SlideShare a Scribd company logo
1 of 48
Download to read offline
Diabetes Mellitus
in Children
Dr. C.S.N.Vittal
Definition
Diabetes a chronic metabolic disorder characterized by
hyperglycemia
as a cardinal biochemical feature, caused by
deficiency of insulin or its inaction,
manifested by
abnormal metabolism of
carbohydrates, protein and fat.
Historical
Symptoms of DM were first mentioned in the ‘Ebers’ papyrus (about 1550 BC)
‘Diabetes’ (siphon/diuresis) first used by the Turkish physician Aretaeos of Capadokia
(ad 130–200)
The sweetness of diabetic urine (‘mellitus’ = sweet), first mentioned in 6th century
by Thomas Willis (1674)
Matthew Dobson (1775) showed that the sweet taste was due to sugar and that
serum also tasted sweet
Von Mering & Minkowski showed that total pancreatectomy resulted in DM
The discovery of insulin by Banting and Best in 1922
Types of Diabetes mellitus
(β-cell destruction, usually leading to absolute insulin deficiency)
Type 1A :- Immune mediated (with islet cell antibodies)
Type 1B: - Idiopathic. Without autoantibodies
Type 1
Predominantly insulin resistance with relative insulin deficiency OR a
predominantly secretory defect with insulin resistance
Type 2
Type 3
Type 4
Proposed to describe the hypothesis that Alzheimer’s disease, is triggered
by a type of insulin resistance and insulin-like growth factor dysfunction that
occurs specifically in the brain
New proposal - is associated with older ageNot Final
Types of Diabetes Mellitus - Other Specific types:
• Genetic defects in b cell function: MODY, Neonatal DM, Mitochondrial disorders
• Genetic defects in insulin: Insulin receptor defects, Type A insulin resistance
• Exocrocrine pancreatic diseases: Pancreatitis, cystic fibrosis, hemochromtosis
• Drug / chemical induced: Steroids, diagoxide, phynetoin, interferon, L-
asparaginase,
• Immune mediated
• Endocrinopathies: Growth hormone excess, Cushing’s syndrome,
hyperthyroidism
• Infections: CMV, Coxsackieviruses
• Gestational diabetes
• Neonatal diabetes
Type I DM
• Commonest form in children
• Insulin deficiency due to damage to beta cells
• Needs lifelong insulin replacement
• Characterized by autoimmune destruction of pancreatic
islet β-cells.
• Both genetic susceptibility and environmental factors
contribute to the pathogenesis.
Type I DM - Incidence
• Incidence in India - 10.5/100,000/year.
• Peaks of presentation occur in 2 age groups:
• at 5-7 yr of age (infectious) and
• at the time of puberty (gonadal steroids ).
• Risk is higher, if the affected parent is father (7% compared to 4%, if
mother is affected).
• Identical twins, concordance rates of only 30-40%
• Known associations include the HLA DR3/4-DQ2/8 genotype, HLA-B39
T1DM - Stages
Preclinical β-cell autoimmunity with progressive defect of insulin secretion1
Onset of clinical diabetes,2
Transient remission “honeymoon period,”3
Established diabetes during which there may occur acute and/or chronic
complications and decreased life expectancy.
4
T1DM - The Hygiene Hypothesis
• Lack of exposure to childhood infections
may increase an individual's chances of
developing autoimmune diseases,
including T1DM
• Decreased exposure to certain parasites
and other microbes in early childhood
may lead to an increased risk of
autoimmunity in later life, including
autoimmune diabetes.
T1DM - Pathogenesis
Genetic susceptibility (predisposed individuals)

Environmental factors like seasonal infections,
dietary factors cowmilk protein exposure, drugs

Leading to insulitis (autoimmune disease)

