ECONTENT JUVENILE DIABETES MELLITUS.pptx

The most prevalent endocrine condition in children is diabetes mellitus. Children only develop type 1 diabetes mellitus. Diabetes mellitus is a condition in which the body either produces insufficient amounts of insulin or does not react appropriately to the insulin that is
generated, resulting in excessively high blood sugar (glucose) levels.

1. JUVENILE DIABETES MELLITUS PRESENTED BY, AGILA LAKSHMANAN(MSC.NURSING),BPNI(COUNSELLOR), NURSING TUTOR, DEPARTMENT OF CHILD HEALTH NURSING, SHRI SATHYA SAI COLLEGE OF NURSING, AFFILIATED BY SHRI BALAJI VIDYAPEETH UNIVERSITY- PUDUCHERRY

2. INTRODUCTION The most prevalent endocrine condition in children is diabetes mellitus. Children only develop type 1 diabetes mellitus. Diabetes mellitus is a condition in which the body either produces insufficient amounts of insulin or does not react appropriately to the insulin that is generated, resulting in excessively high blood sugar (glucose) levels.

3. DEFINITION Diabetes mellitus is a condition of hyperglycemia caused by deficiencies in insulin production, insulin action, or both, resulting in disruptions in carbohydrate, protein, and lipid metabolism, characterized by hyperglycemia and glycosuria.

4. INCIDENCE DIABETES MELLITUS TYPE I: Two age groups experience the peaks of presentation: viral (ages 5-7) and gonadal steroids (during puberty). About 13,000 new instances of type 1 diabetes mellitus are diagnosed each year in the United States, where the incidence is 1.7 per 1000 individuals (American Diabetes Association, 1999). When the population is over 20, the incidence drops to 5 per 100,000.

5. If a person has a parent or sibling who has type 1 diabetes mellitus, their risk of developing the disease rises to 1 in 20; if an identical twin has the condition, their risk rises to 1 in 3. The school-age time is when it usually first appears.

6. DIABETES MELLITUS TYPE II: When puberty begins, the incidence of type 2 diabetes peaks. Type 2 diabetes has been identified in children as young as five. Some groups, such as American Indians, African Americans, Latinos, and people with Asian heritage, are more likely to have type II diabetes. Females are more likely than males to have it.

7. CLASSIFICATION Diabetes is classified into 2 categories : Type 1: (insulin insufficiency caused by beta cell death) is more common in children since it typically affects young people. Children with type 1 diabetes require insulin therapy for the rest of their lives. Therefore, "insulin dependent diabetes mellitus" (IDDM) was another name for this type.

8. CLASSIFICATION Type 2: Insulin insufficiency with primary insulin resistance. The term "non-insulin dependent diabetes mellitus (NIDDM)" was once used to describe type 2 diabetes. Type 2 diabetes was once thought to be an adult condition, but with the present obesity epidemic, it is now increasingly being found in children.

9. OTHER SPECIFIC TYPES Genetic defects of beta cell function (HNF-1alpha, HNF-4 alpha glucokinase, mitochondrial DNA). Genetic defects in insulin action ( leprechanism , lipoatrophic diabetes). Diseases of the exocrine pancreas (pancreatitis, cystic fibrosis, fibrocalculous pancreatopathy , surgery). Endocrinopathies (acromegaly, cushing syndrome, hyperthyroidism).

10. OTHER SPECIFIC TYPES cont.. Pentamidine, steroids, Dilantin, thiazides, and diazoxide are examples of drugs or chemicals. Infection (cytomegalovirus, congenital rubella). Immune-mediated diabetes in uncommon forms (anti-insulin receptor antibiotics, stiff-man syndrome). Other genetic syndromes (down, Klinefelter, turner, and wolfram) are occasionally linked to diabetes. Diabetes during pregnancy.

11. ETIOPATHOGENESIS Environmental factors: In people who are genetically predisposed, environmental conditions are required to initiate autoimmunity.

12. ETIOPATHOGENESIS cont … Infectious illnesses: The development of type 1 diabetes is linked to CMV and mumps. Congenital rubella syndrome is one instance of such a relationship.

13. ETIOPATHOGENESIS cont … Toxins in the environment: Type 1 diabetes has been linked to the use of nitrosomines and rodenticides.

14. ETIOPATHOGENESIS cont … The nutrients: In genetically predisposed newborns, early exposure to cow's milk protein may play a significant role in the later development of diabetes.

15. ETIOPATHOGENESIS cont … Autoimmunity: The autoimmune death of beta cells causes type 1 diabetes. Serum samples from patients with type 1 diabetes have been found to include islet cell cytoplasmic (ICA) and surface (ICSA) autoantibodies. ICA typically occurs months or years before type 1 DM manifests clinically.

