Diabetes type 1

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  • When your child is too sweetBy Dr Liaw Siew Ching


  • IDDM/ Type I DMIntroductionPhysiology of diabetes in cell failure in type 1 DMDKALong term management of diabetes

  • Definition of DM:

    Symptoms of diabetes with random blood sugar >11.1mmol/l or,Fasting plasma glucose >7.0mmol/l (fast for 8H) or,2 hour postload glucose >11.1mmol/l in OGTT (glucose load with 75g anhydrous glucose desolved in water or 1.75g/kg)Introduction


  • Type I DM (95%) Autoimmune destruction of the pancreatic islet cellsType 2 DM A combination of cell failure and insulin resistantCystic fibrosis-related diabetesMaturity onset diabetes of the youngGenetic syndromes( Downs syndrome, Wolfram syndrome, neonatal diabetes

    Aetiology of diabetes in children


  • Europe: Scandinavia and the UK have the highest rates of diabetes in Europe. There is a >10-fold difference in incidence across Europe, which might be accounted for in part by the distribution of high-risk HLA-DQ alleles.North America: Canada has incidence rates comparable to those of Northern Europe (22/100,000 per year). The US has a lower rate (16/100,000 per year), whereas Mexico has a rate of 1.5/100,000 per year.South America: Rates are generally low, except in Argentina and Uruguay.Africa (sub-Saharan): Estimated rates are generally low.Eastern Mediterranean and the Middle East: Rates vary between 1/100,000 per year (Pakistan) and 8/100,000 per year (Egypt). South-East Asia: A steady increase from a low baseline in countries such as India and China. Due to their vast populations, these will make a large contribution to the future global incidence of type 1 diabetes.Western Pacific: Rates are low, with the exception of Australia and New Zealand.




  • Physiology of diabetes in cell failure in type 1 DM

  • Physiology of diabetes in cell failure in type 1 DM

    Lymphocytic infiltration destroying beta cells.After 80-90% of the beta cells are destroyed, hyperglycemia develops.85% patients have circulating islet cell antibodies and detectable anti-insulin antibodies. Commonly found islet cell antibodies are antibodies against glutamic acid decarboxylase (GAD), an enzyme found within pancreatic beta cells.

  • Physiology of diabetes in cell failure in type 1 DM

    Insulin also increases the permiability of many cells to potassium, magnesium and phosphate ions. Insulin activates sodium-potassium ATPases in many cells, causing a flux of potassium into cells.

  • Classic symptomsNausealethargy

  • Physiology of diabetes in cell failure in type 1 DM

  • Diabetic ketoacidosisLow insulin leads to DKALiver glycogen mobilization to form glucoseMuscle protein breakdown to form free amino acidsAdipose tissue breakdown of triglycerides to form free fatty acids which oxidized to form ketone bodiesExcess glucose in glomerular filtrate leads to glucosuria.

  • DKARemember : children can die from DKA

    DefinitionBlood glucose > 11Venous pH

  • Remember : children can die from DKABSPED Recommended DKA Guidelines 2009

  • Causes of DKA

  • Clinical presentation of DKADehydration, ketosis, acidosis, infection.

  • Assessment of severityPresent of one or more of the following may indicate severe DKABlood ketone over 6mmol/lHCO3
  • Principle of managementGeneral resuscitationConfirm diagnosisFull clinical assessmentFluid managementInsulin

  • ManagementFM + deficit. Initially use 1/2NS with 3/4g KCLContinuous low dose intravenous infusion. No need bolus.Make up a solution of 1 unit per ml of human soluble insulin (e.g. Actrapid) by adding 50 units (0.5 ml) insulin to 50 ml 0.9% saline in a syringe pump. Attach this using a Y-connector to the IV fluids already running. Do not add insulin directly to the fluid bags.Run at 0.1 units/kg/hour (0.1ml/kg/hour). The insulin dose needs to be maintained at 0.1 units/kg/hour to switch off ketogenesis.There are some paediatricians who believe that 0.05 units/kg/hour is an adequate dose. There is no firm evidence to support this.

  • Blood glucose level
  • HUSM DKA SOP 2009Although serum potassium appear normal, but total body potassium is low and worsened with insulin infusion.

    Serum Potassium (mmol/l)Replacement

  • Target of therapyReduction of blood ketone by 0.5mmol/l/hIncrease bicarb by 3mmol/l/hReduce capillary blood sugar by 3.0mmol/l/hMaintain k+ between 4.0-5.5mmol/l

  • Resolution of DKApH>7.3 unitsBicarb >15mmol/lBlood ketone < 0.6mmol/l or urine ketone nil.

    S/c insulin can be started.

  • Long Term Management of DM Type IPrinciples of insulin therapy

    Guidelines on dosage:During the partial remission phase, total daily insulin dose is usually 0.5 IU/kg/day. Prepubertal children (outside the partial remission phase) usually require insulin of 0.71.0 IU/kg/day.During puberty, requirements may rise to 1 - 2 IU/kg/day.

    Frequently used regimens:Twice Daily Regimens2 daily injections of a mixture of a short or rapid acting insulin with and intermediate-acting insulins (before breakfast and the main evening meal)Approximately 2/3 intermediate-acting insulin and 1/3 of the total daily insulin dose is short acting insulin. Ex: Mixtard 70/302/3 of the total daily dose is given in the morning and 1/3 in the evening

  • Three injections dailyA mixture of short, rapid and intermediate-acting insulins before breakfast; A rapid-acting analogue or regular insulin alone before afternoon snack or the main evening meal. And an intermediate- acting insulin before bed.

    Basal-bolus RegimenOf the total daily insulin requirements, 40 - 60% should be basal insulin, the rest pre-prandial rapid-acting or regular insulin.If using regular insulin, inject 20 - 30 min before each main meal (breakfast, lunch; and the main evening meal); if using rapid-acting insulin analogue inject immediately before or after each main meal (e.g. breakfast, lunch; and the main evening meal). Basal cover is given once daily at bedtime. However sometimes twice daily injections may be needed (the other dose usually before breakfast). Insulin pump regimens are regaining popularity with a fixed or a variable basal dose and bolus doses with meals.Patient should learn about carbohydrate counting to adjust dose of pre-prandial insulin.

    Long Term Management of DM Type I

  • Long Term Management of DM Type I

  • Australian Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents

  • Calorie countingSick day managementFasting and surgery

    Long Term Management of DM Type I

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