Diabetes in Childhood Flashcards
Why is an early diagnosis important?
- Scotland has 5th highest incidence of T1D (Type 1 diabetes) in the world
- In Scotland 300 children under the age of 15 years are diagnosed with T1D annually
- 1 in 4 are diagnosed in DKA (diabetic ketoacidosis)
- Rising to 1 in 3 under the age of 5 years
- The mortality & morbidity in DKA are related to the length of time between the onset of DKA and initiation of treatment: in the UK 10 children die and 10 children suffer permanent neurological disability per annum
What are the symptoms of Type 1 in childhood?
- Toilet (using more)
- Thirsty
- Thinner
- Tired
How do we test for Type 1 immediately?
- Finger prick capillary glucose test
- If result >11mmol/l telephone urgently to local specialist team for same day review
Describe the overall presentation of type 1 diabetes
- Subsequent POLYURIA & secondary POLYDIPSIA
- NOCTURNAL ENURESIS – earliest symptom 89% aged 4 years +
- DEHYDRATION [constipation in 10% under 5 years]
- WEIGHT LOSS - 50% of age 10-14, but only 2% less than 2 years old
- LETHARGY [10-20% all ages] & BEHAVIOURAL CHANGES
- BLURRED VISION (osmotic effect on lens)
- VAGINAL CANDIDIASIS
Describe insulin secretion without diabetes
- Normal insulin secretion: 0.7 – 0.9 units/kg/day
- Approx 30-40% total daily insulin is secreted during basal periods to suppress lipolysis, proteolysis + glycogenolysis
- In response to a meal [bolus] – rapid insulin secretion [FIRST PHASE INSULIN SECRETION]
- Second phase follows + is sustained until normoglycaemia restored, continuous
Describe insulin treatment in children
-Must be started as soon as possible after diagnosis [usually within 6 hours if ketonaemia is present]
-Children can develop dehydration + acidosis within 24 hours of first presentation.
-Children < 2years old are most at risk. [30% newly diagnosed have had at least one related medical visit before the diagnosis]
=This is to prevent metabolic decompensation and diabetic ketoacidosis
Why are ketones formed in type 1 diabetes?
-Lack of insulin therefore no inhibition to hormone sensitive lipase
=require alternative energy source
=fat broken down to fatty acids causing acetyl CoA production to exceed the oxidative capacity of Krebs cycle
=ketones (beta-hydroxybutyrate in blood)
What are the most common causes of diabetic ketoacidosis?
-DKA: IS THE RESULT OF AN ABSOLUTE or RELATIVE DEFICIENCY OF INSULIN
=Newly diagnosed diabetes
In children with established TIDM – the risk is 1-10% per patient per year
=Infections (counter-regulatory hormones opposite insulin)
=Non compliance with treatment [75%]. Children whose insulin is administered by a responsible adult rarely have episodes of DKA
=Potential complication of insulin pump therapy (rapid acting)
Describe the pathophysiology of DKA
- An accelerated catabolic state, impaired peripheral glucose utilization, increased lipolysis + ketogenesis
- Hyperglycaemia + hyperketonaemia cause osmotic diuresis + dehydration (gastric stasis and IBS, unable to process fluid load)
- Dehydration becomes a major feature [vomiting - in child with diabetes vomiting is sign of insulin deficiency until proved otherwise]
- Lactic acidosis from hypoperfusion
What are the signs and symptoms of DKA?
- Dehydration
- Nausea, vomiting + abdominal pain, mimicking an acute abdomen
- Acidotic respiration [ Kussmaul ] ‘deep + sighing’
- Altered conscious level
What is the clinical presentation of DKA?
- Biochemical data:
- pH < 7.3 +/or bicarbonate < 15 mmol/L
- Base excess: strongly negative
- High anion gap
- Hyperglycaemia
- Hyperketonaemia
What are the key aims in paediatric DKA management?
- Meticulous monitoring of clinical condition of the patient and the biochemical data
- Correct dehydration SLOWLY [over 48 hours in those < 18 years]
- Correct acidosis SLOWLY + reverse ketosis – i.v insulin infusion and NOT bicarbonate therapy
- Restore BG to near normal
- Avoid complications of therapy: paediatric cerebral oedema
What is the education plan for the newly diagnosed child?
-Ward based - basic education
=Commence basal bolus insulin regimen
=Home based - social issues
=School/Nursery visits
-Clinic based - on-going package of care
=New patient clinic
=Review clinic
=Young Person’s clinic (aged 14-18 years)
What technology can people with type 1 diabetes use?
- FreeStyle Libre 2 system= interstitial insulin monitoring, Bluetooth app
- Continuous blood monitors
- Apps to calculate carbohydrates/ portions so match the insulin
- Hopefully 4-9 mmol/l of blood glucose
What are the aims of sick day management?
- Do not omit insulin. Always check blood ketone value.
- Switch off ketogenesis [requires additional insulin]
- Ensure sufficient carbohydrate substrate is available
- Achieve normoglycaemia: =Febrile patients generally have an increased insulin requirement [25-50%], =Patients with D+V with no ketonaemia may have a reduced insulin requirement. [20% in each dose given]
- Altered insulin doses may be required for up to one week after the intercurrent illness.
- Treat the current illness
