Definition, epidemiology and classification of diabetes in children and adolescents

1. Definition, epidemiology and classification ofdiabetes in children and adolescents Dr: PeymanEshraghi Assistant professor of pediatric endocrinology Mashhad school of medicine

3. Definition • Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. If ketones are present in blood or urine, treatment is urgent, because ketoacidosis can evolve rapidly.

4. تاریخچه • اولین سند در1500 سال پیش از میلاد مسیح در یکی از قبرهای اهرام ثلاثه مصرتوسط باستان شناس انگلیسی بنام جورج عبرس پیدا شد.این لوحه بنام عبرس پاپیروس مشهور است و ذکرکرده است که این بیماران زیاد آب مینوشند،ادرار بیش از حد دارند،آب بدنشان تحلیل میرودو زودتر میمیرند.برای درمان چهار روز مخلوطی از غلات، برنج،سبزیجات و خاک پیشنهاد شده.در قرن دوم میلادی آری تیاس اسم این بیماری را دیابت میگذارد.دیابت در زبان یونانی بمعنی سیفون است.یعنی آبی که از بالا میآید و از پایین خارج میشود.

5. در قرن پنجم میلادی دو پزشک هندی با چشیدن ادرار تشخیص دادند ادرار دیابتیها شیرین است و آنرا مدهومه ها (ادرار عسلی)نامیدند. • در قرن 16 یک پزشک سوییسی بعد از جوشاندن ادرار بیماران متوجه ماده سفیدی میشودو میگوید این نمک است. • در قرن 17 توماس ولس پزشک انگلیسی دوباره ادرار بیماران را میجوشاند و در می یابد آن ماده سفید قند است. • در قرن 18 متیو داپسون برای اولین بار شرح میدهد که نه تنها ادرار دیابتیها بلکه سرم آنها نیز شیرین است و پزشکان برای اولین بار متوجه میشوند که علت بیماری در خون است.

6. در ابتدای قرن بیستم نظریه بنیادین علت دیابت مطرح شد:بیماری دیابت بعلت کمبود ماده ایست که لوزالمعده سالم آنرا میسازد. گیورگ زولزر ،دانشمند آلمانی در سال 1908نشان داد با تزریق عصاره لوزالمعده میتوان وارد شدن گلوکز به ادرار را کاهش داد.سپس در سال 1921فردریک بنتینگ پروتیینی بنام انسولین را از لوزالمعده بدست آوردکه با تزریق آن به کودکی 14 ساله در تورنتوی کاناداعلایم دیابت بهبود یافت و جایزه نوبل سال 1923را برای وی به ارمغان آورد.

7. کاشف انسولينfredricbanting

8. Diagnostic criteria for diabetes in childhood and adolescence • Three ways to diagnose diabetes are possible and each, in the absence of unequivocal hyperglycemia, must be confirmed, on a subsequent day, by any one of the three methods given in Table

9. Criteria for the diagnosis of diabetes mellitus • 1. Symptoms of diabetes plus casual plasma glucose concentration ≥11.1 mmol/L (200 mg/dl)∗. Casual is defined as any time of day without regard to time since last meal. or • 2. Fasting plasma glucose ≥7.0 mmol/l (≥126 mg/dl).† Fasting is defined as no caloric intake for at least 8 h. or • 3. 2-hour postload glucose ≥11.1 mmol/l (≥200 mg/dl) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water or 1.75 g/kg of body weight to a maximum of 75 g . • ∗Corresponding values (mmol/L) are ≥10.0 for venous whole blood and ≥11.1 for capillary whole blood and †≥6.3 for both venous and capillary whole blood

10. In the absence of symptoms or presence of mild symptoms of diabetes, hyperglycemia detected incidentally or under conditions of acute infective, traumatic, circulatory or other stress may be transitory and should not in itself be regarded as diagnostic of diabetes. • An OGTT should not be performed if diabetes can be diagnosed using fasting, random or post-prandial criteria as excessive hyperglycemia can result.

11. Impaired glucose tolerance (IGT) and impaired fasting glycemia (IFG) • FPG<5.6 mmol/l (100 mg/dl) = normal fasting glucose • FPG 5.6–6.9 mmol/l (100–125 mg/dl) = IFG • FPG≥7.0 mmol/l (126 mg/dl) = diagnosis • 2 hour postload glucose<7.8 mmol/l (140 mg/dl) = normal glucose tolerance • 2 hour postload glucose 7.8—11.1 mmol/l (140–199 mg/dl) = IGT • 2 hour postload glucose>11.1 mmol/l (200 mg/dl) = diagnosis of diabetes

12. Epidemiology of type 1 diabetes • type 1 diabetes accounts for over 90% of childhood and adolescent diabetes, less than half of individuals with type 1 diabetes are diagnosed before the age of 15 years. • Mean annual incidence rates for childhood type 1 diabetes (0–14 years age group) comparing different countries of the world are shown in Figure 1 (0.1 to 57.6 per 100,000)

14. In Asia, the incidence of type 1 diabetes is extremely low • A seasonal variation in the presentation of new cases is well described, with the peak being in the winter months • Type 1 diabetes is 2–3 times more common in the offspring of diabetic men (3.6–8.5%) compared with diabetic women (1.3–3.6%)

15. The possibility of other types of diabetes should be considered in the child who has: • an autosomal dominant family history of diabetes. • associated conditions such as deafness, optic atrophy or syndromic features. • marked insulin resistance or require little or no insulin outside the partial remission phase. • A history of exposure to drugs known to be toxic to beta cells or cause insulin resistance.

16. Classification

17. Neonatal diabetes • Permanent cases have been associated with pancreatic aplasia, activating mutations of KCNJ11, which is the gene encoding the ATP-Sensitive Potassium-Channel Subunit Kir6.2

18. Mitochondrial diabetes • Mitochondrial diabetes is commonly associated with sensorineural deafness and is characterised by progressive non-autoimmune beta-cell failure.

19. Cystic fibrosis and diabetes • Cystic Fibrosis related diabetes (CFRD) is primarily due to insulin deficiency, but insulin resistance during acute illness, secondary to infections and medications (bronchodilators and glucocorticoids),may also contribute to impaired glucose tolerance and diabetes.

20. Screening recommendations vary from testing a random blood glucose level annually in all children with cystic fibrosis ≥14 years old, • Insulin therapy initially may only be needed during respiratory infections due to acute or chronic infective episodes, but eventually insulin therapy is frequently necessary.

21. Drug induced diabetes • In neurosurgery, large doses of dexamethasone are frequently used to prevent cerebral oedema (egdexamethasone 24 mg per day). The additional stress of the surgery may add to the drug-induced insulin resistance, and cause a relative insulin deficiency, sufficient to cause a transient form of diabetes. This will be exacerbated if large volumes of intravenous dextrose are given for diabetes insipidus. An intravenous insulin infusion is the optimal way to control the hyperglycemia which is usually transient.

22. Drug induced diabetes • In oncology, protocols which employ L-asparaginase , high dose glucocorticoids, cyclosporin or tacrolimus (FK506) may be associated with diabetes. L-asparaginase usually causes a reversible form of diabetes (B). Tacrolimus and cyclosporin may cause a permanent form of diabetes possibly due to islet cell destruction.

23. Stress hyperglycemia • Stress hyperglycemia has been reported in up to 5% of children presenting to an emergency department. • The reported incidence of progression to overt diabetes varies from 0% to 32%. • Islet cell antibodies and insulin autoantibody testing had a high positive and negative predictive value for type 1 diabetes in children with stress hyperglycemia .