diabetes mellitus in children

advance in treatment of diabetes mellitus in children

1. Dr.Azad A Haleem AL.Mezori DCH, FIBMS Lecturer University Of Duhok Faculty of Medical Science School Of Medicine-Pediatrics Department 2015 [email protected] Diabetes mellitus in children Duhok Pediatrics Diabetes center

2. Definition It’s a chronic metabolic disorder characterized by hyperglycemia as a cardinal biochemical feature, caused by deficiency of insulin or its action, manifested by abnormal metabolism of carbohydrates , protein and fat

3. Epidemiology Peaks of presentation occur in 2 age groups: at 5-7 yr of age (infectious) and at the time of puberty ( gonadal steroids ). Girls and boys are almost equally affected There is no apparent correlation with socioeconomic status.

4. Incidence rates of type 1 diabetes mellitus by region and country

5. Diagnosis of diabetes is made when: Symptoms + random BGL ≥ 11.1 mmol /L ( ≥200 mg/dl ) (or) Fasting BGL ≥ 7mmol/L ( ≥ 126 mg/dl )

6. ETIOLOGIC CLASSIFICATIONS OF DIABETES MELLITUS Type I diabetes : (β-cell destruction, usually leading to absolute insulin deficiency) Immune mediated. Idiopathic. Type 2 diabetes : (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance). Other specific types : Genetic defects of β-cell function: Chromosome 7, glucokinase (MODY2) Genetic defects in insulin action: Rabson -Mendenhall syndrome Diseases of the exocrine pancreas : Pancreatitis Endocrinopathies : Cushing disease Drug- or chemical-induced : Glucocorticoids Infections: Cytomegalovirus Uncommon forms of immune-mediated diabetes :Stiff-man” syndrome Other genetic syndromes sometimes associated with diabetes :Down syndrome Gestational diabetes mellitus Neonatal diabetes mellitus

7. Physiology The main function of insulin are: 1. Reduce glucose by: ↓ gluconeogenesis ↓ glycogenolysis ↑ uptake of glucose by cell 2. Inhibit fat breakdown (lipolysis) 3. Inhibit protein breakdown (proteolysis)

8. Insulin deficiency will lead to: Hyperglycemia : increase glucose→ osmotic diuresis → polyuria → dehydration → compensatory polydepsia . Proteolysis: → weight loss → Polyphagia . Lipolysis: ↑ free fatty acids and accumulation of acetyl Co-A → Liver → keton bodies → ketonemia → ketonuria & Metabolic acidosis.

9. Presentation: Although most symptoms are nonspecific polyuria , polydepsia, Polyphagia & weight loss. Recurrent infection: skin or UTI. Diabetic Ketoacidosis

10. Investigations: Blood glucose : Fasting glucose > 126 mg/dl & Random > 200 mg/dl. HbA1c: ( glycated haemoglobin ) average over the last 2-3 months . Measures amount of glucose that attaches to haemoglobin , The target HbA1c < 7.5% (58 mmol /mol). Ketone testing: either urine strips, or blood. Urine: glucosuria & Ketonuria if DKA suspected.

11. Management Need team & Special diabetic Clinic? Medical : specialist Specialist Nurses : Dietitian. Psychologist Equipments: insulin, glucometer, Ketones meter and good maintenance. Good follow up.

12. Treatment Insulin Nutrition

13. Types of Insulin

14. Types of presentation If newly diagnosed: DKA: according to Guideline. Only hyperglycemia. Already diabetes on insulin therapy with: DKA: according to Guideline. Presence of ketonemia? Only hyperglycemia? Not controlled?

15. 1. Diabetic Ketoacidosis (DKA): Occurs when there is profound insulin deficiency. It frequently occurs at diagnosis and also in children and youth with diabetes if insulin is omitted, or if insufficient insulin is given at times of acute illness. The biochemical criteria for DKA are: Hyperglycaemia (blood glucose >11mmol/l (~200 mg/dl)) Venous pH <7.3 or bicarbonate <15 mmol /l Ketonaemia and ketonuria

16. Treatment

17. 2. New-Onset Diabetes without Ketoacidosis Ideally, therapy can begin in the outpatient setting, with diabetic team. (we prefer admission). There are many Insulin regimens for treatment with many advantages and disadvantages We have to select one ??

