DIABETES MELLITUS IN CHILDREN: CLINICAL FEATURES, DIAGNOSTICS AND TREATMENT

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DIABETES MELLITUS IN CHILDREN CLINICAL
FEATURES, DIAGNOSTICS AND TREATMENT

• As. Prof. Sakharova Inna. Ye., MD,PhD

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• Diabetes mellitus (DM) ? a metabolic disorder
  of multiple etiologies characterized by chronic
  hyperglycemia with disturbances of carbohydrate,
  fat and protein metabolism resulting from defects
  in insulin secretion, insulin action, or both
  (WHO, 1999)

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• Destruction of ?-cells of islet of Langerhans
  cause an absolute deficiency of insulin, leading
  to type I diabetes mellitus
  (insulin-dependent diabetes mellitus, DM type 1).

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• 10 of all DM cases Insulin deficiency
• Juvenile onset
• HLA DR 34 associations
• 53 of people with type I diabetes have one DR3
  and one DR4, with one of these coming from each
  parent.
• Only 3 of people without diabetes have this
  DR3/DR4 combination.
• 4 genes thought to be important
• 30 - 50 concordance in identical twins
• Positive family history with 10
• Associated with other autoimmune diseases

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Clinical classification of DM type 1.
Severity Glycemic control Complications
- Mild - Moderate - Severe - Ideal - Optimal - Suboptimal - High risk for the life - Acute   - Chronic
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DM severity criteria

• Mild form
• Absence of ketoacidosis in anamnesis
• Absence of micro- and macroangiopathies
• Treatment consists of diet, physical exercises,
  phytotherapy (its enough for ideal glycemic
  control maintaining)

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DM severity criteria

• Moderate form
• In anamnesis ketoacidosis (I-II stages)
• Presence of diabetic retinopathy I st., diabetic
  nephropathy I-III st. or diabetic arthropathy I
  st.
• For achievement of ideal glycemic control is
  necessary to use insulin, or oral drug therapy or
  combination of both

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DM severity criteria

• Severe form
• Non stable course of the disease (frequent
  ketoacidosis cases or coma in anamnesis)
• Presence of different chronic complications
• Patients need permanent insulin injections

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Clinical criteria of glycemic control
Ideal Optimal Suboptimal High risk for the life
Symp-toms of DM are absent Symptoms are absent, but sometimes can be mild hypogly-cemia Polyuria, polydipsia, poor weight gain. Can be episodes of severe hypogly-cemia Poor vision, painful seizures, growth and sexual development retardation, angiopathies, skin infections, episodes of severe hypogly-cemia
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Laboratory criteria of glycemic control
Glucose, (mmol/L) Ideal Optimal Suboptimal High risk for the life
Fasting glycemia 3,6-6,1 4,0-7,0 gt 8,0 gt 9,0
After food glycemia 4,4-7,0 5,0-11,0 11,0-14,0 gt 14,0
Night glycemia 3,6-6,0 Not lt 3,6 lt 3,6 or gt 9,0 lt 3,0 or gt 11,0
HbAlc, lt 6,05 lt 7,6 7,6-9,0 gt 9,0
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The main evident signs of the DM type 1

• hyperglycemia
• - glucose uptake by cells decreased
• - glucose utilisation by cells decreased
• glycosuria
• polyuria
• - excessive urine production
• - blood glucose levels exceed the rate of
  glomerular filtration by the kidneys
• - glucose appears in the urine and acts as an
  osmotic diuretic

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• polydipsia
• - due to dehydration
• polyphagia
• - excessive eating
• - hypothalamic control of appetite has insulin
  sensitive transport systems
• weight loss
• fatigue and weakness

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Diagnostic criteria

• A random blood glucose level greater than 11,1
  mmol/l (i.e.gt200 mg/dl), which is verified on a
  repeat test, is sufficient to make the diagnosis
  of DM
• or
• Fasting blood glucose gt 6,1 mmol/l (gt110 mg/ dl)
  (fasting is no food for gt 8 hours), which is
  verified on a repeat test, is sufficient to make
  the diagnosis of DM

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Oral glucose tolerance test (OGTT)

• Obtain a fasting blood sugar level, then
  administer per os glucose load (1.75 g/kg for
  children max 75 g). Check blood glucose
  concentration again after 2 hours.