B cell damage

Insulin def & Glucose intolerance

Overt diabetes
Physiology of Insulin
1. Reduces blood glucose by:
• i Gluconeogenesis
• i Glycogenolysis
• h Uptake of glucose by cells
2. Inhibits fat breakdown (lipolysis)
3. Inhibits protein breakdown (protolysis)
T1DM - Pathophysiology
• At even lower insulin levels, the liver produces excessive glucose via glycogenolysis and
gluconeogenesis, and fasting hyperglycemia begins.
• Hyperglycemia produces an osmotic diuresis (glycosuria) when the renal threshold is
exceeded (180 mg/dL; 10 mmol/L).
• The resulting loss of calories and electrolytes, as well as the worsening dehydration,
produces a physiologic stress with hypersecretion of stress hormones
• Insulin deficiency and elevated plasma values of the counter regulatory hormones is also
responsible for accelerated lipolysis and impaired lipid synthesis, with resulting increased
plasma concentrations of total lipids, cholesterol, triglycerides, and free fatty acids.
• Insulin deficiency and glucagon excess shunts the free fatty acids into ketone body
formation
T1DM - Presentation
Ketotic onset : DKA ; more common
• - 20- 40% present
 Non Ketotic onset
• Most symptoms are nonspecific >>
T1DM - Non Ketotic onset : 3 - Ps
Polyuria Polydypsia Polyphagia
T1DM - Non Ketotic onset:
Weight loss Nausea & Vomiting Fatigue
T1DM - Non Ketotic onset:
• Recurrent infection: skin or UTI, Vulval moniliasis in female children
Diabetes: Diagnostic Criteria
American Diabetes Association’s (ADA) criteria
# polyuria, polydipsia, and unexplained weight loss with glucosuria and ketonuria.
• Standards in Medical Care of Diabetes-2017. Diabetes Care 40 (Suppl 1):S11–S24, 2017
• ≥ 126 mg/dL (7.0 mmol/L)
• ≥ 200 mg/dL (11.1 mmol/L)
• ≥ 200 mg/dL (11.1 mmol/L)
• ≥ 6.5% (48 mmol/mol)
Other Labs
•Ketone testing: either urine strips, or blood.
•Urine: glucosuria & Ketonuria if DKA suspected.
•TSH & thyroid antibodies
•Serological markers: GAD, IA-2, IA- 2β, or insulin
autoantibodies, islet cell antibodies
•Gene studies: HLA typing
T1DM - Management - Goals
1. Medical management of glycemic control – Insulin Therapy
2. Age adapted structured education
3. Psychosocial care of the family affected
4. Avoidance of acute complications
5. Prevention of chronic complications
Teamwork approach with paediatrician / endocrinologists, diabetic nurse educator, social worker and nutritionist is essential.
(NPH)
(glargine, detemir, deglutec)
(lispro, aspart, glulisine)
T1DM - Insulin Therapy
• Dose (Subcutaneous):
• For prepubertal children : 0.6 unit/kg/day
• For Pubertal children : 1.0 - 1.2 unit/kg/day
• Post pubertal children : 1.0 unit/kg/day
• In the post-ketoacidosis phase : 2 - 2.5 unit/kg/day
T1DM - Insulin Therapy - Regimen
• Intermediate- (NPH) or
long acting insulin
(glarglne or detemir) is
given before dinner or
at bedtime (40-50% of
total daily dose;
• Short-acting Insulin
(aspart or llspro) is given
before each meal (50-
60% of total dally dose;
T1DM - Insulin Therapy - Regimen
• Insulin Is given before breakfast
(two-thirds of daily dose) and
dinner (one-third of dally dose).
• Each Injection Is a combination
of Intermediate- or long-acting
(NPH or detemir; two-thirds of
the total dose and short-
(regular) or rapid-acting Insulin
(llspro or aspart. one-third of
the total dose
• Regular meal pattern Is required
to prevent hypoglycemia
T1DM - Insulin Therapy –
Modified mixed spilt regimen
• Night-time intermediate-
acting Insulin has been shifted
from before dinner to
bedtime.
• This Is indicated In the
presence of nocturnal
hypoglycemia and high pre-
breakfast blood glucose levels.
Insuine administering syringes / pens
T1DM - Insulin Therapy –
Contentious subcutaneous insulin infusion
(Infusion pump):
• An external device that infuses insulin at
a predetermined rate with additional
boluses given at mealtime. The basal
dose can be adjusted for different times
of the day and boluses tailored to
different amount and types of meals to
provide good glycemic control with
limited glycemic variability.
T1DM - Therapy: Newer Advances
• Islet cell transplantation:
• Edmonton protocol: islets cells isolated from pancreas of cadavers are perfused
percutanoeusly into the portal vein, has the advantage of being a minimally invasive
procedure
• Artificial pancreas:
• Include a CGM that is in constant communication with an infusion pump, with a blood
glucose device (eg, a glucose meter) utilized for CGM calibration. An external processor,
such as a cell phone, runs control algorithm software,
• Adjunctive therapies to insulin
(i) insulin sensitizing agents (e.g. biguanides and thiazolidinediones)
(ii) medications altering GI nutrient delivery (e.g., acarbose and amylin)
(iii) other targets of action [e.g., pirenzepine, insulin-like growth factor-1 (IGF-1), or
glucagon like peptide-1
1
2
3
4
5
6
7
8
Education about
diabetes
Differences between
Type 1 & Type 2 DMs
Role of Insulin as life
saving medicine
Skills of insulin
storage, drawing and
mixing insulins
Healthy eating
Hypoglycaemia –
recognition and
management
Honeymoon phase
Sick day guidelines
T1DM - Diabetes Education
T1DM - Nutritional Management
• There is No diabetic diet for children
• Avoid overzealous control
• Children encouraged to have healthy normal diet
• Importance given to consistency of meal timings
• Dietary exchanges and Nutrition Pyramid approaches are
useful
• Occasional treats during special occasions and eating are
allowed
Nutrition – Age related glycemic targets
Target < 6 years 6 – 12 years > 12 years
Blood Glucose
Premeal
Bedtime
100-180 mg/dL
110-200 mg/dL
70-180 mg/dL
100-180 mg/dL
70-130 mg/dL
90-140 mg/dL
HbA1c < 8% < 7.5% < 7.5%
T1DM - Monitoring
• Blood Glucose monitoring
• Self monitoring of blood glucose (SMBG) is critical: Ideally
before each meal and at bed time
• Post meal and midnight blood sugars are required
• Continuous blood glucose monitoring (CGMS): for children
with significant glycemic variability
• HbA1c: every 6 - 12 weeks - a marker of glycemic control over
previous 3 months and is the best predictor of long term
complications.
T1DM - Monitoring
T1DM - Monitoring
T1DM - Monitoring
 HbA1c: A marker of glycemic control over previous 3 months and is the best
predictor of long term complications: every 6 - 12 weeks -
 Microalbuminuria: Once an year from age 11 or 5 yrs after diagnosis
 Retinal examination: Every 1-2 yrs from age 11 or 5 yrs after diagnosis
 Nerve conduction studies: Once an year from age 11 or 5 yrs after diagnosis
 Blood pressure: every 3 months – at least annually from age 11
 Hyperlipidaemia: during first year after diagnosis; very 5 years before
puberty; then every 2 years
 Thyroid function studies
 Growth monitoring: Every visit
 Dental examinations every 2 years
T1DM
Honeymoon Phase
Somogyi Phenomenon
Dawn Phenomenon
Management during Infections
Diabetic Ketoacidosis
Special
Considerations
Type 1 DM : Special Considerations
• Insulin requirements can decrease transiently following
initiation of insulin treatment.
• Treatment by reduce the dose of Insulin accordingly.
Honeymoon
Phase
Type 1 DM : Special Considerations
• In children with Normal dose of Insulin at
Night & Normal midnight glucose
(Normoglycemia),
• Overnight growth hormone & increased
insulin clearance may normally leads to early
morning modest Hyperglycemia.
Treatment: Increase the dose of Long acting
Insulin at Night .
Dawn
Phenomenon
Type 1 DM : Special Considerations
• In children with High dose of Insulin at night (Long
acting) > develop late night (3-4 am) Hypoglycemia
• Exaggerated counter regulatory hormones respons
will increase > Early morning Hyperglycemia.
Treatment: Reduce the dose of Long acting Insulin at
Night .
Somogyi
Phenomenon
Type 1 DM : Special Considerations
During Infections: Sick Day Care
• Frequent blood glucose monitoring
• Regular fluid intake
• Treatment of intercurrent illness
• Tailoring insulin dosage (increasing dose by
10-15%) for milder infections
• Monitoring blood ketone levels
• Sever infection necessitate hospitalization
Management during
Infections
Type 1 DM : Special Considerations
• When to suspect?
• Acute abdomen
• Encephalopathy
• Severe Dehydration / GE
• Sepsis
• Starvation
D K A
T1DM - Complications
 Hypoglycemic episodes – with treatment
 Neuroglycopenic symptoms –
 lethargy, irritability, seizures, coma,
 Adrenergic symptoms –
 Tachycardia, sweating, palpitations
 Treatment with Glucose / glucagon
 Diabetic Keto acidosis
 Lipoatrophy – at injection sites
T1DM - Long Term Sequalae
 Microvascular - retinopathy, nephropathy
 Macrovascular - cerebrovascular, peripheral vascular, coronary artery
disease
 Neuropathy - Peripheral and autonomic
 Cataract
 Restriction of joint mobility
 Thyroid disease
 Coeliac disease
Type 2 DM
 Increasingly encountered in children
 Look for obesity and acanthosis nigricans
 Normal C-peptide levels
 Lack of glutamic acid decarboxylase (GAD) antibodies
 Needs life style modification
 May need insulin along with biguanides
 Children at risk – should be screened regularly
Type 2 DM
An oral glucose tolerance test for early recognition of type 2 diabetes
should be conducted for all overweight children (BMI > percentile 90)
of age 10 or older who have two or more of the following risk factors:
• A close blood relation has type 2 diabetes
• Membership of a group with elevated risk (e.g.EastAsians,Afro-Americans,
Hispanics)
• Extreme obesity (BMI > Percentile 99.5)
• Signs of insulin resistance or of changes associated with it (arterial
hypertension, dyslipidaemia, elevated transaminases, polycystic ovary
syndrome, acanthosis nigricans).
Type 2 DM
Obesity - Acanthosis nigricans
Maturity Onset Diabetes of Young (MODY)
• A group of inherited conditions characterized by impaired cell
function.
• Relatively mild, non-ketotic diabetes in lean individual with
strong family history of diabetes affecting three generations.
• Responds to life style measures and low doses of sulfonylurea.
Differences between Type 1 and Type 2 DMs
Feature Type 1 Type 2 MODY (monogenic)
Onset Sudden Gradual Insidious
Age of onset Mostly children Mostly adults Post-pubertal
Prevalence ~ 10% ~90% < 5%
Body habitat Thin / Normal Often obese Normal
Ketoacidosis Common Rare Rare
Autoantibody Usually present Absent Absent
Endogenous insulin Low or absent Normal, decreased or
increased
C – peptide levels Low High, normal Low, normal
Management Insulin Diet, Metformin Diet, Sulfonylurea
Inheritance Polygenic Polygenic Autosomal dominant
Dr CSN Vittal
World Diabetes Day
14th November

