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In The Name Of God

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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In The Name Of God

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  1. In The Name Of God

  2. Approach to diabetes mellitus in children and Adolescents Dr. Zahra Alian Pediatric Endocrinologist

  3. INTRODUCTION • Diabetes mellitus (DM) is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature.

  4. 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).

  5. Diabetes type 1

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. Diabetes Mellitus type 2

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. Principles of Diabetic Therapy • Prevention of Retinopathy • Treatment of Hypothyroidism • Prevention of Limited joint mobility

  20. Insulin Therapy In Diabetes

  21. Insulin Types

  22. To obtain near-normal glucose control, Insulin is administered in 2-4 injections daily

  23. postprandial hyperglycemia is more strongly associated with cardiovascular risk and mortality than FPG

  24. 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

  25. 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

  26. Follow-up visits are individualize

  27. Insuline syringe • 100 unit • 50 unit • 30 unit

  28. Insulin Pen

  29. Sites of injection

  30. Insulin therapy in type 1 diabetes mellitus

  31. Regimenchoices • Conventionalinsulin therapy(regular and NPH insulins) • Intensive insulin therapy(three or more injections , insulin pump) • Nelson Textbook Of Pediatrics 20th edition 2016

  32. 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

  33. 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)

  34. This is not a rule • control of BS is important • With twice a day insulin injection we can’t control BG

  35. 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

  36. 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

  37. Intensive insulin therapy is recommended for the majority of patients with type 1 diabetes. • Nelson Textbook Of Pediatrics 20th edition 2016

  38. Drawbacks to intensive insulin  • hypoglycemia (increased up to threefold) • Weight gain • cost (three times )

  39. When to start intensive therapy  •  Intensive therapy should be started as early as possible following the diagnosis of type 1 diabetes.

  40. 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.

  41. 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

  42. Disadvantages  • The costs of the pump and supplies are higher • infection at the site of needle insertion • infusion-system failure • diabetic ketoacidosis(more common)

  43. 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

  44. 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

  45. 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

  46. 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

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