Diabetes Mellitus Pada Anak Kuliah

DIABETES MELLITUS DIABETES MELLITUS PADA ANAKPADA ANAK

Eka Agustia RiniEka Agustia Rini

DIABETES MELLITUSDIABETES MELLITUS

High levels of blood glucose : defects in insulin High levels of blood glucose : defects in insulin production, insulin action, or bothproduction, insulin action, or both

Type 1 DiabetesType 1 Diabetescells that produce insulin are destroyed cells that produce insulin are destroyed results in insulin dependenceresults in insulin dependence

Type 2 DiabetesType 2 DiabetesLack of insulin productionLack of insulin production Insufficient insulin action (resistant cells)Insufficient insulin action (resistant cells)

Diabetes - DiagnosisDiabetes - Diagnosis

Symptoms of diabetes plus random plasma Symptoms of diabetes plus random plasma glucose >200mg/dl (11.1mmol/l) orglucose >200mg/dl (11.1mmol/l) or

Fasting plasma glucose >126 mg/dl (7.0 Fasting plasma glucose >126 mg/dl (7.0 mmol/l) ormmol/l) or

2 hour plasma glucose >200 mg/dl during an 2 hour plasma glucose >200 mg/dl during an oral glucose tolerance testoral glucose tolerance test

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

1.1.

GEJALA KLINISGEJALA KLINIS

HIPERGLIKEMI

PoliuriaPolidipsiPoli fagia

KOMPLIKASI-Ketoasidosis-Hipoglikemi-Mikrovaskular-Makrovaskular

Type 1 DMType 1 DM

What Causes Type 1 Diabetes?What Causes Type 1 Diabetes?Autoimmune ResponseAutoimmune ResponseGenetic AbnormalitiesGenetic Abnormalities Viruses Viruses CowsCows milk milk

EtiologyEtiology

80%-85% no affected family member80%-85% no affected family memberAutoimune destruction of pancreas islet Autoimune destruction of pancreas islet

Multiple genetic (predisposition)Enviromental factors (trigger)

viral infection, diet and toxins

Insulin secretionor ≠

PathogenesisPathogenesis

Destruction of Destruction of ββ-cell is quite variable.-cell is quite variable.

Fasting hyperglycemia can rapidly change Fasting hyperglycemia can rapidly change to severe hyperglycemia or ketoacidosis to severe hyperglycemia or ketoacidosis (in infection or other stress).(in infection or other stress).

Manifestation Manifestation little or no insulin little or no insulin secretion secretion low or undetectable C-peptide low or undetectable C-peptide

PathophysiologyPathophysiology

Utilization glucose decreased postprandial hyperglycemia

Glycogenolysis and gliconeogenesis fasting hyperglycemia

Glucosuria

Loss of calorie and electrolyte, dehydration

Insulinopenia

Clinical ManifestationClinical Manifestation

Phase of type 1 DMPhase of type 1 DM1.1. PrediabetesPrediabetes

2.2. Presentation of diabetesPresentation of diabetes

3.3. Partial remission or honeymoonPartial remission or honeymoon

4.4. Chronic phase of lifelong dependency on Chronic phase of lifelong dependency on administrated insulinadministrated insulin

Clinical manifestationClinical manifestation

Polyuria Polyuria or nocturia or nocturia glucosuria glucosuriaPolydipsiaPolydipsiaPolyphagia Polyphagia calories lost in urine calories lost in urineWeight lossWeight loss Monilial Monilial vaginitisvaginitis glucosuria glucosuria

DiagnosisDiagnosis

Symptoms and casual plasma glucose ≥ Symptoms and casual plasma glucose ≥ 200 mg/dL or200 mg/dL or

FPG ≥ 126 mg/dL orFPG ≥ 126 mg/dL or2-h postload glucose ≥ 200 mg/dL2-h postload glucose ≥ 200 mg/dLLow or undetectable C-peptideLow or undetectable C-peptide ICA positiveICA positive

