diabetes mellitus type 2 in children pathophysiology of type 2 DM manifestations of DM Complications , investigation and management of type2 DM in children

1. Pediatric Type 2
Diabetes Mellitus
Dr sayed ismail
sayedahmed1900@gmail.com

2. Introduction
 Type 2 diabetes is a metabolic disorder in which the
body’s response to insulin is reduced, called insulin
resistance.
 Without insulin, glucose remains in the blood and blood
glucose levels increase as a result.
 Insulin production is initially increased by the
pancreatic beta cells to try to counteract the insulin
resistance.
 However, over time there is a progressive decrease in
insulin production and secretion leading to insufficient
insulin levels.
 The incidence of type 2 diabetes in children and
adolescents has markedly increased,due to rising
obesity

5. Risk Factors
for Type 2
Diabetes
• Obese/Overweight
• Low physical activity
• Unbalanced diet
• Family history of diabetes

7. Physical
Examination
1- Obesity : 85% of children with type 2 diabetes are either
overweight or obese (defined as at or above the 85th body mass index
[BMI] for age-based growth charts).
2- Acanthosis nigricans, a marker of insulin resistance, is a
hyperpigmented thickening of the skin; it is frequently seen on the
nape of the neck and in intertriginous areas; it is found in as many as
90% of children with type 2 diabetes.
Acanthosis nigricans

8. Physical Examination:
3- Hypertension . The risk of macrovascular and microvascular
diabetic complications is positively associated with elevated systolic
blood pressure.
4- Retinopathy

9. 5-PCOS is seen in young women
with acanthosis nigricans.
It is characterized by
hyperandrogenism and chronic
anovulation.
Medications that decrease insulin
resistance and/or hyperinsulinemia in
women with this syndrome often
attenuate the hyperandrogenism and
metabolic abnormalities.
Hirsutism in PCOS

10. Signs of
insulin
resistance
• Acanthosis nigricans
• Dyslipidemia
• Polycystic ovary syndrome (PCOS)
• Hypertension

11. Recommendatio
ns
by the American
Diabetes
Association,
 Testing for type 2 diabetes should be considered when a
patient is overweight and has any of the following :
• Family history of type 2 diabetes
• Signs of insulin resistance
• Initial screening may begin at age 10 years or at onset of
puberty if puberty occurs at a young age
• Screening should be performed every 2 years
• A fasting plasma glucose test is the preferred screening
study; if clinical suspicion is high but fasting blood glucose
is normal (< 100 mg/dL), an oral glucose tolerance test
should be considered

12. Diagnosis
• A random plasma glucose 200 mg/dL or
greater in association with polyuria,
polydipsia, or unexplained weight loss is
diagnostic of diabetes
• In an asymptomatic patient, a fasting
plasma glucose value of 126 mg/dL or
greater or a 2-hour plasma glucose value of
200 mg/dL or greater during an oral glucose
tolerance test is also diagnostic of diabetes

13. Other
laboratory
results that
usually
suggest type
2 diabetes
are as
follows:
• Elevated fasting C-peptide level
• Elevated fasting insulin level
• Absence of autoimmune markers (glutamic acid
decarboxylase [GAD] and islet cell antibodies
 Testing for albuminuria
 Fasting lipid profiles should be obtained after
stable glycemia is achieved and every 2 years
thereafter if normal. Optimal values for children
with type 2 diabetes are as follows
• Triglycerides < 150 mg/dL
• Low-density lipoprotein (LDL) < 100 mg/dL
• High-density lipoprotein (HDL) >35 mg/dL

15. Evaluation for Diabetic
Nephropathy
Microalbuminuria is said to
be present if urinary albumin
excretion is 30 mg/24 h
(equivalent to 20 µg/min with a
timed specimen or 30 mg of
albumin per gram creatinine
with a random sample

16. Complicatio
ns
 Acute complications of type 2 diabetes include
 Hyperglycemia,
 Diabetic ketoacidosis (DKA)
 Hyperglycemic-hyperosmolar state(HHS)
 Hypoglycemia.
 Complications from insulin resistance include
hypertension, dyslipidemia, and polycystic ovarian
syndrome (pcos)
 4% of patients with type 2 diabetes initially present
in a hyperglycemic-hyperosmolar coma, which
can lead to cerebral edema and death if not
promptly recognized and treated.

17. Hyperglyce
mic-
hyperosmola
r state(HHS)
 HHS can be caused by stress on the body
(infections, strokes, heart attacks, dehydration),
poor glucose control (therapy noncompliance), or
certain medications (corticosteroids), etc.
 The patient will present with a high blood glucose
(over 600 mg/dL or 33 mmol/L), high osmolality,
and profound dehydration which can lead to low
blood volume (hypovolemia).
 This makes the blood very viscous (thick),
increasing the risk of acute kidney injury (AKI) and
thromboembolic events, such as heart attack and
stroke.
 Management of HHS involves IV fluid replacement
and IV insulin.

20. long-term complications of type 2 diabetes mellitus
•Coronary artery disease

23. Management
goals
 Maintain hemoglobin A1c (HbA1c) levels (< 7%)
• Fasting glycemia of less than 126 mg/dL and
postprandial <200 mg/dL
• Resolution of polyuria, nocturia, and polydipsia
• Healthy body weight
• Maintenance of cardioprotective levels of lipids
and blood pressure (LDL level < 100 mg/dL,
triglyceride < 150 mg/dL, HDL level >35 mg/dL
• Blood pressure < 95th percentile for age, sex, and
height)

24. Treatments
for pediatric
type 2
diabetes
include the
following:
• Diabetes education and lifestyle changes:
• Diet
• Exercise
• Weight control
• Pharmacologic therapy with metformin, insulin, a
sulfonylurea, or another hypoglycemic agent
• Lipid-lowering agents : statins
• blood pressure medications:
• ACE inhibitors are the agents of choice to treat
hypertension and microalbuminuria.

