T1DM

Question 1

T1DM - background (3)

Answer 1

1. Def = autoimmune disorder characterised by T-cell mediated destruction and progressive loss of pancreatic beta-cells leading to eventual insulin deficiency and hyperglycaemia
2. Most common form of DM in children and adolescents (90% of cases). Affects 2/1000 children. Two peaks in presentation = preschool and teenagers
3. Etiology = both genetic and environmental factors. Over 20 different T1DM susceptibility genes identified

Question 2

T1DM - clinical presentation

Answer 2

Early
Classic triad 
1. Excessive drinking (polydipsia)
2. Polyuria
3. Weight loss
Less common 
4. Enuresis (secondary)
5. Skin sepsis, candida and other infections

Late - diabetic ketoacidosis

1. Vomiting, dehydration
2. Abdominal pain
3. Smell of acetone on breath, hyperventilation due to acidosis (Kussmaul breathing)
4. Hypovolaemic shock
5. Drowsiness, coma and death

Question 3

T1DM - ix

Answer 3

1. Dx established in symptomatic child with random BGL >11.1mmol/L. If any doubt, use fasting blood glucose (>7.0mmol/L). Note - diagnostic glucose tolerance test rarely required in children

Other ix:

2. UEC
3. Blood pH (to exclude DKA)
4. Diabetes-related autoantibodies (3) = islet cell antibody (ICA), anti-insulin antibody (IAA), anti-GluAD antibody, anti-IA-2
5. Other autoimmune disease screen = TFTs, thyroid antibodies, celiac disease antibody screen

Question 4

T1DM - mx

Answer 4

1. Intensive educational program for parents and child.
   a. Pathophysiology
   b. Insulin injections (3 - action of insulin, techniques, dose adjustment)
   c. Diet (healthy, high complex carbohydrate, low fat)
   d. Sick day rules during illness to prevent DKA
   e. BGL (finger prick) monitoring
2. Insulin therapy
   - Initial = 0.25 units/kg of quick-acting insulin SC stat, halve dose if 4y or younger
   - Ongoing = twice daily injections of a mixture of short and intermediate-acting insulins, or multiple daily injections (MDI) of insulin using a long-acting insulin analogue at night and pre-meal injections of rapid-acting insulin analogue
3. Nutritional mx and monitoring of glycaemic control
   - Healthy diet with high complex carbohydrate and relatively low fat content
   - BGL home monitoring using portable glucose meter and finger pricking device. Minimal testing frequency 4x/d.
4. Management of acute illness and avoidance of DKA
   - Hypoglycaemia symptoms if BGL

Question 5

TIDM - associated illnesses

Answer 5

1. Autoimmune thyroiditis (5%)
2. Celiac disease (5-10%)
3. Adrenal insufficiency (uncommon)