At the end of this session, the students are able to •Understand the potential presentation of type 1 diabetes. •Plan the appropriate investigations and management of diabetes and challenges the children face. •Explore the social implications of diabetes in children and potential issues with compliance.

1. DIABETES
MELLITUS AND
DIABETES
KETOACIDOSIS
PROFESSOR DR HTWE HTWE SEIN

2. AIMS
• To gain overview of diagnosis and management of type (1)
diabetes and diabetes ketoacidosis

3. LEARNING OUTCOMES
At the end of this session, the students are able to
• Understand the potential presentation of type 1 diabetes.
• Plan the appropriate investigations and management of
diabetes and challenges the children face.
• Explore the social implications of diabetes in children and
potential issues with compliance.

4. CASE—SUSAN 12 YEAR OLD
GIRL
Presents to specialist clinic with her mother for regular follow up
for IDDM
What further details would you like to elicit from the history—
HPC--
– Weight, lethargy, tiredness.
– Polyuria, polydipsia, being woke up for peeing at night, bed
wetting, dysuria etc.
– Abdominal pain, nausea, vomiting, cough, fast breathing, fever,
reduced conscious level, etc.
– Any associated comorbid conditions such as coeliac, thyroid
disease, etc.

5. TYPE 1 DM—FAILURE OF INSULIN
PRODUCTION

6. DKA
Signs Symptoms
• Clinical dehydration/
shock
• Decreased
consciousness
• Kussmaul breathing
• Polyuria / polydipsia
• Abdominal pain
• Nausea and vomiting
• Lethargy

7. SUSAN IS THEN CLERKED BY THE ON-CALL
PAEDIATRIC SHO
• PMH:
– Diagnosed at what age
– clinical presentation at the time of diagnosis
– Any ICU admission for DKA,
– Hb A1c level, diabetes diary, BM check, CHO counting
– Vaccinations
• DH:
– Any insulin injection, any complications, allergic history

8. SUSAN IS THEN CLERKED BY THE ON-CALL
PAEDIATRIC SHO
• FH:
– Family history of diabetes
• SH:
– Impact on family, school, social life.

9. SUSAN IS THEN CLERKED BY THE ON-CALL
PAEDIATRIC SHO
What in particular should the SHO be looking out for in
examination?
• Take 5 minutes to write them down
– Awake? Talking? Confused?
– Hydration status?
– Respiratory rate?
– Pulse rate?
– Signs of chest infection?
– Abdominal tenderness / guarding?
– ENT examination- any sign of infection?

10. SUSAN IS THEN CLERKED BY THE ON-CALL
PAEDIATRIC SHO
The SHO discusses Susan’s case with the on-call
paediatric registrar. They are both happy Sam is
clinically well.
• The SHO orders further investigations.
• Take 5 minutes to write them down

11. INVESTIGATIONS ORDERED BY SHO
Investigations What is it testing for? Why are we testing for it?
Lab glucose Serum glucose Help to confirm the diagnosis
FBC and CRP Signs of inflammation Help to rule out infection
Hb A1c Glycosylated Hb Baseline, useful for monitoring
U&E Basic electrolyte and renal
function
Check no electrolyte
abnormalities, baseline renal
function
Lipid profile Cholesterol, HDL, LDL Baseline, useful for monitoring

12. INVESTIGATIONS ORDERED BY SHO
Investigations What is it testing for? Why are we testing for it?
TFTs TSH, free T4 (usually) Rule out concurrent thyroid
disease
Anti-tTG Commonly tested antibody seen
in coeliac disease
Rule out concurrent coeliac
disease
GAD & Islet cell
antibodies
(if appropriate)
Antibodies commonly seen in T1
DM
Helps to rule out other forms of
diabetes
C-peptide & insulin
(if appropriate)
Level of endogenous insulin
production
Helps to rule out other forms of
diabetes
Urine culture
(if appropriate)
Signs of urine infection Helps to rule out infections
Urine PCR
(if appropriate
Protein levels in urine Baseline useful for monitoring

