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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.