Diabetes in childhood Flashcards
Which hormones maintain blood glucose homeostasis?
glucagon
insulin
Diabetes bloods diagnosis cut offs
fasting >7
2 hours post OGTT >11
random glucose + symptoms >11
Symptoms of diabetes
polydipsia
polyuria
tired
weight loss
2 types of monogenic diabetes mellitus
neonatal diabetes mellitus
MODY
Describe MODY
young age at onset (<25y)
autosomal dominant
family history
absence of signs of insulin resistance (obesity, acanthosis nigricans)
little/no insulin requirement 5 years after diagnosis
stimulated c-peptide >200 pmol/L
T1DM autoantobodies
GAD65
ICA
IA2
ZnT8
Advantages of insulin pumps
delivers insulin in more physiological way
can improve diabetes control
lessens risk of hypoglycaemia
fewer injections/needles
Disadvantages of insulin pumps
intensive therapy, can be hard work
pump failure
not everyone wants visible sign of diabetes
concerns over wearing pump during sport
risk of skin infection at cannula site
expensive
Short term complications of diabetes
DKA
hypoglycaemia
hyperglycaemia
DKA diagnostic criteria
BM >11 mmol/L
ketonaemia > mmol/L
acidosis: pH<7.3, HCO3<15mmol/L
DKA triggers
8Is:
Infection (pancreatitis, pneumonia, UTI)
Infarction (MI)
Infraction (non-compliance with therapy)
infant (pregnancy)
ischaemic (CVA)
illegal (cocaine)
Iatrogenic (steroids etc)
Idiopathic (new onset T1DM)
Mild DKA cut offs
pH 7.2-7.3
HCO3 15
Moderate DKA cut offs
pH 7.1-7.2
HCO3 10
Severe DKA cutoffs
pH <=7.1
HCO3<=5
SPIDER mnemonic for DKA treatment
saline
potassium
insulin
dextrose: with insulin
eat nothing: NBM
reason: find underlying cause + treat
DKA management
IV fluids 1h before insulin
0.9% saline with 40mmol/L KCl
once glucose drops to 12mmol/L change to 0.9%/5 dextrose saline with KCl added
novorapid: 50 units in 50ml normal saline
run at 0.1 units/kg/hour
Complications of DKA
cerebral oedema
hypoglycaemia
hypokalaemia
Risk factors for cerebral oedema in DKA
children<5
new onset diabetes
late presentation (longer symptoms, more acidic pH)
administration of large amounts of fluids
hypotonic fluid administration
early administration of insulin
administration of sodium bicarbonate
bolusing IV insulin
Clinical features of cerebral oedema
headache
drowsiness
incontinence
vomiting
decreased level of consciousness
bradycardia
rising BP
decreasing oxygen sats
CNS signs (abnormal pupil responses, abnormal posturing)
Cerebral oedema treatment
mannitol 0.5g to 1.5g /kg (=2.5-7.5ml/kg 20% mannitol) over 30 mins
3% saline
Cushing’s triad
suggestive of raised ICP
decreased resp rate
decreased heart rate
increased systolic BP
Chronic complications of diabetes
microvascular:
- retinopathy
- nephropathy
- neuropathy
macrovascular:
- cerebrovascular disease
- cardiovascular disease
- peripheral vascular disease
When can a newly-diagnosed T1DM patient leave hospital?
able to do injections + blood glucose monitoring
basic dietary advice - carb counting
hypoglycaemia management
ketone monitoring if sugar levels high
Advice to give about hypoglycaemia treatment
conscious: 10g fast carbohydrate followed by starchy snack
conscious but uncooperative = glucogel followed by starchy snack
unconscious = glucagon IM then starchy snack if possible + hospital
Signs and symptoms of hypoglycaemia
hunger
coma
anxiety
abdominal pain
headache
palpitations
weakness
abnormal cry
blurred vision
fainting
dizziness
confusion
convulsions
irritability
MODY inheritance
monogenic
autosomal dominant
What does MDI stand for with regards to diabetes management?
multiple daily injections
How to calculate total daily dose if insulin
0.75 units/kg
(0.5 units/kg if <5y)
What long-acting insulin analogues are used in children?
tresiba for >2y
levemir for <2y
How to calculate dose of tresiba (long-acting insulin) for children
30% of total daily dose (TDD)
[TDD = 0.75 U/kg]
What rules dictate the insulin:carb ratios in children?
How is this used?
300 rule for <5y
400 rule for 5-11y
500 rule for >11y
eg. child age 6 years, 20kg
insulin:carb ratio = 400/TDD = 400/15 = 27
1:27
1 unit novorapid covers 27 carbs
What is correction factor and how is this calculated in children?
based on 100 rule
20kg 6y old child
correction factor = 100/TDD = 100/15 = 7
1:7
1 unit novorapid will bring blood glucose down 7 mmol/L
Ideal pre-meal blood glucose for diabetics
4-7mmol/L
Degree of dehydration in mild or moderate DKA
5% dehydration
Degree of dehydration in severe DKA
10% dehydration
Why might potassium initially be high in DKA?
due to dehydration
replace potassium if levels are normal or low as insulin will drive it lower
if high –> monitor
When can fixed rate insulin infusion be stopped in DKA?
when ketonaemia has resolved
if ketonaemia still present, continue insulin even if glucose levels have normalised
What observations should be done for patients in DKA?
hourly neuro obs
monitoring for signs of cerebral oedema (particularly hypertension and bradycardia)
