Diabetes Mellitus

Diabetes Mellitus: Excerpt from The 5-Minute Pediatric Consult

David R. Langdon, MD

Diabetes Mellitus - BASICS

Diabetes Mellitus - description

Diabetes mellitus (DM) is a disorder of absolute or relative insulin deficiency that results in hyperglycemia and disrupts energy storage and metabolism. Severe insulin deficiency can lead to ketosis, acidosis, dehydration, shock, and death.

Diabetes Mellitus - epidemiology

• Most common endocrine disorder of childhood
• Type 1 DM: More common in whites of Northern European descent
• Type 2 DM: More common in obese African Americans, Latinos, and Native Americans with strong family history

Diabetes Mellitus - incidence

• Type 1 DM:
  • Annual US incidence is ~19/100,000 in children 10–19 years old.
  • Incidence of type 1 DM is rising by 3% per year, but faster in young children.
• Type 2 DM:
  • Incidence is increasing rapidly in adolescents.
  • May be 8–45% of new cases of diabetes in youth, depending on location

Diabetes Mellitus - prevalence

• Type 1 DM: Prevalence of type 1 diabetes in youth 0–19 years in US is ~2/1,000.
• Type 2 DM:
  • Estimated prevalence of type 2 DM in youth of 4.1/1,000
  • Estimated prevalence of impaired glucose tolerance (IGT) in youth at least 2/1,000

Diabetes Mellitus - risk factors

Diabetes Mellitus - genetics

• Susceptibility to type 1 diabetes associated with HLA region of chromosome 6, 5-fold greater risk with MHC antigen types DR3 and DR4
• Genetic defect in type 2 diabetes unknown
• Maturity-onset diabetes of youth (MODY) is a group of autosomal-dominant syndromes of partial insulin deficiency due to monogenic defects of pancreatic development or insulin secretion; they comprise a small fraction of childhood diabetes.

Diabetes Mellitus - pathophysiology

• Type 1 DM:
  • Loss of pancreatic β cells results in insulin deficiency, leading to hyperglycemia, and predominance of catabolic processes.
  • Hyperglycemia causes hyperosmolality, polyuria, and damage to small blood vessels.
  • Catabolic processes produce ketosis, weight loss, and metabolic acidosis.
• Type 2 DM: Insulin resistance and relative deficiency lead to hyperglycemia, β-cell exhaustion, and changes similar to those in type 1, but initially with greater potential for temporary reversibility.

Diabetes Mellitus - etiology

• Type 1 DM:
  • In genetically susceptible child, an environmental trigger (likely viral) induces expression of DR antigens on β-cell surface
  • Recruitment of cytotoxic lymphocytes
  • Production of anti-insulin and anti-islet cell antibodies (GAD65, ICA512)
  • Progressive inflammatory, autoimmune loss of β-cell mass results in insulin deficiency.
• Type 2 DM:
  • Insulin sensitivity diminishes due to obesity, other factors.
  • Insulin resistance leads to compensatory hyperinsulinemia to maintain euglycemia.
  • In genetically susceptible persons, insulin secretion fails to match demand, resulting in relative deficiency and hyperglycemia.

Diabetes Mellitus - associated conditions

• Type 1 DM: Autoimmune thyroid disease
• Type 2 DM:
  • Obesity
  • Depression
  • Hypertension
  • Fatty liver
  • Hyperlipidemia
  • Sleep apnea
  • Polycystic ovary syndrome

Diabetes Mellitus - DIAGNOSIS

Diabetes Mellitus - signs & symptoms

Diabetes Mellitus - history

• Polyuria, nocturia, and enuresis are related to hyperglycemia >180 mg/dL.
• Polydipsia: Due to polyuria, hyperosmolality
• Duration of symptoms varies by age: May be days in toddlers, months in adolescents
• Polyphagia: Appetite amplified by loss of calories from glycosuria; this is often absent
• Weight loss: Dehydration, loss of calories
• Malaise, nausea, vomiting, abdominal pain, hyperventilation, lethargy due to ketosis, acidosis, electrolyte depletion, hyperosmolality
• Type 2 diabetes may present like type 1 or may be entirely asymptomatic.