MANAGEMENT OF T1DMMANAGEMENT OF T1DM

Diabetes education.Diabetes education. Insulin replacement.Insulin replacement. Nutritional plan.Nutritional plan. Psychological adjustmentPsychological adjustment ExerciseExercise Diabetes campDiabetes camp

Diabetes Management PrinciplesDiabetes Management Principles

An effective insulin regimen An effective insulin regimen Monitoring of glucoseMonitoring of glucose As flexible with food and activity as possibleAs flexible with food and activity as possible Must remember Must remember

Young children need routine and rulesYoung children need routine and rulesYoung children need to develop autonomyYoung children need to develop autonomyYoung children need to explore and Young children need to explore and

experienceexperienceYoung children need to begin to make Young children need to begin to make

decisionsdecisions

The aims of DM management:The aims of DM management:

Optimal metabolic (glycaemic) control.Optimal metabolic (glycaemic) control.Normal growth and development.Normal growth and development.Optimal psychosocial adjustment.Optimal psychosocial adjustment.An individualised plan of diabetes care An individualised plan of diabetes care

incorporating the particular needs of the incorporating the particular needs of the child or adolescent and the family.child or adolescent and the family.

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

INSULIN REPLACEMENTINSULIN REPLACEMENT

Insulin typesInsulin types

Rapid-acting – Lyspro, aspart, glulysineRapid-acting – Lyspro, aspart, glulysineShort-acting – Regular InsulinShort-acting – Regular Insulin Intermediate - Lente, NPHIntermediate - Lente, NPHLong-acting - Ultralente, Glargine, DetemirLong-acting - Ultralente, Glargine, Detemir

Basal Insulin

Prandial BolusesIn

suli

n

0hr 24hr

BG

mg

/dl

PhysiologicPhysiologic Insulin TherapyInsulin Therapy

Fixed dose regimens: Fixed dose regimens: requires scheduled meals and snacks and is not requires scheduled meals and snacks and is not

flexible enough for most young childrenflexible enough for most young children

Basal bolus regimens:Basal bolus regimens:MDIMDI

useful only if child is willing to take frequent injectionsuseful only if child is willing to take frequent injections

Insulin pumps (CSII)Insulin pumps (CSII)child must be willing to wear the pumpchild must be willing to wear the pump

Insulin managementInsulin management

On Target!On Target!Location of injection

Insulin pump therapyInsulin pump therapy Based on what body does naturally Based on what body does naturally

- Small amounts of insulin all the time - Small amounts of insulin all the time ((basal insulinbasal insulin))

- Extra doses to cover each meal or snack- Extra doses to cover each meal or snack ((bolus insulinbolus insulin))

Rapid or Short-Acting InsulinRapid or Short-Acting Insulin

Precision, micro-drop insulin deliveryPrecision, micro-drop insulin delivery

Flexibility Flexibility

Considered as a treatment optionConsidered as a treatment option Initiated and supervised by a specialised Initiated and supervised by a specialised

multidisciplinarymultidisciplinary

NutritionNutrition

adequate energy and nutrients, adequate energy and nutrients, optimal growth and development, optimal growth and development, avoid hyperglycemia or hypoglycemia.avoid hyperglycemia or hypoglycemia.Number of recommended meal : 6/day Number of recommended meal : 6/day

3 main meal (25/20, 25/30 and 20/20) and 3 main meal (25/20, 25/30 and 20/20) and 3 snacks (10%). 3 snacks (10%).

