Diabetes mellitus in children pdf

Adolescence: 1 unit insulin per 8 to 10 g carbohydrate. In type 2 diabetes, patients should be encouraged to lose weight and thus increase insulin sensitivity. Simple steps to improve the diet and manage caloric intake include. Eliminating sugar-containing drinks and foods made of refined, simple sugars eg, processed candies and high fructose corn syrups.

The risk of hypoglycemia in children who have hypoglycemia unawareness or lack the maturity to recognize the symptoms of hypoglycemia can limit aggressive attempts to achieve treatment goals.

A less stringent HbA1c target level HbA1c target levels for type 1 diabetes in children and adolescents have been lowered over time in an effort to reduce complications—lower HbA1c levels during adolescence and young adulthood are associated with a lower risk of vascular complications.

An HbA1c target level of insulin for meals, have an improved ability to correct hyperglycemic values, and are potentially able to detect hypoglycemia earlier, which prevents overcorrection ie, excessive carbohydrate intake as treatment for hypoglycemia, resulting in hyperglycemia.

HbA1c levels correlate well to the percentage of time that blood glucose levels remain in the normal range, termed the percentage time-in-range. HbA1c target levels for type 2 diabetes in children and adolescents are similar to targets in type 1 diabetes, ie liraglutide. More stringent targets for HbA1c metformin alone who achieve significant weight reduction.

Insulin is the cornerstone of management of type 1 diabetes. Regular monitoring of blood glucose levels is essential to prevent complications of diabetes Insulin should be given before a meal, except in young children whose consumption at any given meal is difficult to predict. Dosing requirements vary by age, activity level, pubertal status, and length of time from initial diagnosis.

Within a few weeks of initial diagnosis, many patients have a temporary decrease in their insulin requirements because of residual beta-cell function honeymoon phase. This honeymoon phase can last from a few months up to 2 years, after which insulin requirements typically range from 0.

During puberty, patients require higher doses up to 1. Most people with type 1 diabetes should be treated with MDI regimens 3 to 4 injections per day of basal and prandial insulin or insulin pump therapy as part of intensive insulin regimens with the goal of improving metabolic control.

A basal-bolus regimen is typically the preferred MDI regimen. In this regimen, children are given a daily baseline dose of insulin that is then supplemented by doses of short-acting insulin before each meal based on anticipated carbohydrate intake and on measured glucose levels.

The basal dose can be given as a once-a-day injection sometimes every 12 hours for younger children of a long-acting insulin glargine or detemir , with supplemental boluses given as separate injections of rapid-acting insulin usually aspart or lispro. Glargine or detemir injections are typically given at dinner or bedtime and must not be mixed with short-acting insulin. A basal—bolus regimen may not be an option if adequate supervision is not available, particularly if an adult is not available to give daytime injections at school or daycare.

More fixed forms of MDI regimens can be considered if a basal—bolus regimen is not an option eg, because the family needs a simpler regimen, the child or parents have a needle phobia, lunchtime injections cannot be given at school or daycare but are less commonly used. In this regimen, children usually receive neutral protamine Hagedorn NPH insulin before eating breakfast and dinner and at bedtime and receive rapid-acting insulin before eating breakfast and dinner.

Because NPH and rapid-acting insulin can be mixed, this regimen provides fewer injections than the basal—bolus regimen. However, this regimen provides less flexibility, requires a set daily schedule for meals and snack times, and has been largely supplanted by the analog insulins glargine and detemir because of the lower risk of hypoglycemia. In insulin pump therapy, the basal insulin is delivered at a fixed or variable rate by a continuous subcutaneous infusion of rapid-acting insulin CSII through a catheter placed under the skin.

Mealtime and correction boluses also are delivered via the insulin pump. The basal dose helps keep blood glucose levels in range between meals and at night. Using an insulin pump to deliver the basal dose allows for maximal flexibility; the pump can be programmed to give different rates at different times throughout the day and night.