Diabetes Mellitus - physical exam

• Weight loss may occur in type 1 diabetes.
• Candidal vaginitis and balanitis common in young children with type 1 diabetes
• In ketoacidosis: Dehydration, hyperventilation
• Obesity and acanthosis nigricans (hypertrophic skin pigmentation of neck) in type 2

Diabetes Mellitus - tests

Diabetes Mellitus - lab

• Diagnosis based on blood glucose (BG) level: Fasting BG ≥126, random BG ≥200 mg/dL, or 2-hour BG ≥200 on oral glucose tolerance test (OGTT), and exclusion of stress hyperglycemia
• Glycosuria may be intermittent.
• Ketonuria may occur with both types 1 and 2.
• Hemoglobin A1c reflects BG levels of previous 2–3 months, is nearly always elevated at diagnosis of both types
• GAD, islet cell, and/or insulin autoantibodies nearly always positive in type 1 diabetes, but sometimes in type 2 as well
• In some patients presenting with hyperglycemia and ketosis, it is not possible to distinguish type 1 or type 2 until the course over several months has been followed.
• Some, but not all, adolescents with IGT or impaired fasting glucose (IFG) will progress to type 2 diabetes.
  • IGT is 2-hour glucose between 140 and 200 during OGTT.
  • IFG is fasting glucose between 100 and 125.

Diabetes Mellitus - differencial diagnosis

• UTI (polyuria)
• Renal glycosuria
• Stress-related hyperglycemia
• Drug-induced hyperglycemia (steroids)
• Psychogenic polydipsia
• Pneumonia (in diabetic ketoacidosis [DKA])
• Sepsis (in DKA)
• Acute surgical abdomen (in ketoacidosis)

Diabetes Mellitus - TREATMENT

Diabetes Mellitus - general measures

Insulin is given as a fixed or flexible regimen:

• Total daily dose (TDD) usually ~0.7–1.2 U/kg/d; choose higher range for ketoacidosis presentation, obesity, puberty
• Dose may decline during “honeymoon period.”
• Fixed insulin regimens can be fewer shots, but need consistent schedule and eating.
• Common fixed regimen is split-mixed: 2/3 of TDD in morning (1/3 as short acting and 2/3 long acting), and 1/3 of TDD in evening (with 1/2 as short acting and 1/2 as long acting), either at dinner or split between dinner and bedtime.
• Flexible insulin regimens consist of basal insulin plus a short-acting bolus for every carbohydrate meal and for high blood sugar.
• Basal dosing: 40–50% of TDD is given as 1 injection of glargine (very long acting) or 2 of detemir (Levemir; long acting)
• Boluses of short-acting insulin (lispro or aspart) are given for meals and snacks based on carbohydrate content and BG. Carbohydrate coverage (grams of carbohydrate covered by 1 unit) can be estimated by dividing the TDD into 500. Hyperglycemia coverage can be estimated by dividing the TDD into 1,800 to find how much 1 unit may lower blood sugar.
• SC insulin infusion by pump is another flexible method: Dosing is similar.

Diabetes Mellitus - diet

• Dietary education for type 1 diabetes is directed toward healthy distribution and matching of carbohydrate intake with insulin action
  • Recommended distribution of calories: 55% from carbohydrates (mostly complex); 30% from fats; 15% from protein
  • Fixed insulin regimens require snacks spaced between meals and before bedtime.
  • Carbohydrate counting is essential for flexible insulin regimens and helpful for maintaining consistency for fixed regimens.
• In type 2 diabetes, dietary education is directed toward promoting weight loss.
• Reduction of saturated and trans fats may be beneficial in both types of diabetes.

Diabetes Mellitus - activity

• Frequent exercise reduces BG and insulin requirements in both types of diabetes.
• Exercise may require extra eating or reduced insulin to prevent hypoglycemia in type 1 diabetes.

Diabetes Mellitus - medication

(See insulin regimens under “General Measures”)

In type 2 diabetes, insulin is usually used for symptomatic hyperglycemia. Oral antidiabetic agents may be effective for milder hyperglycemia:

• Metformin is the only oral agent approved for children; it reduces hepatic glucose output.
• Other agents used in adults may be useful in certain circumstances: Sulfonylureas, glinides, thiazolidinediones, α-glucosidase inhibitors, exendin, dipeptidyl protease inhibitors, endocannabinoid antagonists

Diabetes Mellitus - surgery

Bariatric surgery may reverse type 2 diabetes.

