Metabolic Flashcards
How many children are affected by diabetes mellitus and what is the predominant type?
2 in 1000 before age 16
Mostly T1DM
How is T1DM genetically linked?
Main implicated genes appear to be HLA-DR3 and HLA-DR4
There is a strong familial link but also a familial factor
If Father has T1dm chance of child getting it is 1 in 20-30
If Mother has T1DM chance of child having it is 1 in 40-60
30-40% concordance between monozygotic twins
What other disease is T1DM associated with?
Other genetic conditions such as Hypothyroidism, Addison’s, coeliac disease and RA
T1DM can sometimes be triggered…what are the most common triggers?
Enteroviruses
What are the two peaks of presentation of diabetes
Pre-school age
Teenagers
What are some presenting features of diabetes?
Polyuria (nocturia, secondary enuresis) Polydipsia Fatigue Weight loss - failure to grow ***might be diagnosed in this early stage or might be in DKA
How do we diagnose diabetes in children?
Random blood glucose >11.1mol/L DIAGNOSTIC
Fasting blood glucose >7mmol/L or high HbA1c also aid diagnosis
How should T1DM be managed initially?
IF they have presented in acute phase then resuscitate accordingly (fluids, insulin etc.)
Managing a child with diabetes is all about giving them the education to be a part of the management (this has been shown to make blood sugars much more optimal)
What things do children with a diagnosis of T1DM need to be counselled on?
Pathophysiology of diabetes Injection of s/c insulin (technique and sites - belly, rotate sites) Information about diet and carbohydrates (carb counting) DIETICIAN REFERRAL Blood glucose monitoring Recognition of sx of hypoglycaemia Where to get advice Psychological impact DIABETES UK
What forms of insulin therapy are there?
Human analogue (rapid acting with fast onset and short duration of action) Short acting (peak action 2-4 hours, duration 8 hours) Intermediate Acting (peak 4-12h)
What advice should be given to patients about injection sites?
Fatty tissues around the upper arm, lower abdomen and the anterior and lateral thigh - pinch up the skin and inject at 45 degrees. ROTATE SITES (prevent lipoatrophy or lipohypertrophy)
What, vaguely, should a diabetic person’s diet be like?
High in complex carbohydrates and low in fats
High in fibre will prevent short sharp shocks of glucose and encourage more sustained response
How might DKA present in a child?
VERY NON-SPECIFIC Vomiting Abdo pain Dehydration Hyperventilation (acidosis compensation) Drowsiness, LOC, death, coma
What investigations should be offered in children with ?DKA?
Glucose (>11.1)
Blood ketones (>3.0)
U&E (high creatinine suggests dehydration)
Blood gas (acidosis - lactate)
Urinary glucose and ketones
Cardiac monitoring (ECG) T wave for hypokalaemia
Weight
How should DKA in a child be managed?
RESUSCITATE IF SHOCKED
- 0.9% NaCl at 20mls/kg BOLUS
- Monitor fluid input/output, consciousness level
- Insulin therapy
- *Slow infusion 0.05-0.1U/kg - aim for SLOW REDUCTION of 2mmol/L/hr
- Potassium
- **insulin pushes K EC so check levels and then supplement if necessary
Identify and treat a cause and discuss long term control in future
What is moderate and what is severe failure to thrive?
Moderate - fall across 2 gentiles
Severe - fall across 3 or more
How can we estimate the final height of a child?
MID-PARENTAL HEIGHT
- BOYS - (FH+MH+13)/2
- GIRLS (FH+MH-13)/2
What are some ORGANIC causes of failure to thrive?
Impaired suck/swallow (cleft palate, tongue tie)
Chronic illness (Crohn’s, CF)
Inadequate retention (chronic vomiting, GORD)
Malabsorption (Coeliac, CF, CMPA)
Failure to utilise nutrients (T21, CF, Extreme prem)
Increased requirements (CF, malignancy, thyrotoxicosis)
What are some non-organic causes of FTT?
Psychological or environmental deprivation
5-10% of children with FTT - NEGLECT
If there is concern the child is not growing properly what things should you ask in the hx?
- meal time and food hx
- does the child have energy?
- Does the child have D&V?
- Birth hx
- Developmental stage / delay
- Cough - Psychosocial problems at home
What should you look for on an examination a child with FTT?
Dysmorphic features
Bloods - TTG, FBC + Ferritin, U&E, Inflam marks
Signs of malabsorption (distended abdo, thin buttocks,)
Signs of cardiac or resp disease
How should FTT be managed?
Depends on cause
- Eating support
- Identification and treatment of chronic disease
- Support from clinical psychologist
***only need admission if <6m and FTT is severe
