management of diabetes

1. DIABETES MELLITUS,
MANAGEMENT BEYOND
THE NORMS IN
CHILDREN
Dr Oluwayemi Isaac Oludare
Consultant Paediatric Endocrinologist
Ekiti State University Teaching Hospital, Ado-Ekiti
MBBS, FWACP, FESPE

2. OUTLINE
 Introduction
 Epidemiology
 Classification
 Local experience
 Childhood Type 1 DM
 Childhood Type 2 DM
 Type1 vs Type 2 DM
 Maturity onset diabetes of the young (MODY)
 Management of Type 1 DM
 Insulin regimen
 Sick day rule
 Conclusion

3. WHAT IS DIABETES?
Diabetes mellitus is a group of
metabolic diseases characterized
by hyperglycemia resulting from
defects in insulin secretion, insulin
action or both.

4. INTRODUCTION
 DM: known to mankind since ancient times
 Diabetes means “flowing through”
 Mellitus means “sweet as honey”
 In the past DM was diagnosed by tasting the urine!
 Before insulin was discovered, type 1 DM always
resulted in death
 1st human treated with insulin: Leonard Thomson,
14yr/M, Canada, 1922

5. EPIDEMIOLOGY
 Number of people with DM varies in countries
 Worldwide, 430,000 children & adolescents aged ≤
14yrs have DM
 Each year, 77,000 children aged ≤ 14yrs and 119,000
aged ≥ 15yrs are found to have DM
 In the US, ≈ 13,000 new cases of DM are diagnosed in
children every year
 In EKSUTH, 1 new case/yr of DM diagnosed in
children(2010-2016), 5 in 2017, and 6 in 2018 (1 T2DM,
others T1DM);
 Finland has the highest incidence of childhood &
adolescent diabetes
 Childhood & adolescent type 1 DM is very uncommon in
Japan
 Reason for differences not known ?culture & environ

6. ESTIMATED WORLD PREVALENCE OF DIABETES

8. CLASSIFICATION
 Type 1 diabetes
 Autoimmune ß cell destruction causing absolute insulin
deficiency
 Type 2 diabetes
 Caused by either insulin resistance or due to secretory
defects of insulin
 Other types
 Genetic defects (e.g neonatal diabetes, MODY),
diseases of the pancreas, drug induced

9. LOCAL EXPERIENCE
age sex Year/ place
of
diagnosis
Type Therapy outcome
? 5
years
M 2009
EKSUTH
1 Insulin LAMA
9 years M 2011
LTH
Osogbo
1 Insulin Dead
2014
14 years M 2012
EKSUTH
1 Insulin LAMA
9 years F 2014
EKSUTH
1 Insulin Alive &
well
12 years F 2015
Private
hosp(LSH)
2 Metformin & Daonil Alive &
well
15 years M 2015
EKSUTH
1 Insulin Alive &
well

10. CHILDHOOD TYPE 1 DIABETES
 Accounts for 97% of childhood diabetes
 Incidence:
 40.2 per 100,000 in Finland (highest worldwide)
 15.7 – 17.6 per 100,000 in UK
 1.5 per 100,000 in Tanzania
 10.1 per 100,000 in Sudan
 20 per 100,000 in Morocco
 Prevalence:
 209 per 100,000 in England
 0.33 per 1000 in Nigeria
 0.95 per 1000 in Sudan
Incidence rising at 3.4% per year especially in under 5 yr

11. TYPE 1 DM, EPIDEMIOLOGY
 Age:
 Peak incidence between 10-14 years
 Sex:
 Slightly more common in boys
 Some studies in Nigeria, Ethiopia, Sudan, Libya have
suggested it to be more common in girls
 Race:
 More in Caucasians
 Season:
 More in winter

12. Insulin
Glucose production Lipolysis
Hyperglycemia fatty acids
Glycosuria Ketone bodies
Polyuria Acidosis
Thirsty
INSULIN

13. CLINICAL PRESENTATION
 DKA
 Most common mode of presentation in Africa (>85%)
 25% or less present with DKA in UK
 Presentation in DKA represents delayed diagnosis
 Other patients with type 1 DM will present with:
 Polyuria or secondary nocturnal enuresis
 Polydipsia
 Polyphagia
 Weight loss
 Lethargy
 Recurrent infection: candida
 DKA misdiagnosed as:
 Meningitis
 Cerebral malaria
 Pneumonia
 Mortality from DKA very high
(42.5% in Sudan)

14. DIAGNOSIS
 RBG > 11.1mmol/L if child has symptoms
 FBG > 7.0 mmol/L
 Plasma glucose > 11.1 mmol/L following an OGTT
 To reduce DKA in newly diagnosed children
 Refer on the basis of urinalysis or bedside RBG
 Refer by telephone on the day of suspicion
 Do not arrange FBG

15. CHILDHOOD TYPE 2 DM
 Only recognized in the last decade
 Previously thought to occur only in adults
 Prevalence:
 England: 3/ 100,000
 Japan: 13.5/ 100,000
 Taiwan: 15.9/ 100,000
 USA: 7.2/ 100,000
 UK: 0.53/ 100,000

