Diabetes in Children

Question 1

What causes diabetes in children?

Answer 1

3rd most common chronic is disease in children after asthma and CP
Autoimmune disorder caused by T cell mediated destruction of pancreatic beta cells
environmental factors are involved in its development especially insulin dependence
Age of onset usually 5-7 or just before or at the onset of puberty especially during winter.

Question 2

How does diabetes usually present in children?

Answer 2

Polyuria
Polydipsia
Failure to thrive or weight loss + infection
Fatigue 
Ketosis
Abdominal pain, nausea and vomiting 
Blurred vision 
Family history of type 1

Question 3

How is the diagnosis of diabetes made in children?

Answer 3

• Symptoms with random blood glucose greater than or equal to 11.1mmol/L
• Symptoms with fasting (8 hours) blood glucose greater than or equal to >7mmol/L
• Symptoms with HbA1c greater than or equal to 6.5% (48mmol/L) (low does not exclude diabetes as it is not as sensitive).
• No symptoms but raised blood glucose on two occasions

Question 4

What investigations should be done in a child suspected of having diabetes?

Answer 4

C-peptide levels that are low or undetectable
Check autoantibodies status - islet cell antibodies, anti-insulin antibodies anti GluAD antibody and anti-IA2
Screen for other autoimmune antibody diseases such as thyroid diseases

Question 5

Who should be managing a child with diabetes?

Answer 5

Care delivered by a multi-disciplinary team of paediatric diabetics team
24 hour access to advice

Refer to paediatric dietician to discuss diet and avoiding sugary foods

Honeymoon period upon commencing insulin if remission

Question 6

How is insulin treatment managed in children with diabetes?

Answer 6

Insulin
If prepubertal 0.5-1 units/kg/24hours
Pubertal 1.5 units/kg/24 hours
1/3 rapid acting and the rest long acting
2/3 of daily dose given before breakfast and the rest pre dinner
Tailor to individual after this as time progresses

Question 7

How can you calculate the energy needs of a child?

Answer 7

Energy needs are 1500kcal/m^2 or 1000kcal +100-200 per year of age. Should be 30% with each meal and 10% as bedtime snack

Question 8

How often should HbA1c and glucose be monitored in children?

Answer 8

HbA1c should be monitored every 3-6 months

Self-monitoring should occur at least 4 times a day with targets of 5-7mmol/l on waking and 4-7mmol/l before meals.

Question 9

What educations will children require about diabetes?

Answer 9

Education regarding
Insulin during illness and injections (practice on oranges)
Monitoring blood glucose accurately
How to control blood glucose levels
Signs of a low and what to do and how to handle missed meals

Question 10

How should a child suffering from hypoglycaemia be managed?

Answer 10

Mild or moderate – give oral glucose such as tablets or sugary drinks. If uncooperative or unable then give oral glucose gel.
Severe – get help and attempt venous access. Use oral glucose gel if IV access fails. With IV access give glucose 5mL/kg of 10% or by rectal tube if no access. Also glucagon 0.5-1mg IM or slowly IV.

Consciousness should be regained swiftly otherwise recheck glucose. If still low give dexamethasone. If glucose is normal could this be a post ictal state following hypoglycaemic fit. If so, giving glucose will make cerebral oedema worse.

Question 11

What is diabetic ketoacidosis?

Answer 11

DKA is caused by uncontrolled lipolysis (not proteolysis) which results in an excess of free fatty acids that are ultimately converted to ketone bodies. Complications of ketoacidosis are worse in children than adults. They include acidosis, cerebral oedema, hypokalaemia and aspiration pneumonia.

Question 12

How does ketoacidosis present?

Answer 12

Confusion, vomiting, polyuria, polydipsia, weight loss, abdominal pain, dehydration, ketotic breath, high work of breathing, shock, drowsiness and coma.

Question 13

How is a diagnosis of ketoacidosis made?

Answer 13

Hyperglycaemia (>11mmol/L), acidosis (<7.3) and bicarbonate (<15mmol/L) and ketones >3mmol/l in blood and ++ in urine. Severity calculated by pH: mild = pH < 7.3, moderate = pH < 7.2 and severe = pH < 7.1.

Question 14

How is ketoacidosis managed?

Answer 14

1. Check GCS – true coma rare in DKA so exclude other causes
2. Resuscitate – ABC and 10ml/kg of 0.9% saline but be wary of cerebral oedema so only if shocked and clearly dehydrated
3. Blood gas, glucose, ketones and urinalysis to confirm diagnosis. Then weight, FBC, Us and Es and ECG monitoring for hypokalaemia
4. Calculate hydration deficit percentage (but never higher than 10%) then multiply by 10 and give that value per kg as replacement. Add this to maintenance then minus whatever has already been given and give steadily.
5. Fluids should be given as 0.9% saline plus 20mmol KCl per every 500ml. Once glucose is down to 14mmol/L add 5% glucose to the fluid. After 12 hours if Sodium is stable then give 0.45% saline instead.
6. Start IV Insulin after 1 hour of giving fluids. Use fast acting insulin and no Bolus. Give 0.1units/kg/h. Reduce insulin to 0.05units/kg/h only after pH > 7.3 and glucose is <14mmol/L. Stop insulin and convert back to normal SC insulin once ketones are <1mmol/L.

Question 15

Should you give bicarbonate to manage the acidosis?

Answer 15

Do not give bicarb as this increases the risk of cerebral oedema.

Question 16

Does ketonuria correlate to ketoacidosis?

Answer 16

Note ketonuria does not mean there is ketoacidosis. Many people will have ketonuria after an overnight fast or as a result of alcohol.

Question 17

What 3 complications of treatment should you be monitoring for in ketoacidosis?

Answer 17

Monitor closely for signs of cerebral oedema such as headache, behaviour change and also for hypokalaemia. Treat suspected cerebral oedema with Mannitol 1g/kg IV and stop fluids.
Also need to be wary of changes in sodium levels

Question 18

How do you calculate fluid requirements in a dehydrated child?

Answer 18

Calculating Fluids needs 
Maintenance 
First 10kg = 100ml/kg 
Second 10kg = 50ml/kg 
Anything else = 20ml/kg 

Rehydration calculations 
% x weight x 10 
Given over:
24hours in hypo/isonatraemic state 
48 hours in hypernatraemic state (but remember to give 2 days’ worth of maintenance 

If dry mucous membranes and decreased skin turgor then 5% dehydration
If sunken eyes and reduced CAP refill then 8%
Never exceed 10% as its dangerous

Question 19

What are MODY’s

Answer 19

Maturity-onset diabetes in the young

These are a collection of single gene defects that results in diabetes like disorders.

Question 20

What are the 2 most common MODY’s and how are they managed?

Answer 20

The most common are MODY2 which results in stable moderately high glucose levels throughout life and rarely needs treatment.

MODY3 is the most common and results in diabetes developing just after puberty. It can be treated with sulfonylureas for years and rarely needs insulin.