DIABETES MELLITUS

PADA ANAK
Eka Agustia Rini

DIABETES MELLITUS
High levels of blood glucose : defects in insulin
production, insulin action, or both
Type 1 Diabetes
cells that produce insulin are destroyed
results in insulin dependence
Type 2 Diabetes
Lack of insulin production
Insufficient insulin action (resistant cells)

Diabetes - Diagnosis

Symptoms of diabetes plus random plasma

glucose >200mg/dl (11.1mmol/l) or
Fasting plasma glucose >126 mg/dl (7.0
mmol/l) or
2 hour plasma glucose >200 mg/dl during an
oral glucose tolerance test

1.

American Diabetes Association Consensus Statement

Type 2 Diabetes in Children and Adolescents Diabetes
Care 2000;23(3) 381-389.

GEJALA KLINIS
HIPERGLIKEMI

Poliuria
Polidipsi
Poli fagia

KOMPLIKASI
-Ketoasidosis
-Hipoglikemi
-Mikrovaskular
-Makrovaskular

Type 1 DM
What Causes Type 1 Diabetes?
Autoimmune Response
Genetic Abnormalities
Viruses
Cows milk

Etiology
80%-85%

no affected family member

Autoimune destruction of pancreas islet

Multiple genetic (predisposition)

Enviromental factors (trigger)
viral infection, diet and toxins

or Insulin secretion

Pathogenesis
Destruction

of -cell is quite variable.

Fasting

hyperglycemia can rapidly change

to severe hyperglycemia or ketoacidosis
(in infection or other stress).

Manifestation

little or no insulin
secretion low or undetectable C-peptide

Pathophysiology
Insulinopenia
Utilization glucose decreased postprandial hyperglycemia
Glycogenolysis and gliconeogenesis fasting hyperglycemia

Glucosuria
Loss of calorie and electrolyte, dehydration

Clinical Manifestation

Phase of type 1 DM
1.
2.
3.
4.

Prediabetes
Presentation of diabetes
Partial remission or honeymoon
Chronic phase of lifelong dependency on
administrated insulin

Clinical manifestation
Polyuria

or nocturia glucosuria
Polydipsia
Polyphagia calories lost in urine
Weight loss
Monilial vaginitis glucosuria

Diagnosis
Symptoms

and casual plasma glucose

200 mg/dL or
FPG 126 mg/dL or
2-h postload glucose 200 mg/dL
Low or undetectable C-peptide
ICA positive

MANAGEMENT OF T1DM
Diabetes

education.
Insulin replacement.
Nutritional plan.
Psychological adjustment
Exercise
Diabetes camp

Diabetes Management Principles

An

effective insulin regimen

Monitoring of glucose
As flexible with food and activity as possible
Must remember
Young children need routine and rules
Young children need to develop autonomy
Young children need to explore and
experience
Young children need to begin to make
decisions

The aims of DM management:

Optimal

metabolic (glycaemic) control.

Normal growth and development.
Optimal psychosocial adjustment.
An individualised plan of diabetes care
incorporating the particular needs of the
child or adolescent and the family.

Diabetes education

The cause of diabetes.

Insulin replacement ; adjustment, storage, inj. techniques
Blood glucose measurement.
Exercise.
Diabetes and exercise.
Psychological and family adjustment.
Hypoglycaemia and its management.
Diabetes management during illness.
Travel.
Dietetic principles.
Contraception.
Alcohol and Drugs.
Diabetes complications.
Driving.
Smoking.

INSULIN REPLACEMENT

Insulin types
Rapid-acting

Lyspro, aspart, glulysine

Short-acting Regular Insulin
Intermediate - Lente, NPH
Long-acting - Ultralente, Glargine, Detemir

Physiologic Insulin Therapy

Insulin

Prandial Boluses

BG mg/dl

Basal Insulin

0hr

24hr

Insulin management
Fixed

dose regimens:

requires

scheduled meals and snacks and is not

flexible enough for most young children

Basal

bolus regimens:

MDI
useful

Insulin
child

only if child is willing to take frequent injections

pumps (CSII)
must be willing to wear the pump

Location of injection

On Target!

Insulin pump therapy

Based

on what body does naturally

- Small amounts of insulin all the time

(basal insulin)

- Extra doses to cover each meal or snack

(bolus insulin)

Rapid

or Short-Acting Insulin

Precision,

micro-drop insulin delivery

Flexibility
Considered

as a treatment option
Initiated and supervised by a specialised
multidisciplinary

Nutrition
adequate

energy and nutrients,

optimal growth and development,
avoid hyperglycemia or hypoglycemia.
Number of recommended meal : 6/day 3
main meal (25/20, 25/30 and 20/20) and 3
snacks (10%).
Caloric:
1000

cal + 100 cal / year age

Ideal BW + activity (<12 year)

Emergency conditions
Diabetic

ketoacidosis
Hypoglycemia

Longterm complications
Cardiovascular
Neuropathy, Vascular
Eye

Injury, and Amputations.

Complications.
Kidney Damage (Nephropathy).
Other Complications.
Specific Complications in Women.
Diabetes appears to affect female hormones.
Specific Complications for Adolescents.

Diabetic Ketoacidosis
Hyperglycemia
Insulin secretion

Beta Cell Toxicity

+

Insulin resistance 2o
obesity

Relative Insulin Deficiency

Lipolysis

Free
Fatty Acids

Ketonemia
Ketonuria

Manifestation of ketoacisodosis
Ketoacid

accumulate when low insulin levels

Abdominal discomfort
nausea & emesis
Dehydration, but still polyuria
Sign of metabolic acidosis
Diminish of neurocognitiv function coma
The biochemical criteria : hyperglycaemia (> 200
mg/dL), pH <7.3 and or bicarbonate < 15

Type 2 DM

Childhood Obesity
The

prevalence of childhood obesity is

estimated to be 25 to 30 %.
type 2 diabetes is increasing in children
and adolescents obesity
Family history of diabetes is strongly
associated with type 2 diabetes in children

Obesity
Insulin Resistance
Metabolic Syndrome
Type 2DM

Hypertension
NASH
PCOS

Dyslipidemia

Type 2 Diabetes
Diagnosis
Elevated

fasting insulin and hyperglycemia.

