UCD Teaching September 2024.pdf

DIABETES MELLITUS IN CHILDREN Dympna Devenney UCD September 2024 Overview  Definitions  Diagnostic criteria and classification  Aims of management  DCCT  Blood glucose monitoring and technology  Insulin treatment and regimens  Difficulties Definitions  Dia...

DIABETES MELLITUS IN CHILDREN Dympna Devenney UCD September 2024 Overview  Definitions  Diagnostic criteria and classification  Aims of management  DCCT  Blood glucose monitoring and technology  Insulin treatment and regimens  Difficulties Definitions  Diabetes Mellitus is a metabolic disorder of multiply aetiologies characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, action or both  Type 1 diabetes is a chronic auto immune disease in the vast majority and accounts for over 90% of childhood and adolescent diabetes  T cell mediated destruction of the pancreatic beta cells leads to insulin deficiency (WHO 1999) Diagnostic Criteria  Blood glucose measurements AND presence or absence of symptoms  The characteristic signs and symptoms are present  Fasting venous plasma glucose concentrations greater than 7mmols/L AND / OR a random venous plasma glucose concentration taken 2 hours after eating is greater than or equal to 11.1mmols/L (WHO 2000) Classification Type 1 Beta cell destruction, usually leading to absolute insulin deficiency Auto immune Idiopathic Type 2 Ranges from predominantly insulin resistance with relative insulin deficiency to predominantly secretory defect with or without insulin resistance Gestational diabetes Other specific types Type 2 Diabetes in Children  Are obese  No figures for Ireland or the UK  Have a strong family history of type 2 diabetes  Positive family history is present in over 80%  Certain ethnic backgrounds are high risk  Identical twins have an almost 100% concordance  Produce little or no ketonuria rate  Show evidence of insulin  Often asymptomatic resistance  Treatment is based on  Lifestyle, diet exercise  metformin  Oral Hypoglycaemic (sulphonylurea’s)  Insulin sensitizers (thiazolidinediones)  Insulin replace therapy  Combinations of the above Other Types of Diabetes  MODY (maturity onset of diabetes of  CFRD (cystic fibrosis related diabetes) the young)  Primarily due to insulin  Onset before 25 deficiency years  Also insulin resistance  Nonketotic  Poor prognostic sign  Autosomal dominant inheritance  Drug induced  Primary defect in diabetes the function of the pancreatic beta  Stress hyperglycaemia cells 5% of all children who presented in A&E with fever or traumatic  DIDMOAD (diabetes insipidus; injuries had hyperglycaemia (Valerio et al. 1990) diabetes mellitus; optic atrophy; deafness) Causes of Type 1 Diabetes TYPE 1 DIABETES ENVIROMENTAL TRIGGER Congenital rubella; GENETIC FACTOR cow’s milk protein UNKNOWN HLA typing Enteroviral infections Type 1 Diabetes  Is characterised by:  Pre-clinical  Can last months or years  Islet cell anti bodies can be  Pre – clinical detected  Can also detect genetic markers  Clinical  Clinical  Presentation is classical polydypsia; polyuria; weight  Partial remission loss  Can be a rapid or gradual onset  Chronic phase  Partial remission  The honeymoon phase  Never indicates “cure”  Chronic phase  Dependence on exogenous insulin replacement therapy Onset of Diabetes Aims of Diabetes Management  Sub optimal management leads to:  Poor control  Impairs growth  Delays puberty  Irreversible long term micro and macro vascular complications  Diabetes mellitus is the largest cause of:  End stage renal failure  Lower limb amputation  Blindness  The aims of diabetes management are:  Optimal psycho – social adjustment  Optimal glycaemic control  Normal growth and development  Plan of care incorporating the needs of the child and family DCCT  Diabetes Control and Complications Trial  Multi – centre trial over 10 years 7000 screened and 1441 participants  RCT  Two questions  Would intensive therapy prevent the development of diabetic retinopathy?  Would intensive therapy affect the progression of diabetic retinopathy?  The study group had intensive therapy and management and frequent contact with the diabetes team, the control group were had “normal” input DCCT - Results  Retinopathy Risk Reduction  Sustained progression (1st group) 76%  Sustained progression (2nd group) 54%  Proliferative / severe non proliferative 47%  Laser treated 56%  Nephropathy  Microalbuminuria (combined cohorts) 39%  Proteinuria (combined cohorts) 54%  Neuropathy 60% DCCT Normal Blood Glucose Values  WHO values:  Fasting 1.5 Annual Assessment  Eyes screen on diagnosis, screen annually from puberty or annually 5 years after diagnosis  TFT’s / Coeliac screen annually  Micro albuminuria screen annually from puberty or annually 5 years after diagnosis  Full medical assessment  New recommendations suggest lipid profile Toddlers  Dietary problems  Inconsistent food intake  Grazing  Child care issues  Testing/injection problems  Treating as normal  Parental fears School children 5-9  Not eating snacks / lunches  Different activities  Friends  Being part of the group  Snacking on sweets  Parental fears School children10-13  Receptive towards diabetes !!!!!!!!  