Caloric:Caloric:1000 cal + 100 cal / year age1000 cal + 100 cal / year age Ideal BW + activity (<12 year)Ideal BW + activity (<12 year)

Emergency conditionsEmergency conditions Diabetic ketoacidosisDiabetic ketoacidosis HypoglycemiaHypoglycemia

Longterm complicationsLongterm complications Cardiovascular Cardiovascular Neuropathy, Vascular Injury, and Amputations. Neuropathy, Vascular Injury, and Amputations. EEye Complications. ye Complications. Kidney Damage (Nephropathy). Kidney Damage (Nephropathy). Other Complications. Other Complications. Specific Complications in Women. Specific Complications in Women. Diabetes appears to affect female hormones. Diabetes appears to affect female hormones. Specific Complications for Adolescents. Specific Complications for Adolescents.

Diabetic KetoacidosisDiabetic Ketoacidosis

Hyperglycemia Beta Cell Toxicity

Insulin secretion +Insulin resistance 2o

obesity

Relative Insulin Deficiency

LipolysisFree

Fatty AcidsKetonemia

Ketonuria

Manifestation of ketoacisodosisManifestation of ketoacisodosis

Ketoacid accumulate Ketoacid accumulate when low insulin levels when low insulin levels Abdominal discomfortAbdominal discomfort nausea & emesisnausea & emesis Dehydration, but still polyuriaDehydration, but still polyuria Sign of metabolic acidosisSign of metabolic acidosis Diminish of neurocognitiv function Diminish of neurocognitiv function coma coma The biochemical criteria : hyperglycaemia (> 200 The biochemical criteria : hyperglycaemia (> 200

mg/dL), pH <7.3 and or bicarbonate < 15 mg/dL), pH <7.3 and or bicarbonate < 15

Type 2 DMType 2 DM

Childhood Obesity Childhood Obesity

The prevalence of childhood obesity is The prevalence of childhood obesity is estimated to be 25 to 30 %. estimated to be 25 to 30 %.

type 2 diabetes is increasing in children type 2 diabetes is increasing in children and adolescents obesity and adolescents obesity

Family history of diabetes is strongly Family history of diabetes is strongly associated with type 2 diabetes in children associated with type 2 diabetes in children

Type 2 Diabetes - One End of Type 2 Diabetes - One End of the Continuumthe Continuum

Genetic Predisposition

Environmental Trigger

Obesity

Insulin Resistance

Beta

Hyperglycemia

Type 2 Diabetes

Dysfunction

Cell

Insulin Resistance

Obesity

Metabolic SyndromeType 2DM

NASH

PCOSDyslipidemia

Hypertension

Type 2 Diabetes - Risk factorsType 2 Diabetes - Risk factors

Obesity 85% overweight or obese on diagnosisObesity 85% overweight or obese on diagnosis American Diabetes Association: Type 2 diabetes in children and American Diabetes Association: Type 2 diabetes in children and

adolescents (Consensus Statement). adolescents (Consensus Statement). Diabetes CareDiabetes Care 23:381–389, 23:381–389, 2000).2000).

65% of children with type 2 diabetes have first 65% of children with type 2 diabetes have first degree relative with Type 2 diabetesdegree relative with Type 2 diabetes

Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. mellitus among adolescents. J Pediatr.J Pediatr.1996; 128 :608 –6151996; 128 :608 –615

74%-100% have first or second degree relative 74%-100% have first or second degree relative with type 2 diabeteswith type 2 diabetes

American Diabetes Association: Type 2 diabetes in children and American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement). adolescents (Consensus Statement). Diabetes CareDiabetes Care 23:381–389, 23:381–389, 2000).2000).

1.1.

Type 2 Diabetes Risk factorsType 2 Diabetes Risk factors

African American, Hispanic, Asian, Native African American, Hispanic, Asian, Native American descentAmerican descent

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

Increased insulin resistance (puberty,ethnicity, Increased insulin resistance (puberty,ethnicity, inactivity,visceral fat distribution,PCOS) inactivity,visceral fat distribution,PCOS)

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

Female/male 1.7:1Female/male 1.7:1 Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury

PR, Zeitler P. Increased incidence of non-insulin-dependent PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. diabetes mellitus among adolescents. J Pediatr.J Pediatr.1996; 128 :608 –1996; 128 :608 –615615

