Diabetes Mellitus in Children

Jennie Santos, M.D. May 21, 2012

Objectives
To define Diabetes Mellitus and enumerate its different classifications for the pediatric population To describe the etiology, pathophysiology and clinical manifestations of the major classifications of Diabetes Mellitus To describe the laboratory work-up and management of Diabetes Mellitus To enumerate the different complications of Diabetes Mellitus

Diabetes Mellitus
Chronic, metabolic syndrome Hyperglycemia cardinal biochemical feature Heterogeneous group of disorders Incidence: (US) 1: 400 children and adolescents Incidence: (Type 1, Philippines) 0.41: 100,000

Diagnostic criteria
IMPAIRED GLUCOSE TOLERANCE (IGT) Fasting glucose 110125 mg/dL (6.1 7.0 mmol/L) DIABETES MELLITUS (DM) Symptoms of DM plus random plasma glucose 200 mg/dL (11.1 mmol/L) or

2-hr plasma glucose during the OGTT 140 mg/dl but <200 mg/dL (11.1 mmol/L)

Fasting plasma glucose 126 mg/dL (7.0 mmol/L)

or 2-hr plasma glucose during the OGTT 200 mg/dL

Etiologic Classification
Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Other specific types
Genetic defects of -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 Diabetes Mellitus Neonatal Diabetes Mellitus

Type 1 - Etiology
Genetic susceptibility
FOXP3 gene, AIRE gene Major histocompatibility complex (MHC) class II genes Insulin gene locus

Environmental factors
Viral infections Diet Psychological stress

Type 2 - Etiology
A polygenic disease aggravated by environmental factors Has a strong genetic component but genetic basis is complex and incompletely defined
TCF7L2 PPARG KCNJ11

Occurs more frequently in certain ethnic or racial groups

Pacific Islanders Pima Indians African Americans

Type 1 - Pathophysiology

Type 2 - Pathophysiology

Type 1 Clinical Manifestations

Polyuria, nocturia, polydipsia Hyperphagia Weight loss Recurrent infection Symptoms of ketoacid accumulation
Abdominal discomfort, nausea, vomiting

Symptoms of ketoacidosis
Dehydration, Kussmaul respiration, fruity breath odor, changes in sensorium

Type 2 Clinical manifestations

Asymptomatic Obese Mild polyuria and polydipsia Acanthosis nigricans, hypertension, PCOS Striae waist hip ratio

Type 1 Work-up
Blood glucose levels
Fasting: 126mg/dl Random: 200 mg/dl

Urinalysis: glucose, ketones, albumin HbA1c Lipid profile Work-up for Diabetic ketoacidosis: ABG, electrolytes Screening for complications

Testing for Type 2 DM in children

Type 2 Work-up
Blood glucose levels
Fasting: 126mg/dl Random: 200

HbA1c Urinalysis Lipid profile Screening for complications

Goals of treatment
Maintain a balance between tight glucose control and avoiding hypoglycemia To eliminate polyuria and nocturia To prevent ketoacidosis To permit normal growth and development with minimal effect on lifestyle

Type 1 - Management
Subcutaneous Insulin

Type 1 - Management

Type 1 - Management
Other routes of insulin
Insulin pump therapy Oral and inhaled insulin

Non pharmacologic management

Education Nutrition Monitoring Exercise

Type 2 - Management
Glucosidase inhibitors

Glitinides SU Thiazolinediones Biguanides

Biguanides Thiazolinediones

Biguanides Thiazolinediones

Type 1 - Complications

Type 2 - Complications