Diabetes Mellitus PDF

Family guidance during adolescence 1- accept adolescence as human being 2- respect adolescence ideas like & dislike 3- allow increasing independence within safety limitation 4- respect adolescence privacy 5- be available to answer question, give information and provide clear communication...

Family guidance during adolescence 1- accept adolescence as human being 2- respect adolescence ideas like & dislike 3- allow increasing independence within safety limitation 4- respect adolescence privacy 5- be available to answer question, give information and provide clear communication 220  Definition Diabetes mellitus (DM) is an autoimmune disease which result in chronic metabolic disorder caused by an absolute or relative deficiency of insulin manifested by abnormal metabolism of CHO, protein and fat. It is the most common endocrine metabolic disease of childhood and adolescents.  Incidence of IDDM Affect approximately 1 in 500 children and adolescents. Insulin is produced by the beta cells of the islets of Langerhans located in the pancreas. The absence, destruction, or other loss of these cells results in type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). Etiology Most cases (95%) of type 1 diabetes mellitus are the result of 1-environmental factors (viral mumps, chickenpox, cytomegalovirus, hepatitis, congenital rubella or bacterial infection) however the injury of the B-cells, occurs only in susceptible individuals. interacting with a 2- genetic susceptibility person (increased with father's and increased risk with both parents). 221  3- Psychological upset This interaction leads to the development of autoimmune disease directed at the insulin-producing cells of the pancreatic islets of Langerhans. These cells are progressively destroyed, with insulin deficiency usually developing after the destruction of 90% of islet cells. Pathophysiology Insulin is essential to process carbohydrates, fat, and protein.  Insulin reduces blood glucose levels by allowing glucose to enter cells and by stimulating the conversion of glucose to glycogen as a carbohydrate store.  Insulin also inhibits the release of stored glucose from liver glycogen and slows the breakdown of fat to triglycerides, free fatty acids, and ketones. It also stimulates fat storage.  Additionally, insulin inhibits the breakdown of protein and fat for glucose production in both liver and kidneys. 222 223  Hyperglycemia Causes  Infections  Insulin under dosage in a diabetic child  Other factors as trauma or psychological disturbance. Pathophysiology of Hyperglycemia  Hyperglycemia insulin  glucose level in the blood leads to:- 1- breakdown of protein and fat 2- prevents the use and storage of circulating glucose.  The kidneys cannot reabsorb the excess glucose load above renal threshold (180ml/dl) osmotic diuresis glycosuria, polyuria, and dehydration & compensatory thirst (polydipsia).  Proteolysis protein breakdown leads to polyphagia, abdominal pain, vomiting, and weight loss.  ↑Lipolysis Increased fat breakdown leads to ketone bodies ketoacidosis and ketonuria production from free fatty acids  Glucose is the soul energy source for erythrocytes, kidney, and the brain. 224  Symptoms Hyperglycemia  Glycosuria: polyuria, nocturia and often leads to enuresis, polydipsia, dehydration.  Weight loss, although the child's appetite usually remains good.  Symptoms of ketoacidosis due to the excess formation of ketone bodies  Severe dehydration  Smell of ketones  metabolic acidosis.  Abdominal pain, Vomiting  Drowsiness and coma  Other nonspecific findings  Hyperglycemia impairs immunity and renders a child more susceptible to recurrent infection, particularly of the urinary tract, skin, and respiratory tract.  Candidiasis may develop, especially in groin and genital areas. 225  Investigations  Fasting blood glucose > 126 mg/ dl.  Two post prandial >200 mg/dl  Urine glucose  Urine ketones  Random blood glucose level above 200mg/dl (in two different occasions when child free from infection or stress &is not fasting). And has classical symptoms 226   Glycosylated hemoglobin haemoglobin A1c (the result of a nonenzymatic reaction between glucose and hemoglobin.) measured primarily to identify the average plasma glucose concentration over prolonged periods of time 3 mon.  Renal function tests: If the child is otherwise healthy, renal function tests are typically not required. Oral glucose tolerance test (OGTT) unnecessary in diagnosing type 1 diabetes mellitus, Obtain a fasting blood sugar level, then administer an oral glucose load (2 g/kg for children aged 10 y). Check the blood glucose concentration again after 2 hours.  A fasting whole-blood glucose level higher than 120 mg/dL or a 2- hour value higher than 200 mg/dL) indicates diabetes. However, mild elevations may not indicate diabetes when the patient has no symptoms and no diabetes-related antibodies.  Lipid profile Lipid profiles are usually abnormal at diagnosis because of increased circulating triglycerides 227  Complications Long-term complications include the following: 1. Retinopathy 2. Cataracts 3. Hypertension 4. Progressive renal failure 5. Early coronary artery disease 6. Peripheral vascular disease 7. Neuropathy, both peripheral and autonomic 8. Increased risk of infection. Management includes four aspects 1. Nutritional therapy 2. Insulin therapy 3. Exercise adjustment 4. Psychological aspects Nutritional therapy  healthy, balanced diet, high in carbohydrates and fiber and low in fat.  