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Management of

Type 1 Diabetes Mellitus


Laksmi Sasiarini
Divisi Endokrin Metabolik
FK UB RSU dr. Saiful Anwar
Malang
2011

Etiologic Classification of DM
Type 1

B cell destruction, usually leading to absolute insulin deficiency


Immune -mediated
Idiopathic

Type 2

May range from predominantly insulin resistance with relative


insulin deficiency to a predominantly secretory defect with insulin
resistance

Other spesific
types

Genetic defects of B cell function


Genetic defects in insulin action
Diseases of the exocrine pancreas
Endocrinopathies
Drug- or chemical-induced
Infections
Uncommon forms of immune-mediated diabetes
Other genetic syndromes sometimes associated with diabetes

Gestational DM (GDM)

FIGURE 2.4

Estimated number of prevalent cases of type 1 diabetes in children,


0-14 years, by region, 2010

MAP 2.4

New cases of type 1 diabetes in children, 0-14 years (cases per


100,000 aged 0-14 years per year), 2010

Patophysiology
Immune-mediated in more than 90% of cases and
idiopathic in less than 10% prevalence is increased in
pts with other autoimmune diseases (Graves disease,
Hashimoto thyroiditid, Addisons disease).

Most patients with type 1 diabetes at diagnosis have


circulating antibodies:
islet cell antibody (ICA),
insulin autoantibody (IAA),
antibody to glutamic acid decarboxylase (GAD) 65, and
antibody to tyrosine phosphatases (IA-2 and IA2-).

Diagnosis
Peak incidence before school age and again at around
puberty.

Most pts with type 1 DM present with a several-week


history of polyuria, polydipsia, polyphagia, and weight
loss, with hyperglycemia, glycosuria, ketonemia, and
ketonuria.
Approxiamtely 30% of children who present with newly
diagnosed type 1 DM are ill with diabetic ketoasidosis
(DKA).

The criteria diagnosis of DM :


1)

Symptoms of diabetes (thirst, increased urination,


unexplained weight loss) plus a random plasma glucose
concentration greater than 200 mg/dL (11.1 mmol/L).
(2) Fasting plasma glucose greater than 126mg/dL (7.0
mmol/L) after an overnight (at least 8-hour) fast
(3) Two-hour plasma glucose greater than 200 mg/dL
(11.1mmol/L) during a standard 75-g oral glucose tolerance
test

In the asymptomatic child/adolescent who is screened because of high


risk for diabetes, blood glucose examination should be repeated on a
second day to confirm the diagnosis.

Whats the differentiation between type 1 and


type 2 diabetes management ??

The management of diabetes in children must take the


major differences between children of various ages and
adults into account :
education component (intense and complex)
diabetes
care
(glycemic
control,
insulin
management, blood glucose monitoring, nutrition,
exercise)
the consequences of hypoglycemic events
risks for diabetic complications

Diabetes
Education

Ideally, the education should be provided by a team of


certified professionals (physician, nurse, dietitian, and
mental health professional) is dedicated to
communicating basic diabetes management skills within
a context that addresses family dynamics and issues
facing the whole family.
Education is best provided with sensitivity to the age and
developmental stage of the child, both with regard to the
educational approach and content of the material
delivered.

IDENTIFICATION
Children with diabetes should wear ID indicating that
they have diabetes.

DIABETES CARE

Glycemic control
Insulin management
Blood glucose monitoring
Medical nutrition therapy
Exercise

GLYCEMIC CONTROL

(ADA, 2005)

INSULIN
MANAGEMENT

Theres no one established formula for determining a


childs insulin requirement usually based on body
weight, age, and pubertal status.
Newly diagnoses type 1 DM :
initial total daily dose ~ 0.5 1.0 units/kg.
Insulin requirements increase with growth and, in
particular, during puberty (due to hormonal influences).
Children with diabetes often require multiple daily
injections of insulin (basal bolus regimen).

Honeymoon phase
Increase insulin production within several weeks after
the initiation of insulin therapy insulin requirements
may fall below the initial dose.
cell destruction continues during this phase
progressive loss of cell .

BLOOD GLUCOSE
MONITORING

Use glucose levels to make insulin dose adjustments


acutely for rapid- or short-acting insulins and after
observing patterns over several days to adjust doses of
long-acting insulins.

Use insulin-to-carbohydrates ratios and correction doses


for high and low blood glucose levels.

Test at least 4x a day.


Periodically test postpandrials, before- and after-exercise,
and nocturnal glucose levels.

Medical Nutrition
Therapy

Consultation with a dietitian to develop/discuss the


medical nutrition plan is encouraged.
Evaluate height, weight, BMI, and nutrition plan annually
(at least every year).

Meal plans must be individualized to accommodate food


preferences, cultural influences, physical activity
patterns, and family eating patterns and schedules.
Calories should be adequate for growth and restricted if
child becomes overweight.

EXERCISE

Children and adolescents with type 1diabetes should


adhere for a min. of 3060 min of moderate physical
activity daily.

Blood glucose monitoring


before exercise is recommended.

For prolonged vigorous exercise, hourly BG monitoring


during the exercise, as well as BG monitoring after
completion of exercise, is recommended to guide
carbohydrate intake and prospective insulin dose
adjustment for recurring exercise events.

At the onset of a new sports season, frequent blood


glucose monitoring during the 12-h post exercise period
should be undertaken to guide insulin dose adjustments.

In
the
child
or
adolescent
(particularly
if
overweight/obese), physical exercise should be
encouraged and sedentary activity discouraged.

Acute Complications
Growth assessment
Diabetic Ketoacidosis (DKA)
Hypoglycemia

Diabetic Ketoacidosis
Consequence of absolute or relative insulin deficiency
resulting in hyperglycemia and accumulation of ketone
bodies in the blood, with subsequent metabolic acidosis.
DKA at diagnosis
DKA after diagnosis
the most common cause is omitted insulin injection
(emotional stress).
Recurrent DKA
Almost always due to insulin omission (higher
incidence of psychiatric illness, miss insulin doses)

Hypoglycemia
Frequency of hypoglycemia should be determined at
every visit.
Presence of hypoglycemia unawareness should be
assessed at every visit.
If hypoglycemia unawareness is present or if
symptomatic hypoglycemia is frequent, blood glucose
targets should be reassessed.
Severe hypoglycemia in children 5 years of age may be
associated with cognitive deficits; thus, blood glucose
goals are higher for this age-group.

Recognition of hypoglycemia symptomatology is


developmental and age-dependent; the limitations of
infants and toddlers to detect such symptoms may
influence treatment goals and monitoring frequency.

Treatment of hypoglycemia requires the administration of


rapidly absorbed glucose, glucagon, and intravenous
glucose with treatment based on the severity of the
hypoglycemia

Summary
The diagnosis of type 1 diabetes in children is usually
straight forward and requires no specialized testing.

Ideally, every child newly diagnosed with type 1 diabetes


should be evaluated by a diabetes team qualifed to
provide up to date pediatric-spesific education and
support.
Education is best provided with sensitivity to age and
developmental stage of the child.

Summary
The ideal goal of near-normalization of blood glucose
levels is generally the same as that for adults, however,
special considerations must be given to the risk of
hypoglycemia.

Insulin requirements are usually based on body weight,


age, and pubertal status (using multiple daily injection
regimen or an insulin pump).
Evaluate height, weight, BMI, and nutrition plan annually.

Summary
In the child or adolescent, physical exercise should be
encouraged and sedentary activity discouraged.

Blood glucose
recommended.

monitoring

before

exercise

is