Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DIABETES MELLITUS IN CHILDREN: CLINICAL FEATURES, DIAGNOSTICS AND TREATMENT As. Prof. Sakharova Inna. Ye., MD,PhD 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) Destruction of -cells of islet of Langerhans cause an absolute deficiency of insulin, leading to type I diabetes mellitus (insulindependent diabetes mellitus, DM type 1). • 10% of all DM cases Insulin deficiency • Juvenile onset • HLA DR 3+4 associations: o 53% of people with type I diabetes have one DR3 and one DR4, with one of these coming from each parent. o 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 Etiology of DM type 1 Genetic factors Autoimmune factors Environmental factors Clinical classification of DM type 1. Severity - Mild Glycemic control Complications - Ideal - Acute - Optimal - Moderate - Suboptimal - Chronic - High risk for the life - Severe DM severity criteria • - Mild form Absence of ketoacidosis in anamnesis Absence of micro- and macroangiopathies Treatment consists of diet, physical exercises, phytotherapy (it’s enough for ideal glycemic control maintaining) 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 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 Clinical criteria of glycemic control Ideal Optimal Suboptimal High risk for the life Symptoms of DM are absent Symptoms are absent, but sometimes can be mild hypoglycemia Polyuria, polydipsia, poor weight gain. Can be episodes of severe hypoglycemia Poor vision, painful seizures, growth and sexual development retardation, angiopathies, skin infections, episodes of severe hypogly-cemia Laboratory criteria of glycemic control Glucose, Ideal (mmol/L) Optimal Subopti mal High risk for the life Fasting glycemia After food glycemia Night glycemia 3,6-6,1 4,0-7,0 > 8,0 > 9,0 4,4-7,0 5,0-11,0 11,0-14,0 > 14,0 HbAlc, % < 6,05 3,6-6,0 Not < 3,6 < 3,6 or > 9,0 < 7,6 7,6-9,0 < 3,0 or > 11,0 > 9,0 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 polydipsia - due to dehydration polyphagia - excessive eating - hypothalamic control of appetite has insulin sensitive transport systems weight loss fatigue and weakness Diagnostic criteria: • A random blood glucose level greater than 11,1 mmol/l (i.e.>200 mg/dl), which is verified on a repeat test, is sufficient to make the diagnosis of DM or • Fasting blood glucose > 6,1 mmol/l (>110 mg/ dl) (fasting is no food for > 8 hours), which is verified on a repeat test, is sufficient to make the diagnosis of DM 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. Oral glucose tolerance test (OGTT) Diagnosis Time of checking Glucose level (mmol/L) Whole blood Plasma Fasting 6,1 7,0 In 2 hours 11,1 11,1 Fasting Impaired Glucose In 2 hours Tolerance (IGT) Impaired Fasting Fasting Glycaemia (IFG): In 2 hours 6,1 7,0 Diabetes mellitus 7,8 11,1 7,8 11,1 5,6 6,1 6,1 7,0 7,8 7,8 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) • Urinary albumin:creatinine ratio (normal level 2,5mg/mmol for men and <3,5 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 • Fructosamine level in blood • Islet cell antibodies; • Fasting lipid profile (cholesterol, triglycerides, HDL/LDL calculation) • Level of C-peptide and insuline in blood Instrumental studies: • • • • • ECG US examination of abdominal cavity Fundoscopy Densitometry Rheovasography of legs Optimal therapy for diabetes mellitus must include Insulin A regimen for physical fitness Psychological support Nutritional management Daily insulin doses for children: Age Insulin dose (Units/kg) Infants (< 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 > 12 years 1,0 and more Insulin has 3 basic formulations: • short-acting, regular insulin (aktrapid) • medium- or intermediate-acting (protaphan, isophane, lente) • and long-acting (ultralente) 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 The catheter at the end of the insulin pump is inserted through a needle into the abdominal fat of a person with diabetes. 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. 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) • 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.