More Related Content

What's hot

Diabetes mellitus in children; types, pathophysiology and diagnosis
Diabetes mellitus  in children; types, pathophysiology and diagnosisDiabetes mellitus  in children; types, pathophysiology and diagnosis
Diabetes mellitus in children; types, pathophysiology and diagnosisJoyce Mwatonoka
 
Childhood diabetes mellitus and its complications
Childhood diabetes mellitus and its complicationsChildhood diabetes mellitus and its complications
Childhood diabetes mellitus and its complicationsDr. Saad Saleh Al Ani
 
Day care management of diabetes mellitus in children
Day care management of diabetes mellitus in childrenDay care management of diabetes mellitus in children
Day care management of diabetes mellitus in childrenKannan Chinnasamy
 
Approach to a child with failure to thrive
Approach to a child with failure to thriveApproach to a child with failure to thrive
Approach to a child with failure to thriveSingaram_Paed
 
Diebetes mellitus type 1
Diebetes mellitus type 1Diebetes mellitus type 1
Diebetes mellitus type 1Priyank Ghanchi
 
Pediatric hypoglycemia
Pediatric hypoglycemiaPediatric hypoglycemia
Pediatric hypoglycemiaOsama Arafa
 
DIABETES MELLITUS an up-to-date 2017- 2018
DIABETES MELLITUS an up-to-date 2017- 2018DIABETES MELLITUS an up-to-date 2017- 2018
DIABETES MELLITUS an up-to-date 2017- 2018Md. Zahirul Islam
 
Cow’s milk protein allergy in infants and children
Cow’s milk protein allergy in infants and childrenCow’s milk protein allergy in infants and children
Cow’s milk protein allergy in infants and childrenAzad Haleem
 
Pediatric malabsorption syndromes
Pediatric  malabsorption syndromesPediatric  malabsorption syndromes
Pediatric malabsorption syndromesAzad Haleem
 
Evaluation of short stature in children
Evaluation of short stature in childrenEvaluation of short stature in children
Evaluation of short stature in childrendrtariqktk
 
Inflammatory bowel disease (ibd) in children
Inflammatory bowel disease (ibd) in childrenInflammatory bowel disease (ibd) in children
Inflammatory bowel disease (ibd) in childrenJoyce Mwatonoka
 
