Paediatric And
Adolescent Diabetes
Care
Dr Noman Ahmad
3rd February 2011
Cork University Hospital
1
Presentation Outline
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Definition
Classification
Pathophysiology
Clinical Presentation
Insulin types and regimens
Insulin dose in different age groups
Follow-up/Monitoring
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Learning Objectives
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Understanding of insulin pharmacokinetics
Right insulin regimen
Aims of glycaemic control
Complexity of management in different age
groups
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Definition
Diabetes mellitus is group of metabolic diseases
characterised by chronic hyperglycaemia resulting
from defects in insulin secretion, action or both
International society of paediatric
and adolescent diabetes
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Insulin Physiology
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Classification
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Type 1 diabetes (IDDM)
Type 2 diabetes (NIDDM)
Monogenic diabetes (MODY)
Neonatal diabetes (Transient first 3 months)
Mitochondrial diabetes
Cystic fibrosis related diabetes (CFRD)
Drug induced hyperglycaemia
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Pathophysiology T1DM
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Autoimmune destruction (T1A DM)
Non autoimmune destruction (T1B DM)
Multiple genes
HLA genes (DR, DQ alpha, DQ beta)
 Autoantigen (Islet cells, Insulin, glutamic acid
decarboxylase GAD 65, Isulinoma associated
protien 2 IA-2, Zinc transporte ZnT8
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Pathophysiology T1DM
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Environmental factors
Viruses (Entero, Coxsackie, EBV)
 Cow’s milk
 Perinatal factors
 Vitamin D
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Pathophysiology T1DM
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Association with other autoimmune diseases
Thyroid 20%
 Adrenal 1.7%
 Coeliac disease 10%
 Polyglandular autoimmune disease
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Pathophysiology T1DM
Genetic predisposition
HLA associations
Environment
Viruses, toxins, cow’s milk
Immune dysregulation
GAD 65, IA-2,Insulin, ZnT8,Islet cells
Beta islet cell destruction
Insulin deficiency
Type 1 diabetes
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Pathophysiology of T2DM
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Presentation of T1DM
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Classic (most common)
 Polyuria,
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polydipsia and weight loss
Diabetic ketoacidosis
 Hyperglycaemia,
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metabolic acidosis and ketonuria
Silent
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Usually siblings of known cases
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Presentation of T2DM
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Girls 1.7 times more common
Obesity, signs of insulin resistance (acanthosis
nigricans)
Strong family history, LBW, gestational diabetes
Insulin resistant states (puberty, PCOS)
Impaired OGTT
Elevated A1C
DKA
Hyperosmolar coma with no ketunuria
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Acanthosis Nigricans
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INSULIN TYPES
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Short acting
Regular
 Analogs (Novorapid,Humolog,Apidra)
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Intermediate acting
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NPH
Long acting
Detemir (Levemir)
 Glargine (Lantus)
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Pharmacokinetics
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Pharmacokinetics
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Insulin Regimens
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Conventional
 Premixed
(Mixtard 30, Novomix 30)
 Short acting(Novorapid) and intermediate acting (NPH)
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Intensive
 MDI
(Lantus or Levemir and Novorapid)
 Insulin pump (CSII)
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Insulin Regimens
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Conventional
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Positives
 Twice a day
 No carbohydrate counting
 Good for new patients and school going kids
 Less chance of DKA
Negatives
 Non physiological
 Less flexible
 More risk of hypoglycaemia
 Loose glycaemic control
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Conventional Regimen
Novorapid
0 30
Insultard
(NPH)
4
6
12
16
18
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Insulin Regimen (MDI)
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Insulin Regimen (MDI)
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Intensive
 Positive
Physiological
 Flexible
 Less risk of hypoglycaemia
 Good for teenagers
 Less long term side effects
 Better glyceamic control
 Negatives
 More injections
 Carbohydrate counting
 More risk of DKA
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Insulin Pump
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Continuous basal infusion
Bolus with every meal or snack
Correction bolus
Regular or rapid insulin
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Insulin Pump
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Insulin Pump
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Insulin Pump
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Advantages
 Flexible
 Precise
 Better
glycaemic control
 Less variability
 Less Hypoglycemia
 Less long term complication
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Insulin Pump
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Disadvantage
 Tethered
with device
 Cost
 Infection
 Equipment
failure
 Carbohydrate counting
 DKA
 Hinder in some activities
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Injection Sites
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Fast absorption in abdomen
Slow in legs
Intermediate in arms
Subcutaneous fat
Skin very slow absorption
Muscles too fast
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High Insulin Doses
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Growth
Puberty
Sickness
Stress
Active/competitive sports
Steroid therapy
No physical activity
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Target Blood Glucose
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Preprandial
 CDA 2008
0-6 years 6-12
 6-12 years 4-10
 >12 years 4-7
 ISPAD 2009
 5-8 for all kids
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2 hours postprandial
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5-10 for all kids
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Target HbA1C
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CDA 2008
 <6
years
 6-12
 >12 years
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8.5%
< 8%
≤ 7%
ISPAD 2009
<
7.5% for all kids
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Clinic Visit
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History
 Glucose
diary
 Hypoglycaemia
 Intercurrent illness
 Thyroid, adrenal, coeliac
 Exercise
 Hypoglycaemia supplies
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Clinic Visit
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Examination
 Growth,
weight, BP
 Thyroid
 Injection
sites
 Finger poke sites
 Pubertal exam
 Retinal exam
 Prayer signs
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Clinic Visit
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Investigations
 HbA1C
every 3 months
 TSH annually
 Coeliac screen
 Lipid profile
 Albumin creatinine ratio
 Eye exam
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Infants And Toddlers
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Brain is very sensitive to hypoglycaemia
Sensitive to Regular/rapid insulin
Picky eater
May need to give insulin after meals
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Adolescents
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Insulin resistance
Non compliance
Fabrication
Denial
Eating out and snacking
Family conflicts
Alcohol
Eating disorders
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QUESTIONS
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