Acute presentations of diabetes

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Acute presentations of diabetes

• Dr Debbie Matthews
• Consultant Paediatric Endocrinologist
• Newcastle Hospitals NHS

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Emma

• Presented at 10 months of age referred by GP
• 3 day history of vomiting poor feeding
• 1 day history of lethargy shortness of breath
• O/E pyrexial 38C, shocked, dehydrated (c7),
  tachypnoeic RR 70. Poorly responsive, modified
  GCS 8

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Investigations

• Na 131, K 5.2, urea 12.2, creatinine 123
• FBC Hb 13.1, WCC 13.8, Plts 244
• Blood culture no growth
• CXR ? Hyperexpanded, lungfields clear
• What other investigations would you do?

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Diabetic ketoacidosis

• Hyperglycaemia (BG gt11mmol/L)
• Ketonaemia
• Acidosis (pHlt7.3, HCO3 lt15mmol/L)
• Glycosuria
• Ketonuria

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Management of diabetic ketoacidosis (1)

• General Resuscitation A, B, C
• If shocked, give 10ml/kg of 0.9 saline as bolus
  and repeat as necessary
• Assess degree of dehydration
• Ix include BG, blood gas, UE, bicarbonate, FBC,
  osmolality

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Management of diabetic ketoacidosis
(2)Conscious level

• Half hourly neurological observations
• If in coma or deteriorates-
• Record GCS or AVPU scale
• Transfer PICU
• Consider instituting treatment for cerebral
  oedema

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Management of diabetic ketoacidosis (3)Degree
of dehydration

• 3 just detectable
• 5 dry mucous membranes
• 7.5 sunken eyes, ?skin turgor, poor CRT
• 10 poor perfusion, thready pulse
• Use recent weight

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Management of diabetic ketoacidosis (4) Full
examination

• Weight
• ? Evidence of cerebral oedema
• ? Infection
• ?Ileus

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Management of diabetic ketoacidosis (5)Consider
PICU if-

• Severe acidosis pHlt7.1, marked hyperventilation
• Severe dehydration with shock
• ? GCS
• Suspected cerebral oedema
• lt2 years of age

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Management of diabetic ketoacidosis
(6)Observations

• Strict fluid balance including urine output
• Half hourly neuro obs initially
• Hourly capillary BG monitoring
• Weigh bed or twice daily weight

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Management of diabetic ketoacidosis(7)Fluids

• Fluid to be given over 48 hours
• (48hrs maintenance deficit) - resuscitation
  fluid
• Initial fluid 0.9 saline 20mmol KCl per 500ml
• Once BG lt14mmol/l, change to 0.45 saline 5
  dextrose 20mmol KCl
• Check UE blood gas every 2-4 hours

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Potassium in DKA

• Total body potassium depleted in DKA
• Plasma levels low, normal or high
• Levels fall when insulin is given
• Give 20mmols/l per 500 mls

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Insulin therapy in DKA

• Essential to switch off ketogenesis reverse
  acidosis
• Delay start of insulin therapy for c 1 hour while
  rehydration fluid is running
• Continuous low dose insulin infusion is preferred
  method for treating DKA

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Insulin therapy in DKA (2)

• 50 units Actrapid in 50mls 0.9 saline via
  syringe pump.
• Starting dose of insulin 0.05u/kg/hr
• If plasma glucose remains gt 20, review dose and
  consider increasing to 0.07 or 0.1u/kg/hr
• If BG falls by gt5mmol/l/hr or to lt 14mmol/l,
  change to 0.45 saline 5 dextrose KCl

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Insulin therapy in DKA (3)

• If BG is 4-6mmol/l change to 0.45saline 10
  dextrose with added potassium
• If BG falls lt4mmol/l, give bolus of 2ml/kg 10
  dextrose and then continue as above. Retest BG
  after 30 minutes
• If BG remains low, discuss with Consultant. It
  may be appropriate to reduce the insulin infusion
  although not to stop it

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Changing to subcutaneous insulin

• Child may still have urinary ketones
• Child should be able to tolerate oral food/fluids
• Discontinue insulin infusion 10-60 minutes after
  the first subcutaneous injection, depending on
  type of insulin used

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General Comments

• Remember children can die from DKA
• They can die from-
• Cerebral oedema
• Hypokalaemia
• Aspiration pneumonia

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Signs symptoms of cerebral oedema

• Headache and slowing of pulse rate
• Change in neurological status restlessness,
  confusion, drowsiness, incontinence
• Specific neurological signs cranial nerve
  palsies, abnormal posturing
• Rising BP
• Reduced SpO2

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Management of cerebral oedema