16. ETIOPATHOGENESIS cont … Genetics Beta cell damage can be caused by a variety of genetic changes, the majority of which are found on chromosome 6 within the major histocompatibility complex.

17. PATHOPHYSIOLOGY

18. CLINICAL MANIFESTATIONS The onset of disease is usually acute over a period of few weeks with classical triad features, Polyuria, polyphagia and polydipsia Other features include: Nocturia Enuresis Weight loss General weakness Tiredness

19. CLINICAL MANIFESTATIONS cont.. Body pain Fainting attack due to hypoglycemia Abdominal pain Nausea ,Vomiting Irritability Vulvovaginitis in girls Skin infections like dry skin

20. CLINICAL MANIFESTATIONS cont.. Diabetic coma may be the first presenting feature. The child with DKA may present in. Precomatosed state with drowsiness Cherry red lips Tachypnoea Poor wound healing

21. CLINICAL MANIFESTATIONS cont.. In comatosed state the child may have extreme hyperpnoea ( kussamal breathing) Acetone breath Soft and sunken eyeballs Rigid abdomen Decreased body temperature Dehydration

22. CLINICAL MANIFESTATIONS cont.. Rapid weak pulse Decreased blood pressure Circulatory collapse Renal failure may develop with fluid-electrolyte imbalance

23. CLINICAL MANIFESTATIONS cont.. There may be precipitating factors like infection Trauma Intercurrent infections

24. DIAGNOSTICS TESTS Casual plasma glucose concentration >200 mg /dl (11.1 mmol/L) on two separate occasions with symptoms of diabetes suggest the diagnosis. Fasting plasma glucose levels > 126 mg/dl (7.0 mmol/L) on two occasions is suggestive.

25. DIAGNOSTICS TESTS The oral glucose tolerance test (OGTT) is rarely needed to confirm the diagnosis in children . OGTT is performed with an oral glucose 1.75g /kg of ideal body weight up to a maximum of 75g. The fasting plasma glucose must be > 126 mg/dl and the 2 hours value must be > 200 mg /dl in two occasions.

26. MANAGEMENT Diabetes mellitus is a multi-organ disease that is complicated. Integration of the following is necessary for proper therapy: Insulin therapy Fitness and physical activity Nutritional control S ocial and emotional support to delay the development of both acute and long-term issues.

27. INSULIN THERAPY To maintain an ideal blood glucose level, children frequently require multiple daily insulin injections before meals and before bed. Insulin comes in a variety of forms. There are several methods for administering insulin therapy to kids and teenagers; the best one for the child and family should be choosen .

28. INSULIN THERAPY cont … Initial requirement of insulin may be 1 to 1.75 units/kg/day Then the dose may be less than 0.5 units /kg/day after 12 to 16 weeks. The total calculated dose is administered in divided amount 2/3 rd dose in morning and 1/3 rd dose at night. Split mix regimen can be followed with 2/3 rd lente (intermediate acting) and 1/3 rd regular (short acting)

29. INSULIN THERAPY cont … The basal bolus insulin regimen has been documented to result in stable glycemic control. Insulin can be administered by an insulin pump or by multiple daily injections. With basal - bolus therapy, basal insulin is administered with each meal and snack based on the carbohydrate grams consumed.

30. INSULIN THERAPY cont … This means that a child may get 6 to 7 injections a day. Stress, infection, and illness may either increase or decrease insulin needs If based –bolus therapy for type 1 diabetes is to be effective , the child and family need to do each of the following : -Monitor the blood glucose four to eight times a day and once a week at midnight and 3 am. -Consistency count carbohydrate consumed. -Anticipate exercise in the daily routine.

31. EXERCISE AND PHYSICAL ACTIVITY Exercise programs increases glucose utilization and sensitivity of muscles of insulin. The usual exercises include vigorous walking, jogging, swimming, aerobic exercise and games like tennis. Children should be taught about the effect of exercise on blood glucose and adjustments to be made in insulin dose and diet.

32. NUTRITION The goal is for optimizing glucose, blood pressure and lipid levels with weight. Carbohydrates: The amount of carbohydrates in diet can liberalized up to 55 to 60% of total calories. Concentrated carbohydrates like candies, sugar, sweet, chocolates and cakes to be avoided. Fiber: Increase in diet fiber is associated with lower glucose level in diabetic. The present advice is an intake of 20 to 35 g/day from a varied diet.

33. NUTRITION Protein: Protein intake should be evaluated in terms of its effect or renal hemodynamics, growth and development and glycemic status. Fats: The type and amount of dietary fat in children with diabetes have implications in adult coronary artery disease.