Hypoglycemia in children
Hypoglycemia in childrenHypoglycemia in children
Hypoglycemia in childrenSujay Bhirud
 
Congenital Hypothyrodism
Congenital HypothyrodismCongenital Hypothyrodism
Congenital HypothyrodismLifecare Centre
 
Approach to Hypoglycemia in childhood
Approach to Hypoglycemia in childhoodApproach to Hypoglycemia in childhood
Approach to Hypoglycemia in childhoodRavi Kumar
 
Approach to hypoglycemia in infants and children
Approach to hypoglycemia in infants and childrenApproach to hypoglycemia in infants and children
Approach to hypoglycemia in infants and childrenAbdulmoein AlAgha
 
Thyroid disorders in children
Thyroid disorders in childrenThyroid disorders in children
Thyroid disorders in childrenSayed Ahmed
 

What's hot (20)

Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
Diabetes mellitus in children; types, pathophysiology and diagnosis
Diabetes mellitus  in children; types, pathophysiology and diagnosisDiabetes mellitus  in children; types, pathophysiology and diagnosis
Diabetes mellitus in children; types, pathophysiology and diagnosis
 
Childhood diabetes mellitus and its complications
Childhood diabetes mellitus and its complicationsChildhood diabetes mellitus and its complications
Childhood diabetes mellitus and its complications
 
Type 1 diabetes in children
Type 1 diabetes in childrenType 1 diabetes in children
Type 1 diabetes in children
 
Day care management of diabetes mellitus in children
Day care management of diabetes mellitus in childrenDay care management of diabetes mellitus in children
Day care management of diabetes mellitus in children
 
Approach to a child with failure to thrive
Approach to a child with failure to thriveApproach to a child with failure to thrive
Approach to a child with failure to thrive
 
Diebetes mellitus type 1
Diebetes mellitus type 1Diebetes mellitus type 1
Diebetes mellitus type 1
 
Pediatric hypoglycemia
Pediatric hypoglycemiaPediatric hypoglycemia
Pediatric hypoglycemia
 
DIABETES MELLITUS an up-to-date 2017- 2018
DIABETES MELLITUS an up-to-date 2017- 2018DIABETES MELLITUS an up-to-date 2017- 2018
DIABETES MELLITUS an up-to-date 2017- 2018
 
Failure To Thrive
Failure To ThriveFailure To Thrive
Failure To Thrive
 
Cow’s milk protein allergy in infants and children
Cow’s milk protein allergy in infants and childrenCow’s milk protein allergy in infants and children
Cow’s milk protein allergy in infants and children
 
Pediatric malabsorption syndromes
Pediatric  malabsorption syndromesPediatric  malabsorption syndromes
Pediatric malabsorption syndromes
 
Evaluation of short stature in children
Evaluation of short stature in childrenEvaluation of short stature in children
Evaluation of short stature in children
 
Childhood diabetes presentation
Childhood diabetes presentationChildhood diabetes presentation
Childhood diabetes presentation
 
Inflammatory bowel disease (ibd) in children
Inflammatory bowel disease (ibd) in childrenInflammatory bowel disease (ibd) in children
Inflammatory bowel disease (ibd) in children
 
Hypoglycemia in children
Hypoglycemia in childrenHypoglycemia in children
Hypoglycemia in children
 
Congenital Hypothyrodism
Congenital HypothyrodismCongenital Hypothyrodism
Congenital Hypothyrodism
 
Approach to Hypoglycemia in childhood
Approach to Hypoglycemia in childhoodApproach to Hypoglycemia in childhood
Approach to Hypoglycemia in childhood
 
Approach to hypoglycemia in infants and children
Approach to hypoglycemia in infants and childrenApproach to hypoglycemia in infants and children
Approach to hypoglycemia in infants and children
 
Thyroid disorders in children
Thyroid disorders in childrenThyroid disorders in children
Thyroid disorders in children
 

Similar to Diabetes Mellitus in Children - for UGs

#Diabetes mellitus disease ppt presentation
#Diabetes mellitus disease ppt presentation#Diabetes mellitus disease ppt presentation
#Diabetes mellitus disease ppt presentationrk17602629
 
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC KETOACIDOSIS
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC  KETOACIDOSIS DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC  KETOACIDOSIS
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC KETOACIDOSIS Rakesh Verma
 
DIABETES MELLITUS
DIABETES MELLITUS DIABETES MELLITUS
DIABETES MELLITUS arunmtin
 
2023 Diabetes Mellitus.pptx
2023 Diabetes Mellitus.pptx2023 Diabetes Mellitus.pptx
2023 Diabetes Mellitus.pptxNimonaAAyele
 
Diabetes mellitus (dm) and DKA
Diabetes mellitus (dm) and DKADiabetes mellitus (dm) and DKA
Diabetes mellitus (dm) and DKAStephen ram
 
Diabetes mellitus (dm) And DKA
Diabetes mellitus (dm) And DKADiabetes mellitus (dm) And DKA
Diabetes mellitus (dm) And DKAStephen ram
 
Diabetes mellitis.pptx
Diabetes mellitis.pptxDiabetes mellitis.pptx
Diabetes mellitis.pptxMuhammad Adnan
 
Approach to Diabetes mellitus.ppt.pptx
Approach to Diabetes mellitus.ppt.pptxApproach to Diabetes mellitus.ppt.pptx
Approach to Diabetes mellitus.ppt.pptxFebithaVP
 
Diabetes in young
Diabetes in young Diabetes in young
Diabetes in young ikramdr01
 
diabetes mallitus ppt.pptx
diabetes mallitus ppt.pptxdiabetes mallitus ppt.pptx
diabetes mallitus ppt.pptxSwati Yadav
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitusSara Ravi
 
