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This article discusses the approach to managing diabetes mellitus in children and adolescents, including the different types of diabetes, clinical presentations, diagnosis criteria, treatment principles, and insulin therapy options.
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Approach to diabetes mellitus in children and Adolescents Dr. Zahra Alian Pediatric Endocrinologist
INTRODUCTION • Diabetes mellitus (DM) is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature.
INTRODUCTION • The major forms of diabetes are classified: • deficiency of insulin secretion due to pancreatic β-cell damage (T1DM) • insulin resistance occurring at the level of skeletal muscle, liver, and adipose tissue, with various degrees of β-cell impairment (T2DM).
EPIDEMIOLOGY • T1DM accounts for about 10% of all diabetes. • It is not limited to childhood. • Approximately 50% of individuals with T1DM present as adults. • Two-thirds of new diagnoses of diabetes in patients ≤ 19 years of age. • Nelson Textbook Of Pediatrics 20th edition 2016
CLINICAL PRESENTATION • Childhood type 1 diabetes can present in several different ways : • Classic new onset • Diabetic ketoacidosis • Silent (asymptomatic) incidental discovery • Nelson Textbook Of Pediatrics 20th edition 2016
Classic new onset • most common presentation • Symptoms include polyuria, polydipsia, weight loss despite increased appetite initially (polyphagia), and lethargy. • Nelson Textbook Of Pediatrics 20th edition 2016
Diabetic ketoacidosis • frequency of DKA as the initial presentation for childhood type 1 diabetes varies from 15 to 67 percent. • Young children (<6 years of age) or from a low socioeconomic background are more likely to have DKA as their initial presentation of type 1 diabetes. • Nelson Textbook Of Pediatrics 20th edition 2016
Silent presentation • less common • Typically occurs in children who have another close family member with type 1 diabetes • The diagnosis is made based upon an elevated blood glucose concentration. • Nelson Textbook Of Pediatrics 20th edition 2016
Criteria for diagnosis DM • Symptom of diabetes + Random plasma Glucose ≥200 mg/dl or • Fasting plasma Glucose ≥126 mg/dl fasting:no caloric intake for at least 8h or • 2 hr plasma Glucose ≥200mg/dl during an OGTT OGTT:1.75 g/kg (max 75g)glucose load • HbA1c>6.5 • Nelson Textbook Of Pediatrics 20th edition 2016
Introduction • Type 2 diabetes is a progressive syndrome that gradually leads to complete insulin deficiency during the patient’s life. • Lifestyle modification (diet and exercise) is an essential part of the treatment regimen, and consultation with a dietitian is usually necessary. • Nelson Textbook Of Pediatrics 20th edition 2016
There is no particular dietary or exercise regimen ,but most centers recommend a lowcalorie, low-fat diet and 30-60 min of physical activity at least 5 times/ wk. • Nelson Textbook Of Pediatrics 20th edition 2016
Commonly observed behaviors • skipping meals • heavy snacking • excessive daily television viewing, video game playing, and computer use. • non–eating (emotional eating, television-cued eating, boredom) and cyclic dieting (“yo-yo” dieting). • Nelson Textbook Of Pediatrics 20th edition 2016
Treatment • is frequently challenging and may not be successful unless the entire family buys into the need to change their unhealthy lifestyle. • It is recommended that oral hypoglycemic agents be introduced at the time of diagnosis. • Nelson Textbook Of Pediatrics 20th edition 2016
Principles of Diabetic Therapy • Controlled diabetes • Prevention of DKA • Avoidance of hypoglycemia • Providing normal growth by recording height and weight on pediatric growth charts • Prevention of obesity
