DIABETES MELLITUS PADA ANAK

Eka Agustia Rini

DIABETES MELLITUS
High levels of blood glucose : defects in insulin production, insulin action, or both Type 1 Diabetes cells that produce insulin are destroyed results in insulin dependence Type 2 Diabetes Lack of insulin production Insufficient insulin action (resistant cells)

Diabetes - Diagnosis

Symptoms of diabetes plus random plasma glucose >200mg/dl (11.1mmol/l) or Fasting plasma glucose >126 mg/dl (7.0 mmol/l) or 2 hour plasma glucose >200 mg/dl during an oral glucose tolerance test

American Diabetes Association Consensus Statement Type 2 Diabetes in Children and Adolescents Diabetes Care 2000;23(3) 381-389.

1.

GEJALA KLINIS
HIPERGLIKEMI

Poliuria Polidipsi Poli fagia

KOMPLIKASI -Ketoasidosis -Hipoglikemi -Mikrovaskular -Makrovaskular

Type 1 DM
What Causes Type 1 Diabetes? Autoimmune Response Genetic Abnormalities Viruses Cows milk

Etiology
80%-85% no affected family member Autoimune destruction of pancreas islet

Multiple genetic (predisposition) Enviromental factors (trigger)

viral infection, diet and toxins

or Insulin secretion

Pathogenesis

Destruction of -cell is quite variable. Fasting hyperglycemia can rapidly change to severe hyperglycemia or ketoacidosis (in infection or other stress).

Manifestation little or no insulin secretion low or undetectable C-peptide

Pathophysiology
Insulinopenia
Utilization glucose decreased postprandial hyperglycemia Glycogenolysis and gliconeogenesis fasting hyperglycemia

Glucosuria

Loss of calorie and electrolyte, dehydration

Clinical Manifestation

Phase of type 1 DM
1.
2. 3. 4.

Prediabetes Presentation of diabetes Partial remission or honeymoon Chronic phase of lifelong dependency on administrated insulin

Clinical manifestation
Polyuria or nocturia glucosuria Polydipsia Polyphagia calories lost in urine Weight loss Monilial vaginitis glucosuria

Diagnosis
Symptoms and casual plasma glucose 200 mg/dL or FPG 126 mg/dL or 2-h postload glucose 200 mg/dL Low or undetectable C-peptide ICA positive

MANAGEMENT OF T1DM

Diabetes education. Insulin replacement. Nutritional plan. Psychological adjustment Exercise Diabetes camp

Diabetes Management Principles

An effective insulin regimen Monitoring of glucose As flexible with food and activity as possible Must remember Young children need routine and rules Young children need to develop autonomy Young children need to explore and experience Young children need to begin to make decisions

The aims of DM management:

Optimal metabolic (glycaemic) control. Normal growth and development. Optimal psychosocial adjustment. An individualised plan of diabetes care incorporating the particular needs of the child or adolescent and the family.

Diabetes education

The cause of diabetes. Insulin replacement ; adjustment, storage, inj. techniques Blood glucose measurement. Exercise. Diabetes and exercise. Psychological and family adjustment. Hypoglycaemia and its management. Diabetes management during illness. Travel. Dietetic principles. Contraception. Alcohol and Drugs. Diabetes complications. Driving. Smoking.

INSULIN REPLACEMENT

Insulin types
Rapid-acting Lyspro, aspart, glulysine Short-acting Regular Insulin Intermediate - Lente, NPH Long-acting - Ultralente, Glargine, Detemir

Physiologic Insulin Therapy

Prandial Boluses

Basal Insulin BG mg/dl

0hr

24hr

Insulin management

Fixed dose regimens:

requires scheduled meals and snacks and is not flexible enough for most young children

Basal bolus regimens:

MDI
useful

only if child is willing to take frequent injections must be willing to wear the pump

Insulin pumps (CSII)

child

Location of injection

On Target!

Insulin pump therapy

Based on what body does naturally

- Small amounts of insulin all the time
(basal insulin)

- Extra doses to cover each meal or snack

(bolus insulin)

Rapid or Short-Acting Insulin Precision, micro-drop insulin delivery Flexibility Considered as a treatment option Initiated and supervised by a specialised multidisciplinary

Nutrition
adequate energy and nutrients, optimal growth and development, avoid hyperglycemia or hypoglycemia. Number of recommended meal : 6/day 3 main meal (25/20, 25/30 and 20/20) and 3 snacks (10%). Caloric:

1000 cal + 100 cal / year age Ideal BW + activity (<12 year)

Emergency conditions

Diabetic ketoacidosis Hypoglycemia

Longterm complications

Cardiovascular Neuropathy, Vascular Injury, and Amputations. Eye Complications. Kidney Damage (Nephropathy). Other Complications. Specific Complications in Women. Diabetes appears to affect female hormones. Specific Complications for Adolescents.