25. Pharmacologi
c Therapy
 Pharmacologic therapy is indicated when
the disease is not well controlled with diet
and exercise.
 Metformin should be the first oral agent
used in children and teenagers with an
HbA1c level of less than 9%.
 If metformin is unsuccessful as
monotherapy, the addition of insulin, may
be appropriate

26. Insulin therapy
indiocations
1. Symptomatic patients with persistent
hyperglycemia
2. HbA1c of more than 9%,
3. ketoacidosis.
 After blood glucose levels are normalized, efforts
to taper insulin with progressive substitution of an
oral agent are undertaken.

27. Managemen
t Algorithm
 Diabetes education is indicated, including lifestyle
changes to achieve healthy weight goals.
 First-line therapy is metformin at 1000-2000 mg/d.
Goals include a fasting glucose level goal of less
than 126 mg/dL and/or an HbA1c level of less than
7%. If goals in step 1 are achieved, continue
therapy.
 If goals in step 1 not achieved after 3 months
(fasting glucose level >126 mg/dL or HbA1c level
>7%),
 add 0.4-0.6 U/kg of 24-hour insulin at bedtime
(Glargine or Levemir). If combination therapy is
adequate, continue therapy.
 If combination therapy is inadequate after 3
months, intensify insulin therapy until the fasting
plasma glucose level is less than 126 mg/dL and
the HbA1c level is less than 7%

29. To protect these
patients from
future
cardiovascular
disease,
treatment
should
emphasize the
following:
• Improvement of glycemia, dyslipidemia, and
hypertension
• Weight management
• Blood glucose monitoring 2-3 times daily (more
often when insulin treatment is being adjusted)
• Evaluation every 3 months at the diabetes clinic
(more often, as necessary, when treatment is being
adjusted)

30. Monitoring
should be
performed as
follows:
 HbA1c values and lipid profile every 3 months
• Microalbuminuria and fasting lipid profile (annually)
• eye examination (annually)
• Blood pressure evaluation and careful neurologic
examination (at each clinic visit)

31. Patient
Education
 Practical skills training includes the
following:
• Insulin injections (if insulin needed plan)
• Blood and/or urine testing for ketone bodies
• Hypoglycemia recognition and treatment
• Emergency telephone contact procedure
• Psychosocial adjustment to the diagnosis
• Importance of regular follow-up
• Basic dietary advice

32. Prognosis
After 30 years of postpubertal
diabetes, 44.4% of people with type 2
diabetes and 20.2% of people with
type 1 diabetes develop
 Diabetic nephropathy.

33. Stroke
prevention
In 2010, the
American Heart
Association-
American Stroke
Association
released updated
guidelines for the
primary prevention
of stroke
 1-Hypertension
 A lower risk of stroke IF systolic blood pressure levels are less
than 140 mm Hg and diastolic blood pressure is less than 90 mm
Hg.
 In patients who have hypertension with diabetes or renal disease,
the blood pressure goal is less than 130/80 mm Hg.
 Hypertensives agents that are useful in the diabetic population
include ACE inhibitors and angiotensin receptor blockers (ARBs).
 2-Dyslipidemia
 statins is recommended in patients with coronary heart disease or
certain high-risk conditions, for the primary prevention of ischemic
stroke.

34. 3-Diet
 A diet that is low in sodium and high in potassium is to reduce blood pressure.
 Diets that promote the consumption of fruits, vegetables,
 low-fat dairy products, such as the DASH (Dietary Approaches to Stop
Hypertension)-style diet, help to lower blood pressure and may lower risk of stroke.
4-Physical activity
 Increasing physical activity is associated with a reduction in the risk of stroke. The
goal is to engage in at least 30 minutes of moderate intensity activity on a daily
basis.

35. Medications:
dose of Metformin
10 to <17 years
Immediate-release
Initial: 500 mg PO q12hr
Maintenance: Titrate qWeek
by 500 mg; no more than
2000 mg/day in divided
doses
Extended-release
500 mg PO qDay with
dinner; increase the dose in
increments of 500 mg
weekly, up to a maximum
dose of 2,000 mg (20 mL)
once daily, with the evening
meal
 Metformin (Glucophage),
 reduce hepatic glucose production; they also increase peripheral
insulin sensitivity.
 Because of its anorexigenic effects, many treated children maintain or
lose weight.
 metformin can lead to ovulatory cycles and resumption of regular
menses in patients with PCOS,
 Metformin improve all aspects of the lipid profile
 It cannot be used in renal or hepatic insufficiency or decompensated
congestive heart failure requiring pharmacologic therapy (due to an
increased risk for lactic acidosis).
 Metformin may decrease intestinal absorption of glucose, . It is a
major drug used in obese patients with type 2 diabetes.
 Because of adverse gastrointestinal (GI) effects from metformin, titrate
the drug slowly and have patients take the medication during (rather
than before) meals.
 Metformin will gradually be increased until the patient’s HbA1c levels
begin to decrease.
 The A1C target for a patient on monotherapy with metformin is ≤ 6.5%

36. Insulin
degludec
(Tresiba)
 approved by the FDA to improve glycemic
control in pediatric patients aged ≥1 y with
type 2 DM.
 peak plasma time is 9 h and the duration of
action is at least 42 h.
 Usual initial dose range: 0.2-0.4 units/kg
 Starting dose in insulin naïve patients
• 10 units SC qDay

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