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Diabetes mellitus in children BASIM AL-ZOUBI

Diabetes mellitus in children BASIM AL-ZOUBI. Types of DM in Children Type 1 DM Type 2 DM MODY Type Neonatal DM. TYPE 1 DM. Maturity-onset diabetes in youth (MODY) autosomal dominant noninsulin-dependent diabetes onset in the second or third decade of life Neonatal DM

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Diabetes mellitus in children BASIM AL-ZOUBI

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  1. Diabetes mellitus in children BASIM AL-ZOUBI BASIM A-ZOUBI

  2. Types of DM in Children • Type 1 DM • Type 2 DM • MODY Type • Neonatal DM BASIM A-ZOUBI

  3. TYPE 1 DM BASIM A-ZOUBI

  4. Maturity-onset diabetes in youth (MODY) • autosomal dominant • noninsulin-dependent diabetes • onset in the second or third decade of life • Neonatal DM • Due to mutations in the genes encoding potassium channel of the beta-cell (KCNJ11, encoding the Kir6.2 subunit, and ABCC8, encoding the SUR1 subunit) or a mutation in the insulin gene. • In ABCC8 mutation treatment is possible with oral hypoglycemic agents that stimulate endogenous insulin secretion through binding to the sulfonylurea receptor (SUR1). BASIM A-ZOUBI

  5. Epidemiology The prevalence of diabetes among school-aged children is about 2/1,000 in USA and UK. The incidence is variable according to the different countries and it varies from 0.6/100,000 in China to 42.9/100,000 in Finland. There are small peaks in incidence at 4 to 6 years of age and a larger peak at 10 to 14 years of age. BASIM A-ZOUBI

  6. Pathogenesis Type 1 diabetes is caused by T cell–mediated autoimmune destruction of the beta cells of the pancreas believed to be triggered by an environmental factor in a genetically susceptible individual and lead to absolute insulin deficiency. The largest genetic component of the risk of diabetes is the major histocompatibility complex on chromosome 6, including the DR3-DQ2 and DR4- DQ8 alleles that increase risk and the DR2-DQ6 allele, which is protective. BASIM A-ZOUBI

  7. Inheritance of HLA-DR3 or -DR4 antigens increase the risk for the development of T1DM by 2- to 3-folds When both DR3 and DR4 are inherited, the relative risk for the development of diabetes is increased by 7- to 10-fold. BASIM A-ZOUBI

  8. However, only 10% to 20% of individuals who have type 1 diabetes have a similar family history. BASIM A-ZOUBI

  9. Risk of developing type 1 diabetes for individuals who have an affected relative For siblings Overall 6% HLA identical 15% HLAnonidentical 1% Offspring From father 6% From mother 2% Both parents 30% BASIM A-ZOUBI

  10. T1DM may be associated with other autoimmune diseases such as thyroiditis, celiac disease, multiple sclerosis, and Addison disease. BASIM A-ZOUBI

  11. DM1 ANTIBODIES • The islet cell antibodies (ICA) • Insulin autoantibodies (IAA) • Glutamic Acid Decarboxylase antibodies (GAD/GAD 65) • Transmembrane Tyrosine Phosphatase IA-2 or ICA512 BASIM A-ZOUBI

  12. In the nonobese child, testing for autoimmunity to β cells is not necessary. BASIM A-ZOUBI

  13. Environmental risk Factors viral infections Although the etiologic role of viral infections in human T1DM is controversial, coxsackie, cytomegalovirus, rubella, and mumps can infect human β cells. Seasons New cases are seen more commonly in Autumn and winter. Vit. D It has been found that Diabetes risk may be increased by low vitmain D level in young infants. BASIM A-ZOUBI

  14. Cow's milk Breastfeeding seems to provide protection against the risk of developing type 1 diabetes. The reaction of an infant's immature immune system to a protein found in cow's milk infant formula called beta-lactoglobulin may explain the suspected link between early consumption of cow's milk and an increased risk of developing type 1 diabetes later. Chemical toxins Ingestion of the rodenticide vacor is associated with the development of type 1 diabetes. Stress BASIM A-ZOUBI

  15. Diagnosis • symptoms of diabetes are • polydipsia, • polyuria, • polyphagia, and weight loss. • Bedwetting • diabetic ketoacidosis (DKA) presention with nausea, vomiting, abdominal pain, dehydration, lethargy and coma . BASIM A-ZOUBI

  16. Diagnostic criteria for DM • Fasting plasma glucose at or above 126 mg/dL (7.0 mmol/L). • Random plasma glucose at or more than 200 mg/dl associated with DM symptoms. • 2-hour post challenge plasma glucose value at or above 200 mg/dL (11.1 mmol/L) on an oral glucose tolerance test. • One third of new diabetes cases in children 10 to 19 years of age were due to type 2 diabetes. BASIM A-ZOUBI