Problems during School Aged.pptx
Problems during School Aged.pptxProblems during School Aged.pptx
Problems during School Aged.pptxbrokebunny
 
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...RajdeepaKundu
 
type1diabetes.pptx
type1diabetes.pptxtype1diabetes.pptx
type1diabetes.pptxSumeraAhmad5
 

Similar to Diabetes Mellitus in Children - for UGs (20)

#Diabetes mellitus disease ppt presentation
#Diabetes mellitus disease ppt presentation#Diabetes mellitus disease ppt presentation
#Diabetes mellitus disease ppt presentation
 
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC KETOACIDOSIS
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC  KETOACIDOSIS DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC  KETOACIDOSIS
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC KETOACIDOSIS
 
Dm arun
Dm arunDm arun
Dm arun
 
DIABETES MELLITUS
DIABETES MELLITUS DIABETES MELLITUS
DIABETES MELLITUS
 
2023 Diabetes Mellitus.pptx
2023 Diabetes Mellitus.pptx2023 Diabetes Mellitus.pptx
2023 Diabetes Mellitus.pptx
 
Diabetes mellitus (dm) and DKA
Diabetes mellitus (dm) and DKADiabetes mellitus (dm) and DKA
Diabetes mellitus (dm) and DKA
 
Diabetes mellitus (dm) And DKA
Diabetes mellitus (dm) And DKADiabetes mellitus (dm) And DKA
Diabetes mellitus (dm) And DKA
 
Diabetes mellitis.pptx
Diabetes mellitis.pptxDiabetes mellitis.pptx
Diabetes mellitis.pptx
 
Approach to Diabetes mellitus.ppt.pptx
Approach to Diabetes mellitus.ppt.pptxApproach to Diabetes mellitus.ppt.pptx
Approach to Diabetes mellitus.ppt.pptx
 
Care Conference Diabetes
Care Conference DiabetesCare Conference Diabetes
Care Conference Diabetes
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
Diabetes in young
Diabetes in young Diabetes in young
Diabetes in young
 
diabetes mallitus ppt.pptx
diabetes mallitus ppt.pptxdiabetes mallitus ppt.pptx
diabetes mallitus ppt.pptx
 
Diabetes pharmacotherapy(1)
Diabetes pharmacotherapy(1)Diabetes pharmacotherapy(1)
Diabetes pharmacotherapy(1)
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
2. diabetes mellitus
2. diabetes mellitus2. diabetes mellitus
2. diabetes mellitus
 
Problems during School Aged.pptx
Problems during School Aged.pptxProblems during School Aged.pptx
Problems during School Aged.pptx
 
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...
Alpha-amylase inhibitors: alternative approach for the treatment of type 2 di...
 
Diabetes
DiabetesDiabetes
Diabetes
 
type1diabetes.pptx
type1diabetes.pptxtype1diabetes.pptx
type1diabetes.pptx
 

More from CSN Vittal

Pediatric HIV.pdf
Pediatric HIV.pdfPediatric HIV.pdf
Pediatric HIV.pdfCSN Vittal
 
Epilepsy in Children.pptx
Epilepsy in Children.pptxEpilepsy in Children.pptx
Epilepsy in Children.pptxCSN Vittal
 
Complementary feeding - Guidelines.pptx
Complementary feeding - Guidelines.pptxComplementary feeding - Guidelines.pptx
Complementary feeding - Guidelines.pptxCSN Vittal
 
Approach to seizures in a child
Approach to seizures in a childApproach to seizures in a child
Approach to seizures in a childCSN Vittal
 
TB in pediatrics
TB in pediatricsTB in pediatrics
TB in pediatricsCSN Vittal
 
Acute rheumatic fever in Children
Acute rheumatic fever in ChildrenAcute rheumatic fever in Children
Acute rheumatic fever in ChildrenCSN Vittal
 
Resp Distress Syndrome
Resp Distress SyndromeResp Distress Syndrome
Resp Distress SyndromeCSN Vittal
 
Diseases of Pleura
Diseases of PleuraDiseases of Pleura
Diseases of PleuraCSN Vittal
 
Portal Hypertension in Children
Portal Hypertension in ChildrenPortal Hypertension in Children
Portal Hypertension in ChildrenCSN Vittal
 
Approach to GI Bleeding in Children
Approach to GI Bleeding in ChildrenApproach to GI Bleeding in Children
Approach to GI Bleeding in ChildrenCSN Vittal
 
Orange the World
Orange the World Orange the World
Orange the World CSN Vittal
 
Diagnostic Tests for PGs
Diagnostic Tests for PGsDiagnostic Tests for PGs
Diagnostic Tests for PGsCSN Vittal
 
Neonatal jaundice
Neonatal jaundiceNeonatal jaundice
Neonatal jaundiceCSN Vittal
 
Newborn Resuscitation
Newborn ResuscitationNewborn Resuscitation
Newborn ResuscitationCSN Vittal
 
Acute Kidney Injury for UGs
Acute Kidney Injury for UGsAcute Kidney Injury for UGs
Acute Kidney Injury for UGsCSN Vittal
 
Hyperthyroidism in children
Hyperthyroidism in childrenHyperthyroidism in children
Hyperthyroidism in childrenCSN Vittal
 
Dibetic Ketoacidosis in Children
Dibetic Ketoacidosis in ChildrenDibetic Ketoacidosis in Children
Dibetic Ketoacidosis in ChildrenCSN Vittal
 
Acute Respiratory Infections - for UGs
Acute Respiratory Infections - for UGsAcute Respiratory Infections - for UGs
Acute Respiratory Infections - for UGsCSN Vittal
 
Acute glomerulonephritis for UGs
Acute glomerulonephritis for UGsAcute glomerulonephritis for UGs
Acute glomerulonephritis for UGsCSN Vittal
 

More from CSN Vittal (20)