16. CHILDREN AT RISK OF DEVELOPING TYPE 2 DM
 Obese
 Family history of type 2 DM
 Signs of insulin resistance
 Puberty

17. ACANTHOSIS NIGRICANS

18. NATURAL HISTORY OF TYPE 2 DM
Impaired Glucose Tolerance
Type 2 Diabetes
Normal Glucose tolerance

19. PROFILE OF SANDWELL CHILDREN WITH TYPE 2
DIABETES
• All obese
• Mean age at presentation : 12yrs
• 70% have acanthosis nigricans
• 53% of south Asian, 30% Caucasian, 7% Afro-Caribbean
• 84% Family history
• 30% persistent microalbuminuria
• 30% dyslipidaemia

20. LONG TERM OUTLOOK
• 14 times more risk of myocardial infarction
• In Canadian cohort of 51, by the age of 33 years:
4 had died
3 on dialysis
1 had toe amputated
1 was blind

21. Type 1 Type 2
Age of onset Any age Pubertal or older
Symptoms at onset DKA
Polyuria, polyphagia,
polydipsia, weight loss etc
Many are asymptomatic
but can present with 3P’s
etc. DKA rare but can
occur
BMI Normal but can be high Usually obese
Family History 2-4% 80%
Autoimmunity 85% isletcell/GAD
Thyroid dysfunction,
celiac disease associated
Not associated
TYPE 1 VS TYPE 2

22. Maturity onset diabetes of the
young (MODY)
• MODY describes dominantly inherited,
monogenic defects of insulin secretion
occurring at any age AND no longer
includes any forms of type 2 diabetes
• Many mutations identified

23. Clues to suspecting MODY
• Mild to moderate hyperglycemia (7-14 mmol/l)
discovered before 30 years of age.
• A first degree relative with a similar degree of
diabetes.
• Absence of positive antibodies or other
autoimmunity (e.g., thyroid disease) in patient
and family.
• Persistence of a low insulin requirement (e.g.,
less than 0.5 u/kg/day) past the usual
"honeymoon" period.

24. MANAGEMENT OF TYPE 1
DIABETES
 NICE guideline states that children and young
people should be offered ongoing integrated
Package of care by a Multidisciplinary Paediatric
Diabetes team.
 Team should consist of Consultant Paediatric
Diabetologist, dietician, Paediatric diabetic nurse,
Child Psychologist.
 Patients must have access to ophthalmology and
podiatry.

26. THERAPEUTIC GOALS FOR ALL CHILDREN
WITH DIABETES
Optimal metabolic Control
Normal physical development
Normal Psychosocial development
Optimal quality of Life

27. MANAGEMENT
 Initiate insulin treatment usually basal bolus.
 Dietetic advise
 Structured Education
 Ongoing surveillance, annual reviews
 Psychosocial support
 Transition
 24 hour Telephone contact
 Self management is the main principle of care

28. TARGETS
 HBA1c <7.5%
 Pre meal Blood glucose 4-8mmol/l
 Post meal BG Target less than 10mmol/l
 Healthy , well adjusted child

29. INSULIN REGIMENS
 Basal bolus
 Twice daily regimens
 Continuous subcutaneous insulin infusion (CSII)

30. Type of
insulin
examples Onset
of
action
Peak
action
duration
Rapid acting 1.Novorapid
2.Humalog
Lispro
10 mins 1-2 hrs 3-4 hrs
Short acting Actrapid 30 mins 2-3hrs 3-6hrs
Intermediate
acting
insulutard 2-4hrs 4-10hrs 10-16hrs
Long acting 1.Lantus
(Glargine)
2. Levemir
(Determir)
2-4 hrs No Peak 20-24hrs
INSULIN TYPES, & TIME OF ACTION

31. INSULIN REGIMENS
 Twice daily using pre-mixed or biphasic insulin e.g
-Mixtard 10, mixtard 20, mixtard 30
-Humulin M1, M2, M3, M4
-Novomix 30
-Humalog 25

32. TWICE DAILY REGIME
Starting dose: 0.5U/kg 2/3rd am, 1/3rd pm
Routine: meal times fixed
Meals: 3 main meals and 3 snacks
Insulin administered 30 mins before meals

33. Twice daily regimens
Target blood glucose is 4-8mmol/l in teens and 4-10mmol/l in
younger ones
Pre breakfast blood glucose reflect pre evening meal insulin dose
and vice versa
Use pattern recognition (3 DAYS ) to adjust insulin dose

34. SICK DAY RULES
 Never omit insulin
 Drink plenty of fluids
 More frequent blood sugar monitoring
 Check for ketones (e.g use of ß-ketone strips)
 Use of correction doses of short acting insulin
 Early contact with Diabetes team

35. MANAGEMENT (TYPE 2 DIABETES)
 Healthy eating and Regular exercise
 Drugs : Metformin, insulin
 Surveillance and treatment of complications

36. CONCLUSION
 Type 1 diabetes is the commonest type of
childhood diabetes
 Refer promptly by phone
 Childhood T2D is an emerging problem
 Transition to adult services needs to be
planned/improved

37. NO CHILD SHOULD DIE OF DIABETES!
In resuscitating diabetic patients
ABC should be followed by
Don’t
Ever
Forget
Glucose

38. THANK
YOU