Peads: Diabetes in children Flashcards
Types of diabetes in childhood
Type 1 Diabetes
- 92-99% of all diabetes in children
- Approx 50% is genetic- polygenic
Type 2 Diabetes
- 1-5 %
- about 40% is genetic-polygenic
MODY
- <1%
- 100 % genetic- monogenic
Secondary
- CF Related Diabetes (CFRD)
- Steroid induced
Simple pathophysiology of Type 1 Diabetes Mellitus
Absolute insulin deficiency secondary to beta -cell destruction
Diagnostic criteria fr T1DM
- Elevated random sugar (>11.1 mmol/l) + presence of symptoms
- Polyuria
- Polydipsia
- Weight loss
- Lethargy
- Fasting glucose of >7.0 mmol/l
- Positive OGTT
Possible aetiology of T1DM
- Genetic
- Immune mediated
- Islet cell, insulin, GAD auto-antibodies →positive in children with T1DM
- Various other hypothesis
Prevalence of diabetes mellitus in children in the UK
- Affects 1 in 450 children in the UK
- 26,500 affected children in the UK
- Incidence in the UK is increasing by 4% per year
Functions of glucose
- Primary cellular fuel
- Glucose metabolism via mitochondria generates ATP which is cellular form of energy
Sources of glucose
- Gut absorption
- Glycogen
- Gluconeogenesis
What are the cells in the pancreas?
Exocrine and Endocrine functions:
- Islets of Langerhans(1-2% of mass)
- Beta cells (70%)- insulin
Insulin actions on the liver
Liver
- Promotes glucose storage as glycogen
- Prevents glycogen breakdown
- Reduces Alanine (gluconeogenic precursor)
- Prevents ketonogenesis
Insulin actions on the muscle
Muscle
- Promotes Glucose uptake
- Inhibits glycogenolysis and promotes glycogen synthesis
- Increases uptake of Alanine (amino acid)
Insulin action on Adipose tissue
Adipose Tissue
- Promotes glucose uptake and conversion to triglyceride
- Prevents lipolysis of triglyceride into FFA and Glycerol
Ketogenesis in the liver
- FFA → ketones (acetoactate and 3 oH butyrate)
- Ketones makes you sick →DKA
Insulin Regime options
- MDI (Multiple daily Insulin)
- SCII (Sub-cutaneous Insulin infusion)
- Twice daily premixed insulin
Aims of insulin treatments
- Mimicking of physiological insulin secretion
- Normal or near normal blood glucose
- Minimisation of symptoms
- Prevention of complications
Normal levels of insulin delivery (in a healthy pancreas)
In the normal pancreas:
- low background level (basal) secretion of insulin throughout the day and night
- spikes of increased secretion of insulin with meals and snacks to deal with the carbohydrate from that meal
Advantages and disadvantages of Basal Bolus
Advantages
- Much more flexibility
- Can alter doses according to size of meal
- Less need to have between meal snacks
- If child unwell & not eating can omit doses of fast insulin
Disadvantages
- At least 4 injections a day
- Need injection at school
Components of insulin pump
Advantages of SC insulin infusion (insulin pump)
Advantages
- No need for injections
- Fine tuning of doses
- Picky eaters/grazers
- Boluses in school
- Sport
- Independence
- Easier to bolus in company
Disadvantages of SC insulin pump
Disadvantages
- Expensive
- Need to wear all the time
- Visible sign of diabetes
- Intensive treatment
- Risk of DKA
Advantages and disadvantages of BD mixtures regimen
Advantages
- Convenient
- Only 2 injections a day
- No injections in school
Disadvantages
- Lack of flexibility
- Have to be up & injected by 9am at latest
- Have to have 3 snacks a day & 3 meals a day
- Difficult to adjust
Education for a child with DM
- Dietary education and healthy food behaviours
- Understanding carbohydrate intake
- Support and understanding and advice on child and families habits and activities
- Education on the insulins used, administration options, and their actions
- Continuing education and support to facilitate good glycaemic control whilst avoiding significant hypoglycaemia
What’s carbohydrate counting?
Adjusting insulin dose based on the carbohydrate content of the food eaten
How often to monitor blood sugar levels?
- very important to monitor regularly
- ideally pre meals + 2 hours after + waking + bedtime
- New NICE recommendation is to monitor 6-8 times a day
What are the target blood sugar levels?
