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DIABETES MELITUS

TYPE I
Dr. H. Hakimi Sp.A.K
Dr. H Charles Darwin Siregar Sp.A
Dr. Melda Deliana Sp.A.K
Dr. Siska Mayasari Lubis, SpA
PEDIATRIC ENDOCRINOLOGY
MEDICAL SCHOOL USU/H. Adam Malik
HOSPITAL
Medan

Introduction
• Chronic disease
• Difficult to cure
• Major DM group in children.

DM Classification based on
etiology (ADA,1998)
1. DM type I ( B cell destruction) :
a. immune mediated
b. idiopathic
2. DM type II (insulin resistant)
3. DM other type
a. genetic defect of B cell function
b. genetic defect of insulin function
c. pancreas exocrine disease
d. endocrinopathy
e. drug and chemical substance induction
f. Infection
g. uncommon immune mediated DM
h. Genetic syndrome related to DM
4. DM gestasional

characterised by chronic hyperglicemy • Caused by autoimunne process which destroy pancreas B cell insulin production decrease or stopped .Definition • Systemic disorder because glucose metabolism disorder.

BW15.DR3.Patogenese Addison disease Tirodiditis hashimoto Anemia pernisiosa Viral infection HLA B8.DR4 activation autoantibody process langerhans islets destruction Pancreas B cell function failure Insulin secretion decrease or stop DM type I Chemical exposure .

blood glucose ad random >200mg/dl – Asymptomatic : blood glucose ad random >200mg/dl .diagnostic criteria • Normal blood glucose : <126 mg/dl ( 7 mmol/L) • Diagnose is determined if one of this criteria fulfilled : – Polyuria . polyphagy. polydipsy. decrease weight .

75 gr/W in 200-250 cc water in 5 minutes • GTT result intepretation : – DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200 mg /dl – Impaired Glucose tolerance : fasting blood glucose <140 mg/dl or at 2nd hour : 140 – 199 mg/dl – Normal : fasting blood glucose < 110 mg/dl or at 2nd hour : < 140 mg/dl .Glucose tolerance test (GTT) • GTT is not nesecary if distinguished symptoms are found • Indication : GTT in doubtful case • glucose dose : 1.

etc .000 foo age < 5 yrs old • Peak incidence : – Age 5 – 6 yrs old – 11 yrs old • New cases >50% : >20 yrs old • Genetic and environment factors : HLA pattern. virus. toxin. lowest in Japan 2/ 100.Epidemology • Incidence is higher in Caucasian • Highest in Finland 43/100.000 .

hyperglycemy • Delayed diagnose : ketoacidosis with all the consequences .Clinical appearance • Acute • Polyuria. rapid weight decrease. polydypsy.

Enjoy social life 2. Able to manage disease independently .DM type I management • • Good metabolic control with normal blood glucose level Unified team Objective Spesific objective 1. optimal growth 2. Free from symptoms 1. Good metabolic control without causing hypoglycemy 4. Prevent complications 3. Patient doesn’t manipulate disease 6. normal emosional development 3. Few school absence days and active in school 5.

and drug distribution • Important to know : – somogyi effect – dawn effect – Morning hyperglycemy . culture. social economic.Insulin • Earlier : pig/cow pancreatic gland purification • Recombinant technology : human insulin • Usage based on age .

and in surgery or combination with medium acting insulin – For toddler : prevent hypoglycemy .Insulin • Ultra short acting insulin ( lispro ) – Give 15 min before meal – Useful in sick day management and before meal injection • Short acting insulin – For acute stage : ketoacidosis. new patient. injection before meal.

Insulin • Medium acting Insulin – Used twice daily for patient with same daily routine pattern – Widely used in children • Mix Insulin – Standard mixture ( short+medium acting insulin) – Good metabolic control – For young age child with low education parent .

25 1 4 short acting 0.Insulin • Insulin pen • Mixing insulin • Storage : temp 4 – 8 oC not in freezer Type onset (hour) peak(hour) duration(hour) Ultra short acting 0.5 –1 2-4 5-8 Medium acting 1-2 4-12 8-24 Long acting 2 6-20 18-36 .

surgery . sick days. adolescent.Insulin Regiment • • • • • Insulin usage principal Depend on Indonesia situation and condition Use glucometer and routine daily home testing Objective parameter : Serum HbA1c / 3 months Insulin dose adjustment : – For metabolic control – Honeymoon period.