The following are the most recent recommendations:  Carbohydrates should provide 55- 60% of daily energy intake  Fat should provide 25% of daily energy intake.  Protein should provide15-20% of daily energy intake. ( three main meals and three snack) Breakfast ---- snack---- lunch------ snack-----dinner-----snack (if blood glucose less than 160) Decrease cholesterol (fat, eggs yolk-only 4eggs/ week) 228 The aim of dietary management is 1- help children have overall good health, normal growth, and a healthy weight. 2- balance the child's food intake with insulin dose and activity and to keep blood glucose concentrations as close as possible to reference ranges, avoiding extremes of hyperglycemia and hypoglycemia. There is no single right amount of carbohydrates that child should eat. The recommended carb. intake is different for each child and can even differ in the same child from day to day. Adequate intake of complex carbohydrates (eg, cereals) is important before bedtime to avoid nocturnal hypoglycemia. 229  Encourage your child to eat lots of green and orange vegetables every day - like carrots and broccoli. And choose vitamin-rich brown rice or sweet potatoes instead of white rice or regular potatoes.  Also look at the sodium (salt) content on food labels. Eating too much sodium is linked to high blood pressure (hypertension). Some kids with diabetes have hypertension  pay attention to the amount of fat and the type of fat. Saturated fats, cholesterol, and trans fats can contribute to the development of heart disease. Children with diabetes are at greater risk for heart disease.  Protein doesn't affect blood glucose unless you eat more than your body needs.  After a high-fat meal, your child's blood glucose may be elevated up to 12 hours after the meal.  Carbs usually enter the blood stream an hour after consumption and are usually out of the blood stream in 2 hours. That's why you should check your child's blood glucose levels before he or she eats, and then again 2 hours later. Insulin therapy  Insulin has 3 basic formulations: short-acting (eg, regular, soluble, lispro, aspart, glulisine), medium-acting or intermediate-acting (eg, isophane, lente, detemir), and long-acting (eg, ultralente, glargine).  Combinations are also available in a variety of concentrations that vary around the world, ranging from 10/90 mixtures (ie, 10% regular, 90% isophane) to 50/50 mixtures. 230   Rate of absorption (hot, massage, exercise, depth of injection, site abdomen rapid than arm & thigh). Exercise  Diabetic pt., can participate in daily physical activity  Effect of exercise on pt.,  1- improvement G&D  2- improvement glucose metabolism  3- mental & cardiovascular function  Complication :- hypoglycemia (during or within hours after exercise)  Guide line Daily with same intensity each time – Avoid exercise in extreme heat, or poor control of bl., glucose (300 or more). If hypoglycemia S&S start, stop exercise, eat CHO, rest for 15 min. continue or not exercise. 231  Psychological aspects:  Inform parents about the disease  Allow parent to express felling  Treat the child as normal not allow him to use his disease  Encourage him to maintain normal activity  Emphasize that daily management as a routine  Help him to be independent as possible School - Inform teacher & his colleagues, school nurse to help him in such emergency - Participate in school activities - Achievement is normal (school) 232  Infection  Frequent skin care, good observation  If wound clean with water then put antiseptic solution, avoid use sticky adhesive tapes which damage skin.  Foot care :- clean daily, cut toes nail with clipper, straight line, change stocks  Stocking must be made of cotton, suitable size, avoid tight elastic that may reduce circulation.  Shoes : keep space in front big toe and should be closed from all sides  Wear suitable clothes, away from infected person  Regular dental care and check up Crisis management  Hypoglycemia:- occur suddenly or over min. Most common, if child age under 9 years --- bl.Glu. Less than 40 and Child age 9 years ---- 50 Degree: Mild------ 40-50 Moderate ---- 20-40 Severe ------ less than 20 if bl. Glu. Reach zero child will died Causes  Delay of eating, omission of food, loss (vomiting – diarrhea) Little food, after exercise. S&S Hunger, lethargy, irritable, confusion, sweating, tachycardia, pallor. 233 Treatment Mild  give food or sweet Moderate  3teaspoon sugar & cup of water recovery after few minutes. Severe  hospitalization to justify it If frequent hypoglycemia  CNS damage  epilepsy or learning difficulties Diabetic Ketoacidosis ( diabetic coma)  Lead to morbidity and mortality  Causes : infection, omission of insulin, emotional stress  S&S :- it takes hours or days, to start thirst, stomach up set, large volume of urine, loss of wt., abdominal pain, dehydration, rapid breathing, disorientation of coma.  