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CHILDHOOD AND ADOLESCENT DIABETES Dr Machira E DEFINITION OF DIABETES A metabolic syndrome characterized by hyperglycaemia as key biochemical abnormality.

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Presentation on theme: "CHILDHOOD AND ADOLESCENT DIABETES Dr Machira E DEFINITION OF DIABETES A metabolic syndrome characterized by hyperglycaemia as key biochemical abnormality."— Presentation transcript:



3 DEFINITION OF DIABETES A metabolic syndrome characterized by hyperglycaemia as key biochemical abnormality. Defects in insulin production Autoimmune or other destruction of beta cells Insulin insensitivity Impaired action of insulin on target tissues

4 DIABETES EPIDEMIC 230 million affected in 2006 350 million within 20 years Most rapid in Indian and Asian subcontinents 350 fold variation in incidence worldwide. Highest known in Finland and lowest in china

5 Epidem cont  Annual incidence varies worldwide; 0.1 China, Venezuela 38.0 Finland  Most European countries 20/100,000  50% of cases occur during purberty

6 Principal Aims of treatment achieve good metabolic control attain normal growth and development avoid serious hypoglycemia prevent long term complications of diabetes

7 TYPES OF DIABETES  Type 1 DM  Type 2 DM  MODY  Atypical DM  Neonatal DM  Diabetes Secondary to; Cystic fibrosis Steroid treatment Pancreatectomy for persist hyperinsulinaemic hypoglycaemia of infancy

8 NEONATAL DM  incidence 1:400,000 births  transient, thought due to delay in the maturation of the ß-cells → hypoinsulinaemia  small gestational age  present in the first few days or weeks with polydipsia, polyuria, marked weight loss, severe dehydration, vomiting  have hyperglycaemia, glycosuria but no ketonuria

9 NEONATAL DM cont… Treatment of Neonatal DM;  rehydrate  give continuous infusion of insulin  once stable give once daily long acting s.c insulin  treatment needed for a few days to 18 months (median 3 months)  some may develop permanent DM, others develop T2DM later in life

10 CHARACTERISTICS OF PREVALENT FORMS OF 1º DM IN CHILDREN AND ADOLESCENTS TYPE 1TYPE 2 PrevalenceCommonIncreasing Age of presentationThroughout ChildhoodPuberty OnsetAcute SevereInsidious to Severe Ketosis at OnsetCommon≥ 1/3 Affected relative5-10 %75-90 % Female : Male1 : 12 : 1 InheritancePolygenicPolygenic HLA-DR ¾  associationNo association EthnicityAll, CaucasiansAll Insulin Secretiondecreased/absentVariable Insulin SensitivityNormal when controlled↓ Insulin dependencePermanentEpisodic ObesityNo> 90 % Pancreatic Auto Abs Yes (85-98 %)No Acathosis nigrans No Common

11 EPIDEMIOLOGY OF TYPE 1 Increasing in recent years Geographic variation: incidence increasing in specific areas with trend toward earlier age of presentation. Relative affluence Lack of treatment Age of onset peaks Preschool: 5-7 years Puberty Autumn/winter peaks


13 PATHOGENESIS(AUTOIMMUNE) Immunological activation Progressive beta-cell destruction Insufficient beta-cell function Dependent on exogenous insulin Risk of ketoacidosis

14 IDIOPATHIC TYPE Non-autoimmune type 1 diabetes No autoimmune markers Permanent insulinopenia Ketoacidosis People of African and Asian origin

15 DIAGNOSIS TYPE 1 DM Symptoms may be present from 1 week to 6 months  Polyuria (nocturnal enuresis), polydipsia, weight loss, anorexia or hyperphagia, lethargy, constipation, blurred vision, infection (esp. perineal candiadiasis in girls, infants and toddlers of both gender)  T1DM ­ classic symptoms ± DKA  T2DM - symptoms + ketonuria in 1/3 of adolescents - symptoms + DKA in 25 % of adolescents LAB TESTS RBS > 11.1 mmol/l (IGT RBS= 7.8-11.1) FBS > 7.0 mmol/l (IFG FBS=6.1-6.9) 2 hr pp > 11.1 mmol/l OGTT - 75g in water in children > 43 kg - 1.75 g/kg in water in children < 43kg  Serum C-peptide  Serum insulin levels  Islet cell antibodies

