Professional Documents
Culture Documents
onfirmed;
at methodical meeting
of hospital pediatrics 1 department
hief of department
professor _____________V. A. Kondratyev
______ _________________ 2013 y.
METODOLOGICAL INSTRUCTIONS
FOR STUDENTS SELF-WORK TO PREPARE FOR PRACTICAL STUD
Educational discipline
module
Substantial module
Theme of the lesson
Course
Faculty
pediatrics
3
11
DIABETES MELLITUS AT CHILDREN
5
medical
Dnepropetrovsk, 2013.
1.Urgency of the theme: Insulin-dependent diabetes mellitus (DM) is one of the most
widespread diseases of endocrine system at children and adolescents. In Ukraine there is more
than 5 thousand children having diabetes. Thus it is annually registered from 500 to 1000 cases of
again revealed sick children which forms 5-10 per 100 thousand children's population of Ukraine.
DM is chronic disease, basis of which is quickly progressing absolute or relative insulin
insufficiency and hyperglycemia, which causes severe metabolic disorders, up to development of
comas.
High morbidity, severity of the course of the disease, fast progressing development of
complications, disability and high death rate of persons of young and mature age, having DM in
the childhood, define an urgency of a problem of type I diabetes.
Timely diagnostics and the organisation of contemporary adequate treatment of type I diabetes at
children allow not only to improve quality of a life of person, having incurable disease, but also
considerably increase the life time.
2. Specific goals:
A.Student should know:
1. Definition of "diabetes mellitus ".
2. Classification of DM at children.
3. Contemporary considerations on the aetiology and pathogenesis of diabetes:
Value of genetic factors .
Value of infectious diseases.
Immunity disorder.
Value of pancreatic diseases.
Value of mental and physical factors.
4. Clinical symptoms of different variants of diabetes course at children.
5. An insulin-dependent diabetes at children.
6. A latent diabetes at children.
7. A manifested diabetes at children.
8. Criteria of compensation of diabetes at children.
9. Contemporary requirements to insulin-therapy of diabetes.
10. Complications of insulin-therapy, prevention and treatment.
11. Principles of dietotherapy of diabetes mellitus at children.
12. Principles of urgent help at different kinds of comas in children.
13. Principles of dispensary measures of children having DM.
B.Student should be able:
1. To develop the scheme of diagnostic search at DM.
2. To take the history of the patient with DM.
3. To examine the patient.
4. To evaluate the laboratory data. To choose from analyses the data which testify the DM.
5. To reveal clinical criteria of diagnosis of different forms of DM.
6. To formulate the developed clinical diagnosis according to classification.
7. To make the differential diagnosis of diabetes with other childhood diseases.
8. Make a differential diagnosis of DMs comas with comas of other origin.
9. To appoint treatment taking into account the disease form.
10. To carry out disease prophylaxis.
Definition
Fasting blood glucose level. N - 3, 3-5,5 Mmol/l
Blood glucose level after food intake. N - 4, 47,0 Mmol/l
Urine glucose level. N - 0.
Ability of carbohydrates uptake; it is defined by
means of glucose tolerance test.
Defines quality of control of the disorder of
carbohydrate metabolism. N - 6%.
Fasting glycemia 7, 0-9,0, Mmol/l postprandial 11, 1-14,0 Mmol/l, at night no less < 3,6
Mmol/l, 1<7,6%.
Fasting glycemia 4, 0-7,0 Mmol/l, postprandial 5, 0-11,0 Mmol/l, at night- no less < 3,6 or >9,0
Mmol/l, 1 7, 6-9,0 %.
Fasting glycemia >9,0 Mmol/l, postprandial>14,0 Mmol/l, at night -< 3,0 or >11,0 Mmol/l,
1 >9,0 %.
Quantity of the product which contains 12 g of
light carbohydrates.
Beginning of action: 30 (10-20) minutes, action
peak: 1-3 hour, the maximum duration of action:
6-8 (3-5) h.
Beginning of action: 1-2 hour, action peak: 4-12
hour, the maximum duration of action: 18-24
hour.
