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T1DM
Presenter – Saurabh Agarwal (8th Semester, AIIMS, Jodhpur)
Goals
• Strict glycemic control and avoiding hypoglycemia
• To eliminate polyuria and nocturia
• To prevent ketoacidosis
• To permit normal growth and development with minimal effect on lifestyle
• Parent & patient education – disease, treatment, insulin administration, charting
of daily blood glucose results, detection of hypoglycemia and its immediate
management
• Insulin therapy
• Physical activity
• Nutritional counselling
• Psychosocial support
Insulin therapy
• Prolonged hyperglycemia impairs neurological development
• Dosing – depends on body weight and pubertal stage of child
• Dose adjustments are made until the target BG levels & HbA1c are not achieved.
Insulin regimens
A. Intensive (Basal bolus regimen)
more closely mimics physiologic insulin secretion
suppresses lipolysis and hepatic glucose production
dose can be adjusted as per meal glucose content and BG levels more stable
glycemic control and fewer episodes of hypoglycemia
cons – frequent BG monitoring & insulin injections, calculation of dietary
carbohydrates.
Types -
i. multiple daily injections
ii. continuous insulin pumps
Multiple daily injections
• Use once a long acting insulin e.g., glargine along with pre-snack or pre-meal short
acting insulin (adjustable dose based on dietary content and current BG levels)
• E.g.,
1. short (70%) + intermediate (30%)
2. short (50%) + long (50%)
Insulin pumps
• Can be recommended in following cases:-
1. Recurrent severe hypoglycemia
2. Wide fluctuations of blood glucose levels
3. Micro/macrovascular complications
4. Young children & infants
5. Adolescents with eating disorders
6. Pregnant adolescents
B. Conventional (twice-daily infusion)
using intermediate acting insulin twice and short-acting 2-3 times a day
For a 36 kg child who is started on 0.5 U/kg/d, the total dose is 18 U. Two-thirds of it
is given bbf -12U and one-third before evening meal – 6U. At each inj 1/3 is short-
acting and 2/3 is intermediate acting.
Blood glucose monitoring
• Ideally should be checked 4-6 times a day
• But it can be modified as per the patient’s need and affordability
Mild Severe
Patient can recognize the symptoms and Associated with loss of consciousness or
is able to self-treat seizure
• Management
Give fast acting glucose (e.g., sugar, honey, sweet drink) immediately – 0.3 g/kg
Re-test BG 10-15 minutes later to confirm if the levels are in normal limits (> 100
mg/dL). If the BGL remains low or symptoms persist, repeat the above step.
Severe hypoglycaemia with loss of consciousness ± convulsions (or if the child is
vomiting)
1. Glucagon (prefer) – im or sc <12y 0.5 mg
>12y 1.0 mg or 10-30mcg/kg of bw
2. If glucagon not available – iv dextrose 10% or 25%
Nutritional management
• A dietitian should be consulted so that the meals are planned as per the insulin regimen.
• Growth monitoring every 6 months to check for adequate calorie intake
• 45-55% calories – CHO (70% complex CHO, low glycemic index foods e.g., whole-grain breads, pasta,
temperate fruits and dairy products)
• Use of sucrose is not forbidden, but it should be kept up to 10% of total energy
Protein requirement
• High fiber diet (for >2 y old age in years + 5 = g/day)
1y 2 g/kg
• Restricted salt intake if hypertensive
10 y 1 g/kg
• 30-35% calories – fats (<10% saturated fats, 10 % PUFA ω-3 & 6 FA, no trans-fats)
Adolescence 0.8-0.9 g/kg
• 15-20% calories - Protein (restriction, if microalbuminuria develops)
• Sweeteners may be used if necessary
• “Diabetic” foods are also not recommended because they are expensive, often high in fat and may
contain sweeteners with laxative effects. These include the sugar alcohols such as sorbitol.
• Routine vitamin & mineral supplements not required
Physical activity
• 30-60 min of moderate to vigorous intensity exercise daily
• But pre-exercise BG levels should be >100 mg/dL, can consume 1-1.5 g CHO/kg of
body weight during strenuous exercise
• If BG >250 mg/dL with ketonuria/ketonemia, exercise should be avoided.
Psychosocial support
• Affects lifestyle and interpersonal relationships of entire family
• Feelings of anxiety & guilt with denial & rejection are common
• Shared responsibility by both patient and parents has better outcomes
Sick day care
• Many illnesses with fever raise blood glucose levels d/t stress hormones
• Illnesses with GI symptoms can cause hypoglycemia d/t poor food intake, poor absorption &
changes intestinal motility
• Management –
1. do not stop insulin, but dose can be titrated as per BG levels
2. evaluate & treat acute illness
3. monitor BG levels 3-4 hourly & ketones 1-2 times/day
4. antipyretics, adequate fluid intake, easily digested foods
5. avoid strenuous exercise
6. admission – young dehydrated child, n/v, ketonuria, acute illness is severe
DKA management
Follow-up
• Weight should be measured at each visit, and Height every six months. Pubertal status should be
noted at relevant ages.
• HbA1c is ideally measured every three months. Target level is <7.5%.
• Blood pressure should be measured at least annually.
• After two years duration of diabetes, eyes should be checked for visual acuity, cataracts and
retinopathy annually.
• Peripheral and autonomic neuropathy should be assessed by history, physical examination and
sensory tests for vibration, thermal sensation or light touch.
• Urinary protein (and also serum creatinine if possible) should be measured after two years diabetes
duration, and annually thereafter.
• Fasting blood lipids should be performed when diabetes is stabilised in children aged over 12 years.
• Other conditions may occur with diabetes including hypothyroidism or hyperthyroidism, coeliac
disease, and Addison’s disease (rare) – screening for these may be appropriate.
Bibliography
• ISPAD. Pocketbook for Management of Diabetes in Childhood and Adolescence in
Under-resourced Countries, 2017.
• DiMeglio LA, Acerini CL, Codner E, et al. ISPAD Clinical Practice Consensus
Guidelines 2018: Glycemic control targets and glucose monitoring for children,
adolescents, and young adults with diabetes. Pediatr Diabetes. 2018;19(Suppl.
27):105–114.
• Smart CE, Annan F, Higgins LA, Jelleryd E, Lopez M, Acerini CL. ISPAD Clinical
Practice Consensus Guidelines 2018: Nutritional management in children and
adolescents with diabetes. Pediatr Diabetes. 2018;19 (Suppl. 27):136–154.
• Levitsky LL, et al. Management of Type 1 DM in Children & Adolescents.
UpToDate.com, 2019.
• Nelson Textbook of Pediatrics, 20e (2016)
THANK YOU