DIABETES Paediatrics and Adolesence Dr Aisling Myers Clinical Lecturer.
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Transcript of DIABETES Paediatrics and Adolesence Dr Aisling Myers Clinical Lecturer.
DIABETES DIABETES Paediatrics and Paediatrics and
AdolesenceAdolesence
Dr Aisling MyersDr Aisling Myers
Clinical LecturerClinical Lecturer
ClassificationClassification Type 1 (Autoimmune, Idiopathic)Type 1 (Autoimmune, Idiopathic) Type 2 Type 2
OthersOthers Genetic defects of Genetic defects of ββ-cell function (e.g. MODY)-cell function (e.g. MODY) Pancreatic diseases (e.g. cystic fibrosis)Pancreatic diseases (e.g. cystic fibrosis) Endocrinopathies (e.g. Cushing Syndrome)Endocrinopathies (e.g. Cushing Syndrome) Iatrogenic (e.g. Glucocorticoids)Iatrogenic (e.g. Glucocorticoids) Infections (e.g. Congenital Rubella)Infections (e.g. Congenital Rubella) Other syndromes (e.g Prader Willi Syndrome)Other syndromes (e.g Prader Willi Syndrome)
Gestational Gestational
Diabetes – Type 1 Diabetes – Type 1
Most common metabolic disease in the Most common metabolic disease in the youngyoung
Third most common chronic disorder in Third most common chronic disorder in childhood after asthma and cerebral palsychildhood after asthma and cerebral palsy
Life threatening, life longLife threatening, life long Incidence rising, presenting at younger Incidence rising, presenting at younger
ageageChronic hyperglycaemiaChronic hyperglycaemiaDefect in insulin secretion / actionDefect in insulin secretion / action
NormoglycaemiaNormoglycaemia
Uncontrolled Diabetes MellitusUncontrolled Diabetes Mellitus
Insulin deficiencyInsulin deficiency
PathogenesisPathogenesis Deficiency of insulin secretionDeficiency of insulin secretion
Prone to ketoacidosisProne to ketoacidosis
T-cell mediated pancreatic islet T-cell mediated pancreatic islet ββ-cell destruction-cell destruction ββ-cell destruction – occurs at variable rate-cell destruction – occurs at variable rate Process begins months/years before presentation with Process begins months/years before presentation with
clinical symptoms. ? Viral triggerclinical symptoms. ? Viral trigger Clinically symptomatic when ~ 90% of Clinically symptomatic when ~ 90% of ββ-cells destroyed-cells destroyed
HLA genes – 8-10 fold risk if HLA-DR3 or HLA-DR4HLA genes – 8-10 fold risk if HLA-DR3 or HLA-DR4
Serological Markers Serological Markers
Serological markers present in 85-90% at Serological markers present in 85-90% at presentationpresentation
Autoimmune pathologic processAutoimmune pathologic process Islet cell Autoantibodies (ICA)Islet cell Autoantibodies (ICA) Insulin Autoantibodies (IAA)Insulin Autoantibodies (IAA)Glutamic Acid Decarboxylase (GAD)Glutamic Acid Decarboxylase (GAD)
EpidemiologyEpidemiology
Over 50% diagnosed before 15 yrsOver 50% diagnosed before 15 yrs T1DM – accounts for >90% of childhood and T1DM – accounts for >90% of childhood and
adolescent diabetesadolescent diabetes Type 2 – becoming more commonType 2 – becoming more common Incidence variable - Highest in Finland.Incidence variable - Highest in Finland. 12 – 15% will have affected first degree relative12 – 15% will have affected first degree relative 3 times more likely to develop diabetes if father 3 times more likely to develop diabetes if father
also affected vs motheralso affected vs mother Screening unethical unless part of trial – no Screening unethical unless part of trial – no
effective methods of preventioneffective methods of prevention
Diagnosis 1Diagnosis 1 Symptoms……plusSymptoms……plus
Hyperglycaemia (random blood sugar Hyperglycaemia (random blood sugar >11mmol/litre)>11mmol/litre)
OrOr Fasting blood sugar >7.0 mmol/litreFasting blood sugar >7.0 mmol/litre
OrOr 2hr post prandial sugar >11 mmol/litre2hr post prandial sugar >11 mmol/litre