• Exclude hypoglycaemia
• Give mannitol 0.5g/kg stat over 15 minutes.
  Repeat after 2 hrs if no response
• Nurse with head elevated to 450
• Restrict IV fluids to 2/3 maintenance and replace
  deficit over 72 hours
• Transfer to PICU
• Arrange CT scan to exclude other pathology

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Summary

• DKA is serious complication of diabetes and can
  be fatal
• Metabolic abnormalities need to be reversed
  slowly over 48 hours
• The insulin deficiency needs to be corrected by
  continuous insulin infusion

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Other acute presentations of diabetes mellitus

• "Walking wounded"
• Incidental finding of hyperglycaemia or
  glycosuria
• These may be non-diabetic
• Early diabetes
• Non-Type 1 diabetes

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Chronic Management of Type 1 Diabetes mellitus

• Dr Debbie Matthews
• Consultant Paediatric Endocrinologist
• Newcastle Hospitals NHS

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Aims of treatment

• No symptoms day to day
• Good general health
• Normal growth puberty
• Normal school peer group relations
• Prevention of long term complications

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Patient Pathway from diagnosis

• 12 year old girl admitted as emergency from GP
  with 3/52 H/O polyuria, polydipsia and weight
  loss
• Blood glucose 25mmol/l.
• Otherwise well
• How will you manage this patient?

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How????

• Multidisciplinary team
• Paediatrician with special interest
• Diabetes specialist nurse
• Dietitian
• Psychologist
• Input from GP, SW, school teachers, sports
  coaches
• Support from family critical

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Insulin molecule is found in hexamers
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Insulin Preparations

• Rapid acting insulin analogues
• Short acting (soluble)
• Intermediate
• Long acting analogues

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Rapid acting insulin analogues

• Novorapid
• Amino acid at B28 has aspartic acid
  substituted for proline which prevents hexamer
  formation and speeds up action

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Long acting insulin analogues

• Insulin Glargine
• Formulated at pH4 and injected as
  water-soluble.
• At pH7, forms hexamers precipitates under
  skin. Gradually released in biologically active
  form.
• Claimed to be "peakless"

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Injection devices
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Insulin administration

• Abdomen gt Arm gt Bottom
• Timing of insulin-
• rapid-acting
• basal

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Insulin regimens

• Insulin doses 0.5-1.0u/kg/d
• Up to 1.5u/kg/d in puberty
• Frequency from once daily to multiple injections
• CSII (continuous subcutaneous infusion of insulin)

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Minimed Insulin pump
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Blood testing
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Blood testing

• Pre-prandial aim 4-8
• Post-prandial aim lt10
• Number of tests per day
• What about night-time monitoring?
• CGMS

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Advantages of continuous blood glucose monitoring
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Patient with insulin pump and continuous blood
glucose monitor
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Food Carbohydrate Counting

• Healthy eating
• Diet more flexible with multiple injection
  regimens and CSII
• DAFNE

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"Hypos"

• "Four is the floor"
• Recognition of symptoms
• Pre-school children suffering significant hypos
  may be at risk of longterm neurocognitive
  dysfunction
• "Dead-in-bed"
• Alcohol

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Treatment of hypos

• Dextrose tablets or lucozade
• Give 10g CHO Wait 15 mins. If still symptomatic,
  repeat.
• Give long-acting CHO when no longer symptomatic
• Glucagon

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Glucagon kit
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Treatment of high blood glucose levels

• Exercise
• Novorapid/ Humalog
• The "100 Rule"

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Exercise

• Blood testing
• Effects of exercise on blood glucose
• Effect of exercise on insulin sensitivity

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Monitoring of diabetes

• Glycaemic control
• HbA1c
• Blood glucose results
• Annual review for associated conditions and late
  effects
• Other concerns
• EDUCATION

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HbA1c
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Other conditions associated with Type 1 diabetes

• Coeliac disease
• Thyroid disease
• Addisons disease
• Other autoimmune conditions

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Normal jejunal biopsy and biopsy in coeliac
disease
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Longterm complications of diabetes relevant to
children young people

• Risk of complications is related to duration of
  condition glycaemic control. Some genetic
  component
• Macrovascular disease
• Microvascular disease
• Eyes
• Kidneys
• Nerves

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Complications seen in adolescents with Type 1
diabetes

• Background retinopathy
• Microalbuminuria
• Painful peripheral neuropathy
• Autonomic neuropathy

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How????