Beginning of action: 0, 5-1,0 h., action peak: 5-9
h., the maximum duration of action: 18-24 h..
Beginning of action: 0,5-1,0 h., action peak: 5-9
h., the maximum duration of action: 18-24 h.
Beginning of action: 10-20 min., action peak: 13h., 4-12 hour., the maximum duration of action:
18-24 hour.
Beginning of action: 1, 0-2,0 h., without peak,
the maximum duration of action: 11-24 hour
(Lantus), 16-24 hour (Levemir).
7,34
Negative
0, 6-1,7 Mmol/l
300 msm/l
3. Glycosuria
4. Tolerance to carbohydrates
5.Glycosylated haemoglobin (1, 1)
6. DM compensation (optimal glycemic control)
7. DM subcompensation (suboptimal glycemic
control)
8. DM decompensation (glycemic control of
high risk)
9. Bread unit
10. Insulin of short action (Actrapid NM,
Humulin Regular, Insuman Rapid) and its
analoges ( Novorapid, Epaidra, Humalog)
11. Insulin of long action
(Protafan NM , Humulin NPH, Insuman Bazal)
12. Preliminary mixed 30/70 (Mikstard 30/70,
Humulin 3)
13.Preliminary mixed 50/50
14 Preliminary mixed analog of insulin.
(Novomix 30)
Diabetes mellitus type II (with prevailing resistance to insulin and relative insulin insufficiency or
with mainly secretory defect and thr resistance to insulin or without it).
Gestational diabetes mellitus
Other specific types:
. Genetic defects of the -cells function:
. Genetic defects at the insulin action:
. Diseases of the eczocrine part of the pancreas:
D. Endocrinopathies:
E. Diabetes mellitus, induced by drugs and chemical agents
F. Infections:
G. Unusual forms of immunogenic diabetes:
H. Other genetic syndromes, associated with diabetes:
Classification according to the degree of severity
Light form. Absent cetoacydosis, comas in anamnesis, there are no micro and macrovascular
complications of DM, there can be a diabetic retinopathy of the 1 degree or nephropathy of thr 12 degrees, achievement of ideal (optimum) glycemic control of DM is reached by the diet,
physical activities, phytotherapy.
Moderate severety:
In the anamnesis cetoacydosis; diabetic retinopathy of the 1 degree
(nonproliferative), diabetic nephropathy of the 3 degree (stage of microalbuminuria), diabetic
arthropathy, hayropathy of the first stage, diabetic foot angyopathy of the 2-3 st., diabetic distal
polyneuropathy, for the achievement of ideal (optimum) glycemic control insulin or the tableted
sugar-lowering medications or their combinations are used.
Severe form. Labile course of disease (frequent ketoacydosis, ketoacydotic comas), diabetic
retinopathy of the 2 st. (preproliferative) or 3 st. (proliferative), nephropathy of the 4 st.
(proteinuria stage) or 5 st. with chronic kidney disease, autonomic diabetic neuropathy of
different organs, somatic polyneuropathy with the expressed pain syndrome, diabetic
encephalopathy, diabetic cataracta, including the decreased vision, diabetic macroangiopathy,
diabetic osteoarthropathy, , hayropathy of the 2-3 st., delay of physical and sexual development
(Mauriac and Nobekur's syndrome), patients need permanent injections of insulin.
Classification by the degree of glycemic control:
- ideal;
- optimal;
- suboptical;
- high risk for life.