OrOr OGTTOGTT
Diagnosis 2Diagnosis 2
PresentationPresentation Polyuria, polydipsia, weight lossPolyuria, polydipsia, weight loss Glycosuria, KetonuriaGlycosuria, Ketonuria Diabetic Ketoacidosis (DKA) – urgentDiabetic Ketoacidosis (DKA) – urgent Non-ketotic hyperosmolar stateNon-ketotic hyperosmolar state Recent onset enuresis in previously trained childRecent onset enuresis in previously trained child Vaginal candidiasis (prepubertal)Vaginal candidiasis (prepubertal) VomitingVomiting Chronic weight loss, failure to thriveChronic weight loss, failure to thrive Recurrent skin infectionsRecurrent skin infections
ManagementManagement
Urgent (same day) referral to multidisciplinary Urgent (same day) referral to multidisciplinary paediatric diabetes care teampaediatric diabetes care team
AdmissionAdmission or home based care or home based care Admit:Admit:
DKADKA <2 yrs old<2 yrs old Social / Emotional issuesSocial / Emotional issues Family living long distance from hospitalFamily living long distance from hospital Peripheral hospitalPeripheral hospital
DKADKA
Clinical historyClinical history Polyuria, polydipsia, wgt loss, abdo pain, weakness, Polyuria, polydipsia, wgt loss, abdo pain, weakness,
vomiting, confusion, stupor, coma.vomiting, confusion, stupor, coma.
Clinical signsClinical signs Dehydration, smell of ketones, lethargy, drowsiness, Dehydration, smell of ketones, lethargy, drowsiness,
Kussmaul breathingKussmaul breathing
Biochemical signsBiochemical signs Ketones (blood/urine), hyperglycaemia (>11), acidosis Ketones (blood/urine), hyperglycaemia (>11), acidosis
(pH < 7.3), other electrolyte abnormalities(pH < 7.3), other electrolyte abnormalities
DKADKA
AAirway irway BBreathing reathing CCirculation (ABC)irculation (ABC) Admit ICUAdmit ICU IV access x 2IV access x 2 OxygenOxygen Fluid resuscitation / IV Insulin / PotassiumFluid resuscitation / IV Insulin / Potassium Electrolyte monitoring (hrly, 2hrly, 4hrly) – KElectrolyte monitoring (hrly, 2hrly, 4hrly) – K+ +
Close monitoring Close monitoring Sepsis/InfectionSepsis/Infection Neurological deterioration Neurological deterioration Cerebral oedemaCerebral oedema
InsulinInsulin
Subcutaneous insulin Subcutaneous insulin when clinically well when clinically well and tolerating food / and tolerating food / fluidsfluids
Injection sitesInjection sites AbdomenAbdomen ThighsThighs ButtocksButtocks
Insulin PreparationsInsulin Preparations
PreparationPreparation OnsetOnset DurationDuration
Rapid acting*Rapid acting* 15 mins15 mins 2 – 5 hours2 – 5 hours
Short actingShort acting 30 – 60 mins30 – 60 mins Up to 8 hoursUp to 8 hours
Intermediate Intermediate actingacting
1 – 2 hours1 – 2 hours 16 – 35 hours16 – 35 hours
Long actingLong acting 1 – 2 hours1 – 2 hours > 24 hours> 24 hours
Insulin RegimensInsulin Regimens
1, 2 or 3 injections per day: rapid or short 1, 2 or 3 injections per day: rapid or short acting insulin premixed or self mixed with acting insulin premixed or self mixed with intermediate acting insulinintermediate acting insulin
MDI regimen: rapid or short acting insulin MDI regimen: rapid or short acting insulin before meals with intermediate or long before meals with intermediate or long acting insulinacting insulin
Insulin pump therapy (CSII) – most Insulin pump therapy (CSII) – most physiological. Requires commitment , physiological. Requires commitment , competence and good family supportcompetence and good family support
Phases of DiabetesPhases of Diabetes Preclinical diabetesPreclinical diabetes
Months or years prior to presentationMonths or years prior to presentation Antibodies (Islet cell, Insulin, Glutamic Acid Antibodies (Islet cell, Insulin, Glutamic Acid