Principles of Diabetic Therapy • Detection of associated diseases • Prevention and treatment of hyperlipidemia • Treatment of hypertension • Prevention of emotional disorders • Prevention of chronic vascular disease
Principles of Diabetic Therapy • Prevention of Retinopathy • Treatment of Hypothyroidism • Prevention of Limited joint mobility
To obtain near-normal glucose control, Insulin is administered in 2-4 injections daily
postprandial hyperglycemia is more strongly associated with cardiovascular risk and mortality than FPG
Starting Doses of Insulin (units/kg/day) NO DIABETIC KETOACIDOSIS • Prepubertal 0.25-0.50 • Pubertal 0.50-0.75 • Postpubertal 0.25-0.50 • Nelson Textbook Of Pediatrics 20th edition 2016
Starting Doses of Insulin (units/kg/day) DIABETIC KETOACIDOSIS Prepubertal 0.75-1.0 Pubertal 1.0-1.2 Postpubertal 0.8-1.0 Nelson Textbook Of Pediatrics 20th edition 2016
Insuline syringe • 100 unit • 50 unit • 30 unit
Regimenchoices • Conventionalinsulin therapy(regular and NPH insulins) • Intensive insulin therapy(three or more injections , insulin pump) • Nelson Textbook Of Pediatrics 20th edition 2016
Conventional regimen • NPH at least twice a day (at breakfast and a second dose either at dinner or bedtime) • with a rapid-acting or short-acting insulin two or three times a day • The rapid- or short-acting insulin would be given at breakfast and dinner, lunch • Nelson Textbook Of Pediatrics 20th edition 2016
½-2/3 total daily dose :before breakfast (2/3 NPH & 1/3 rapid- or short-acting insulin) • ¼ lunch • 1/3-1/4 before dinner or at bedtime (1/3 to 1/2 as rapid- or short-acting insulin and 2/3 to 1/2 as NPH)
This is not a rule • control of BS is important • With twice a day insulin injection we can’t control BG
Intensive regimens • Multiple daily injections • The basal insulin glargine should be , 25-30% of the total dose in toddlers and 40-50% in older children. , with premeal/snack boluses of rapid- or short-acting insulin • Nelson Textbook Of Pediatrics 20th edition 2016
Glargine may be given every 12 hr in young children if a single daily dose of glargine does not produce complete 24 hr basal coverage. • Nelson Textbook Of Pediatrics 20th edition 2016
Intensive insulin therapy is recommended for the majority of patients with type 1 diabetes. • Nelson Textbook Of Pediatrics 20th edition 2016
Drawbacks to intensive insulin • hypoglycemia (increased up to threefold) • Weight gain • cost (three times )
When to start intensive therapy • Intensive therapy should be started as early as possible following the diagnosis of type 1 diabetes.
Insulin pump Should be considered in: • Recurrent severe hypoglycemia • Wide fluctuations in BG levels • Suboptimal diabetes control • Microvascular complications and/or risk factors for macrovascular complications.
Advantages of continuous subcutaneous insulin : • better glycemic control . • lower A1C and premeal glucose levels • insulin absorption is less variable from day to day • fewer episodes of hypoglycemia • Nelson Textbook Of Pediatrics 20th edition 2016
Disadvantages • The costs of the pump and supplies are higher • infection at the site of needle insertion • infusion-system failure • diabetic ketoacidosis(more common)
Age-specific blood glucose ranges • Target Premeal • <5 years : 100 to 200 mg/dL • 5 to 11 years : 80 to 150 mg/dL • 12 to 15 years : 80 to 130 mg/dL • 16-18years:70-120mg/dl • Nelson Textbook Of Pediatrics 20th edition 2016
Ideally, the blood glucose concentration should range from approximately 80 mg/dL in the fasting state to 140 mg/dL after meals. • Nelson Textbook Of Pediatrics 20th edition 2016
Target Hemoglobin A1c forEach Age Group >5 yr 7.5-9.0 5-11 yr 6.5-8.0 12-15 yr 6.0-7.5 16-18 yr 5.5-7.0 Nelson Textbook Of Pediatrics 20th edition 2016
BLOOD GLUCOSE MONITORING • ADA recommends testing of blood glucose at least four times a day. • (fasting & 2 hr after meals) • At 3 AM 3-4×mo