Pediatric HIV.pdf
Pediatric HIV.pdfPediatric HIV.pdf
Pediatric HIV.pdf
 
Epilepsy in Children.pptx
Epilepsy in Children.pptxEpilepsy in Children.pptx
Epilepsy in Children.pptx
 
Complementary feeding - Guidelines.pptx
Complementary feeding - Guidelines.pptxComplementary feeding - Guidelines.pptx
Complementary feeding - Guidelines.pptx
 
Approach to seizures in a child
Approach to seizures in a childApproach to seizures in a child
Approach to seizures in a child
 
TB in pediatrics
TB in pediatricsTB in pediatrics
TB in pediatrics
 
Dengue fever
Dengue fever Dengue fever
Dengue fever
 
Acute rheumatic fever in Children
Acute rheumatic fever in ChildrenAcute rheumatic fever in Children
Acute rheumatic fever in Children
 
Resp Distress Syndrome
Resp Distress SyndromeResp Distress Syndrome
Resp Distress Syndrome
 
Diseases of Pleura
Diseases of PleuraDiseases of Pleura
Diseases of Pleura
 
Portal Hypertension in Children
Portal Hypertension in ChildrenPortal Hypertension in Children
Portal Hypertension in Children
 
Approach to GI Bleeding in Children
Approach to GI Bleeding in ChildrenApproach to GI Bleeding in Children
Approach to GI Bleeding in Children
 
Orange the World
Orange the World Orange the World
Orange the World
 
Diagnostic Tests for PGs
Diagnostic Tests for PGsDiagnostic Tests for PGs
Diagnostic Tests for PGs
 
Neonatal jaundice
Neonatal jaundiceNeonatal jaundice
Neonatal jaundice
 
Newborn Resuscitation
Newborn ResuscitationNewborn Resuscitation
Newborn Resuscitation
 
Acute Kidney Injury for UGs
Acute Kidney Injury for UGsAcute Kidney Injury for UGs
Acute Kidney Injury for UGs
 
Hyperthyroidism in children
Hyperthyroidism in childrenHyperthyroidism in children
Hyperthyroidism in children
 
Dibetic Ketoacidosis in Children
Dibetic Ketoacidosis in ChildrenDibetic Ketoacidosis in Children
Dibetic Ketoacidosis in Children
 
Acute Respiratory Infections - for UGs
Acute Respiratory Infections - for UGsAcute Respiratory Infections - for UGs
Acute Respiratory Infections - for UGs
 
Acute glomerulonephritis for UGs
Acute glomerulonephritis for UGsAcute glomerulonephritis for UGs
Acute glomerulonephritis for UGs
 

Recently uploaded

Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 

Recently uploaded (20)

Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 

Diabetes Mellitus in Children - for UGs

  • 2. Definition Diabetes a chronic metabolic disorder characterized by hyperglycemia as a cardinal biochemical feature, caused by deficiency of insulin or its inaction, manifested by abnormal metabolism of carbohydrates, protein and fat.
  • 3. Historical Symptoms of DM were first mentioned in the ‘Ebers’ papyrus (about 1550 BC) ‘Diabetes’ (siphon/diuresis) first used by the Turkish physician Aretaeos of Capadokia (ad 130–200) The sweetness of diabetic urine (‘mellitus’ = sweet), first mentioned in 6th century by Thomas Willis (1674) Matthew Dobson (1775) showed that the sweet taste was due to sugar and that serum also tasted sweet Von Mering & Minkowski showed that total pancreatectomy resulted in DM The discovery of insulin by Banting and Best in 1922
  • 4. Types of Diabetes mellitus (β-cell destruction, usually leading to absolute insulin deficiency) Type 1A :- Immune mediated (with islet cell antibodies) Type 1B: - Idiopathic. Without autoantibodies Type 1 Predominantly insulin resistance with relative insulin deficiency OR a predominantly secretory defect with insulin resistance Type 2 Type 3 Type 4 Proposed to describe the hypothesis that Alzheimer’s disease, is triggered by a type of insulin resistance and insulin-like growth factor dysfunction that occurs specifically in the brain New proposal - is associated with older ageNot Final
  • 5. Types of Diabetes Mellitus - Other Specific types: • Genetic defects in b cell function: MODY, Neonatal DM, Mitochondrial disorders • Genetic defects in insulin: Insulin receptor defects, Type A insulin resistance • Exocrocrine pancreatic diseases: Pancreatitis, cystic fibrosis, hemochromtosis • Drug / chemical induced: Steroids, diagoxide, phynetoin, interferon, L- asparaginase, • Immune mediated • Endocrinopathies: Growth hormone excess, Cushing’s syndrome, hyperthyroidism • Infections: CMV, Coxsackieviruses • Gestational diabetes • Neonatal diabetes
  • 6. Type I DM • Commonest form in children • Insulin deficiency due to damage to beta cells • Needs lifelong insulin replacement • Characterized by autoimmune destruction of pancreatic islet β-cells. • Both genetic susceptibility and environmental factors contribute to the pathogenesis.
  • 7. Type I DM - Incidence • Incidence in India - 10.5/100,000/year. • Peaks of presentation occur in 2 age groups: • at 5-7 yr of age (infectious) and • at the time of puberty (gonadal steroids ). • Risk is higher, if the affected parent is father (7% compared to 4%, if mother is affected). • Identical twins, concordance rates of only 30-40% • Known associations include the HLA DR3/4-DQ2/8 genotype, HLA-B39
  • 8. T1DM - Stages Preclinical β-cell autoimmunity with progressive defect of insulin secretion1 Onset of clinical diabetes,2 Transient remission “honeymoon period,”3 Established diabetes during which there may occur acute and/or chronic complications and decreased life expectancy. 4
  • 9. T1DM - The Hygiene Hypothesis • Lack of exposure to childhood infections may increase an individual's chances of developing autoimmune diseases, including T1DM • Decreased exposure to certain parasites and other microbes in early childhood may lead to an increased risk of autoimmunity in later life, including autoimmune diabetes.
  • 10. T1DM - Pathogenesis Genetic susceptibility (predisposed individuals)  Environmental factors like seasonal infections, dietary factors cowmilk protein exposure, drugs  Leading to insulitis (autoimmune disease)  B cell damage  Insulin def & Glucose intolerance  Overt diabetes
  • 11. Physiology of Insulin 1. Reduces blood glucose by: • i Gluconeogenesis • i Glycogenolysis • h Uptake of glucose by cells 2. Inhibits fat breakdown (lipolysis) 3. Inhibits protein breakdown (protolysis)
  • 12. T1DM - Pathophysiology • At even lower insulin levels, the liver produces excessive glucose via glycogenolysis and gluconeogenesis, and fasting hyperglycemia begins. • Hyperglycemia produces an osmotic diuresis (glycosuria) when the renal threshold is exceeded (180 mg/dL; 10 mmol/L). • The resulting loss of calories and electrolytes, as well as the worsening dehydration, produces a physiologic stress with hypersecretion of stress hormones • Insulin deficiency and elevated plasma values of the counter regulatory hormones is also responsible for accelerated lipolysis and impaired lipid synthesis, with resulting increased plasma concentrations of total lipids, cholesterol, triglycerides, and free fatty acids. • Insulin deficiency and glucagon excess shunts the free fatty acids into ketone body formation
  • 13. T1DM - Presentation Ketotic onset : DKA ; more common • - 20- 40% present  Non Ketotic onset • Most symptoms are nonspecific >>
  • 14. T1DM - Non Ketotic onset : 3 - Ps Polyuria Polydypsia Polyphagia
  • 15. T1DM - Non Ketotic onset: Weight loss Nausea & Vomiting Fatigue
  • 16. T1DM - Non Ketotic onset: • Recurrent infection: skin or UTI, Vulval moniliasis in female children
  • 17. Diabetes: Diagnostic Criteria American Diabetes Association’s (ADA) criteria # polyuria, polydipsia, and unexplained weight loss with glucosuria and ketonuria. • Standards in Medical Care of Diabetes-2017. Diabetes Care 40 (Suppl 1):S11–S24, 2017 • ≥ 126 mg/dL (7.0 mmol/L) • ≥ 200 mg/dL (11.1 mmol/L) • ≥ 200 mg/dL (11.1 mmol/L) • ≥ 6.5% (48 mmol/mol)
  • 18. Other Labs •Ketone testing: either urine strips, or blood. •Urine: glucosuria & Ketonuria if DKA suspected. •TSH & thyroid antibodies •Serological markers: GAD, IA-2, IA- 2β, or insulin autoantibodies, islet cell antibodies •Gene studies: HLA typing
  • 19. T1DM - Management - Goals 1. Medical management of glycemic control – Insulin Therapy 2. Age adapted structured education 3. Psychosocial care of the family affected 4. Avoidance of acute complications 5. Prevention of chronic complications Teamwork approach with paediatrician / endocrinologists, diabetic nurse educator, social worker and nutritionist is essential.
  • 21. T1DM - Insulin Therapy • Dose (Subcutaneous): • For prepubertal children : 0.6 unit/kg/day • For Pubertal children : 1.0 - 1.2 unit/kg/day • Post pubertal children : 1.0 unit/kg/day • In the post-ketoacidosis phase : 2 - 2.5 unit/kg/day
  • 22. T1DM - Insulin Therapy - Regimen • Intermediate- (NPH) or long acting insulin (glarglne or detemir) is given before dinner or at bedtime (40-50% of total daily dose; • Short-acting Insulin (aspart or llspro) is given before each meal (50- 60% of total dally dose;
  • 23. T1DM - Insulin Therapy - Regimen • Insulin Is given before breakfast (two-thirds of daily dose) and dinner (one-third of dally dose). • Each Injection Is a combination of Intermediate- or long-acting (NPH or detemir; two-thirds of the total dose and short- (regular) or rapid-acting Insulin (llspro or aspart. one-third of the total dose • Regular meal pattern Is required to prevent hypoglycemia
  • 24. T1DM - Insulin Therapy – Modified mixed spilt regimen • Night-time intermediate- acting Insulin has been shifted from before dinner to bedtime. • This Is indicated In the presence of nocturnal hypoglycemia and high pre- breakfast blood glucose levels.