Insulin Injection • Injection technique : subcutaneous with pinchet • Self injection • Local reaction : rare .

protein 25%.Meal adjustment • Objective : achieve good metabolic control without ignoring calory requirement • Total calory : 1000 + (age(year)x100) calory per day • Carbohydrate 60 – 65% . lipid <30% .

Metabolic Control Metabolic Target(mg/dl) Excellent good moderate poor Preprandial <120 <140 <180 >180 Postprandial <140 <200 <240 >240 Urine reduction - - +-+ >+ HbA1c <7% 7-7.9% 8-9% >10% .

Management • Management when diagnosed – Insulin : start 0.5 U/kg/day. gradually adjust – education • ketoacidosis management – – – – Insulin Fluid elektrolite balance Acid base balance • Management while surgery • Management while Ramadhan fasting • Complication .

tired. affective disorder l Adrenergic (depression. visual disturbance Sweating. sleepy. pale. anxious . tachycardy. headache.Complication • Short term complication : hypoglicemy. ketoacidosis • Hypoglycemy : blood glucose < 50 mg/dL neurogenic symptoms neuroglycopeny Cholinergic weak.angry). Palpitation.hungry. coma. convulsion Tremor.numb dizziness.

Long term complication • Retinopathy • Nefropathy • Growth & development disorder .

Hypoglycemy • Prevention – Regular insulin management – Regular food intake – Parent supervision and education • Therapy – Mild/moderate hypoglycemy • Give 10 – 20 gr of carbohydrate followed by snack • Lemonade honey glucose tablet can be used – Severe hypoglycemy • Unconscious / convulsion • Oral medication is rarely used shile unconscious • Parent education  inject glucagon 0.5 mg or 1 mg for child > 5 yrs old .

Education • Objective – – – – – – Understand the disease Motivation Type 1 DM management skill Positive attitude Good metabolic control Logic decision of daily management • First education --> at hospital • Continous education : – Camp – School • Advice on : – Long journey – Alkoholic and smoker .

Growth and diabetes • Monitor: – Body height/3 months – Body weight – Physical and mental development .

Psychosocial aspects • Family education • Parent training on DM care • Advice parent not to give excessive protection .

Body weight measurement (kg) 2. bolus if orthostatic or shock occurs 5.Administration of normal saline (0.Calculate total fluid given within 48 hours .Ketoacidosis Protocol 1.Calculation of free water deficit 4.Calculate excess of water deficit after the third bolus 6.9NS).Calculate maintainance fluid requiremmnt for the next 48 hours 7.Dehidration therapy decision 3.

45NS . Calculate the value of fluid exchange per hour divided by the value on number 7 per 48 hour 9.Sodium -patient with Na>145mmol/L: 0.1 unit/BW/hour 10.Ketoacidosis Protocol 8. Make and start regular insulin drip at 0.9NS -patient with Na<145mmol/L:0.Determine fluid type which is used as substitute : .Perform fluid exchange at insulin drip at substract of number 9 from 8 11.

Patient with BG>15mmol/L: don’t give dextrose . .5% dextrose .Patient with BG<15mmol/L: give 5-12.Ketoacidosis Protocol -Potassium -Urine (-) : don’t give K+ -Urine (+) : add KCL20-40mmol/L -Give K+ as half Chloride/half phophate at first 8 hour -Dextrose .Try to maintain BG 10-15mmol/l without adding isulin dose.

mildly hyperventilate. Severe headache.Ketoacidosis Protocol -Bicarbonate : NaHCO3 is not advised 12. bradicardy. consciousness or blood pressure changes.Observe neurological signs to see whether cerebral oedem exists. give mannitol 1 gr/kgBB/iv bolus) . postural signs and incontinence  Perform rapid intervention (intubate. Start fluid replacement therapy as mention on umber 11 with the value in number 10 13. dilated pupil.

antisipate the change of K. capillary pH value/ 2 – 4 hrs -Follow Ca and P value if phosphate is given -Re. whether the child response ? -Follow Na.check urine glucose and ketone 15. Re.evaluate every fluid change . dextrose.HCO3.Cl.K.Ketoacidosis Protocol 14. etc value . Follow laboratorium value: -Follow BG/ 30-60 mnt.