  17. MANAEGEMENT OF TYPE 1 DM BASIM A-ZOUBI

  18. BASIM A-ZOUBI

  19. NUTRITION No special nutrition. No particular food should be considered forbidden. It is recommended that approximately 30-35% of dietary energy intake should be derived from fat (mainly mono- and polyunsaturated fats), 15% from protein and 50-55% from carbohydrate. Approximately 70% of the carbohydrate content should be derived from complex carbohydrates such as starch. BASIM A-ZOUBI

  20. The total daily caloric intake 20% at breakfast, 20% at lunch, and 30% at dinner, 10% for each of the midmorning, midafternoon, and evening snacks Intake of sucrose and highly refined sugars should be limited. Alternative sweeteners: Use of a variety of sweeteners can be used. Carbohydrate Counting: Each carbohydrate exchange unit is 15 g. BASIM A-ZOUBI

  21. Meals and snacks should be taken at about the same time of the day every day. • meal times and contents correlates with daily activities, e.g. taking physical exercise or sitting at a desk? • Extra insulin when necessary, e.g. at parties, or when eating lots of sweet things. • fresh fruit as a snack better than drinking fruit juice. • A high fibre content in TH food. BASIM A-ZOUBI

  22. BASIM A-ZOUBI

  23. Glucose Monitoring Continuous Glucose Monitoring System (CGMS) The interstitial glucose levels lag 13 min behind the blood glucose values at any given level. The CGMS values tend to have a high correlation coefficient for blood glucose values ranging between 40 and 400 mg/dL. BASIM A-ZOUBI

  24. Elevated fasting blood sugar at the morning may be due: Dawn Phenomenon : Which due overnight growth hormone secretion and increased insulin clearance. Somogyi Phenomenon: Which is due to rebound from late night or early morning hypoglycemia, thought to be due to an exaggerated counter-regulatory response. BASIM A-ZOUBI

  25. HbA1C • Glucose is bound to haemoglobin in the red blood cells. • The level of HbA1c depends on the blood glucose levels during the life span of the red blood cells. • A red blood cell lives for about 120 days. • HbA1c reflects the average blood glucose during the previous 2-3 months. BASIM A-ZOUBI

  26. Transplantation Transplantation of segment of the pancreas is done usually in those patients who need kidney transplantation at the same time in which the immunosuppressive regimen is indicated for the renal transplantation. Transplantation of isolated islet cells have been tried but only half of the cases remained insulin free for 2 years. Stem cell transplantation BASIM A-ZOUBI

  27. Complications • Acute Comlications • DKA • Hypoglycemia BASIM A-ZOUBI

  28. DKA DKA is the most common cause of death in children who have type 1 diabetes and isassociated with a significant risk of morbidity. BASIM A-ZOUBI

  29. Clinical manifestations of diabetic ketoacidosis • Dehydration • Rapid, deep (Kussmaul respiration) • Nausea, vomiting, and abdominal pain • Progressive loss of consciousness • Fever only when infection is present BASIM A-ZOUBI

  30. Definition of DKA ¤ Hyperglycemia (blood glucose > 11 mmol/L ≈ 200 mg/dL]) ¤ Venous pH < 7.3 or bicarbonate < 15 mmol/L ¤ Ketonemia and ketonuria BASIM A-ZOUBI

  31. Supportive measures ¤ Secure the airway ¤ Insert peripheral intravenous catheter ¤ A cardiac monitor should be used to assess T waves for evidence of hyper- or hypokalemia ¤ Give oxygen to patients with severe circulatory impairment or shock. BASIM A-ZOUBI

  32. Monitoring ¤ Hourly:vital signs, neurological evaluation, fluid input and output. ¤ Capillary blood glucose should be measured hourly ¤ Laboratory tests: Na, K, glucose, blood urea nitrogen and blood gases every 2 then 4 hours. BASIM A-ZOUBI

  33. Goals of therapy ¤ Correct dehydration ¤ Correct acidosis and reverse ketosis ¤ Restore blood glucose to near normal ¤ Avoid complications of therapy ¤ Identify and treat any precipitating event BASIM A-ZOUBI

  34. Fluids and salt. • In moderate DKA use 5-7% and in sever DKA use 7-10% dehydration. • ¤ If needed to restore peripheral circulation, give 0.9% saline 10–20 mL/kg over 1–2 h, and repeat it, if necessary ( not more than 30 ml/kg). • ¤ Add calculated maintenance (for 24-48 hrs) and estimated deficit, subtract the amount already given as resuscitation fluid, and give the total volume over the next 24 - 48 hours. i.e. • ¤ Subsequent fluid management should be with a solution with a tonicity equal to or greater than 0.45% saline • . BASIM A-ZOUBI