3. Etiopathogenetic theories of diabetes at children's age.
Risk factors: hereditary predisposition, exogenous factors (viral infections, effects of chemicals,
toxins, obesity, increased fat, simple carbohydrates consumption,). Pathogenetically DM - an
autoimmune disease. Stages of pathogenesis
- Genetic predisposition
- Initiation of autoimmune processes by different agents
- Stage of active autoimmune processes (chronic autoimmune insulit)
- Progressive decrease in secretion of insulin
- Death of 80-90% of pancreatic -cells pancreas, process manifestation
- Full destruction of pancreatic -cells
- Hyperglycemia, deficiency of glucose in the cell, activation of glycogenolysis, then gluconeogenesis, accumulation of ketone bodies, acids with the development of diabetic
ketoacydosis.
after calculation of quantity of calories which fall on carbohydrates, define quantity of the
grain units (GU) for the possibility of carrying out mutual substitution of products (10-12 g of
carbohydrates of food are accepted for 1 GU) that allows to replace products by equivalent
amount of carbohydrates;
8. Requirements to the insulin administration at children.
For the treatment of children and adolescents only human genetically engineered insulin or insulin
analogs are recommended for usage.
There are used medications of ultrashort, short action, medium, long action and a mix of insulin
medications of different duration action in the different ratio.
Daily requirement for insulin:
Diabetes debut - 0, 5-0,6 U/kg
Remission period - < 0,5 U/kg
Long-lasting diabetes - 0, 7-0,8 U/kg
Glycemic control with high risk (ketoacydosis)- 1, 0-1,5 U/kg
Prepubertal period - 0, 6-1,0 U/kg
Puberal period - 1, 0-2,0 U/kg
9. Complications of insulin therapy, their prevention and treatment.
Lipodistrofy: Changes of skin and subcutaneous tissues in the form of atrophy or hypertrophy
in the places of insulin injection.
Treatment:
1 . Change of places of insulin injection.
2 . Physiotherapeutic treatment: laser therapy to the lipodistorfic regions; ultrasonic therapy on
lipodistorfic regions - independently or alternating to laser therapy; hyperbaric oxygenation.
Somodzhi's syndrome is the chronic overdose of insulin, after hypoglycemic hyperglycemia.
Develops at patients with poor control over DM. Clinical manifestations: increased appetite,
growth acceleration, obesity (frequently by Cushing type), hepatomegaly, tendency to the
ketoacydosis, to the hypoglycemic events (mainly at night and early in the morning)
Hypoglycemia is the condition caused by absolute or relative insulin excess.
Light (1 degree): it is diagnosed by the patient and treated by sugar intake
Moderate (the 2nd degree): the patient can't eliminate the hypoglycemia by himself, treatment is
by sugar intake with the help of assistance
Severe (3rd degree): the patient in stupor, unconscious or in a coma, needs parenteral therapy
(glucagon or intravenous administration of glucose)
Asymptomatic, "biochemical hypoglycemia".
Rendering the urgent help
Light (1 degree) and moderate hypoglycemia (the 2nd degree):
- 10-20 g of "fast" carbohydrates
- 1-2 slices of bread
Severe hypoglycemia (the 3rd degree):
- In the prehospital setting:
children younger than 5 years: 0,5 mg of glucagon intramuscularly or subcutaneously
children older than 5 years: 1,0 mg of a glucagon intramuscularly or subcutaneously
If there is no effect within 10-20 min. - to check glycemia
- In the hospital setting intravenously by bolus:
20% solution of glucose (dextrose) 1 ml/kg (or 2 ml/kg of 10% solution) in 3 minutes,
then - 10% solution of glucose of 2-4 ml/kg, to check glycemia level, if there the patient is
still unconsciousness - to administer 10-20% glucose solution to achieve glycemia level
within 7-11 mmol/l, to check glycemia level each 30-60 min.
Arises slowly, than DKA. Thirst, poliuriya, decreased weight, signs of severe dehydration (the
expressed dryness of skin and mucous membranes, tachycardia, decreased tone of the eyeballs,
progressing weakness, brown covering of the tongue, decreased muscular tone, tendon reflexes,
oliguriya that turns to anury, temperature normal or increased, neurologic symptoms: feeling of
twitching in the muscles of extremities, aphasia, spasms, paresis, pathological symptoms,
nistagmus, hallucinations, delirium, absence of the smell of acetone in exhaled air, absence of
Kussmaul breathing (only in case of lactatacydosis), disordered consciousness - stupor or coma.
