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Paediatric And Adolescent Diabetes Care. Dr Noman Ahmad 3 rd February 2011 Cork University Hospital. Presentation Outline. Definition Classification Pathophysiology Clinical Presentation Insulin types and regimens Insulin dose in different age groups Follow-up/Monitoring.
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Paediatric And Adolescent Diabetes Care Dr Noman Ahmad 3rd February 2011 Cork University Hospital
Presentation Outline • Definition • Classification • Pathophysiology • Clinical Presentation • Insulin types and regimens • Insulin dose in different age groups • Follow-up/Monitoring
Learning Objectives • Understanding of insulin pharmacokinetics • Right insulin regimen • Aims of glycaemic control • Complexity of management in different age groups
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
Classification • 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
Pathophysiology T1DM • 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
Pathophysiology T1DM • Environmental factors • Viruses (Entero, Coxsackie, EBV) • Cow’s milk • Perinatal factors • Vitamin D
Pathophysiology T1DM • Association with other autoimmune diseases • Thyroid 20% • Adrenal 1.7% • Coeliac disease 10% • Polyglandular autoimmune disease
Presentation of T1DM • Classic (most common) • Polyuria, polydipsia and weight loss • Diabetic ketoacidosis • Hyperglycaemia, metabolic acidosis and ketonuria • Silent • Usually siblings of known cases
Presentation of T2DM • 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
INSULIN TYPES • Short acting • Regular • Analogs (Novorapid,Humolog,Apidra) • Intermediate acting • NPH • Long acting • Detemir (Levemir) • Glargine (Lantus)
Insulin Regimens • Conventional • Premixed (Mixtard 30, Novomix 30) • Short acting(Novorapid) and intermediate acting (NPH) • Intensive • MDI (Lantus or Levemir and Novorapid) • Insulin pump (CSII)
Insulin Regimens • Conventional • 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
Novorapid Insultard(NPH) 0 30 4 6 12 16 18 Conventional Regimen
Insulin Regimen (MDI) • 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
Insulin Pump • Continuous basal infusion • Bolus with every meal or snack • Correction bolus • Regular or rapid insulin
Insulin Pump • Advantages • Flexible • Precise • Better glycaemic control • Less variability • Less Hypoglycemia • Less long term complication
Insulin Pump • Disadvantage • Tethered with device • Cost • Infection • Equipment failure • Carbohydrate counting • DKA • Hinder in some activities
Injection Sites • Fast absorption in abdomen • Slow in legs • Intermediate in arms • Subcutaneous fat • Skin very slow absorption • Muscles too fast
High Insulin Doses • Growth • Puberty • Sickness • Stress • Active/competitive sports • Steroid therapy • No physical activity
Target Blood Glucose • Preprandial • CDA 2008 • 0-6 years 6-12 • 6-12 years 4-10 • >12 years 4-7 • ISPAD 2009 • 5-8 for all kids • 2 hours postprandial • 5-10 for all kids
Target HbA1C • CDA 2008 • <6 years 8.5% • 6-12 < 8% • >12 years ≤ 7% • ISPAD 2009 • < 7.5% for all kids
Clinic Visit • History • Glucose diary • Hypoglycaemia • Intercurrent illness • Thyroid, adrenal, coeliac • Exercise • Hypoglycaemia supplies
Clinic Visit • Examination • Growth, weight, BP • Thyroid • Injection sites • Finger poke sites • Pubertal exam • Retinal exam • Prayer signs
Clinic Visit • Investigations • HbA1C every 3 months • TSH annually • Coeliac screen • Lipid profile • Albumin creatinine ratio • Eye exam
Infants And Toddlers • Brain is very sensitive to hypoglycaemia • Sensitive to Regular/rapid insulin • Picky eater • May need to give insulin after meals
Adolescents • Insulin resistance • Non compliance • Fabrication • Denial • Eating out and snacking • Family conflicts • Alcohol • Eating disorders