  35. Insulin therapy • Begin with 0.1 U/kg/h. insulin infusion. . • The dose of insulin should usually remain at 0.1 unit/kg/h at least until resolution of DKA (pH > 7.30, bicarbonate > 15 mmol/L and/or closure of the anion gap). • To prevent a rapid decrease in plasma glucose concentration and hypoglycemia, 5% glucose should be added to the 0.45% saline (5% glucose in 0.45% saline ) when the plasma glucose falls to approximately 14–17 mmol/L (250–300 mg/dL. BASIM A-ZOUBI

  36. Potassium replacement Start replacing potassium after initial volume expansion (1-2 hours) and concurrent with starting insulin therapy. BASIM A-ZOUBI

  37. Acidosis Alkali therapy may be given only to patients with severe acidemia (arterial pH, 6.9), and patients with life-threatening hyperkalemia. ¤ Bicarbonate then may be given cautiously at a dose of 1–2 mmol/kg over 60 min. BASIM A-ZOUBI

  38. Introduction of oral fluids and transition to SC insulin injections Oral fluid should be given only when there is substantial clinical improvement. BASIM A-ZOUBI

  39. Treatment of cerebral edema ¤ Give mannitol ¤ Reduce the rate of fluid administration by one-third. ¤ Hypertonic saline (3%), 5–10 mL/kg over 30 min, may be an alternative to mannitol, especially if there is no initial response to mannitol. ¤ Elevate the head of the bed. BASIM A-ZOUBI

  40. LONG-TERM COMPLICATIONS: RELATION TO GLYCEMIC CONTROL. 1-microvascular complications, specifically, retinopathy and nephropathy; 2- macrovascular complications, particularly accelerated coronary artery disease, cerebrovascular disease, and peripheral vascular disease; and 3- neuropathies, both peripheral and autonomic, affecting a variety of organs and systems . In addition, cataract may occur more frequently. BASIM A-ZOUBI

  41. Hypoglycemia • Hypoglycemia, a blood glucose concentration less than 60 mg/dL (3.3 mmol/L. • Symptoms of hypoglycemia include • sweating, hunger, and palpitations, headache, dizziness, diplopia, and confusion. coma and seizures. • Mild-to-moderate hypoglycemia is treated by ingesting 10 to 15 g of glucose • Sever cases may need Glucagone injection or Dextrose 10% iv bolus. BASIM A-ZOUBI

  42. Insulin Therapy The initial total amount of insulin varies from 0.5 to 2 U/kg per day. BASIM A-ZOUBI

  43. Glulisine BASIM A-ZOUBI N Engl J Med 2005;352:174-83.

  44. Rapid-acting insulin analogues • insulin lispro approved in 1996 • insulin aspart approved June 7, 2000 • insulin glulisine approved in 2007 • Often referred to as ‘bolus’ or ‘prandial’ insulins. • provide higher and more rapidly peaking insulin concentrations, which are required for peripheral glucose utilization following meals. BASIM A-ZOUBI *Clin Pharmacokinet 2008; 47 (9): 595-610 *Drugs 2008

  45. Intermediate Insulins Isophane NPH insulins. Lente insulins Suitable for twice daily regimens and for prebed dosage in basal-bolus regimens. BASIM A-ZOUBI Pediatric Diabetes 2007: 8 (Suppl. 6): 49–56

  46. Premixed Insulins • can reduce potential errors in drawing up insulin. • Do not allow for much flexibility in adjusting for blood glucose levels or variability in food intake and activity, all of which • are important factors in the management of T1DM in • children. BASIM A-ZOUBI

  47. Basal Insulin • The new basal insulin analogues are • Glargine approved April 20, 2000 • Detemir. Approved in 2005 • They show a more predictable insulin effect with • less day-to-day variation compared with NPH • insulin. • Glargine is not approved in children younger than 6 while Detemir is approved in children over 2 years. BASIM A-ZOUBI *Pediatr Diabetes 2005: 6: 150–154.

  48. The effect of glargine lasts for 20 to 24 h while that for detemir is between 6 and 23 h according to the dose given.* BASIM A-ZOUBI

  49. BASIM A-ZOUBI Idealized insulin curves for prandial insulin with a rapid-acting analogue (insulin aspart, insulin lispro, or insulin glulisine) with basal insulin given as insulin glargine or insulin detemir Chapter 20. The Management of Type 1 Diabetes Irl B. Hirsch, M.D., and Jay S. Skyler, M.D. Updated: August 27, 2006

  50. Basal–bolus regimens Can be achieved by MDI INSULIN PUMP MDI by using a long-acting insulin analog as the basal insulin with rapid- or short-acting insulin for the meal (bolus) insulin. Other regimens for basal insulin include NPH accompanied by daytime boluses of rapid- or short-acting insulin. BASIM A-ZOUBI

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