If no treatment --- death 234  Accident Prevention Introduction is a third on the list of causes of child mortality - It's happening by chance. Definition of accident happening or a event that not expected and thus not controllable Injury wrongful or unjust happening that cause physical harm or damage and preventable and controllable. Incidence and causes There are different factors which increase the incidence of injuries in children which are:- a- factors related to child b- factors related to mother c- factors related to environment Age:- toddler & preschool. Factors related to child :-  want to explore ( curiosity).  has no experience.  short memory span.  poor attention and concentration 235   lack of self control  careless in play  imitation of behavior of adult people. Factors related to mother not able to observe the child during all the day. - careless Factors related to environment:- Furniture arrangement ( crowded, place, sharp edged equipment) Accident comprise – Unsafe Acts and/or Unsafe Conditions Unsafe Conditions Unsafe acts  Fire hazards, excessive  Using equipment in the wrong amounts of flammable way or for the wrong task materials  Failure to wear protective  Defective tools or equipment equipment  Horseplay Inadequate housekeeping, Failure to warn others of danger walkways blocked, materials incorrectly stored Accident Prevention – What can you do? Do not cut corners, always use the correct equipment for the task Think of others, be observant Make sure you fully understand any instructions, if in doubt ASK NEVER ignore safety instructions REMEMBER ACCIDENTS ARE PREVENTABLE 236 1-FALL Cause:  Unstable gait of the toddler ( bad coordination).  Presence of objects on floor or / and wet of floor.  Lack of supervision,  Curiosity of the children,  Badly designed house as poor lighting. 237  Prevention:-  Keep floors free of toys, obstacles and keep floor dry.  Close supervision when toddler learns to walk.  Never leave babies unattended on raised surfaces.  Always ensure bed-rail of the baby cot is raised.  Avoid placing “step-stones” such as a chair next to a window. First Aid:  Don’t panic. Call for help if necessary.  Check the level of consciousness of the infant/child.  Examine the child if airway is clear (e.g. can talk, cry or not); if breathing is adequate and circulation is normal (observe colour of the face, depth and rate of breathing).  If breathing and circulation are normal, check for any other injuries on the body.  If bleeding occurs, ensure there is no foreign body in the wound. Apply direct pressure to stop bleeding by covering a clean gauze on it and add pressure on the gauze by your hand. Elevate the injured limb.  If deformity is seen on the injured part, do not move it and call for help immediately. 238  2- CHOKING ( aspiration of foreign bodies) Cause: Accidental swallowing of foreign body, child can aspirate any fine particle however it will be:-  Metal  safety pins  Plastic leads  Foods finger foods carrots- small dry seeds (popcorn- peanuts).  The object may be lodged in trachea or bronchi. - larynx severe dyspnea. - bronchus complete obstruction. Prevention:  Choose toys appropriate to the age of children. Avoid toys with detachable small parts.  Ensure small objects are kept out of reach of children.  Pull cords on curtains and blinds should be kept short and out of reach of children.  Strings and plastic bags should be kept out of reach of children.  Instruct children not to play while eating.  Never let children use milk bottle by themselves without adult’s supervision.  Never use pillow for baby under one year of age.  Never leave children alone in a bath tub or basin filled with water. 239  First Aid:  Do not panic. Remove the cause from the patient.  Call for help immediately.  Perform CPR if necessary.  Removal by direct laryngoscope or bronchoscope.  The main treatment is prevention. 3- BURN/SCALD Cause: Scald by hot water, burn by fire, touch on hot objects such as cooking utensils, iron. Prevention:  For adults, never hold a hot drink/food and a child at the same time.  Ensure milk or other foodstuff is at a reasonable temperature before feeding.  Ensure proper fence or door is installed at the entrance of kitchen. Such must be closed at all times. Instruct children not to go into kitchen.  While cooking, pay extra attention to the stove fire and the cooking utensil. Turn the pan handle away from the front, and close to the wall.  When running a bath for a child, always test water temperature beforehand.  All hot objects including an iron or containers with hot matter must not be placed near the margin of a table. 240   Avoid using tablecloth. Matches and lighters should be placed out of reach of children.  Instruct children not to wander around when adults are preparing for a meal.  Warn children never play with fire. 4 POISONING Cause:- Mother  busy Medication Material that make the work at home easier ‫( المنظفات‬careless storage) Food poisoning, accidental swallowing of drugs, detergents‫ المنظفات‬, insecticides, etc. Prevention:  Keep medicines and chemicals out of sight and reach of children, preferably in an isolated, locked cabinet‫خزانة‬.  Always store chemicals in their original containers with appropriate labels.  Never tell children drugs are “sweets” as this may give a wrong idea to children.  Ensure toys and dining utensils bought meet the international standard, e.g. coloring materials being non-toxic.  Discard of unused drugs  Never put any product not intended for eating or for drinking in food or leverage container (corrosive). 241