Compliance  Self injecting  Learning new tasks  Negotiating parental versus self control  Experimenting  Parental fears Adolescents  Negotiating parental versus self control  Experimenting  Drugs, alcohol, smoking, sex  Risk taking behaviour  Parental fears Factors Impeding good control in childhood  Insulin deficiency is more complete  Variable food intake  Recurrent infections  Variable exercise pattern  Varying rates of growth and development  Hormonal changes insulin resistance especially during puberty  Behavioural problems associated with psycho social difficulties  Conflict between parents and a young person  Difficulty in adherence to regimen Psycho social issues in children and adolescents  Being different from their peers  Lack of spontaneity  Regimented life  Coping with embarrassing situations  Fear of long term complications  Feelings of being continually judged  Constant need to compromise and think of diabetes  Sibling rivalry  Peer group pressure  Concern of being a failure to parents Psycho social issues in parents  Fear of hypoglycaemia  Fear of the long term complications  Guilt of genetic transfer  Frustration at never having perfect glycaemic control  Lack of flexibility / clock watching  Extra responsibility  Constant need to explain to carers / friends / clubs  Frustration at others not recognising the complexity of care  Constant conflict between responsibility and over protection  Difficulties in allowing adolescents to take over their care  Extra costs Recipe for causing family breakdown  Give a family member a chronic disease – give it to a child  Make the disease of uncertain aetiology indicate heredity because this will make everyone feel guilty  Make treatment essential to well being time consuming and difficult  Make it painful  Make treatment interfere with normal lifestyle because this upsets everyone  Make self discipline essential to success of the treatment as this absolves all the professionals  Enrol a large multidisciplinary team uncertain of goals of treatment so they can give the family conflicting adviceLuther Travis APRG 1999 Case Study  Jane 14 years old diagnosed 4 year ago, fairly good control using MDI  Admitted 28/08/16 DKA  Admitted 03/09/16 DKA  Admitted 08/09/16 DKA  Admitted 13/09/16 DKA  Attended 15/09/16 Reference list  Kuppermann N et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378:2275-87. DOI: 10.1056/NEJMoa1716816  Nallasamy K et al. Low-Dose vs Standard-Dose Insulin in Pediatric Diabetic Ketoacidosis. A Randomized Clinical Trial. JAMA Pediatr. 2014; 168(11): 999 – 1005 DOI: 10.1001/jamapediatrics.2014.1211  Health Service Executive (HSE). (2020). Paediatric type 1 diabetes resource pack [PDF]. Retrieved from https://www.hse.ie/eng/about/who/cspd/ncps/paediatrics- neonatology/resources/paediatric-type-1-diabetes-resource-pack-mar- 2020.pdf  Health Service Executive (HSE). (n.d.). Model of care for all children and young people with type 1 diabetes in Ireland [PDF]. Retrieved from https://www.hse.ie/eng/services/publications/clinical-strategy-and- programmes/moc-young-people-with-type-1-diabetes . Reference list  Health Service Executive (HSE). (n.d.). Paediatric Type 1 Diabetes Resource Pack. Clinical Strategy and Programmes Division. Retrieved from https://www.hse.ie/eng/about/who/cspd/ncps/paedia trics-neonatology/resources/paediatric-type-1- diabetes-resource-pack.pdf  Health Service Executive (HSE)(2021). (n.d.). Meeting the Care Needs of Primary School Children with Diabetes. Clinical Strategy and Programmes Division. Retrieved from https://www.hse.ie/eng/about/who/cspd/ncps/paedia trics-neonatology/resources/meeting-care-needs- primary-school-children-with-diabetes1.pdf Reference list  Beck, J.K. and Cogen, F.R., 2015. Outpatient management of pediatric type 1 diabetes. Journal of Pediatric Pharmacology and Therapeutics, 20(5), pp.344-357. doi: 10.5863/1551-6776-20.5.344. PMCID: PMC4596120.  Yafi M, Shah A, Velez K. Narrative review of the role of technology in pediatric diabetes: from testing blood glucose to subcutaneous automated therapy and hope for cure. Transl Pediatr. 2023 Sep 18;12(9):1725-1734. doi: 10.21037/tp-23-145. Epub 2023 Sep 14. PMID: 37814709; PMCID: PMC10560351.