DIABETES MELITUS

TYPE I
Dr. H. Hakimi Sp.A.K
Dr. H Charles Darwin Siregar Sp.A
Dr. Melda Deliana Sp.A.K
Dr. Siska Mayasari Lubis, SpA
PEDIATRIC ENDOCRINOLOGY
MEDICAL SCHOOL USU/H. Adam Malik
HOSPITAL
Medan

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

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

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

Patogenese
Addison disease

Tirodiditis hashimoto

Anemia pernisiosa

Viral infection

HLA B8,DR3,BW15,DR4 activation

autoantibody process
langerhans islets destruction

Pancreas B cell function failure

Insulin secretion decrease or stop
DM type I

Chemical exposure

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

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 200-250 cc water in 5
minutes
GTT result intepretation :
DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200
mg /dl
Impaired Glucose tolerance : fasting blood glucose <140
mg/dl or at 2nd hour : 140 199 mg/dl
Normal : fasting blood glucose < 110 mg/dl or at 2nd hour : <
140 mg/dl

Epidemology
Incidence is higher in Caucasian
Highest in Finland 43/100.000 , lowest in Japan 2/
100.000 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

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

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 doesnt manipulate disease
6. Able to manage disease
independently

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

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, new patient, injection before
meal, and in surgery or combination with medium acting
insulin
For toddler : prevent hypoglycemy

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

Insulin

Insulin pen
Mixing insulin
Storage : temp 4 8 oC not in freezer

Type

onset (hour)

peak(hour)

duration(hour)

Ultra short acting

0,25

short acting

0,5 1

2-4

5-8

Medium acting

1-2

4-12

8-24

Long acting

6-20

18-36

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

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

Meal adjustment
Objective : achieve good metabolic control
without ignoring calory requirement
Total calory : 1000 + (age(year)x100) calory
per day
Carbohydrate 60 65% , protein 25%, lipid
<30%

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%

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

Complication
Short term complication : hypoglicemy, ketoacidosis
Hypoglycemy : blood glucose < 50 mg/dL
neurogenic symptoms

neuroglycopeny

Cholinergic

weak, headache, visual disturbance

Sweating,hungry,numb

dizziness, tired, sleepy, affective disorder l

Adrenergic

(depression,angry), coma, convulsion

Tremor, tachycardy, pale, Palpitation,

anxious

Long term complication

Retinopathy
Nefropathy
Growth & development disorder

Hypoglycemy
Prevention
Regular insulin management
Regular food intake
Parent supervision and education

Therapy
Mild/moderate hypoglycemy
Give 10 20 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

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

Growth and diabetes

Monitor:
Body height/3 months
Body weight
Physical and mental development

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

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

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

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

Ketoacidosis Protocol
-Bicarbonate : NaHCO3 is not advised
12. Start fluid replacement therapy as mention on umber 11 with
the value in number 10
13.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)

Ketoacidosis Protocol
14. Follow laboratorium value:
-Follow BG/ 30-60 mnt, whether the child response ?
-Follow Na,K,Cl,HCO3, 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