Decarboxylase) - positiveDecarboxylase) - positive PresentationPresentation Partial remissionPartial remission (“ (“HoneymoonHoneymoon” Phase)” Phase)
80% of cases transient decrease in insulin 80% of cases transient decrease in insulin requirementsrequirements
Duration – weeks to monthsDuration – weeks to months Important to inform parents that this phase is transient Important to inform parents that this phase is transient
ChronicChronic Lifelong insulin therapyLifelong insulin therapy
EducationEducation
InsulinInsulinMonitoring glycaemic control (HbA1C)Monitoring glycaemic control (HbA1C)DietDietExerciseExerciseSmoking / Alcohol / Substance misuseSmoking / Alcohol / Substance misuse Intercurrent illness (sick days)Intercurrent illness (sick days)Hypoglycaemic episodesHypoglycaemic episodes
Avoidance, detection, managementAvoidance, detection, management
Multidisciplinary TeamMultidisciplinary Team
Consultant and diabetic teamConsultant and diabetic teamDiabetic Nurse SpecialistsDiabetic Nurse SpecialistsDieticianDieticianPsychologyPsychologySocial WorkerSocial WorkerOphthalmology Ophthalmology ChiropodyChiropodyGPGP
Follow-UpFollow-Up
Aim for frequent blood sugar monitoring Aim for frequent blood sugar monitoring (usually 4 BM’s daily – fingerprick)(usually 4 BM’s daily – fingerprick)
Aim for pre-prandial sugar: 4 – 8 mmol/LAim for pre-prandial sugar: 4 – 8 mmol/LAim for post-prandial sugar: < 10mmol/LAim for post-prandial sugar: < 10mmol/LAdjust insulin doses accordinglyAdjust insulin doses accordinglyLiaise with diabetic team (phone / clinic)Liaise with diabetic team (phone / clinic)Monitor sugars more often during Monitor sugars more often during
intercurrent illnessintercurrent illness
Clinic VisitsClinic Visits Monitor growth (height, weight, BMI)Monitor growth (height, weight, BMI) Pubertal development Pubertal development HbA1C (< 7.5%)HbA1C (< 7.5%) Check injection sitesCheck injection sites Review foot careReview foot care Annual screenAnnual screen
RetinopathyRetinopathy Nephropathy (Microalbuminuria, Blood Pressure)Nephropathy (Microalbuminuria, Blood Pressure) Associated conditionsAssociated conditions
Thyroid diseaseThyroid disease Coeliac DiseaseCoeliac Disease
Ongoing CareOngoing Care
Constant re-educationConstant re-educationEncourage family involvementEncourage family involvementPsychology (NB in teenage years)Psychology (NB in teenage years)Tailor insulin therapy and delivery Tailor insulin therapy and delivery
methods to each patient / familymethods to each patient / familyScreen for complicationsScreen for complicationsTransition to adult care – smoothTransition to adult care – smooth
Surgical ProceduresSurgical Procedures
In centres with facilities for care of In centres with facilities for care of children/young people with diabeteschildren/young people with diabetes
Agree protocol for safe management.Agree protocol for safe management.Ensure first on list.Ensure first on list. Inform anaesthetic teamInform anaesthetic teamCheck regular blood sugarsCheck regular blood sugarsCheck electrolytes (K)Check electrolytes (K)Check for glycosuria, ketonuriaCheck for glycosuria, ketonuria
ComplicationsComplications Short Term / OngoingShort Term / Ongoing
HypoglycaemiaHypoglycaemia DKADKA Sick daysSick days Lipohypertrophy (48%)Lipohypertrophy (48%) PsychologicalPsychological
Long TermLong Term RetinopathyRetinopathy NephropathyNephropathy NeuropathyNeuropathy Macrovascular DiseaseMacrovascular Disease
HypoglycaemiaHypoglycaemia
Carry T1DM identification (bracelet)Carry T1DM identification (bracelet) Rapid access to CHO and blood sugar monitorRapid access to CHO and blood sugar monitor Educate carers re glucagon administration and Educate carers re glucagon administration and