2. The paraclinical: blood glucose >33 mmol/l, arterial blood >7,3, ketonuriya absent or low,
anion difference <12 mecv/l, osmolarity >320 mOsml, additional criteria: blood bicarbonate>15
mecv/l, serum ketones low.
Treatment should be carry out at the resuscitation and intensive care unit.
Regidratation. At osmolarity >320 mOsml treatment should begin with 0.45% of NaCl solution
intravenously, at osmolarity osmolarity <320 mOsml - treatment should begin with 0.9% NaCl
solution. Infusional therapy is carried out gradually for 48 hours. It should be stopped with
restoration of consciousness, absence of vomiting, possibility of independent reception of liquid.
Insulin ttherapy. Insulin (only short action) is adnministered by small doses, continuously
intravenously. First hour: intravenously - 0,15 U/kg. Then - each hour intravenously 0,1 U/kg/h
mixed with 0,9% of NaCl (on each 100 ml of 0,9% of NaCl add 10 U insulin). If there is no
positive dynamics for the first 2-3 hours - the dose of insulin doubles. When glycemia decreases
to 13-14 mmol/l the dose of insulin should be cut twice (approximately 2-3 U per hour).
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Answer D. The description is of an obese adolescent female with candida vaginitis (the vaginal
discharge) and acanthosis nigricans (the nuchal dark rash) consistent with type II diabetes. This
condition is far more common in overweight children, especially those with a family history of
the condition.
Question 9. An adolescent with type I diabetes has a dramatically elevated glycosylated
hemoglobin (hemoglobin A1C ) level, indicating poor control of his diabetes over at least the
preceding
A. 8 h
B. 1 week
C 1 month
D. 2 months
E. 6 months
The answer is D. Glucose is nonenzymatically attached to hemoglobin to form glycosylated
hemoglobin. The major component of this reaction proceeds very slowly and is irreversible until
the hemoglobin is destroyed. The concentration of glycosylated hemoglobin thus reflects glucose
concentration over the half-life of the red cell, or about 2 to 3 months. The adolescent in the
question may have had poor control of his diabetes for longer than 2 to 3 months, but a
glycosylated hemoglobin is unable to determine this.
Question 10. A14-year-old with type 1 diabetes is admitted with diabetic ketoacidosis. Initial
laboratory values are as follows: glucose 563 mg/dL, sodium 136 meq/L, potassium 4.3 meq/L,
chloride 107 meq/L, CO2 9 meq/L, BUN 18 mg/dL, creatinine 0.6 mg/dL, and calcium
9.7 mg/dL. She receives a 10 cc/kg bolus of normal saline followed by IV fluids consisting
of 1/2 normal saline, as well as IV insulin. Eight hours into therapy, she develops muscle
weakness. In addition, her electrocardiogram shows flat T waves as well as U waves. What is the
most likely cause of her symptoms?
A. cerebral edema
B. hyponatremia
C. hypoglycemia
D. hypokalemia
E. hypocalcemia
Answer D. Deficiency of insulin resulting in diabetic ketoacidosis (DKA) can be associated with
several metabolic derangements. Insulin acts to drive potassium intracellularly and deficiency
of insulin decreases this movement of potassium from the extracellular space to the intracellular
space. In addition, as acidosis develops secondary to excessive ketone production, potassium is
further shifted extracellularly in exchange for a hydrogen ion which moves in the opposite
direction. With hyperglycemia, osmotic diuresis ensues and extracellular potassium is lost in the
urine. Therefore, patients with DKA are depleted of potassium even if serum levels are normal or
elevated. Patients are at risk for developing hypokalemia as treatment is initiated. Both insulin
administration and correction of acidosis shift potassium back to the intracellular compartment,
therefore dropping serum levels. Symptoms and signs of hypokalemia include muscle weakness
that may progress to paralysis, cardiac dysrhythmias, as well as flat or absent T waves and the
presence of a U wave on ECG. Potassium levels should be monitored closely and potassium
replacement started as long as hyperkalemia is not present and the patient has voided.