16 Uncertain diagnosis: Oral glucose tolerance test 75 g glucose load after 8 hours fasting Readings taken in fasting state and at 1 and 2 hours Possible problems

17 Impaired glucose tolerance Impaired fasting glucose Intermediate states Increased risk of developing diabetes Prevention strategies to prevent or delay progression Increased risk of cardiovascular disease

18 DIAGNOSIS cont … TYPE 2 DM  prevalence is  parallel to childhood obesity  in the UK present in 2 % of children < 16 yrs of age  in the USA present in 35 % of newly diagnosed patients 10-19 yrs  puberty plays a key role due to the  insulin resistance  75 % have acanthosis nigrans at presentation  absence of obesity doesn’t R/O T2DM

19 DIAGNOSIS cont …  patient may be symptomless  screen patients who are obese with F h/o DM   blood glucose   serum c-peptide and insulin levels  ancanthosis nigrans  hypertension  polycystic ovary syndrome – 30 % IGT, 4 % T2DM  dyslipidaemia

20 Risk factors for T2DM  insulin resistance – usually associated with obesity  F h/o DM in 1 st or 2 nd degree relative  ethnicity; African-American, Hispanic, Caribbean, Asian-American  small for gestational age (IUGR)  maternal gestational diabetes  insulin resistance of puberty  lack of physical activity  high calorie diet


22 TREATMENT: Asymptomatic T2DM Diabetes Education Nutrition Exercise B/G monitoring Re-evaluate after 3 months lifestyle modification successful FBS < 7.2 mmol/l HbA1c < 7 % lifestyle modification fails FBS > 7.2 mmol/l HbA1c > 7 % continue and re-evaluate in 3 months commence treatment with metformin, re-evaluate in 3 months if metformin fails, add bed-time long acting insulin re-evaluate 3 months, intensity insulin therapy to achieve goals

23 PHARMACOLOGIC THERAPY  Insulin + metformin only medications approved by FDA in children with T2DM  Patient with - severe hyperglycaemia - weight loss - ketosis or ketoacidosis …require treatment as in T1DM until B/G levels are normal  Since patients are insulin resistant they require ~ 2 iu/kg/day initially, which is ↓ gradually as patient is put on metformin and may be weaned off insulin  give metformin as 500mg o.d,  500mg b.d, max 2g daily  long acting insulins i.e insulatard,glargine are effective basal insulins given together with metformin

24 Insulin types and action Onset (hrs)Peak (hrs)Duration (hrs) Rapid lispro aspart <¼¾-2½3½-4½ Short soluble regular ½-12-46-8 Intermediate NPH lente 1-2 1-3 6-12 18-24 Long acting ultralente glargine detemir 4-6 3-4 1-2 8-20 3-24 3-8 24 or more ≥24 or more 12-24 (dose- dependent)

25 HbA 1C Pre-meal2 hours post-meal Target for most people with diabetes <7%4-7mmol/L * 90-130mg/dl *1 5-10mmol/L * <180mg/dl *1 IDF Global guideline for Type 2 diabetes *2 <6.5%<6.0mmol/L <110mg/dl <8.0mmol/L <145mg/dl Adjusting insulin – what are the targets? * CDA 2003, *1 ADA 2004, *2 IDF 2005 Treatment targets should be individualized, especially for very young and very old Absence of hypoglycaemia

26 Adjusting insulin Pattern management Watch levels for 2-3 days Address hypoglycaemia first Aim for target fasting levels next Adjust by 2-4 units or 10% Wait 2-3 days

27 Which insulin to adjust when? Blood glucoseInsulin to be changed FastingBedtime or supper intermediate- or long-acting Post-breakfastMorning short- or rapid-acting insulin Pre-lunchMorning intermediate-acting insulin Post-lunchMorning intermediate-acting insulin or lunchtime short- or rapid-acting insulin Pre-supper (dinner)Morning intermediate-acting insulin Post-supper (dinner)Supper-time short- or rapid-acting insulin During the nightSupper-time or bedtime intermediate- acting