18. Insulin regimens Conventional Insulin therapy : Twice daily mixed Insulin. Intensive Insulin therapy: Basal – Bolus(3 Injections): 2 bolus of short acting before breakfast and lunch + Mixture of short acting and Intermediate acting at evening meal. 2 . Basal – Bolus(3 +1 Injections): 3 bolus of short acting before breakfast + lunch + evening meal + Intermediate acting before bedtime. 3. Basal – Bolus(3 +1 Injections): 3 bolus of Rapid acting before breakfast + lunch + evening meal + Long acting before bedtime. 4. Basal – Bolus(3 +1 Injections): Long acting before bedtime. Rapid acting before meal according to Carbohydrate Counting and Insulin Correction

19. 2. New-Onset Diabetes without Ketoacidosis Insulin regimens 50% of the total daily dose Rapid -acting insulin ( NovoRapid Pen) divided up between 3 pre-meal boluses 50% of the total daily dose long-acting insulin ( Lantus ® (insulin glargine Pen) single evening injection Insulin requirements: Start with 0.5 IU/kg/day Pre-pubertal 0.7-1.0 IU/kg/day. During puberty 1 and even up to 2 U/kg/day. The correct dose of insulin is that which achieves the best glycaemic control

20. BLOOD GLUCOSE MONITORING Blood glucose monitoring should ideally be carried out 4-6 times a day , however, this is dependent on the availability of testing strips. Recommended target blood glucose levels: Blood Glucose Targets for Most People with Diabetes During the day 4.5-7mmol/l 80-125mg/dl Overnight & pre breakfast 5.5 -8mmol/l 100-145 mg/dl

21. 3. Management of High Blood Glucose and Ketones but not DKA Ketone testing: either urine strips, or blood. Should be performed: During illness with fever and/or vomiting. When blood glucose is above 14 mmol /l (250 mg/dl) in an unwell child or when persistent blood glucose levels above 14 mmol /l (250 mg/dl) are present. When there is persistent polyuria with elevated blood glucose, especially if abdominal pain or rapid breathing are present. There is an immediate risk of ketoacidosis if the blood ketone level is ≥ 3.0 mmol /l. Insulin treatment is needed urgently. Consider medical evaluation of patient.

22. 3. Management of High Blood Glucose and Ketones but not DKA blood ketones Results Action Follow up 0.1 – 1 mmol /l acceptable No action 1- 3 mmol /l reduce it < 1 mmol /l Retest hourly . 10% of Total Daily Dose ( not more than 10 units) Repeat dose after 2 hours if ketones not < 1 mmol /l & the glucose level > 250 mg/dl (14mmol/l) ≥ 3.0 mmol /l. Risk of DKA? reduce it < 1 mmol /l Retest hourly . 1/6 of Total Daily Dose ( not more than 15 units) Repeat dose after 2 hours if ketones not < 1 mmol /l & the glucose level > 250 mg/dl (14mmol/l) Drink plenty of liquids that contain no calories, for example a glass of water every thirty minutes Try to identify the cause of the high reading.

23. Exercise Regular exercise; improves glucoregulation by increasing insulin receptor number. No form of exercise, including competitive sports, should be forbidden to the diabetic child. In patients who are in poor metabolic control, vigorous exercise may precipitate ketoacidosis because of the exercise-induced increase in the counter-regulatory hormones. A major complication of exercise in diabetic patients is the presence of a hypoglycemic reaction during or within hours after exercise.

24. The major contributing factor to hypoglycemia with exercise is an increased rate of absorption of insulin from its injection site. In anticipation of vigorous exercise, additional carbohydrate exchange may be taken before exercise, and glucose should be available during and after exercise. The total dose of insulin may be reduced by about 10-15% on the day of the scheduled exercise. Exercise

25. Diet There are 3 main nutrients in foods—fats, proteins, and carbohydrates. Fats :  Fat typically doesn't break down into sugar , and in small amounts, it doesn't affect blood glucose levels. Proteins :  Protein doesn't affect blood glucose unless the patient eat more than the body needs. Carbohydrates :  Carbohydrates affect blood glucose more than any other nutrient.

26. Diet The same total caloric intake as usual in normal child is given with the same ratio 50% CHO 35% Fat 15% Proteins Number of meals is preferred to be three fixed major with two snakes in between.

27. What is Carbohydrate (CHO) Counting? is a method of matching your insulin requirements with the amount of carbohydrate you eat and drink. It is an effective way of managing the condition that, once mastered, will lead to better blood glucose control, greater flexibility and freedom of lifestyle.

28. To be successful using carbohydrate counting, you need to: be motivated and able to take the time required to improve diabetes management do simple arithmetic (add, subtract, multiply and divide) understand insulin action read food labels count carbohydrates understand the relationship between carbohydrate and insulin

29. Carbohydrate Counting and Insulin Correction adjusting insulin Calculate amount of carbohydrate that patient eat. Think about activity/exercise Check blood glucose level. Ideally, the measurement after the meal should be within 30-50 points or ( 2 mmol /l) of the pre-meal levels. If it's not, need Carb Counting, Meal Plans, and Insulin Adjustment?  