Only 20% present with polyuria, polydipsia,
and weight loss.
Etiology
One third of new diabetics presenting
between 10-19 years had NIDDM.

Pinhas-Hamiel J Pediatr 1996;128:608-615.

 Acanthosis

nigricans and polycystic

ovarian syndrome (PCOS), disorders
associated with insulin resistance and
obesity, are common in youth with type 2
diabetes

Currently, type

2 diabetes are usually

diagnosed over the age of 10 years and
are in middle to late puberty

Acanthosis Nigricans

Dr. George Datto

Acanthosis Nigricans
Hyperpigmentation

and velvety thickening that

occurs in neck, axilla, and other skin folds

In

pediatrics, commonly in obese children.

Also seen in malignancies and other insulin
resistant syndromes.

Obese

pediatric + acanthosis have higher

fasting insulin and lower insulin sensitivity

Type 2 Diabetes - One End of

the Continuum
Genetic
Predisposition

Beta
Hyperglycemia
Cell
Dysfunction
Type 2
Diabetes

Environmental
Trigger
Obesity
Insulin
Resistance

Type 2 Diabetes - Risk factors

Obesity 85% overweight or obese on diagnosis

65% of children with type 2 diabetes have first

degree relative with Type 2 diabetes

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR,

Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus
among adolescents. J Pediatr.1996; 128 :608 615

74%-100% have first or second degree relative with

type 2 diabetes

1.

American Diabetes Association: Type 2 diabetes in children and

adolescents (Consensus Statement). Diabetes Care 23:381389, 2000).

American Diabetes Association: Type 2 diabetes in children and

adolescents (Consensus Statement). Diabetes Care 23:381389, 2000).

Type 2 Diabetes Risk factors

African American,

American descent

Hispanic, Asian, Native

American Diabetes Association Consensus Statement Type

2 Diabetes in Children and Adolescents Diabetes Care
2000;23(3) 381-389.

Increased

insulin resistance (puberty,ethnicity,

inactivity,visceral fat distribution,PCOS)

American Diabetes Association Consensus Statement Type

2 Diabetes in Children and Adolescents Diabetes Care
2000;23(3) 381-389.

Female/male

1.7:1

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR,

Zeitler P. Increased incidence of non-insulin-dependent diabetes
mellitus among adolescents. J Pediatr.1996; 128 :608 615

Type 2 Diabetes- Prevalence

4.1/100,000 for all 15-19 year old American

Indians up to 50.9/100,000 for 15-19 yr old
Pima Indian

Fagot-Campagna A, Pettitt DJ, Engelgau MM, Ros Burrows N,

Geiss LS, Valdez R, et al. Type 2 diabetes among North
American children and adolescents: an epidemiological review
and a public health perspective. J Pediatr 2000; 136: 664-672

Estimated incidence of type 2 diabetes

7.2/100,000/yr (Ohio 1994)

10 fold increase from 1982-1994

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury

PR, Zeitler P. Increased incidence of non-insulin-dependent
diabetes mellitus among adolescents. J Pediatr.1996; 128 :608
615

Type 2 Diabetes - Risk

Lifetime

risk of diabetes for

individuals born in 2000
1

in 3 for males
2 in 5 for females
Narayan

KM, Boyle JP, Thompson TJ, Sorensen SW,

Williamson DF: Lifetime risk for diabetes mellitus in
the United States. JAMA290 :1884 1890,2003

Components of the Met Syndr in Childhood

Abnormal

blood lipids (HDL cholesterol <40mg/dl or

triglycerides >150mg/dl LDL>130mg/dl).

Impaired

glucose tolerance (fasting glucose > 100

(110) mg/dl, random glucose >200mg/dl).
Obesity (BMI >95% for age and sex)
Elevated blood pressure (SBP or DBP > 90% for
age).

Screening (ADA recomendation)

1.

10 years /puberty

2. BMI > p 85, BB > 120%

Family history
Special ethnic
Insulin resistent

OGTT every 2 years

Impaired glucose tolerance

Increased

incidence of impaired glucose

tolerance in obesity clinic population
25% of obese children (aged 4-10yrs)
21 % of obese adolescents (aged11-18 yrs)

Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B,

Allen K, Savoye M, Rieger V, Taksali S, Barbetta G,
Sherwin RS, Caprio S: Prevalence of impaired glucose
tolerance among children and adolescents with marked
obesity. N Engl J Med 346:802810, 2002

Diagnosis criteria
Diabetes mellitus
1. Symptom DM + Glucose random > 200 mg/dl
2. Fasting blood glucose > 125 mg/dl
2. Blood glucose, 2 hr OGTT > 200 mg/dl
Prediabetes
1. Gula darah puasa terganggu (> 11O & <125)
2. Toleransi glukosa terganggu (> 140 mg/dl & <
> 200 mg/dl)

Treatment of Type 2 DM
Lifestyle

changes
Pharmaceutical therapy
Biguanides
Sulfonylureas
Meglitinide
Thiazolidenediones
Monitoring for complications
Hypertension and hyperlipidemia treatment

Nutrisi treatment
Children or adolescent calori requirement
Carbohydrat
Protein
Fat

: 55%-60%
: 10-20%

: 30%