28 Insulin practicalities Timing Soluble insulin: 30-45 minutes pre-meal Short-acting insulin analogues: no more than 15 minutes pre-meal and can be given post-meal Intermediate- or long-acting insulins do not have to be given in relation to a meal

29 Side effects Hypoglycaemia Weight gain Lipohypertrophy Lipoatrophy Insulin oedema Allergic reaction

30 STANDARD CARE OF PATIENTS WITH T2DM WeightEach Visit HeightEach Visit B/G monitoringEach Visit Blood pressureEach Visit HbA1c3-6 months intervals Dilated eye examAt diagnosis & yearly Lipid profileAt diagnosis & yearly Urine micro a/bAt diagnosis & yearly Feet and teethAt diagnosis & yearly

31 POINTS TO NOTE IN CLINICAL EXAM PTS (T1DM) ANNUAL REVIEM HeightGrowth failure WeightPoor or excessive PubertyDelayed puberty SkinLipohypertrophy injection sites Necrobiosis lipodica MouthDental caries Eyes (dilated)Presence of retinopathy FeetSigns of poor care HandsFinger prick sites Limited j+ mobility (“prayer sign”) CardiovascularHT (Random Chol and Trig) EndocrineGoitre, signs of hypo or hyperthyroidism (TSH)  Pigmentation – Addison’s dx NeurologicalImpaired vibration or pin prick sense

32 T1DM: Associated cxns 1. Abnormal growth and pubertal development uncontrolled DM → ↓ final height 2. In young children (< 5yrs) severe recurrent hypo’s → impaired brain development studies show- ↓ visuospatial skills - ↓ psychomotor efficiency - ↓ attention span - ↓ memory DCCT children > 13yrs with severe hypo’s there was no impairment in cognitive function 3. Limited joint mobility thickening and stiffness of the periarticular connective tissue mainly in the hands (5 th finger spreading to the rest) Prevalence. 1978- 31 %. 2001- 7 % 4. Microvascular cxns. retinopathy. nephropathy. neuropathy R/O these cxns – annual review T1DM- prepubertal 5 yrs after ∆ - pubertal 2 yrs after ∆ T2DM- at ∆ 5. Dyslipidaemia T1DM- prepubertal 5 yrs after ∆ - pubertal 2 yrs after ∆ T2DM- at ∆  cholestrol levels during puberty and thereafter  risk of atherosclerosis predisposing to macrovascular cxns

33 Education to parents and children  Knowledge of DM pre-existing current - what is DM, causes, consequence, life long cxns  Concept of “diabetes team”  Insulin; role types (short, long acting) injection techniques storage  B/G monitoring when and how interpretation of B/G levels and adjustment of insulin doses  Diet  Exercise effect of exercise on CHO and insulin requirements

34 Education to parents and children cont …  Hypoglycaemia causes consequences- neurological impairement < 5 yrs - hypo unwareness treatment- sweets, sweet drink, sandwich - glucose powder - glucagon I.M inject < 5 yrs 0.5mg > 5 yrs 1.0mg - 10 % dextrose I.V 5ml/kg prevention- B/G < 4mmol/l during day - B/Bed : younger child (8 p.m) … B/G > 9mmol/l : older child (10 p.m) … B/G > 7mmol/l if less give additional night snack  Measurement of urinary ketones - when and how  Foot care

35 Education to parents and children cont …  Dental care  “Honeymoon period” - what is it - adjustment of insulin doses  Management of DM during intercurrent illnesses - continue insulin - monitor B/G regularly - test for urinary ketones regularly - eat CHO reg. - adjust dose of insulin to treat hyperglycaemia - hypoglycaemia … correct it ↓ insulin dose encourage patient to eat small meals frequently -treat underlying illness  long term microvascular cxns  importance of carrying patient identification - medical card - bracelet

36 Education to parents and children  importance of follow-up by team - Paediatrician/Endocrinologist, Diabetic Educators, Nutritionist, Podiatrist, Dentist, Opthalmologist  Diabetes youth camps  Adolescents – smoking, Alcohol

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