Diabetes Mellitus - FOLLOW UP

Diabetes Mellitus - complications

• DKA: Most common cause of hospitalization and death in type 1 diabetes in childhood. See separate article.
• Hypoglycemia: This most common acute complication limits achievable glycemic control. If severe, may cause seizure, unconsciousness
• Long-term harm may be reduced by better glycemic control:
  • Nephropathy: Microalbuminuria, hypertension are 1st manifestations before adulthood
  • Retinopathy: Blood vessel changes may occur in childhood, but not vision loss
  • Neuropathy: Diminished nerve conduction velocity common, symptoms uncommon
  • Vasculopathy: Large-vessel disease begins in childhood, but clinical effects occur in adults.
  • Prenatal harm to infants of diabetic mothers: Birth defects occur early, large size late
  • Growth failure (Mauriac syndrome) and delayed sexual maturation
• Depression, family stress, higher divorce rate

Diabetes Mellitus - patient monitoring

• Regular appointments with diabetes specialist every 3 months to assess management:
  • Is diabetes interfering with emotional health, family relationships, school attendance, athletic activities, or social development?
  • Is family minimizing hospitalization risks from hypoglycemia or DKA with appropriate adjustment of insulin, recognition of lows, glucagon availability, ketone testing, and telephone contact?
  • Is family reducing long-term complication risk by keeping HbA1c lower and by avoiding or treating other risk factors?
  • Examination: Growth, weight, pubertal status, blood pressure, thyromegaly, liver size, injection sites, feet, skin lesions
• Meet with nutritionist periodically or as needed to reassess meal plan.
• Meet with psychologist or social worker as needed to address psychosocial issues.
• Annual screening for long-term complications:
  • Urine for microalbumin
  • Lipid profile, T4, TSH, celiac screen
  • Eye exam to detect early retinopathy

Diabetes Mellitus - bibliography

1. American Diabetes Association. Clinical practice recommendations: 2007. Diabetes Care. 2007;30:S3–S103.
2. American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics. 2000;105:671–680.
3. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986.
4. Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents. Lancet. 2007;369:1823–1831.
5. Weiss R, Dufour S, Taksali SE, et al. Prediabetes in obese youth: A syndrome of impaired glucose tolerance, severe insulin resistance, and altered myocellular and abdominal fat partitioning. Lancet. 2003;362:951–957.

Diabetes Mellitus - ADDITIONAL READING

• Sperling M, ed. Diabetes mellitus in children. Pediatric Clinics of North America. Philadelphia: WB Saunders; 2005:1533–1872.

Diabetes Mellitus - CODES

Diabetes Mellitus - icd9

250.0 Diabetes mellitus without mention of complication

Diabetes Mellitus - PATIENT TEACHING-MED

• Home BG monitoring before meals, when feeling hypoglycemic or ill
• Insulin injection and site rotation
• Oral carbohydrate for mild hypoglycemia; glucagon 1 mg IM for severe hypoglycemia

Diabetes Mellitus - diet

Carbohydrate counting

Diabetes Mellitus - activity

Detecting or preventing hypoglycemia during or after physical exercise

Diabetes Mellitus - prevent

Checking urine for ketones when blood sugar is high or child feels ill; extra insulin for ketones

Diabetes Mellitus - FAQ

• Q: What is the next big management change?
• A: Continuous glucose sensors allow patients to avoid symptomatic high and low glucoses by detecting trends, to see the outcome of management decisions, and to reduce the risk of severe nocturnal hypoglycemia.
• Q: What is the risk of diabetes in a sibling or child of a person with type 1 DM?
• A: It is 5–10% in 1st-degree relatives (siblings, offspring) and 40–50% in identical twins.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Gestational diabetes

• Back to disease: Gestational diabetes: Introduction
• Next Book Extract About Gestational diabetes: Surveys relating to Gestational diabetes
• More Book Extracts: All Online Books for Gestational diabetes

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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