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Paediatric And Adolescent Diabetes Care

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

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  1. Paediatric And Adolescent Diabetes Care Dr Noman Ahmad 3rd February 2011 Cork University Hospital

  2. Presentation Outline • Definition • Classification • Pathophysiology • Clinical Presentation • Insulin types and regimens • Insulin dose in different age groups • Follow-up/Monitoring

  3. Learning Objectives • Understanding of insulin pharmacokinetics • Right insulin regimen • Aims of glycaemic control • Complexity of management in different age groups

  4. 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

  5. Insulin Physiology

  6. 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

  7. 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

  8. Pathophysiology T1DM • Environmental factors • Viruses (Entero, Coxsackie, EBV) • Cow’s milk • Perinatal factors • Vitamin D

  9. Pathophysiology T1DM • Association with other autoimmune diseases • Thyroid 20% • Adrenal 1.7% • Coeliac disease 10% • Polyglandular autoimmune disease

  10. Pathophysiology T1DM

  11. Pathophysiology of T2DM

  12. Presentation of T1DM • Classic (most common) • Polyuria, polydipsia and weight loss • Diabetic ketoacidosis • Hyperglycaemia, metabolic acidosis and ketonuria • Silent • Usually siblings of known cases

  13. 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

  14. Acanthosis Nigricans

  15. INSULIN TYPES • Short acting • Regular • Analogs (Novorapid,Humolog,Apidra) • Intermediate acting • NPH • Long acting • Detemir (Levemir) • Glargine (Lantus)

  16. Pharmacokinetics

  17. Pharmacokinetics

  18. 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)

  19. 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

  20. Novorapid Insultard(NPH) 0 30 4 6 12 16 18 Conventional Regimen

  21. Insulin Regimen (MDI)

  22. 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

  23. Insulin Pump • Continuous basal infusion • Bolus with every meal or snack • Correction bolus • Regular or rapid insulin

  24. Insulin Pump

  25. Insulin Pump

  26. Insulin Pump • Advantages • Flexible • Precise • Better glycaemic control • Less variability • Less Hypoglycemia • Less long term complication

  27. Insulin Pump • Disadvantage • Tethered with device • Cost • Infection • Equipment failure • Carbohydrate counting • DKA • Hinder in some activities

  28. Injection Sites • Fast absorption in abdomen • Slow in legs • Intermediate in arms • Subcutaneous fat • Skin very slow absorption • Muscles too fast

  29. High Insulin Doses • Growth • Puberty • Sickness • Stress • Active/competitive sports • Steroid therapy • No physical activity

  30. 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

  31. Target HbA1C • CDA 2008 • <6 years 8.5% • 6-12 < 8% • >12 years ≤ 7% • ISPAD 2009 • < 7.5% for all kids

  32. Clinic Visit • History • Glucose diary • Hypoglycaemia • Intercurrent illness • Thyroid, adrenal, coeliac • Exercise • Hypoglycaemia supplies

  33. Clinic Visit • Examination • Growth, weight, BP • Thyroid • Injection sites • Finger poke sites • Pubertal exam • Retinal exam • Prayer signs

  34. Clinic Visit • Investigations • HbA1C every 3 months • TSH annually • Coeliac screen • Lipid profile • Albumin creatinine ratio • Eye exam

  35. Infants And Toddlers • Brain is very sensitive to hypoglycaemia • Sensitive to Regular/rapid insulin • Picky eater • May need to give insulin after meals

  36. Adolescents • Insulin resistance • Non compliance • Fabrication • Denial • Eating out and snacking • Family conflicts • Alcohol • Eating disorders

  37. QUESTIONS

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