advice to seek medical assistance if failing to advice to seek medical assistance if failing to respond (seizures can occur if untreated)respond (seizures can occur if untreated)
Patients – increase awareness and respond Patients – increase awareness and respond appropriatelyappropriately
Avoid over corrections at meals especially at Avoid over corrections at meals especially at night – overnight or fasting hyponight – overnight or fasting hypo
Avoid very low HbA1CAvoid very low HbA1C
DKADKA
Untreated – stupor, coma, deathUntreated – stupor, coma, deathFollow proposed guidelines for institutionFollow proposed guidelines for institution Initial management in HDUInitial management in HDUTransfer to paeds ICU if not respondingTransfer to paeds ICU if not respondingOutrule co-existing sepsisOutrule co-existing sepsisMonitor closely for signs of deteriorationMonitor closely for signs of deterioration
Impaired consciousnessImpaired consciousnessSuspected cerebral oedemaSuspected cerebral oedema
Sick DaysSick Days
Sick Day RulesSick Day RulesExtra blood sugarsExtra blood sugarsCheck for ketonesCheck for ketonesHrly / 2 hrly snacksHrly / 2 hrly snacks If persistent vomiting or if not tolerating – If persistent vomiting or if not tolerating –
bring to hospitalbring to hospitalRegular phone contact with nurse Regular phone contact with nurse
specialist/teamspecialist/teamNEVER OMIT INSULINNEVER OMIT INSULIN
Psychological / Social IssuesPsychological / Social Issues
Emotional / BehaviouralEmotional / BehaviouralFamily ConflictFamily ConflictAnxiety / DepressionAnxiety / DepressionEating DisordersEating DisordersCognitive DisordersCognitive DisordersBehavioural / Conduct DisordersBehavioural / Conduct DisordersNon – compliance Non – compliance
ComplicationsComplications
Long Term - RetinopathyLong Term - Retinopathy
Visual impairmentVisual impairment BlindnessBlindness Poor glycaemic Poor glycaemic
controlcontrol Laser treatment if Laser treatment if
sight threateningsight threatening Ophthalmology check Ophthalmology check
annually from 12 annually from 12 years or if diagnosed years or if diagnosed >5yrs>5yrs
Long Term - NephropathyLong Term - Nephropathy
Renal failureRenal failure HypertensionHypertension Early morning urine for Early morning urine for
microalbuminuriamicroalbuminuria Albumin:Creatinine ratioAlbumin:Creatinine ratio Monitor BP at clinic visitsMonitor BP at clinic visits Screen annually from 12 Screen annually from 12
yrs or if diagnosed > 5yrsyrs or if diagnosed > 5yrs
Long Term - MacrovascularLong Term - Macrovascular
StrokeStroke
Ischaemic Heart Ischaemic Heart DiseaseDisease
Peripheral Vascular Peripheral Vascular DiseaseDisease
Associated Associated Conditions/ComplicationsConditions/Complications
Impaired growth and developmentImpaired growth and developmentLate pubertal developmentLate pubertal developmentObesity (excessive exogenous insulin Obesity (excessive exogenous insulin
assoc with high energy intake)assoc with high energy intake)Autoimmune conditionsAutoimmune conditions
HypothyroidismHypothyroidismHyperthyroidismHyperthyroidismCoeliac DiseaseCoeliac DiseaseAddison’s DiseaseAddison’s Disease
Other types of DiabetesOther types of Diabetes
Type 2 DiabetesType 2 Diabetes
Rising prevalence – associated with Rising prevalence – associated with increasing obesityincreasing obesity
Type 2 DiabetesType 2 Diabetes
Insulin resistanceInsulin resistanceAcanthosis nigricansAcanthosis nigricansHigh insulin or c-peptide levelsHigh insulin or c-peptide levelsDyslipidemiaDyslipidemiaPolycystic ovarian syndromePolycystic ovarian syndrome
More common in ethnic minority groupsMore common in ethnic minority groupsJapan – more common than T1DMJapan – more common than T1DM
Type 2 DiabetesType 2 Diabetes