30. Insulin sensitivity : is how much 1 unit of rapid acting insulin will generally lower your blood glucose over 2 to 4 hours in a fasting or pre-meal state. Insulin sensitivity : 100/Total daily units .  Carbohydrate sensitivity :  is a great way to estimate how many grams of carbohydrate will be covered by one unit of Rapid acting Insulin. Carbohydrate sensitivity: 500/ Total daily units for adult  

31. Roughly according to Age the Insulin to CHO ratio : Less than 5 years : 1unites /25 gm 5 to 8 years : 1unites /20 gm. 8 to 11 years : 1unites /15 gm. 11 to 18 years : 1unites /10 gm AGE (yr) TARGET GLUCOSE (mg/ dL ) TOTAL DAILY INSULIN (U/kg/day)* BASAL INSULIN, % OF TOTAL DAILY DOSE BOLUS INSULIN Units Added per 100 mg/dL Above Target Units Added per 15 g at Meal 0-5 100-200 0.6-0.7 25-30 0.50 0.50 5-12 80-150 0.7-1.0 40-50 0.75 0.75 12-18 80-130 1.0-1.2 40-50 1.0-2.0 [‡] 1.0-2.0

32. Example 15 years old with DM on 25 units Lantus and 8 Novorapid at meal times. Prelaunch RBS= 10 mmol /l ≈ 180 mg/dl She planned to eat Potato for lunch (50 g Carbohydrate)? How much Insulin? Target BG 4.5-7 ≈ 6 (110 mg/dl) , so need to reduce it by 70 mg/dl Total daily insulin= 50/day Insulin sensitivity : 100/Total daily units =100/50=2 it mean 1 unit will drop BG by 2 mmol (35 mg/dl) therefore will need 2 units. Carbohydrate sensitivity: 500/ Total daily units =500/50=10 , so need 1 unit for every 10 g. potato is appoximatily 50 g, therefore need to take 5 units to cover food. Total 7 units.

33. Note : In general these 3 factors will aid in estimating correct mealtime does of insulin (rapid acting insulin ) Check blood glucose Estimate amount of carbohydrate about to be eaten. Consider any exercise done before this meal or any exercise after meal.

34. Expert meter

35. Patient Education

36. Family Education

37. Dietary Education

38. Nurse Advices & Education

39. Nurse Advices & Education

40. Psychological support & Education

41. Screening for complications and associated conditions height and weight & state of injection sites at each clinic visit. Thyroid disease & coeliac disease at diagnosis and annually. annual foot care reviews. Regular dental and eye examinations every 2 years. from the age of 12 years: blood pressure, retinopathy, microalbuminuria & S.Creatinine .

42. The following complications, although rare, should be considered at clinic visits: juvenile cataracts necrobiosis lipoidica Addison's disease. Routine screening for elevated blood lipid levels and/or neurological function is not recommended for children and young people with type 1 diabetes. Screening for complications and associated conditions

43. Special consideration Partial Remission or Honeymoon Phase in Type 1 Diabetes Somogi Phenomena Dawn Phenomena. Management of DM during Infection.

44. Partial Remission or Honeymoon Phase in Type 1 Diabetes Insulin requirements can decrease transiently following initiation of insulin treatment. This has been defined as insulin requirements of less than 0.5 units per kg of body weight per day with an HbA1c < 7%. Ketoacidosis at presentation and at a young age reduce the likelihood of a remission phase. It is important to advise the family of the transient nature of the honeymoon phase to avoid the false hope that the diabetes is spontaneously disappearing. Treatment by reduce the dose of Insulin Accordingly.

45. In children with High dose of Insulin at Night (Long acting) develop late night(3-4 a.m ) Hypoglycemia Counter regulatory hormon will increase Early morning Hyperglycemia . Treatment: Reduce the dose of Long acting Insulin at Night . Somogyi Phenomenon

46. In children with Normal dose of Insulin at Night & Normal midnight glucose (Normoglycemia) , Counter regulatory hormone may normally increase Early morning Hyperglycemia . Treatment: Increase the dose of Long acting Insulin at Night . Dawn Phenomenon

47. Infection may precipitate hyperglycemia or DKA . Mild infection should be treated + increase the dose of Insulin by 10 – 15%. Sever infection necessitate hospitalization. Management during Infection

48. Important information Do not shake the insulin as this damages the insulin? After first usage, an insulin vial should be discarded after 3 months if kept at 2-8 C or 4 weeks if kept at room temperature. Intermediate-acting and short-acting/rapid-acting insulin, can be combined in one Syringe. Use 4mm needle for injection of Insulin SC.

49. THANKS FOR YOUR Attention

50. Dundee

51. Dundee

52. Ninewell Hospital

53. Tayside Children's Hospital