Cerebral edema is the most common cause of morbidity related to DKA and most often
occurs after treatment is initiated. It is not associated with weakness or ECG changes.
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Hyponatremia can also complicate therapy for DKA. Hyponatremia is not associated with the
patients symptoms or ECG changes. It should be noted that for every 100 mg/dL increase in
serum glucose, the serum sodium will decrease by roughly 1.6 meq/L. Therefore, the
patients original sodium would correct to nearly 142 meq/dL if the hyperglycemia is
considered. Hypocalcemia is associated with neuromuscular excitability and prolonged
QT interval. Hypoglycemia is another possible complication of DKA and blood sugars
must be monitored closely.
Question 11. A 3-year-old child has been diagnosed with type I diabetes mellitus, hyperosmolar
coma. The laboratory confirmed the diagnosis. Which laboratory findings are characteristic for
such condition?
A High hyperglycemia without ketonemia
B Hyperglycemia and ketonemia
C Hyperglycemia and glucosuria
D Hyperglycemia and ketonuria
E Hyperglycemia and high indicators of acid-base balance
Question 12 . A 6-year-old child has thirst, polyuria, increased appetite throughout two months.
He has lost 3 kg. Within a week night enuresis has occured. During investigation hyperglycemia
14 mmol/l is diagnoses. The diabetes, type I is established. What is the most probable
pathogenesis of this disorder?
A Autoimmune
B Viral
C Bacterial
D Neurogenous
E Viral-bacterial
Question 13. 9-year-old boy has diabetes for the first year. Takes insulin (Humulin R, NPH) 0,4
U/kg/24 hr. Insulin is injected subcutaneously into the shoulder using syringe-handle. What
should be done to prevent lypodistrophy?
A To change the place of insulin injection
B To limit fat in the diet
C To reduce insulin dose
D To pass change insulin medication periodically
E To prescribe antioxidants
Question 14. 10-year-old girl has addressed to the doctor with complaints to thirst, frequent
urination, loosing weight. The patient feels herself being ill for about a month. Objectively: the
pathology of internal organs isn't revealed. What laboratory investigation should be done first?
A Fasting blood glucose
B Urine sugar from 24 hr urine collection
C Urine acetone
D Glucose tolerance test
E Glykimic profile
Question 15 . 10-year-old boy has diabetes. During inspection the smell of acetone from the
mouth is noted. Blood sugar - 20,5 mmol/l, urine sugar - 20 g/l, acetone in urine - (+++). How
could the presense of acetone in exhaled air and urine be explained?
A Incresed breakdown of cetogenous amino acids and lipids.
B Disorders of water-electrolite balance.
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Literature
1. Nelson Textbook of Pediatrics. - 18th ed. / Ed. by R. Kliegman et al.-Philadelphia: Saunders
Co, 2007.- 3146 p.
2. Pediatry. Guidance Aid / . .. ; .. , .. . : ,
2007 . 158 .
3. Paediatrics at a glance / Ed. by L.Miall et al. - Blackwell Science Ltd. 2003.
4. Pediatric Clinical Advisor: instant diagnosis and treatment / [edited by] Paul D. Chan et al.
2nd ed. Elsevier. - 2007
5. Practical pediatrics. - 5th ed. / Ed. by M.J.Robinson, D.M.Roberton Elsevier. 2003.
6. Rapid paediatrics / Ed. by Helen Brough ... [et al.]. - Blackwell Publishing Ltd. 2004.
7. Rudolph`s pediatrics. - 21th ed. / Ed. by A.M. Rudolph et al. - McGraw-Hill. 2003.
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8. Clinical Pediatric Endocrinology - 5th ed. / Edited by Charles G.D. Brook et al. - Blackwell
Publishing Ltd 2005.
9. Handbook of Clinical Pediatric Endocrinology - 1st ed. / Edited by Charles G.D. Brook,
Rosalind S. Brown. - Blackwell Publishing Ltd. 2008.
Performed by senior lecturer Badogina L.P., assistant Tkachenko N.P.
Approved _________________20____y.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
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