dr. H. Hakimi, Sp.AK dr. H. Charles Darwin Siregar, Sp.A dr. Melda Deliana, Sp.AK dr. Siska Mayasari Lubis, Sp.A PEDIATRIC ENDOCRINOLOGY

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1 DIABETES MELITUS TYPE I dr. H. Hakimi, Sp.AK dr. H. Charles Darwin Siregar, Sp.A dr. Melda Deliana, Sp.AK dr. Siska Mayasari Lubis, Sp.A PEDIATRIC ENDOCRINOLOGY MEDICAL SCHOOL USU/H. Adam Malik HOSPITAL Medan

2 Introduction Chronic disease Difficult to cure Major DM group in children.

3 DM Classification based on etiology (ADA,1998) 1. DM type I ( B cell destruction) : a. immune mediated b. idiopathic 2. DM type II (insulin resistant) 3. DM other type a. genetic defect of B cell function b. genetic defect of insulin function c. pancreas exocrine disease d. endocrinopathy e. drug and chemical substance induction f. Infection g. uncommon immune mediated DM h. Genetic syndrome related to DM 4. DM gestasional

4 Definition Systemic disorder because glucose metabolism disorder, characterised by chronic hyperglicemy Caused by autoimunne process which destroy pancreas B cell insulin production decrease or stopped

5 Patogenese Addison disease Tirodiditis hashimoto Anemia pernisiosa Viral infection Chemical exposure HLA B8,DR3,BW15,DR4 BW15 DR4 activation ation autoantibody process langerhans islets destruction Pancreas B cell function failure Insulin secretion decrease or stop DM type I

6 diagnostic criteria Normal blood glucose : <126 mg/dl ( 7 mmol/l) Diagnose is determined if one of this criteria fulfilled : Polyuria, polydipsy, psy, polyphagy, decrease ease weight, blood glucose ad random >200mg/dl Asymptomatic : blood glucose ad random >200mg/dl

7 Glucose tolerance test (GTT) GTT is not nesecary if distinguished symptoms are found Indication : GTT in doubtful case glucose dose : 1,75 gr/w in cc water in 5 minutes GTT result intepretation : DM: fasting blood glucose > 140 mg/dl or at 2 nd hour >200 mg /dl Impaired Glucose tolerance : fasting blood glucose <140 mg/dl or at 2 nd hour : mg/dl Normal : fasting blood glucose < 110 mg/dl or at 2 nd hour : < 140 mg/dl

8 Epidemology Incidence is higher in Caucasian Highest in Finland 43/ , lowest in Japan 2/ foo age < 5 yrs old Peak incidence : Age 5 6 yrs old 11 yrs old New cases >50% : >20 yrs old Genetic and environment factors : HLA pattern, virus, toxin, etc

9 Clinical appearance Acute Polyuria, polydypsy, rapid weight decrease, hyperglycemy Delayed diagnose : ketoacidosis with all the consequences

10 DM type I management Good metabolic control with normal blood glucose level Unified team Objective Spesific objective 1. Free from symptoms 1. optimal growth 2. Enjoy social life 2. normal emosional development 3. Prevent complications 3. Good metabolic control without causing hypoglycemy 4. Few school absence days and active in school 5. Patient doesn t manipulate disease 6. Able to manage disease independently

11 Insulin Earlier : pig/cow pancreatic gland purification Recombinant technology : human insulin Usage based on age, social economic, culture, and drug distribution Important to know : somogyi effect dawn effect Morning hyperglycemy

12 Insulin Ultra short acting insulin ( lispro ) Give 15 min before meal Useful in sick day management and before meal injection Short acting insulin For acute stage : ketoacidosis, i new patient, injection i before meal, and in surgery or combination with medium acting insulin For toddler : prevent hypoglycemy

13 Insulin Medium acting Insulin Used twice daily for patient with same daily routine pattern Widely used in children Mix Insulin Standard mixture ( short+medium acting insulin) Good metabolic control For young age child with low education parent

14 Insulin Insulin pen Mixing insulin Storage : temp 4 8 o C not in freezer Type onset (hour) peak(hour) duration(hour) Ultra short acting 0, short acting 0, Medium acting Long acting