13. SUSAN’S INVESTIGATION RESULTS COME
BACK IN NORMAL RANGE EXCEPT:
• Lab glucose (non-fasting) 18.4 mmol/l
• Hb A1c:61mmol/l (8.2%)
Diagnosis—type 1 DM (poorly controlled)

14. EARLY MORNING HYPERGLYCEMIA
(BEFORE BREAKFAST)
• Dawn phenomenon
– hormones (growth
hormone, cortisol,
and catecholamines)
– Not enough insulin.
• 3am blood glucose—high
• Somogyi effect
– Too low blood sugar level
– hormones (such as growth
hormone, cortisol, and
catecholamines) are
released.
– "rebound hyperglycemia."
• 3am blood glucose—low

15. Hyperglycaemia
Polyuria
Polydypsia
Weight loss
Excessive tiredness
DIAGNOSIS OF TYPE 1 DM
THINK ABOUT TYPE 2 DM IN CHILDREN IF
 Strong family history
 Obese at presentation
 Black or Asian family origin
 Have no insulin requirement or have an insulin requirement less
than 0.5units/kg/D after partial remission phase
 Show evidence of insulin resistance( acanthosis nigricans)

17. DEFINITION OF DM
• Currently HbA1c is not considered a suitable diagnostic test for diabetes or
intermediate hyperglycaemia. The following Table summarises the 2006 WHO
recommendations for the diagnostic criteria for diabetes and intermediate
hyperglycaemia.
• Diabetes Fasting plasma glucose 2–h plasma
glucose*
≥7.0mmol/l (126mg/dl) or ≥11.1mmol/l
(200mg/dl)
• Impaired Glucose Tolerance (IGT)Fasting plasma glucose 2–h plasma
glucose*
<7.0mmol/l (126mg/dl) And ≥7.8 and
<11.1mmol/l
(140mg/dl and 200mg/dl)
• Impaired Fasting Glucose (IFG) Fasting plasma glucose 2–h plasma
glucose*
6.1 to 6.9mmol/l and (if measured)
(110mg/dl to 125mg/dl) <7.8mmol/l
(140mg/dl)

18. DIAGNOSIS OF DIABETES
Blood glucose
mmol/L
6.0 7.0
Fasting
7.8 11.1
Non-fasting
Normal Impaired Diabetic
Normal Impaired Diabetic

19. HOW COULD YOU MANAGE SUSAN AT THE MOMENT?
OR
Susan was started on a basal-bolus insulin regime
with
• Lantus (insulin glargine) once a day at night
and
+

20. HOW COULD YOU MANAGE SAM AT THE
MOMENT?
Total daily requirement of Insulin 0.5-1 U/kg/day with 40-60% long-acting
insulin
• HbA1c target level of 48 mmol/l (6.5%) or lower is ideal to minimise the
risk of long-term complications. [new 2015]
• Advise children and young people with type 1 diabetes and their family
members or carers (as appropriate) to routinely perform at least 5
capillary blood glucose tests per day. [new 2015]
• Encourage young people with type 1 diabetes to attend clinic 4 times a
year because regular contact is associated with optimal blood glucose
control. [2004, amended 2015]
• HbA1C 4 times a year
• Need to review injection sites
• May experience a partial remission phase ( honeymoon period) during
which a low dose of insulin ( 0.5units/kg/day)may be sufficient to
control HbA1C<6.5%

21. BLOOD GLUCOSE TARGET
• Fasting plasma glucose level of 4-7 mmol/L on waking
• Plasma glucose level of 4-7 mmol/L before meals at other times
of the day
• Plasma glucose level of 5-9 mmol/L after meals
• Plasma glucose level of at least 5 mmol/L when driving ( new
2015)

22. HOW COULD YOU MANAGE SUSAN AT THE
MOMENT?
• She is then visited by the diabetes specialist nurse and a
dietician.
• Susan and her family spend a long time with these
hospital professionals discussing her diagnosis, how she
will need to take insulin and the lifestyle changes she will
need to make.
What issues may children with type 1 diabetes and
their families face?