For some children, the pump offers an added degree of control, whereas others find wearing the pump inconvenient or develop sores or infections at the catheter site. Children must rotate their injection and pump sites to avoid developing lipohypertrophy. Lipohypertrophy is an accumulation of lumps of fatty tissue under the skin. The lumps occur at insulin injection sites that have been overused and can cause variation in blood glucose levels because they can prevent insulin from being absorbed consistently.

Premixed regimens are not a good choice but are simpler and may improve adherence because they require fewer injections. Children are given set doses twice daily, with two thirds of the total daily dose given at breakfast and one third at dinner. However, premixed regimens provide much less flexibility with respect to timing and amount of meals and are less precise than other regimens because of the fixed ratios.

Clinicians should use the most intensive management program children and their family can adhere to in order to maximize glycemic control and thus reduce the risk of long-term vascular complications.

Hypoglycemia Hypoglycemia Hypoglycemia unrelated to exogenous insulin therapy is an uncommon clinical syndrome characterized by low plasma glucose level, symptomatic sympathetic nervous system stimulation, and central Most children have several mild hypoglycemic events per week and self-treat with 15 g of fast-acting carbohydrates eg, 4 oz of juice, glucose tablets, hard candies, graham crackers, or glucose gel.

Oral carbohydrates may be tried, but glucagon 1 mg IM is usually used if neuroglycopenic symptoms eg, behavioral changes, confusion, difficulty thinking prevent eating or drinking. If untreated, severe hypoglycemia can cause seizures or even coma or death. Real-time continuous glucose monitoring devices can help children with hypoglycemia unawareness because they sound an alarm when glucose is below a specified range or when glucose declines at a rapid rate see Monitoring glucose and HbA1c levels Monitoring glucose and HbA1c levels Diabetes mellitus involves absence of insulin secretion type 1 or peripheral insulin resistance type 2 , causing hyperglycemia.

Because early detection of ketones is crucial to prevent progression to DKA and minimize need for emergency department or hospital admission, children and families should be taught to check for ketones in the urine or capillary blood using ketone test strips. Blood ketone testing may be preferred in younger children, those with recurrent DKA, and insulin pump users or if a urine sample is difficult to obtain. Small urine ketone levels or blood ketone levels 0. Also, additional fluid should be given to prevent dehydration.

Parents should be instructed to call their health care provider or go to the emergency department if ketones increase or do not clear after 4 to 6 hours, or if the clinical status worsens eg, respiratory distress, continued vomiting, change in mental status. As in type 1 diabetes, lifestyle modifications, with improved nutrition and increased physical activity, are important. If acidosis is not present, metformin is usually started at the same time. Insulin requirements may decline rapidly during the initial weeks of treatment as endogenous insulin secretion increases; insulin often can be stopped several weeks after regaining acceptable metabolic control.

Metformin is an insulin sensitizer and is the only oral antihyperglycemic drug approved for patients oral drugs used in adults Oral Antihyperglycemic Drugs General treatment of diabetes for all patients involves lifestyle changes, including diet and exercise.

Metformin should be started at a low dose and taken with food to prevent nausea and abdominal pain. A typical starting dose is mg orally once a day for 1 week, which is increased weekly by mg for 3 to 6 weeks until reaching the maximal target dose of mg 2 times a day. The goal of treatment is an HbA1c level of at least metformin alone, basal insulin or liraglutide should be started.

Unfortunately, about half of adolescents with type 2 diabetes ultimately fail metformin monotherapy and require insulin. If patients fail to meet targets using dual therapy with metformin and basal insulin, rapid-acting prandial insulin may also be added. This injectable noninsulin antihyperglycemic drug enhances glucose-dependent insulin secretion and slows gastric emptying.

Liraglutide is started at 0. It may also reduce appetite and promote weight loss. The most common adverse effects of GLP-1 agonists are gastrointestinal, especially nausea and vomiting. Liraglutide can be used if metformin is not tolerated or added on if HbA1c target levels are not achieved with metformin alone within 3 months. Liraglutide can be used in place of or in combination with insulin as part of intensive treatment of type 2 diabetes.

