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Diabetes mellitus in children

ByHenry CummingsMBBS, FMCPaedDelsuth, Oghara1Pre-testDm is the commonest endocrine disorder in childrenOnly type 1 dm occurs in childrenTIDm is a non progressive low-insulin catabolic stateExogenous insulin replacement remains the only form of replacement therapyIn managing DKA, always add kcl to the initial rehydrating fluid.

2Childhood Diabetes mellitusDefinitionTypesPatho physiologyClinical featuresModalities of managementComplications, short term, long termRecent advancementsConclusion

3DEFINITION BY WHO:

DM is a metabolic disorder of multiple aetiologies characterised by chronic disturbances of carbohydrate, fat & protein metabolism, resulting from defects in insulin secretion, insulin action or both.DM is the commonest endocrine disease in childhood & adolescence.

4MAGNITUDE OF THE PROBLEMOverall incidence 1 to 2 per 1000 school age children. Estimated prevalence of childhood DM in 2003 were:430,000 globally250,000 live developing countries.63,000 live in 58 poorest countries(least developed countries).

5TYPES OF DMType 1 DM(IDDM)Beta cell autoimmune destructionAbsolute insulin deficiencyRequires insulin for survivalAccounts for over 90% of childhood DMPeak age incidence 10-12 yearsSlight male predominanceProne to ketosis

6Type 2 DM (NIDDM)Insulin resistance with relative deficiency ORSecretory defect with or without resistanceDoes not require insulin for survivalStrong genetic componentNot prone to ketosisAcanthosis nigrans may be presentNo islet cell antibodiesAssociated with overweight teenagers

7Maturity onset diabetes of the youth (MODY)Early onset of dominantly inherited type 2 DMNon- obese childrenNo islet cell antibodiesFamily history in several generationIdentified genetic mutations e.g mutations of glucokinase or hepatic nuclear factor 1 & 2 genesNon- ketoticTwo (or at least one)family member diagnosed before age of 25 years

8Neonatal Diabeteshyperglycemia requiring insulin in the first 3months of lifeRare condition 1:400,000Associated with IUGR50% of cases are transientAssociated with paternal isodomy & other imprinting defects of Chr 6In transient NND permanent DM may appear later in life9Secondary diabetes mellitusMay be associated with cystic fibrosis, hemochromatosis, drugs such as L-Asparaginase

10Criteria for diagnosisSymptoms of DM and casual plasma glucose conc > 11.1mmol/L(200mg/dl) (10 for venous)

FPG > 7.0mmol/L(126mg/dl) (6.3 for venous and cap)

2hr post load of glucose >11.1mmol/L during an OGTT11 blood sugarsNormal RPG: 70 140mg/dlNormal FBS:70 100mg/dlHypoglycemia:Mild40 70mg/dlSevere40mg/dlNeonatal5mmol/l, ketonemiaVenous ph 15mmol/L, stable serum Na+ 135 145mmol/L, No emesis;

then switch to SC insulin (maintain IV insulin 30min after SC)

Ketones may take longer to clear

51HYPOKALEMIC = give with initial resuscitation20mmol/lEUKALEMIC = at the time of insulin intro

HYPERKALEMIC = when patient makes urinePOTASSIUM 52Max dose 0.5mmol/kg/hr

If hypokalemia persist then reduce insulin infusion rate!

ECG monitoring helps!Potassium 53Is given cautiously only ifpH < 6.9HCO3 < 5mmol/l

1 2mmol/kg over one hour!Acidosis 54Hourly monitoring and charting of Blood pressureRespiratory rateHeart rateLevel of consciousnessBlood sugarBlood ketonesElectrolyte and urea(Ca,PO4,Mg)Input /outputInsulin givenMonitoring/charting55Inadequate rehydrationHypoglycemiaHypokalemiahypophosphatemiaCerebral edemaComplications of therapy56Management of DKAFollow up57PG >33.3 mmol/L (600 mg/dL)

Arterial pH >7.30

Serum bicarbonate >15 mmol/L

Small ketonuria, absent to low ketonemia Effective serum osmolality >320 mOsm/kgStupor or coma

HHS (Hyperglycemic hyperosmolar state)58Long-term complications RetinopathyCataractsHypertensionProgressive renal failure Early coronary artery disease Peripheral vascular disease Neuropathy, both peripheral and autonomicIncreased risk of infectionInjection-site hypertrophyGrowth failure. Delayed puberty

59Recent advancementsWhole pancreas transplantationIslet cell transplantationEngineered stem cells manipulated genetically to produce insulinTechniques to protect b cells from autoimmune attack ImmunotherapyAlternate non invasive routes for insulin administrationChemical alteration of insulin moleculeArtificial pancreasAdding c peptide to insulinImplantable insulin pumpsNew blood glucose meters

60ConclusionDM (particularly T1DM), a common and potentially life threatening endocrine disorder in children is often misdiagnosed or poorly managedHaving a regularly updated management protocol in our Paediatric units will greatly improve the level and quality of care these children receive.Thank you for listening.61Post testDm is the commonest endocrine disorder in childrenOnly type 1 dm occurs in childrenTIDm is a non progressive low-insulin catabolic stateExogenous insulin replacement remains the only form of replacement therapyIn managing DKA, always add kcl to the initial rehydrating fluid.

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