Diabetes Mellitus in children for medical students
• It’s a chronic metabolic disorder characterized
by hyperglycemia as a cardinal biochemical
feature, caused by deficiency of insulin or its
action, manifested by abnormal metabolism
of carbohydrates, protein and fat
• Peaks of presentation occur in 2 age groups: at
5-7 yr of age (infectious) and at the time of
puberty (gonadal steroids ).
• Girls and boys are almost equally affected
• There is no apparent correlation with
Incidence rates of type 1 diabetes mellitus by region and
Diagnosis of diabetes is made when:
• Symptoms +
• random BGL ≥ 11.1 mmol/L (≥200 mg/dl) (or)
• Fasting BGL ≥ 7mmol/L (≥ 126 mg/dl)
ETIOLOGIC CLASSIFICATIONS OF DIABETES MELLITUS
Type I diabetes: (β-cell destruction, usually leading to absolute insulin deficiency)
Type 2 diabetes: (may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly secretory defect with insulin resistance).
Other specific types :
Genetic defects of β-cell function:Chromosome 7, glucokinase (MODY2)
Genetic defects in insulin action:Rabson-Mendenhall syndrome
Diseases of the exocrine pancreas: Pancreatitis
Endocrinopathies: Cushing disease
Drug- or chemical-induced : Glucocorticoids
Uncommon forms of immune-mediated diabetes :Stiff-man” syndrome
Other genetic syndromes sometimes associated with diabetes :Down syndrome
Gestational diabetes mellitus
Neonatal diabetes mellitus
• The main function of insulin are:
• 1. Reduce glucose by:
• ↓ gluconeogenesis
• ↓ glycogenolysis
• ↑ uptake of glucose by cell
• 2. Inhibit fat breakdown (lipolysis)
• 3. Inhibit protein breakdown (proteolysis)
Insulin deficiency will lead to:
1. Hyperglycemia: increase glucose→ osmotic
diuresis → polyuria → dehydration →
2. Proteolysis: → weight loss → Polyphagia.
3. Lipolysis: ↑ free fatty acids and
accumulation of acetyl Co-A → Liver → keton
bodies → ketonemia → ketonuria &
1. Although most symptoms are nonspecific
2. polyuria , polydepsia, Polyphagia & weight
3. Recurrent infection: skin or UTI.
4. Diabetic Ketoacidosis
• Blood glucose : Fasting glucose > 126 mg/dl &
Random > 200 mg/dl.
• HbA1c: (glycated haemoglobin) average over
the last 2-3 months. Measures amount of
glucose that attaches to haemoglobin, The
target HbA1c < 7.5% (58 mmol/mol).
• Ketone testing: either urine strips, or blood.
• Urine: glucosuria & Ketonuria if DKA
• Need team & Special diabetic Clinic?
• Medical: specialist
• Specialist Nurses:
• Equipments: insulin, glucometer, Ketones
meter and good maintenance.
• Good follow up.
Types of presentation
If newly diagnosed:
1. DKA: according to Guideline.
2. Only hyperglycemia.
Already diabetes on insulin therapy with:
1. DKA: according to Guideline.
2. Presence of ketonemia?
3. Only hyperglycemia? Not controlled?
1. Diabetic Ketoacidosis (DKA):
• Occurs when there is profound insulin deficiency.
• It frequently occurs at diagnosis and also in
children and youth with diabetes if insulin is
omitted, or if insufficient insulin is given at times
of acute illness.
• The biochemical criteria for DKA are:
Hyperglycaemia (blood glucose >11mmol/l
Venous pH <7.3 or bicarbonate <15 mmol/l
Ketonaemia and ketonuria
Management of DKA
• Management should be in centers with experience and
where vital signs, neurologic status, and biochemistry
can be monitored with sufficient frequency to prevent
• Fluid infusion should precede insulin administration by
• an initial bolus of 20 mL/kg 0.9% saline is followed by
0.45% saline calculated to supply maintenance and
replace 10% dehydration.
• Insulin administration (0.1 U/kg/h)
• Potassium (K) must be replaced early and sufficiently.
• Bicarbonate administration is contraindicated.
2. New-Onset Diabetes without
• Ideally, therapy can begin in the outpatient
setting, with diabetic team. (we prefer
• There are many Insulin regimens for
treatment with many advantages and
• We have to select one ??
A. Conventional Insulin therapy: Twice daily mixed Insulin.
B. Intensive Insulin therapy:
1. Basal – Bolus(3 Injections):
o 2 bolus of short acting before breakfast and lunch +
o Mixture of short acting and Intermediate acting at evening meal.
