Diabetes and Insulin Function Quiz

Diabetes Mellitus in Children

• A chronic metabolic disorder characterized by hyperglycemia
• Caused by insulin deficiency or impaired insulin action
• Affects carbohydrate, protein, and fat metabolism
• Often presents in two age groups: 5-7 years (potentially infectious) and during puberty (10-14 years)
• Girls and boys are affected equally
• No correlation with socioeconomic status
• Incidence rates vary significantly by region and country (see next section for specific examples)

Definition

• Hyperglycemia is a defining biochemical feature
• Results from abnormal carbohydrate, protein, and fat metabolism
• Can be an autoimmune disorder, potentially genetically predisposed or triggered by external factors

Epidemiology

• Peaks of presentation occur in two age groups: 5-7 years and during puberty
• Girls and boys are roughly equally affected
• No clear socioeconomic correlation

Incidence Rates

• Incidence rates of Type 1 diabetes vary significantly by region and country. Specific rates for various regions and countries are shown on corresponding slides.

Diagnosis of Diabetes

• Diagnosis is determined by positive symptoms plus any of the following:
  • Random blood glucose (BGL) ≥ 11.1 mmol/L (≥200 mg/dl)
  • Fasting BGL ≥ 7 mmol/L (≥126 mg/dl)
  • Oral glucose tolerance test (OGTT)
  • Hemoglobin A1c (HbA1c) < 7.5% (58 mmol/mol)
• Ketones testing (urine strips/blood) if DKA is suspected

Etiologic Classifications of Diabetes Mellitus

• Type 1: Beta cell destruction, usually leading to absolute insulin deficiency (immune mediated or idiopathic)
• Type 2: May range from predominantly insulin resistance to predominantly secretory defect with insulin resistance
• Other specific types: Genetic defects of beta-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

Physiology of Insulin

• Insulin's primary functions:
  • Reduce glucose levels (through inhibiting gluconeogenesis and glycogenolysis, while increasing glucose uptake by cells)
  • Inhibit fat breakdown (lipolysis)
  • Inhibit protein breakdown (proteolysis)

Insulin Deficiency and its Effects

• Leads to:
  • Hyperglycemia
  • Polyuria (excess urination)
  • Polydipsia (excess thirst)
  • Polyphagia (excess hunger)
  • Weight loss
  • Ketoacidosis (presence of ketones in blood)

Presentation

• Non-specific symptoms common
• Polyuria, polydipsia, polyphagia, and weight loss
• Recurrent infections (skin or UTI)
• Diabetic ketoacidosis (DKA) in some cases

Investigations

• Blood Glucose: Fasting glucose > 126 mg/dl and Random > 200 mg/dl needed for diagnosis
• HbA1c (glycated hemoglobin): Measures average glucose levels over 2-3 months
• Ketone testing (urine/blood): Crucial when DKA is a concern
• Urine testing: Glucosuria (presence of glucose in the urine) and ketonuria (presence of ketones) if DKA is suspected.

Management

• Needs a team approach (medical specialists, specialist nurses, dietitian, psychologist)
• Special diabetic clinic is necessary for some patients
• Insulin and related supplies are necessary
• Continuous monitoring of blood glucose and ketones
• Regular follow up visits, including specific monitoring for complications (such as height, weight, injection sites, annually, thyroid disease, coeliac disease, Diabetic foot,regular dental and eye examinations, blood pressure, retinopathy, microalbuminuria & S.Creatinine from age 12. HbA1c every 3 months )

Treatment (Insulin)

• Crucial for managing blood glucose levels
• Various types of insulin with varying onset, peak times, and durations (see types of insulin for specific details.

Treatment(Diet)

• A normal diet with healthy proportions of carbohydrates (CHO), fat and protein is required.
• Three meals a day with two snacks in between.

Treatment(Exercise)

• Regular exercise can improve glucoregulation and increase insulin receptor numbers
• Competitive sports should be avoided until metabolic control improves
• Vigorous exercise in poorly controlled patients may lead to ketoacidosis
• Hypoglycemic reactions may occur

Patient Education

• Crucial for understanding and managing diabetes, using patient-centered/family-driven educational resources

Family Education

• Important to educate families about diabetes management

Dietary Education

• Importance of carbohydrate and insulin monitoring through a diary. Specific examples are provided on several slides.

Screening for Complications

• Regular monitoring of height, weight, and injection sites
• Annual screening for thyroid disease and celiac disease
• Regular foot care reviews, dental and eye exams are necessary (blood pressure, diabetic foot, retinopathy, microalbuminuria, S.Creatinine from age 12)
• HbA1c every 3 months

Special Considerations

• Partial remission/honeymoon phase in type 1 diabetes (this phase may occur following initiation of treatment and lasts for a limited time)
• Somogyi phenomena (hypoglycemia at night, triggering a counter-regulatory response, causing early-morning hyperglycemia)
• Dawn phenomena (early morning hyperglycemia)
• Management during infection, including dose adjustments as needed.

Partial Remission/Honeymoon Phase

• Transient decrease in insulin requirements after treatment initiation.
• Less than 0.5 units/kg/day insulin requirement and HbA1c<7%.
• Ketoacidosis reduces likelihood of the remission phase. A transient phase. Important to avoid false hope.

Somogyi Phenomenon

• High dose of insulin at night leads to late-night hypoglycemia, triggering a counter-regulatory response, causing early-morning hyperglycemia
• Treatment: Reduce dose of long-acting insulin at night.

Dawn Phenomenon

• Counter-regulatory hormones lead to early morning hyperglycemia even with a normal dose of night-time insulin.
• Treatment: Increase the dose of long-acting insulin at night.

Management During Infection

• Infections can cause a rise in blood sugars. Mild cases call for a small increase in insulin dose (10-15%). Severe infections necessitate hospitalization. Adjustments need to be individualized.

Important Information

• Do not shake insulin vials (shaking causes damage)
• Discard insulin vials after 3 months (if refrigerated) or 4 weeks (if kept at room temperature) if needed
• Combine intermediate-acting and short-acting/rapid-acting insulin in one syringe.
• 4mm needle for SC insulin injections (safe practices during insulin injection)

Nurse Advice/Education

• Giving advice and education to patients and their families on practical aspects of diabetes

Psychological Support & Education

• Important for patients and their families to understand and navigate the emotional aspects of having diabetes.

Types of Presentations

• DKA at new diagnosis (the most standard diagnosis)
• Only hyperglycemia at new diagnosis
• DKA if patient in current insulin therapy
• Presence of ketonemia (some level of blood ketone)
• Only Hyperglycemia in current insulin therapy (not adequately managed)