Commonly presents in mid-pubertyCommonly presents in mid-pubertyConfused with MODY (monogenic maturity Confused with MODY (monogenic maturity
onset diabetes of the young)onset diabetes of the young)Screen if obese, positive family history or Screen if obese, positive family history or
signs of insulin resistancesigns of insulin resistanceLifestyle changes – diet, exerciseLifestyle changes – diet, exercisePharmacotherapy – not licensed in Pharmacotherapy – not licensed in
childrenchildrenEarly intervention – best preventionEarly intervention – best prevention
Neonatal DiabetesNeonatal Diabetes
Very rare (1 in 400,000 births)Very rare (1 in 400,000 births) Insulin requiring hyperglycaemia in first 3-6 mths Insulin requiring hyperglycaemia in first 3-6 mths
of lifeof life May be associated with IUGR (intra uterine May be associated with IUGR (intra uterine
growth retardation)growth retardation) 50% cases transient50% cases transient Permanent – associated with pancreatic aplasia, Permanent – associated with pancreatic aplasia,
genetic mutationsgenetic mutations Predisposition to impaired glucose tolerance and Predisposition to impaired glucose tolerance and
Type 2 diabetes in later lifeType 2 diabetes in later life
Cystic Fibrosis (CFRD)Cystic Fibrosis (CFRD) Insulin deficiencyInsulin deficiency Insulin resistanceInsulin resistance
InfectionsInfections Medications (steroids, bronchodilators)Medications (steroids, bronchodilators)
Occurs late in disease (adolescence, early adulthood)Occurs late in disease (adolescence, early adulthood) Cirrhosis contributes to insulin resistanceCirrhosis contributes to insulin resistance Onset of CFRD – poor prognostic indicatorOnset of CFRD – poor prognostic indicator Poor control – promotes catabolismPoor control – promotes catabolism Screening – OGTT as part of annual screen >10yrsScreening – OGTT as part of annual screen >10yrs Insulin doses usually smaller than in classic T1DM Insulin doses usually smaller than in classic T1DM
MODYMODY
Maturity Onset Diabetes of the YoungMaturity Onset Diabetes of the YoungSingle gene disorder causing Single gene disorder causing ββ cell cell
dysfunctiondysfunctionAutosomal dominant family historyAutosomal dominant family historyEndogenous insulin secretionEndogenous insulin secretionNot prone to ketoacidosisNot prone to ketoacidosisNo signs of insulin resistanceNo signs of insulin resistanceUsually require less insulin than classic T1DMUsually require less insulin than classic T1DMMutations found in >80% of patients (5)Mutations found in >80% of patients (5)
Other causesOther causes
Drug-induced diabetesDrug-induced diabetesNeurosurgery (Dexamethasone)Neurosurgery (Dexamethasone)Oncology (chemotherapy)Oncology (chemotherapy)
Stress HyperglycaemiaStress HyperglycaemiaReported in up to 5% attendances to A&EReported in up to 5% attendances to A&EAcute illness, trauma, post seizure, feverAcute illness, trauma, post seizure, feverRecheck blood sugar series when wellRecheck blood sugar series when well
Islet Cell TransplantationIslet Cell Transplantation
Islet cells replaced with harvested donor Islet cells replaced with harvested donor cellscells
Typically receive cells from up to 3 donorsTypically receive cells from up to 3 donorsExperimental therapyExperimental therapyShortage of donor materialShortage of donor materialStill require insulin therapyStill require insulin therapyAnti-rejection drugs – severe side effectsAnti-rejection drugs – severe side effects
The FutureThe Future
Key PointsKey Points
Lifelong diseaseLifelong diseaseNever omit insulinNever omit insulinHealthy lifestyle for all the familyHealthy lifestyle for all the familyGood glycaemic controlGood glycaemic controlScreen for complicationsScreen for complications
Prevention better than cure!Prevention better than cure!
Thank YouThank You