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Oral glucose tolerance test (OGTT)
Diagnosis Time of checking Glucose level (mmol/L) Glucose level (mmol/L)
Diagnosis Time of checking Whole blood Plasma
Diabetes mellitus Fasting ? 6,1 ? 7,0
Diabetes mellitus In 2 hours ? 11,1 ? 11,1
Impaired Glucose Tolerance (IGT) Fasting ? 6,1 ? 7,0
Impaired Glucose Tolerance (IGT) In 2 hours ? 7,8 ? 11,1 ? 7,8 ? 11,1
Impaired Fasting Glycaemia (IFG) Fasting ? 5,6 ? 6,1 ? 6,1 ? 7,0
Impaired Fasting Glycaemia (IFG) In 2 hours ? 7,8 ? 7,8
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Laboratory studies

• Blood glucose (glycemic profile). Blood glucose
  tests using capillary blood samples, reagent
  sticks, and blood glucose meters are the usual
  methods for monitoring day-to-day diabetes
  control
• Urinalysis for glucose (glucosuric profile)
• Serum electrolytes?
• Protein in urine, microalbuminuria - urinary
  albumin excretion rate (normal level ? 20 mg min)

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• Urinary albumincreatinine ratio (normal level ?
  2,5mg/mmol for men and lt3,5 for women)
• Ketone bodies in urine and blood (With
  hyperglycemia and heavy glycosuria, ketonuria is
  a marker of insulin deficiency and potential DKA)
• White blood cell count and blood and urine
  cultures to rule out infection?
• Glucosylated hemoglobin (HbAlc)
• N 6-9 for diabetic patient

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• Fructosamine level in blood
• Islet cell antibodies
• Fasting lipid profile (cholesterol,
  triglycerides, HDL/LDL calculation)
• Level of C-peptide and insuline in blood

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Instrumental studies

• ECG
• US examination of abdominal cavity
• Fundoscopy
• Densitometry
• Rheovasography of legs

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Optimal therapy for diabetes mellitus must include

• Insulin
• A regimen for physical fitness
• Psychological support
• Nutritional management

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Daily insulin doses for children
Age Insulin dose (Units/kg)
Infants (lt 1 year) 0,1 - 0,125
Toddlers (1-3 years) 0,15 0,17
3-9 years 0,2 0,5
9-12 years 0,5 0,8
gt 12 years 1,0 and more
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• Insulin has 3 basic formulations
• short-acting, regular insulin (aktrapid)
• medium- or intermediate-acting (protaphan,
  isophane, lente)
• and long-acting (ultralente)

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The main rules of insulinotherapy im children

• In ketoacidosis should be used only regular
  insulin
• Optimal frequency of injections is 4-5 times per
  day (if 4 times 9 a.m.(regular), 13
  p.m.(regular), 18 p.m. (regular), 22 p.m
  (medium-acting) if 5 times 6 a.m.(regular), 9
  a.m.(regular), 14 p.m. (regular), 19 p.m.
  (regular), 23 p.m (regular)
• Can be used insulin pompes

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The catheter at the end of the insulin pump is
inserted through a needle into the abdominal fat
of a person with diabetes.
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Designer Ellaluna Taylor has come up with her
Flex insulin pump system that targets active
diabetes sufferers, as this system functions as a
unique prosthetic skin that can be worn under
clothing, functioning as a discreet glucose
management solution. It comes with a PDA-like
glucose eReader that will talk to the device,
where the latter runs on soft battery technology
while its MEMS Nano Pump is used for increased
dosage accuracy and reliability.
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Treatment of diabetic coma (DKA III stage)

• An initial intravenous bolus of regular insulin
  at 0.1 U/kg body weight, followed by a continuous
  infusion of regular insulin at a dose of 0.1
  U/kg/hour is the standard therapy (before 50 U of
  insulin should be diluted in 50 ml of normal
  saline than 1 ml will have 1 U of insulin)

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• When glucose decreased to 14 mmol/L (250 mg/dL)
  insulin can be injected subcutaneously (dose 1
  U/kg/day).
• If the patient is hemodynamically stable,
  isotonic saline can be given at a rate of 15-20
  mL/kg/hour for the first several hours. Once the
  serum glucose level is below 200-250 mg/dL, the
  fluids should be changed to one-half normal
  saline with dextrose (D5 1/2NS) given at a rate
  sufficient to replace the free water loss induced
  by the osmotic diuresis.

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Thanks for attention