absorption of longer
acting insulin.
Buttocks (upper outer quadrantmay be useful in small children).
Lateral aspect of arm (in small children with little subcutaneous fat,
intramuscular injection is more likely and it may cause unsightly bruising).
Cleaning or disinfection of skin is not necessary unless hygiene is a real problem.
Infection at injection sites is rare

Children and adolescents should

be encouraged to inject
consistently within the same site
(abdomen, thigh, buttocks, arm)
at a particular time in the day, but
must avoid injecting repeatedly
into the same spot to prevent
lipohypertrophy.

Adverse effects of Insulin

Hypoglycemia
Lipoatrophy
Lipohypertrophy
Obesity
Insulin allergy
Insulin antibodies
Insulin induced edema

Glycaemic control in diabetic patients

Blood sugar :
Pre meal B-sugar between 70-140mg/dl.
Postprandial B-sugar less than 180mg/dl.
OR
Infant & toddler is between 100-220,240mg/dl.
Children is between 80-180mg/dl.
Young people is between 60-160mg/dl.
HbA1c <7.5

Specific monitoring

Use frequent self-monitoring of blood glucose.(SMBG)

HbA1c :

6-7% ideal
7-8% accepted
8-8.5% extra action
>8.5% not accepted

New monitoring systems

Continuous blood glucose monitoring:

The recent introduction of systems for CGM is an exciting advance.

CGM reveals postprandial fluctuations in glucose level .

Identify an asymptomatic nocturnal hypoglycaemia.

It is useful in programming overnight basal insulin rates for pump therapy.

The Targets
Age

Blood sugar goal range (mg/dl)

Before meals

H1AC

After meal /bed time

Toddler and preschool(6years)

100_180

100_200

8.5

School age(6_12years)

90_180

100_180

<8

Adolescents and young

adults(13_19 years)

90_130

90_150

<7.5

Smogyi &Dawn phenomena.

Meal planning

Diet based on food contents, CHO exchange diet & patient likes & dislikes.
Teach family about good child nutrition.
Children will eat when they are hungry.

Diet & Meal planning

Diet contains :
55-60% of total calories CHO.
20-30 of total calories fat.
15% of total calories protein.
Divided 3 meals & 3 snacks:
Each snack consist of 10% of total requirement.
Breakfast 20%
Lunch 30%
Dinner 20%
Extra snack must be taken before exercise and every hour awake
during sleep time.

Carbohydrate
Avoid simple table sugar & food contains table sugar.
Complex CHO preferred.
Encourage high fiber diet:

Maintain good metabolic control.

Prolonged digestion & slow absorption.
Reduce absorption of free simple sugar, cholesterol & LDL.

Protein
Can be found in meat, milk products, chickens, eggs and fish, Small
amount of protein in grains, breads, nuts and vegetables.
High protein intakes may contribute to diabetic nephropathy.
Low intake may reverse preclinical nephropathy.

Fat intake
Vegetable oil preferred than animal fat.
Low fat dairy products.

Remove visible fat from meat.

limiting number of egg yolk.

CHO
Sugary foods and chocolates.

Starches, bread, potato and biscuits.

High fiber starches, brown breads,

brown pasta and cereals.

Non CHO
Fatty food- cream, butters and fries .
Protein food, chicken, fish, meat, cheese, eggs .

Vegetables, tea, fruits, low cal. drinks.

Exercises
Decreases insulin requirement in diabetic subjects by increasing
both sensitivity of muscle cells to insulin & glucose utilization.
It can precipitate hypoglycemia in the unprepared diabetic patient.
It may worsen pre-existing diabetic retinopathy.

Hypoglycemia
in diabetic patients

Blood sugar <70 mg%

Hypoglycaemia
Type 1 diabetics should be informed that they should always have access to
an immediate source of carbohydrate (glucose or sucrose) and blood
glucose monitoring equipment for immediate confirmation and safe
management of hypoglycaemia.
Children and young people, their parents, school teachers and other carers
should be offered education about the recognition and management of
hypoglycaemia.

Mild Hypoglycaemia (BS 50-70mg/dl):

Give 15 gm of simple carbohydrate :- (Role of 15)

3 tea spoon of sugar or
3 packets of table sugar dissolved in water,
Or 120 mL (1/2 glass) of juice or regular soft drink,
Or (1table spoon) of honey.
Avoid Chocolate, milk (fat will cause slow absorption of sugar).
Then test blood after 15 min if still low retreated with 15 g of additional
carbohydrate. If BS >70 mg/dL, ingestion of a small complex carbohydrate
snack shortly to prevent recurrence, generally advisable.
Give the next meal or snack at the usual time.
Normal activity can be resumed after treating mild hypoglycaemia.

Severe/moderate hypoglycaemia
(unconscious or convulsions, vomiting)
Can be treated with Glucagon I.M injection:
0.5mg if < 20Kg
1mg if > 20Kg

Intravenous glucose is the preferable hospital treatment of severe

hypoglycaemia ( 1-2 ml/kg of 10% dextrose).
Close observation and blood glucose monitoring is essential.

Preventing hypoglycaemia
Educate patient about:
Eat meals and snacks on time.
Pay attention to early warning signs to avoid further symptoms.
Eat extra carbohydrate for heavy exercise or extended activity.
Perform extra blood sugar checks before, during, and after activity.

Carefully calculate dose and accurately draw insulin dose.

Diabetic follow up
At every clinic

Check HbA1c.
Check injection sites.
Measure height , weight and calculate body mass index.

Annual follow up
Once a year:
micro albumin uria.
Check for retinopathy.
Screen for thyroid disease.
Review foot care.
Screen for celiac disease.

Practical problems
Non-availability of insulin in poor countries.
injection sites & technique.
Insulin storage & transfer.
Mixing insulin preparations.
Insulin & school hours.
Adjusting insulin dose at home.
Sick-day management.
Recognition & Rx of hypo at home.

Recommendations
Insulin treatment must be started as soon as possible after
diagnosis.
In all age groups, as close to physiological insulin replacement as
possible and optimal glycemic control must be the aim, which
should include the consideration of an intensive insulin regimen.
However, no insulin injection regimen satisfactorily mimics normal
physiology.

Improvements in glycemic control, particularly when provided

by intensive insulin treatment with MDI or pump therapy,
reduces the risks of vascular complications.

Whatever insulin regimen is chosen, it must be supported by

comprehensive education appropriate the age, maturity and
individual needs of the child and family.