  • 26. T1DM - Insulin Therapy – Contentious subcutaneous insulin infusion (Infusion pump): • An external device that infuses insulin at a predetermined rate with additional boluses given at mealtime. The basal dose can be adjusted for different times of the day and boluses tailored to different amount and types of meals to provide good glycemic control with limited glycemic variability.
  • 27. T1DM - Therapy: Newer Advances • Islet cell transplantation: • Edmonton protocol: islets cells isolated from pancreas of cadavers are perfused percutanoeusly into the portal vein, has the advantage of being a minimally invasive procedure • Artificial pancreas: • Include a CGM that is in constant communication with an infusion pump, with a blood glucose device (eg, a glucose meter) utilized for CGM calibration. An external processor, such as a cell phone, runs control algorithm software, • Adjunctive therapies to insulin (i) insulin sensitizing agents (e.g. biguanides and thiazolidinediones) (ii) medications altering GI nutrient delivery (e.g., acarbose and amylin) (iii) other targets of action [e.g., pirenzepine, insulin-like growth factor-1 (IGF-1), or glucagon like peptide-1
  • 28. 1 2 3 4 5 6 7 8 Education about diabetes Differences between Type 1 & Type 2 DMs Role of Insulin as life saving medicine Skills of insulin storage, drawing and mixing insulins Healthy eating Hypoglycaemia – recognition and management Honeymoon phase Sick day guidelines T1DM - Diabetes Education
  • 29. T1DM - Nutritional Management • There is No diabetic diet for children • Avoid overzealous control • Children encouraged to have healthy normal diet • Importance given to consistency of meal timings • Dietary exchanges and Nutrition Pyramid approaches are useful • Occasional treats during special occasions and eating are allowed
  • 30. Nutrition – Age related glycemic targets Target < 6 years 6 – 12 years > 12 years Blood Glucose Premeal Bedtime 100-180 mg/dL 110-200 mg/dL 70-180 mg/dL 100-180 mg/dL 70-130 mg/dL 90-140 mg/dL HbA1c < 8% < 7.5% < 7.5%
  • 31. T1DM - Monitoring • Blood Glucose monitoring • Self monitoring of blood glucose (SMBG) is critical: Ideally before each meal and at bed time • Post meal and midnight blood sugars are required • Continuous blood glucose monitoring (CGMS): for children with significant glycemic variability • HbA1c: every 6 - 12 weeks - a marker of glycemic control over previous 3 months and is the best predictor of long term complications.
  • 34. T1DM - Monitoring  HbA1c: A marker of glycemic control over previous 3 months and is the best predictor of long term complications: every 6 - 12 weeks -  Microalbuminuria: Once an year from age 11 or 5 yrs after diagnosis  Retinal examination: Every 1-2 yrs from age 11 or 5 yrs after diagnosis  Nerve conduction studies: Once an year from age 11 or 5 yrs after diagnosis  Blood pressure: every 3 months – at least annually from age 11  Hyperlipidaemia: during first year after diagnosis; very 5 years before puberty; then every 2 years  Thyroid function studies  Growth monitoring: Every visit  Dental examinations every 2 years
  • 35. T1DM Honeymoon Phase Somogyi Phenomenon Dawn Phenomenon Management during Infections Diabetic Ketoacidosis Special Considerations
  • 36. Type 1 DM : Special Considerations • Insulin requirements can decrease transiently following initiation of insulin treatment. • Treatment by reduce the dose of Insulin accordingly. Honeymoon Phase
  • 37. Type 1 DM : Special Considerations • In children with Normal dose of Insulin at Night & Normal midnight glucose (Normoglycemia), • Overnight growth hormone & increased insulin clearance may normally leads to early morning modest Hyperglycemia. Treatment: Increase the dose of Long acting Insulin at Night . Dawn Phenomenon
  • 38. Type 1 DM : Special Considerations • In children with High dose of Insulin at night (Long acting) > develop late night (3-4 am) Hypoglycemia • Exaggerated counter regulatory hormones respons will increase > Early morning Hyperglycemia. Treatment: Reduce the dose of Long acting Insulin at Night . Somogyi Phenomenon
  • 39. Type 1 DM : Special Considerations During Infections: Sick Day Care • Frequent blood glucose monitoring • Regular fluid intake • Treatment of intercurrent illness • Tailoring insulin dosage (increasing dose by 10-15%) for milder infections • Monitoring blood ketone levels • Sever infection necessitate hospitalization Management during Infections
  • 40. Type 1 DM : Special Considerations • When to suspect? • Acute abdomen • Encephalopathy • Severe Dehydration / GE • Sepsis • Starvation D K A
  • 41. T1DM - Complications  Hypoglycemic episodes – with treatment  Neuroglycopenic symptoms –  lethargy, irritability, seizures, coma,  Adrenergic symptoms –  Tachycardia, sweating, palpitations  Treatment with Glucose / glucagon  Diabetic Keto acidosis  Lipoatrophy – at injection sites
  • 42. T1DM - Long Term Sequalae  Microvascular - retinopathy, nephropathy  Macrovascular - cerebrovascular, peripheral vascular, coronary artery disease  Neuropathy - Peripheral and autonomic  Cataract  Restriction of joint mobility  Thyroid disease  Coeliac disease
  • 43. Type 2 DM  Increasingly encountered in children  Look for obesity and acanthosis nigricans  Normal C-peptide levels  Lack of glutamic acid decarboxylase (GAD) antibodies  Needs life style modification  May need insulin along with biguanides  Children at risk – should be screened regularly
  • 44. Type 2 DM An oral glucose tolerance test for early recognition of type 2 diabetes should be conducted for all overweight children (BMI > percentile 90) of age 10 or older who have two or more of the following risk factors: • A close blood relation has type 2 diabetes • Membership of a group with elevated risk (e.g.EastAsians,Afro-Americans, Hispanics) • Extreme obesity (BMI > Percentile 99.5) • Signs of insulin resistance or of changes associated with it (arterial hypertension, dyslipidaemia, elevated transaminases, polycystic ovary syndrome, acanthosis nigricans).
  • 45. Type 2 DM Obesity - Acanthosis nigricans
  • 46. Maturity Onset Diabetes of Young (MODY) • A group of inherited conditions characterized by impaired cell function. • Relatively mild, non-ketotic diabetes in lean individual with strong family history of diabetes affecting three generations. • Responds to life style measures and low doses of sulfonylurea.
  • 47. Differences between Type 1 and Type 2 DMs Feature Type 1 Type 2 MODY (monogenic) Onset Sudden Gradual Insidious Age of onset Mostly children Mostly adults Post-pubertal Prevalence ~ 10% ~90% < 5% Body habitat Thin / Normal Often obese Normal Ketoacidosis Common Rare Rare Autoantibody Usually present Absent Absent Endogenous insulin Low or absent Normal, decreased or increased C – peptide levels Low High, normal Low, normal Management Insulin Diet, Metformin Diet, Sulfonylurea Inheritance Polygenic Polygenic Autosomal dominant
  • 48. Dr CSN Vittal World Diabetes Day 14th November