15 Insulin Regiment Insulin usage principal Depend on Indonesia situation and condition Use glucometer and routine daily home testing Objective parameter : Serum HbA1c / 3 months Insulin dose adjustment : For metabolic control Honeymoon period, adolescent, sick days, surgery

16 Insulin Injection Injection technique : subcutaneous with pinchet Self injection Local reaction : rare

17 Meal adjustment Objective : achieve good metabolic control without ignoring calory requirement Total calory : (age(year)x100) calory per day Carbohydrate 60 65%, protein 25%, lipid <30%

18 Metabolic Control Metabolic Target(mg/dl) Excellent good moderate poor Preprandial <120 <140 <180 >180 Postprandial <140 <200 <240 >240 Urine reduction >+ HbA1c <7% 7-7,9% 8-9% >10%

19 Management Management when diagnosed Insulin : start 0,5 U/kg/day, gradually adjust education ketoacidosis management Insulin Fluid elektrolite balance Acid base balance Management while surgery Management while Ramadhan fasting Complication

20 Complication Short term complication : hypoglicemy, ketoacidosis Hypoglycemy : blood glucose < 50 mg/dl neurogenic symptoms Cholinergic Sweating,hungry,numb Adrenergic Tremor, tachycardy, pale, Palpitation, anxious neuroglycopeny weak, headache, visual disturbance dizziness, tired, sleepy, affective disorder l (depression,angry), coma, convulsion

21 Long term complication Retinopathy Nefropathy Growth & development disorder

22 Hypoglycemy Prevention Regular insulin management Regular food intake Parent supervision and education Therapy Mild/moderate hypoglycemy Give gr of carbohydrate followed by snack Lemonade honey glucose tablet can be used Severe hypoglycemy Unconscious / convulsion Oral medication is rarely used shile unconscious Parent education inject glucagon 0,5 mg or 1 mg for child > 5 yrs old

23 Education Objective Understand the disease Motivation Type 1 DM management skill Positive attitude Good metabolic control Logic decision of daily management First education --> at hospital Continous education : Camp School Advice on : Long journey Alkoholic and smoker

24 Growth and diabetes Monitor: Body height/3 ht/3 months Body weight Physical and mental development

25 Psychosocial aspects Family education Parent training on DM care Advice parent not to give excessive protection

26 Ketoacidosis Protocol 1.Body weight measurement (kg) 2.Dehidration therapy decision 3.Calculation of free water deficit 4.Administration of normal saline (0,9NS), bolus if orthostatic or shock occurs 5.Calculate excess of water deficit after the third bolus 6.Calculate maintainance fluid requiremmnt for the next 48 hours 7.Calculate total fluid given within 48 hours

27 Ketoacidosis Protocol 8. Calculate the value of fluid exchange per hour divided by the value on number 7 per 48 hour 9. Make and start regular insulin drip at 0,1 unit/bw/hour 10.Perform fluid exchange at insulin drip at substract of number 9 from 8 11.Determine fluid type which is used as substitute : - Sodium -patient with Na>145mmol/L: 0,9NS -patient with Na<145mmol/L:0,45NS

28 Ketoacidosis Protocol -Potassium -Urine (-) : don t give K + -Urine (+) : add KCL20-40mmol/L -Give K + as half Chloride/half phophate at first 8 hour -Dextrose - Patient with BG>15mmol/L: don t give dextrose - Patient with BG<15mmol/L: give 5-12,5% 5% dextrose - Try to maintain BG 10-15mmol/l without adding isulin dose.

29 Ketoacidosis Protocol -Bicarbonate : NaHCO3 is not advised 12. Start fluid replacement therapy as mention on umber 11 with the value in number Observe neurological signs to see whether cerebral oedem exists. Severe headache, consciousness or blood pressure changes, dilated pupil, bradicardy, postural signs and incontinence Perform rapid intervention (intubate, mildly hyperventilate, give mannitol 1 gr/kgbb/iv bolus)

30 Ketoacidosis Protocol 14. Follow laboratorium value: -Follow BG/ mnt, whether the child response? -Follow Na,K,Cl,HCO 3, capillary ph value/ 2 4 hrs -Follow Ca and P value if phosphate is given -Re- check urine glucose and ketone 15. Re- evaluate every fluid change, antisipate the change of K, dextrose, etc value

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