Diabetic Ketoacidosis
Hyperglycemia Insulin secretion

Beta Cell Toxicity +

Insulin resistance 2o obesity

Relative Insulin Deficiency

Lipolysis

Free Fatty Acids

Ketonemia Ketonuria

Manifestation of ketoacisodosis

Ketoacid accumulate when low insulin levels Abdominal discomfort nausea & emesis Dehydration, but still polyuria Sign of metabolic acidosis Diminish of neurocognitiv function coma The biochemical criteria : hyperglycaemia (> 200 mg/dL), pH <7.3 and or bicarbonate < 15

Type 2 DM

Childhood Obesity
The prevalence of childhood obesity is estimated to be 25 to 30 %. type 2 diabetes is increasing in children and adolescents obesity Family history of diabetes is strongly associated with type 2 diabetes in children

Type 2 Diabetes - One End of the Continuum

Genetic Predisposition Environmental Trigger Beta Cell Obesity

Hyperglycemia

Dysfunction
Type 2 Diabetes

Insulin Resistance

Obesity

Insulin Resistance Metabolic Syndrome

Type 2DM NASH PCOS Dyslipidemia

Hypertension

Type 2 Diabetes - Risk factors

Obesity 85% overweight or obese on diagnosis

American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement). Diabetes Care 23:381389, 2000).

65% of children with type 2 diabetes have first degree relative with Type 2 diabetes

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr.1996; 128 :608 615

74%-100% have first or second degree relative with type 2 diabetes

American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement). Diabetes Care 23:381389, 2000).

1.

Type 2 Diabetes Risk factors

African American, Hispanic, Asian, Native American descent

American Diabetes Association Consensus Statement Type 2 Diabetes in Children and Adolescents Diabetes Care 2000;23(3) 381-389.

Increased insulin resistance (puberty,ethnicity, inactivity,visceral fat distribution,PCOS)

American Diabetes Association Consensus Statement Type 2 Diabetes in Children and Adolescents Diabetes Care 2000;23(3) 381-389.
Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr.1996; 128 :608 615

Female/male 1.7:1

Type 2 Diabetes- Prevalence

4.1/100,000 for all 15-19 year old American Indians up to 50.9/100,000 for 15-19 yr old Pima Indian

Fagot-Campagna A, Pettitt DJ, Engelgau MM, Ros Burrows N, Geiss LS, Valdez R, et al. Type 2 diabetes among North American children and adolescents: an epidemiological review and a public health perspective. J Pediatr 2000; 136: 664-672

Estimated incidence of type 2 diabetes 7.2/100,000/yr (Ohio 1994)

10 fold increase from 1982-1994

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr.1996; 128 :608 615

Type 2 Diabetes - Risk

Lifetime
1

risk of diabetes for individuals born in 2000

in 3 for males 2 in 5 for females

Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF: Lifetime risk for diabetes mellitus in the United States. JAMA290 :1884 1890,2003

Components of the Met Syndr in Childhood

Abnormal blood lipids (HDL cholesterol <40mg/dl or triglycerides >150mg/dl LDL>130mg/dl). Impaired glucose tolerance (fasting glucose > 100 (110) mg/dl, random glucose >200mg/dl). Obesity (BMI >95% for age and sex) Elevated blood pressure (SBP or DBP > 90% for age).

Type 2 Diabetes
Diagnosis Elevated fasting insulin and hyperglycemia. Only 20% present with polyuria, polydipsia, and weight loss. Etiology One third of new diabetics presenting between 10-19 years had NIDDM.

Pinhas-Hamiel J Pediatr 1996;128:608-615.

Acanthosis nigricans and polycystic ovarian syndrome (PCOS), disorders associated with insulin resistance and obesity, are common in youth with type 2 diabetes Currently, type 2 diabetes are usually diagnosed over the age of 10 years and are in middle to late puberty

Acanthosis Nigricans

Dr. George Datto

Acanthosis Nigricans

Hyperpigmentation and velvety thickening that occurs in neck, axilla, and other skin folds In pediatrics, commonly in obese children. Also seen in malignancies and other insulin resistant syndromes.

Obese pediatric + acanthosis have higher fasting insulin and lower insulin sensitivity

Screening (ADA recomendation)

1.

10 years /puberty

Family history
Special ethnic

2. BMI > p 85, BB > 120%

Insulin resistent

OGTT every 2 years

Impaired glucose tolerance

Increased incidence of impaired glucose tolerance in obesity clinic population 25% of obese children (aged 4-10yrs)

21 % of obese adolescents (aged11-18 yrs)

Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, Savoye M, Rieger V, Taksali S, Barbetta G, Sherwin RS, Caprio S: Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 346:802810, 2002

Diagnosis criteria
Diabetes mellitus 1. Symptom DM + Glucose random > 200 mg/dl 2. Fasting blood glucose > 125 mg/dl 2. Blood glucose, 2 hr OGTT > 200 mg/dl Prediabetes 1. Gula darah puasa terganggu (> 11O & <125) 2. Toleransi glukosa terganggu (> 140 mg/dl & < > 200 mg/dl)

Treatment of Type 2 DM

Lifestyle changes Pharmaceutical therapy Biguanides Sulfonylureas Meglitinide Thiazolidenediones Monitoring for complications Hypertension and hyperlipidemia treatment

Nutrisi treatment
Children or adolescent calori requirement
Carbohydrat Protein Fat

: 55%-60% : 10-20%

: 30%