23. ISSUES RELATING TO CHILDHOOD DIAGNOSIS OF
DIABETES
Children upset when
injected, parental
anxiety
Dietary modifications-
difficulty getting whole family
on board, children resenting
having to change diet
Allowing children to take
control of insulin injections,
management of their diet
‘Feeling invincible’ not
appreciating risks of non-
compliance with treatment
Teenagers realising they can
lose weight by not taking
insulin
Reluctance to inject at school,
when out with friends
Not liking being
different from
peers
Compliance with outpatient
appointments, screening for
complications of diabetes
Educating families on
how to inject insulin
Teaching families
to carb count
Educating families and children
on the risks of DKA and
hypoglycaemia, and when to
seek help

24. MONITORING OF YOUNG PEOPLE WITH TYPE
1 DM:
• thyroid disease at diagnosis and annually thereafter
until transfer to adult services
• diabetic retinopathy annually from 12 years
• moderately increased albuminuria
(albumin:creatinine ratio [ACR] 3–30 mg/mmol;
'microalbuminuria') to detect diabetic kidney disease,
annually from 12 years
• hypertension annually from 12 years. [new 2015]
• Offer serological testing of coeliac disease.

25. Dietary management
-healthy eating and carb count
- provide food sufficient energy and nutrients for optimal
growth and development.
- eat at least 5 portions of fruit and vegetables each day
Exercise
- Regular exercise – reduce the risk of CVS disease in the long
term
- Be aware that exercise induced hypoglycaemia may occur
several hours after prolonged exerecise
- Additional carbohydrate should be consumed if plasma
glucose levels are <7 mmol/L before exercise

26. SICK-DAY RULE
• Monitor blood glucose
• Monitoring and interpreting blood ketones
• Adjusting insulin regimen
• Food and fluid intake
• When and where to seek further advice or help
• Immunization
• Smoking and substances misuse
• Alcohol drinking
• Dental care
• Psychological and social issue – anxiety and depression
OTHER ISSUES

27. HYPOGLYCAEMIA
• Mild to moderate hypoglycaemia – give 10-20 gm of fast-acting
glucose
• Recheck blood glucose within 15 mins- repeat fast-acting
glucose if hypoglycaemai persists.
• If improve- oral complex long-lasting carbohydrate
• Severe hypoglycaemia – give IV 10% glucose if in the hospital (
maximum 5ml/kg)
• If not in hospital – give IM glucagon or a concentrated oral
glucose gel if the child is conscious

28. IF TYPE 2 DM
• Standard-release Metformin
• Calculate BMI
• Monitoring for complications and associated conditions
- hypertension
- dyslipidemia – measure total cholesterol ,HDL,non-HDL
cholesterol and triglyceride
- diabetes retinopathy
- moderately increased albuminuria

29. JOHN, 11 YEAR OLD-BOY WEIGHING 30 KG
• attends A+E with 3 weeks of lethargy, 1 wk of polyuria
and polydipsia and has started bed wetting again.
• He has been very weak in the last 24hrs and has deep
sighing breathing. His mother also mentions a funny
sweet smell to his breath.
• On examination, he looks pale, with sunken eyes. His
pulse is 145bpm, RR is 35bpm with respiratory distress.
• Central and peripheral capillary refill time is 5s. Blood
pressure is 90/60. Blood glucose reading on a
glucometer as below.

30. KUSSMAUL BREATHING IN
DKA HTTPS://WWW.YOUTUBE.COM/WATCH?V=TG0VPKAE3JS

31. WHAT IS YOUR DIAGNOSIS?
DKA with shock
What is your management?
1. Emergency management with general resuscitation A, B, C
– Airway—ensure that the airway is patent and if the child is
comatose, insert an airway. If consciousness reduced or child has
recurrent vomiting, insert N/G tube, aspirate and leave on open
drainage.
– Breathing Give 100% oxygen by face-mask.
– Circulation Insert IV cannula and take blood samples (see
below). Cardiac monitor for T waves (peaked in hyperkalaemia)
Measure blood pressure and heart rate