Management of monogenic diabetes is individualized and depends on subtype. The glucokinase subtype generally does not require treatment because children are not at risk of long-term complications. Most patients with hepatic nuclear factor 4-alpha and hepatic nuclear factor 1-alpha types are sensitive to sulfonylureas, but some ultimately require insulin. Other oral hypoglycemics such as metformin are typically not effective. In type 1 diabetes, blood glucose levels may need to be checked 6 to 10 times per day to optimize control.

Glucose levels should be measured using a fingerstick sample before all meals and before a bedtime snack.

Levels also should be checked during the night around 2 to 3 AM if nocturnal hypoglycemia is a concern eg, because of hypoglycemia or vigorous exercise during the day, or when an insulin dose is increased. Because exercise can lower glucose levels for up to 24 hours, levels should be checked more frequently on days when children exercise or are more active. To prevent hypoglycemia, children may increase carbohydrate intake or lower insulin dosing when they anticipate increased activity.

Sick-day management should be used with hyperglycemia or illness. Parents should keep detailed daily records of all factors that can affect glycemic control, including blood glucose levels; timing and amount of insulin doses, carbohydrate intake, and physical activity; and any other relevant factors eg, illness, late snack, missed insulin dose.

Patients with type 2 diabetes usually self-monitor blood glucose levels less frequently than in type 1 diabetes, but frequency varies depending on the type of drug therapy used. Children and adolescents taking multiple daily insulin injections, those who are ill, and those with suboptimal control should monitor glucose levels at least 3 times a day.

Those who are on stable regimens of metformin and only long-acting insulin, who are meeting their targets without hypoglycemia, can monitor less frequently, typically twice a day fasting and 2 hours postprandial. Children and adolescents with type 2 diabetes on insulin regimens with multiple daily injections sometimes use continuous glucose monitoring systems, but this is less common than in type 1 diabetes. Continuous glucose monitoring CGM systems are a more sophisticated and effective approach to monitoring that use a subcutaneous sensor to measure interstitial fluid glucose levels every 1 to 5 minutes, thus more closely detecting glucose fluctuations that can then be acted upon in real time.

CGM systems transmit results wirelessly to a monitoring and display device that may be built into an insulin pump or be a stand-alone device. By identifying times of consistent hyperglycemia and times of increased risk of hypoglycemia, CGM systems can help patients with type 1 diabetes more safely reach glycemic goals. Appropriately calibrated CGM devices are now approved for real-time use and can replace routine self-monitoring of blood glucose for some patients. However, depending on the technology used, some CGM results must still be confirmed by periodic fingerstick samples.

Compared to intermittent monitoring, continuous monitoring systems can lower HbA1c levels, increase the percentage of time-in-range, and lower the risk of hypoglycemia. All CGM devices allow targets to be set; alarms will alert the user if glucose levels are above or below the target, and some CGM systems integrated with a pump can also suspend the basal rate for up to 2 hours when glucose level drops below a set threshold.

Although CGM devices can be used with any regimen, they are typically worn by insulin pump users. These systems automate blood glucose management through sophisticated computer algorithms that are on a smartphone or similar device. Artificial pancreas systems link a CGM sensor and insulin pump to determine blood glucose levels and control insulin delivery.

These systems help to more tightly control insulin dosing and limit hyperglycemic and hypoglycemic episodes. In type 2 diabetes, blood glucose levels should be measured regularly but typically less often than in type 1 diabetes. The frequency of self-monitoring of blood glucose should be individualized based on the patient's fasting and postprandial glucose levels, the degree of glycemic control deemed achievable, and the available resources.

The frequency of monitoring should increase if glycemic control targets are not being met, during illness, or when symptoms of hypoglycemia or hyperglycemia are felt. Once targets are achieved, home testing is limited to a few fasting and postprandial blood glucose measurements per week.

HbA1c levels should be measured every 3 months in type 1 diabetes and in type 2 diabetes if insulin is being used or metabolic control is suboptimal. Otherwise, in type 2 diabetes, levels can be measured twice a year, although every 3 months is optimal.

