A 4 years old boy presents with 2

months history of increased

frequency of urination.
On Specific inquiry, mother tells
he is also eating and drinking a
lot for the same duration.
On examination, no significant
abnormality was detected.
 Type 1 Diabetes Mellitus/Insulin
dependant Diabetes mellitus IDDM
Prof Dr Saima Batool
Professor of Paediatrics
UCMD
Learning objectives
Describe etiology of insulin dependent diabetes
mellitus (IDDM).
Describe clinical features of IDDM.
Interpret investigations of IDDM.
Describe steps of management of
IDDM.
Outline follow up steps for a patient having IDDM.
Etiology
T1DM is characterized by low or absent levels of
endogenously produced insulin and by dependence on
exogenous insulin to prevent development of
ketoacidosis.*

* Nelson text book of Pediatrics, 21st edition.

DIABETES MELLITUS
Type I
Type II
 Other types
genetic defects of beta cell function
genetic defects in insulin action
Pancreatic disorders
Drugs
Infections
Genetic syndromes
Types/causes of Type 1 DM(T1DM)
Down syndrome
Turner syndrome
Kline filter syndrome
Friedrich syndrome
Laurence-moon syndrome
Gestational Diabetes
Neonatal Diabetes
PATHOGENESIS
TYPE I Diabetes
 Insulin deficiency

TYPE 2 Diabetes
INSULIN RESISTANCE
Pathogenesis
NATURAL HISTORY
4 distinct stages:
(1)preclinical β-cell autoimmunity with progressive
defect of insulin secretion,
(2) onset of clinical diabetes,
(3) transient remission “honeymoon period,”
(4) established diabetes during which there may
occur acute and/or chronic complications and decreased
life expectancy.
A median age of 7-15 yr, but it may present at any age.
T1DM is characterized by autoimmune destruction of
pancreatic islet β cells.
Both genetic susceptibility and environmental factors
Autoantibodies to β-cell antigens such as islet cell
cytoplasm (ICA), insulin autoantibody (IAA),
antibodies to glutamic acid decarboxylase, and ICA512.
T1DM is associated with other autoimmune
diseases such as thyroiditis, celiac disease, and Addison
disease.
Drugs or chemicals, viruses, mitochondrial gene
defects,Pancreatectomy, and ionizing radiation.
ENVIRONMENTAL FACTORS
Viral Infections: Rubella, enteroviruses, Mumps.
Diet
WHAT ARE THE NORMAL
FUNCTIONS OF INSULIN

ANABOLIC / CATABOLIC
Diabetic Ketoacidosis
Interpret investigations
A baseline Hemoglobin A1c (HbA1c) will be
confirmatory.
Hyperglycemia, glycosuria, and ketonuria can be
determined quickly. Nonfasting blood glucose
greater than 200 mg/dL (11.1 mmol/L) with typical
symptoms is diagnostic with or without ketonuria.
DIABETES MELLITUS
FASTING BLOOD GLUCOSE
126MG/DL
7MMOL/L

BSR
>200MG/DL
PLUS SYMPTOMS OF DIABETES
IMPAIRED GLUCOSE TOLERANCE
FASTING GLUCOSE 100-125MG/DL
5.6-7MMOL/L

2HRS. BLOOD GLUCOSE 140-200MG/DL

>11.1 MMOL/L
Diabetic ketoacidosis
Diabetic ketoacidosis
 20-40 % in new onset diabetes
Blood glucose>250mg/dl
 PH<7.35
Plasma bicarbonate<15meq/l
KETONEMIA,KETONURIA
DIAGNOSIS
Symptoms + BSR>200mg/dl
Electrolytes
Urine for ketones ,Glucose
Acid base balance
Baseline Hemoglobin A1c
Assess for autoimmune diseases
Investigations in DKA
Serum Electrolytes.
Hyponatremia
Hypokalemia
Low chloride
Acid Base balance
Low bicarbonate level
Low pH
Blood examination:
Hemoglobin and hematocrit: raised in DKA
Leukocytosis in case of infection
Steps of management
Treatment
New onset diabetes with
out ketoacidosis
Asymptomatic
Prevent ketoacidosis
Balance of glucose content
Permit normal growth + development
Exogenous insulin
NO COMPLICATIONS
TYPES OF INSULIN
Regular insulin
NPH<Lente
Lispro(L)Aspart (A)
Glargine
Ultralente
TREATMENT REGIME
Regular insulin 1/3
NPH 2/3

2/3 of total dose before breakfast

1/3 before evening meal
DOSES TABLE
EDUCATION
MONITORING BLOOD GLUCOSE
 URINE GLUCOSE/ KETONES
STORING, PREPARING
,INJECTING INSULIN
DIET PLAN
RECOGNISING COMPLICATIONS
 NEW TREATMENT
Basal insulin,Glargine,24 hours
2 to 3 boluses before meals Lispro
Aspart
 Frequent monitoring
 Frequent hypoglycemia
Alternate regime
Insulin pump therapy
(CSII)
Inhaled
Oral insulin

Follow up steps