2. Basal – Bolus(3 +1 Injections):
o 3 bolus of short acting before breakfast + lunch + evening meal +
o Intermediate acting before bedtime.
3. Basal – Bolus(3 +1 Injections):
o 3 bolus of Rapid acting before breakfast + lunch + evening meal +
o Long acting before bedtime.
4. Basal – Bolus(3 +1 Injections):
o Long acting before bedtime.
o Rapid acting before meal according to Carbohydrate Counting
and Insulin Correction
2. New-Onset Diabetes without Ketoacidosis
50% of the total daily dose Rapid -acting insulin
divided up between 3 pre-
50% of the total daily dose long-acting insulin
(Lantus® (insulin glargine
single evening injection
Start with 0.5 IU/kg/day
Pre-pubertal 0.7-1.0 IU/kg/day.
During puberty 1 and even up to 2 U/kg/day.
The correct dose of insulin is that which achieves the best glycaemic control
BLOOD GLUCOSE MONITORING
• Blood glucose monitoring should ideally be
carried out 4-6 times a day, however, this is
dependent on the availability of testing strips.
• Recommended target blood glucose levels:
Blood Glucose Targets for Most People with Diabetes
During the day 4.5-7mmol/l 80-125mg/dl
Overnight & pre breakfast 5.5 -8mmol/l 100-145 mg/dl
• Regular exercise; improves glucoregulation by
increasing insulin receptor number.
• No form of exercise, including competitive sports,
should be forbidden to the diabetic child.
• In patients who are in poor metabolic control,
vigorous exercise may precipitate ketoacidosis
because of the exercise-induced increase in the
• A major complication of exercise in diabetic
patients is the presence of a hypoglycemic
reaction during or within hours after exercise.
• The major contributing factor to hypoglycemia
with exercise is an increased rate of absorption
of insulin from its injection site.
• In anticipation of vigorous exercise, additional
carbohydrate exchange may be taken before
exercise, and glucose should be available
during and after exercise.
• The total dose of insulin may be reduced by
about 10-15% on the day of the scheduled
• There are 3 main nutrients in foods—fats,
proteins, and carbohydrates.
• Fats: Fat typically doesn't break down into sugar ,
and in small amounts, it doesn't affect blood
• Proteins: Protein doesn't affect blood glucose
unless the patient eat more than the body needs.
• Carbohydrates: Carbohydrates affect blood
glucose more than any other nutrient.
• The same total caloric intake as usual in
normal child is given with the same ratio
• 50% CHO
• 35% Fat
• 15% Proteins
• Number of meals is preferred to be three fixed
major with two snakes in between.
Screening for complications and associated
• height and weight & state of injection sites at
each clinic visit.
• Thyroid disease & coeliac disease at diagnosis
• annual foot care reviews.
• Regular dental and eye examinations every 2
• from the age of 12 years: blood pressure,
retinopathy, microalbuminuria & S.Creatinine.
• Partial Remission or Honeymoon Phase in
Type 1 Diabetes
• Somogi Phenomena
• Dawn Phenomena.
• Management of DM during Infection.
Partial Remission or Honeymoon
Phase in Type 1 Diabetes
• Insulin requirements can decrease transiently following
initiation of insulin treatment.
• This has been defined as insulin requirements of less
than 0.5 units per kg of body weight per day with an
HbA1c < 7%.
• Ketoacidosis at presentation and at a young age reduce
the likelihood of a remission phase.
• It is important to advise the family of the transient
nature of the honeymoon phase to avoid the false
hope that the diabetes is spontaneously disappearing.
• Treatment by reduce the dose of Insulin Accordingly.
• In children with High dose of Insulin at Night
(Long acting) develop late night(3-4 a.m)
Hypoglycemia Counter regulatory hormon
will increase Early morning Hyperglycemia.
• Treatment: Reduce the dose of Long acting
Insulin at Night .
• In children with Normal dose of Insulin at
Night & Normal midnight glucose
(Normoglycemia), Counter regulatory
hormone may normally increase Early
• Treatment: Increase the dose of Long acting
Insulin at Night .
• Infection may precipitate hyperglycemia or
• Mild infection should be treated + increase
the dose of Insulin by 10 – 15%.
• Sever infection necessitate hospitalization.
Management during Infection
• Do not shake the insulin as this damages the
• After first usage, an insulin vial should be
discarded after 3 months if kept at 2-8 C or 4
weeks if kept at room temperature.
• Intermediate-acting and short-acting/rapid-
acting insulin, can be combined in one
• Use 4mm needle for injection of Insulin SC.