Patients are screened regularly for complications depending on the type of diabetes see Table: Screening Children for Complications of Diabetes Screening Children for Complications of Diabetes Diabetes mellitus involves absence of insulin secretion type 1 or peripheral insulin resistance type 2 , causing hyperglycemia. If complications are detected, subsequent testing is done more frequently.

Complications detected on examination or screening are treated first with lifestyle interventions: increased exercise, dietary changes particularly limiting saturated fat intake , and cessation of smoking if applicable. Diabetes Technol Ther 21 2 —85, Type 1 diabetes is caused by an autoimmune attack on pancreatic beta-cells, causing complete lack of insulin ; it accounts for two thirds of new cases in children and can occur at any age. Type 2 diabetes is caused by insulin resistance and relative insulin deficiency due to a complex interaction among many genetic and environmental factors particularly obesity ; it is increasing in frequency in children and occurs after puberty.

Most children have symptomatic hyperglycemia without acidosis, with several days to weeks of urinary frequency, polydipsia, and polyuria; children with type 1 diabetes and rarely type 2 diabetes may present with diabetic ketoacidosis. All children with type 1 diabetes require insulin treatment; intensive glycemic control helps prevent long-term complications but increases risk of hypoglycemic episodes.

Advances in diabetes technology, such as continuous glucose monitoring systems, are aimed at improving glycemic control while reducing hypoglycemic episodes. Liraglutide can be used in combination with metformin to improve glycemic control. Psychosocial problems can lead to poor glycemic control through lack of adherence to dietary and drug regimens. Insulin doses are adjusted based on frequent glucose monitoring and anticipated carbohydrate intake and activity levels.

Children are at risk of microvascular and macrovascular complications of diabetes, which must be sought by regular screening tests. The following are some English-language resources that may be useful.

American Diabetes Association: Standards of medical care in diabetes update. International Society for Pediatric and Adolescent Diabetes ISPAD : Clinical practice consensus guideline for glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes update.

From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. The Manual was first published in as a service to the community.

Learn more about our commitment to Global Medical Knowledge. This site complies with the HONcode standard for trustworthy health information: verify here. Common Health Topics. Videos Figures Images Quizzes Symptoms. Symptoms and Signs. Complications of diabetes in children. Diagnosis of diabetes in children Initial evaluation and testing Diagnosis of diabetes type Testing for complications and other disorders Screening for diabetes. Lifestyle modifications Glucose and HbA1c target levels Type 1 diabetes insulin regimens Type 1 diabetes management of complications Type 2 diabetes treatment Monogenic diabetes treatment Monitoring glucose and HbA1c levels Screening for complications of diabetes Treatment reference.

Key Points. More Information. The following sections provide in depth discussion on pharmacological and non-pharmacological managements techniques, and acute and chronic complications. The book concludes with the treatment of diabetes in special cases such as in neonates and infants, and a final section cover miscellaneous topics including genetics of Type 1 diabetes, and educational material for patients and their parents.

Key points Comprehensive guide to the diagnosis and management of diabetes in children Covers both pharmacological and non-pharmacological treatment methods Includes discussion on special cases such as diabetes in neonates and infants Written in association with the CDiC program. It is caused by the inability of the pancreas to produce insulin. Beginning with an introduction to the epidemiology, diagnosis and classification of diabetes, the following chapters describe the different types of diabetes.

Each of the following sections discusses the treatment and management of diabetes and its related disorders. A separate chapter is dedicated to transplantation and emerging treatments. Key points Concise guide to diagnosis and management of diabetes in children and adolescents Emphasis on Type 1 diabetes Easy to read, step by step format Separate chapter dedicated to transplantation and emerging treatments.

This easy-to-read reference presents a succinct overview of clinically-focused topics covering diagnosis, treatment, management, and complications of type 2 diabetes mellitus in pediatric patients. Covers clinical presentation, diagnostic criteria, screening, and other topics related to diagnosis.

Discusses complications such as hypertension, retinopathy, depression, PCOS, fatty liver, and more. Includes information on medications, lifestyle interventions, and surgical treatment. The number of young children being diagnosed with type 1 diabetes is increasing worldwide and an epidemic of type 2 diabetes already at a young age is being.