34. PSYCHOSOCIAL ASPECTS The management and diagnosis and long term management of type 1 DM offers a formidable challenges to the child and family . It requires a ‘therapeutic alliance’ where the family assumes prime treatment responsibilities with the physician and other members of the team acting as consultants.

35. COMPLICATIONS Acute complications are usually reversible. Intermediate complications are potentially reversible. Chronic complications are rarely reversible and are due to micro and macro vascular pathology. The classic trait of retinopathy, nephropathy and neuropathy due to micro vascular etiology are the most common chronic complications and usually manifested in adulthood.

36. ACUTE COMPLICATION DIABETIC KETOACIDOSIS : DKA is the most common and severe manifestation of type 1 diabetes. It occurs as a result of insulin deficiency with concomitant increased production of the stress hormones, glucagon, cortisol and growth hormone. The results in production of ketone bodies.

37. ACUTE COMPLICATION HYPOGLYCEMIA: It is defined as blood glucose levels less than 60 mg/dl. It is characterized by adrenergic symptoms such as sweating, pallor, trembling and tachycardia. It is often due to a mismatch in the use of insulin with the diet and activity of child.

38. ACUTE COMPLICATION cont.. The diagnosis should be confirmed by a quick blood test. Simple carbohydrates like sugar, glucose, honey, fruit juice or carbonates drinks may be offered immediately.

39. ACUTE COMPLICATION cont.. An unconscious child should be given glucagon (0.5 mg in children, 1.0 mg in adolescents) intramuscularly. If glucagon is not available, intravenous glucose should be administered under supervision. The family needs to counseled regarding warming signs of hypoglycemia, its management, possible reason for its occurrence and prevention.

40. INTERMEDIATE COMPLICATIONS LIPOATROPHY: It is due to impurities present in the older insulin preparations. With the introduction of purified animal and human insulins, the incidence of lipohypertrophy is on the increase.

41. INTERMEDIATE COMPLICATIONS cont.. LIMITED JOINT MOBILITY: There is inability to approximate palmer surfaces of the hands in a prayer position, due to flexion contractures of metacarpophalangeal and proximal interphalangeal joints.

42. INTERMEDIATE COMPLICATIONS cont.. Growth failure Is due to under insulinzation and poor metabolic control.

43. INTERMEDIATE COMPLICATIONS cont.. Delay in sexual maturation Impaired intellectual development Hypoglycemia unawareness

44. CHRONIC COMPLICATIONS RETINOPATHY: It is the most common microvascular changes seen in diabetics. The prevalence associated with age, duration of diabetes and puberty.

45. CHRONIC COMPLICATIONS cont.. NEPHROPATHY: It is the most common cause of death in type 1 DM contributing to more than 50 % deaths by 25 to 40 years. Clinically, nephropathy is defined by the leakage of large amount of albumin in urine.

46. CHRONIC COMPLICATIONS cont.. PERIPHERAL NEUROPATHY: It is unusual in children and adolescents with type 1 DM with a prevalence of < 5% below 18 years.

47. DIABETES EDUCATION Children with diabetes and their parents need ongoing educational and emotional support from the health professionals. Diabetic educators need to instill in them the importance of achieving near normal blood glucose and HbA1c level in preventing chronic issues. Meticulous management will need expertise in insulin administration and glucose monitoring at home.

48. NURSING MANAGEMENT cont.. Providing nutritional requirement as planned. Increasing knowledge and skill about insulin therapy among parents. Providing instructions about self monitoring of blood glucose level. Identifying and controlling hypoglycemia. Restoring fluid balance by IV fluid therapy. Reducing fear and anxiety by emotional support. Prevention of infections

49. BIBLIOGRAPHY Bindler and Ball ,” Pediatric nursing” 4th edition 2009, published by drling Kindersley India in south Asia. Pp 1208, 1223. Dorothy R.Marlow , “Textbook of pediatric nursing” 6th edition 2009, elsevier publication. pn 877-887. Ghai O.P,” Essential pediatrics” 4th edition 1985, publisher dr . o. p.ghai . pp 325,20. Nair parthasarthy , “IAP textbook of pediatric” 3rd edition 2007, published by kailas darshan , new delhi .pp-756-762. Wong’s “Essential of pediatric nursing “ 8th edition 2009, elsevier publication .pp 15941615

50. REFERENCES https://www.merckmanuals.com › ... › Hormonal Disorders in Children https://www.slideshare.net/ahmedelhewala9/diabetes-mellitus-in-children https://www.deutsche-diabetes-gesellschaft.de