- 4-7 pre-meals
- 5-9 post meals
- >5 driving
What’s HbA1C?
- HbA1c refers to glycated haemoglobin
- It provides the average blood sugar level over 3 month period
What’s target HbA1C?
HbA1c target
- ≤6.5% or ≤ 48mmol/mol
- Or as close as can be achieved without disabling hypoglycaemia
Microvascular complications of DM
- Microvascular
- Microangiopathy
- Retinopathy
- Nephropathy
- Neuropathy
microvascular complications of DM
Microvascular
- Microangiopathy
- Retinopathy
- Nephropathy
- Neuropathy
macrovascular complication of diabetes
• atherosclerosis
Risk factors that increase the probability of complications in DM
- Duration of diabetes
- Genetic influences
- Sex
- Glycaemic control –HbA1C vs glucose variability
- Hypertension
- Smoking
- Hyperlipidaemia
- Growth hormone axis
What are the aims of annual screenings in a patient with DM?
- Detect complications early
- Potential to reverse some complications with improved glycaemic control
- Treatment can arrest or slow progression
What patients with DM are screened for?
- Height and Weight
- Blood pressure
- Bloods- thyroid, coeliac, lipids
- Urine- microalbuminuria
- Psychology
- Retinopathy >12 years
- Feet
What level of glucose is considered as hypoglycaemia in children?
For children with diabetes sugar< 4mmol/l is to be treated as hypoglycaemia
Signs and symptoms of hypoglycaemia
Management of hypoglycaemia in kids
- Treat with 10-15g fast acting glucose
- Check sugar after 15 mins
- Followed by carbohydrate snack if meal time is >1 hour away
- If sugar has come up to >5.5mmol/l, and eating soon, no need for snack
Initial management of hyperglycaemia
- Give extra correction doses of rapid acting insulin
- •If a consistent pattern, adjust regular insulin doses
- If BG >14 mmol/l, check blood ketones
- Ensure well hydrated
When to check for ketones?
- If BG >14 mmol/l → check blood ketones
- Increasing ketones (>3mmol/l) is a sign of impending DKA
Causes of hyperglycaemia
- Insufficient Insulin
- High intake of glucose foods/drinks
- Intercurrent infection
- Post Hypo
- Stress
- Medications
- Steroids
- Risperidone
- Eating disorders
Sick Day Rules
- Always give basal
- Basal requirements will increase
- Measure BG every 2-4 hours, if >14 check ketones
- Lots of sugar free fluids
- Adjust rapid acting to food eaten
- If not eating, regular sugar containing fluids 10g/hr
- Correction doses of rapid acting if high
- High BG or ketones not improving- hospital
What’s continuous glucose monitoring?
- Measures the interstitial glucose every few minutes
- Offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:
- frequent severe hypoglycaemia or impaired awareness of hypoglycaemia associated with adverse consequences (e.g.seizures or anxiety)
- Or inability to recognise, or communicate about, symptoms of hypoglycaemia (e.g. because of cognitive or neurological disabilities).
Who can be considered for ongoing real-time Continuous Glucose Monitoring?
Consider ongoing real-time continuous glucose monitoring for:
- neonates, infants and pre-school children
- children and young people who undertake high levels of physical activity
- children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (e.g. corticosteroids) that can make blood glucose control difficult.
Who can be considered for intermittent continuous glucose monitoring?
Consider intermittent continuous glucose monitoring to help improve blood glucose control in:
- children and young people who continue to have hyperglycaemia despite insulin adjustment and additional support
Pathophysiology of DKA
- The lack of insulin over time → abnormal metabolic pathways to generate energy for the body’s cells
- These pathways → production of ketones and a metabolic acidosis
* The situation is exacerbated by relative dehydration through glycosuria causing a diuresis and respiratory compensation for the acidosis with hyperventilation to “blow off” carbon dioxide, further disrupting the acid-base balance.
Symptoms of DKA
- Polyuria (nocturia)
- Extreme thirst
- Inability to concentrate
- headaches
- diminished conscious levels
- abdominal pain
- other non-specific symptoms
Principles of management for DKA
- rehydration and electrolyte management (especially a rapid reduction in serum potassium after introduction of insulin (as forces K+ into cells)
- gradual introduction of a fast-acting insulin, either by pump or injection depending on the status of the patient.
The aim of therapy is a gradual correction of all elements to avoid dramatic fluid and electrolyte shifts