32. WHAT IS YOUR MANAGEMENT?
2. Initial fluid bolus
– Only if shocked (poor peripheral pulses, poor capillary
filling with tachycardia, and/or hypotension) give 10 ml/kg
0.9% sodium chloride as a bolus.
– Discuss with a consultant whether a second bolus
should be given.
– Resuscitation fluid – If more than 20 ml/kg 0.9% sodium
chloride has been given by intravenous bolus, subtract any
additional bolus volumes from the total fluid
calculation for the 48-hour period ie if 30 ml/kg has been
given subtract 10 ml/kg from the calculations

33. WHAT IS YOUR MANAGEMENT?
3. Initial investigations
– blood glucose, urea and electrolytes , blood gases (venous or capillary)
– near patient blood ketones (beta-hydroxybutyrate) if available
– + other investigations only if indicated e.g. PCV and full blood count,
CXR, CSF, throat swab, blood culture, urinalysis, culture and sensitivity
etc.

34. JOHN’S BLOOD RESULTS,
• Blood glucose— 30mmol/l
• pH—7.0
• Bicarbonate—13 mmol/l
– beta-hydroxybutyrate –5 mmol/l
What is your diagnosis and prescribe the fluid requirement for John?
DKA
1. AcidosispH <7.3/ plasma HCO3 <18mmol/l
2. Ketonaemiablood beta-hydroxy butyrate >3 mmol/l

35. SEVERITY OF DKA
• Mild or Moderate DKA
– pH 7.1 or above
– Assume 5% fluid deficit
• Severe DKA
– pH below 7.1
– Assume 10% fluid deficit

36. FLUID CALCULATION FOR DKA
• Maintenance fluid requirement
– <10kg give 2ml/kg/hr
– 10-40 kg 1ml/kg/hr
– >40 kg40ml/hr
• Deficit
– Calculated the fluid deficit (either 5% or 10% dehydration
depending on severity of acidosis), divide over 48 hours
• Fluid requirement
– Requirement = Deficit + Maintenance

37. WHAT IS YOUR MANAGEMENT?
4. John required 3 fluid bolus for resuscitation (30ml/kg) to
revive shock, what is the total fluid requirement for John?
a) Volume of fluid
• deficit 10 % x 30 kg = 3000 mls
• minus 10ml/kg resuscitation fluid = - 300 ml
• divide over 48 hours = 2700/48= 56 ml/hr
• plus maintenance fixed rate = 30 ml/hr (1ml/kg/hr)
Total = 86 ml/hour

38. WHAT IS YOUR MANAGEMENT?
b) Type of fluid
• Use 0.9% sodium chloride with 20 mmol potassium chloride in 500
ml (40 mmol per litre) until blood glucose levels are less than 14
mmol/l
• Do not give oral fluids to a child or young person who is receiving
intravenous fluids for DKA until ketosis is resolving and there is no
nausea of vomiting.

39. WHAT SHOULD YOUR DO NEXT AFTER FLUID
MANAGEMENT?
5. Full clinical assessment
– Conscious level—hourly GCS
– Full examination looking for evidence of
• Cerebral oedema
• Infection
• Ileus
6. Insulin
– start an intravenous insulin infusion 1-2 hours after beginning
intravenous fluid therapy.
– Use a soluble insulin infusion at a dosage between 0.05 and 0.1
units/kg/hour.

40. JOHN’S BLOOD GLUCOSE LEVEL IS NOW 13 MMOL/L
7. Continuing Management
– Continue with 0.9% sodium chloride containing 20 mmol potassium
chloride in 500ml until blood glucose levels have fallen to 14 mmol/l.
– Once the blood glucose has fallen to 14 mmol/l add glucose to the fluid
and think about the insulin infusion rate, as follows -
• If ketone levels are less than 3 mmol/l  reduce to or maintain at an insulin
infusion rate of 0.05 units/kg/hr
• If ketone levels are above 3 mmol/l  maintain the insulin infusion rate at
0.05 to 0.1 units/kg/hour to switch off ketogenesis

41. IN SUMMARY
• Type 1 diabetes most commonly presents in childhood
• Mostly sporadic, small inherited component
• Many children will be well at presentation but DKA must not be
missed
• Management is always with insulin but issues can arise with
compliance for a variety of factors, particularly in teenage
children