• Education
• Support
• Empowerment

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Unusual forms of diabetes in children young
people

• Maturity onset diabetes in the young
• Type 2 diabetes
• Steroid-induced diabetes
• Cystic fibrosis related diabetes
• Others eg mitochondrial disease, Friedreich's
  ataxia

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Maturity onset diabetes in the young

• Misnomer - not Type 2 diabetes
• Hereditary, monogenic, usually dominant.
• Mutations in genes causing disruption of insulin
  production or release
• Usually act like mild T1DM but variable
• MODY3 is most common (HNF1a mutation)
• Many forms can be treated with oral hypoglcaemic
  agents

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Maturity onset diabetes in the young (2)

• When to suspect MODY and not T1DM-
• Diagnosis of DM lt 6 months of age
• FH of diabetes with 1 parent affected
• Persistence of low insulin requirements
  (lt0.5U/kg/d)
• Absence of autoantibodies or H/O autoimmune
  disease in family

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Type 2 Diabetes Mellitus

• Patients overweight, especially around abdomen
• Ethnic background (Afro-Caribbean, Asian)
• Family history (but polygenic inheritance, not
  monogenic)
• Associated problems eg hypertension, PCOS

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Causes of Type 2 diabetes
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Type 2 Diabetes (2)

• Typically present with thirst, polyuria,
  infections eg thrush, boils, tiredness
• Often strong FH T2DM
• c5 present with DKA
• 90 have acanthosis

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Acanthosis nigricans
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Type 2 diabetes (3)

• Diagnosis of T2DM with oral glucose tolerance
  test
• Elevated HbA1c, absence of autoantibodies
• Treatment is with lifestyle measures, metformin,
  sulphonylureas, glitazones or insulin
• Becoming more common in young people

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The Obesity Epidemic

• Dr Debbie MatthewsConsultant Paediatric
  EndocrinologistNewcastle Hospitals NHS

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• Energy stores Energy intake minus
  Energy expenditure
• In children, some of energy stores used for growth

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Definition of Obesity

• The definition of obesity in adults is a
  BMIgt30kg/m2
• BMI is not static in children and varies
  according to sex. BMI centiles needed
• UK National BMI percentile classification . Uses
  85th 95th percentiles of 1990 UK data as
  cutoffs for overweight obesity
• International Obesity Taskforce. Centile curves
  drawn that at age18 pass through BMI 30

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Key Facts on Obesity

• Obesity is one of the major public health issues
  in the developed world
• In 2003, 22 ? 23 ? were obese. By 2010, will
  increase to 33 ? 28 ?.
• Childhood obesity in 2-10 year olds in England
  has risen from 9.9 in 1995 to 14.3 in 2004

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Increasing prevalence of obesity in England
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Childhood obesity in Newcastle

• 4287 children in Newcastle were height weight
  measured at school entry or Year 6 in 2006.
• 29.5 children were overweight or obese
• 17.5 children were overweight
• 12 children were obese

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What are the reasons for the increase in
childhood obesity in the UK?

• Environmental
• Less exercise
• Food high in fat and simple sugars
• Effect of poverty
• What about genetics and any underlying pathology?

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Lifestyle issues in children
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The "School run"
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What are the reasons for the increase in
childhood obesity in the UK?

• Environmental
• Less exercise
• Food high in fat and simple sugars
• Effect of poverty
• What about genetics and any underlying pathology?

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What are the reasons for the increase in
childhood obesity in the UK?

• Environmental
• Less exercise
• Food high in fat and simple sugars
• Effect of poverty
• What about genetics and any underlying pathology?

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Leptin deficient child pre and post treatment
with leptin
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Healthy Eating Stall in School
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Healthy Weight, Healthy Lives

• A Cross Government Strategy for England
• New 372 million strategy to help everyone lead
  healthier lives
• Published in Jan 2008 by Alan Johnson Ed Balls
  (Sec of State for Children, Schools Families)
• Targets Early Years, Schools food, sport
  physical activity, planning, transport Health
  Service

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Healthy Weight, Healthy Lives (2)

• National Child Measurement Programme
• Healthy Schools Programme
• Food in Schools Programme
• School Fruit Vegetable Scheme
• Physical Education, School Sport and Club Links
  Programme

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Obesity Strategy for Newcastle upon Tyne

• Obesity is more common in lower socioeconomic and
  socially disadvantaged groups
• Obesity almost 4x more common in Asian than in
  white children
• Target to halt by 2010 (from 2004 baseline) the
  year-on-year increase in obesity in children
  lt11yrs

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Obesity Strategy for Newcastle upon Tyne (2)

• Nurseries should minimise sedentary activities at
  playtime and provide healthy meals
• Healthy Schools Programme
• Mothers encouraged to breast feed
• Teach Cooking skills (community food projects
  throughout city)
• Encourage Physical activity (On the Go)

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• Is it Working???
• "Lost Generation"
• Current parents are the first generation to have
  a life expectancy greater than their children