Type 2 Diabetes- PrevalenceType 2 Diabetes- Prevalence

4.1/100,000 for all 15-19 year old American 4.1/100,000 for all 15-19 year old American Indians up to 50.9/100,000 for 15-19 yr old Indians up to 50.9/100,000 for 15-19 yr old Pima IndianPima Indian

Fagot-Campagna A, Pettitt DJ, Engelgau MM, Ríos Burrows N, Fagot-Campagna A, Pettitt DJ, Engelgau MM, Ríos Burrows N, Geiss LS, Valdez R, et al. Type 2 diabetes among North Geiss LS, Valdez R, et al. Type 2 diabetes among North American children and adolescents: an epidemiological review American children and adolescents: an epidemiological review and a public health perspective. and a public health perspective. J PediatrJ Pediatr 2000; 136: 664-672 2000; 136: 664-672

Estimated incidence of type 2 diabetes Estimated incidence of type 2 diabetes 7.2/100,000/yr (Ohio 1994)7.2/100,000/yr (Ohio 1994)

10 fold increase from 1982-199410 fold increase from 1982-1994 Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury

PR, Zeitler P. Increased incidence of non-insulin-dependent PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. diabetes mellitus among adolescents. J Pediatr.J Pediatr.1996; 128 :608 –1996; 128 :608 –615615

Type 2 Diabetes - RiskType 2 Diabetes - Risk

Lifetime risk of diabetes for Lifetime risk of diabetes for individuals born in 2000individuals born in 20001 in 3 for males1 in 3 for males2 in 5 for females2 in 5 for females

Narayan KM, Boyle JP, Thompson TJ, Sorensen Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF: Lifetime risk for diabetes SW, Williamson DF: Lifetime risk for diabetes mellitus in the United States. mellitus in the United States. JAMAJAMA290 :1884 –290 :1884 –1890,20031890,2003

Components of the Met Syndr in ChildhoodComponents of the Met Syndr in Childhood

Abnormal blood lipidsAbnormal blood lipids (HDL cholesterol <40mg/dl or (HDL cholesterol <40mg/dl or triglycerides >150mg/dl LDL>130mg/dl).triglycerides >150mg/dl LDL>130mg/dl).

Impaired glucose toleranceImpaired glucose tolerance (fasting glucose > 100 (fasting glucose > 100 (110) mg/dl, random glucose >200mg/dl).(110) mg/dl, random glucose >200mg/dl).

ObesityObesity (BMI >95% for age and sex) (BMI >95% for age and sex) Elevated blood pressureElevated blood pressure (SBP or DBP > 90% for (SBP or DBP > 90% for

age).age).

Type 2 DiabetesType 2 Diabetes

DiagnosisDiagnosisElevated fasting insulin and hyperglycemia.Elevated fasting insulin and hyperglycemia.Only 20% present with polyuria, polydipsia, Only 20% present with polyuria, polydipsia,

and weight loss. and weight loss. EtiologyEtiology

One third of new diabetics presenting One third of new diabetics presenting between 10-19 years had NIDDM.between 10-19 years had NIDDM.

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

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

Currently, type 2 diabetes are usually Currently, type 2 diabetes are usually diagnosed over the age of 10 years and diagnosed over the age of 10 years and are in middle to late puberty are in middle to late puberty

Acanthosis NigricansAcanthosis Nigricans

Dr. George Datto

Acanthosis NigricansAcanthosis Nigricans

Hyperpigmentation and velvety thickening that Hyperpigmentation and velvety thickening that occurs in neck, axilla, and other skin foldsoccurs in neck, axilla, and other skin folds

In pediatrics, commonly in obese children. In pediatrics, commonly in obese children. Also seen in malignancies and other insulin Also seen in malignancies and other insulin resistant syndromes.resistant syndromes.

Obese pediatric + acanthosis have higher Obese pediatric + acanthosis have higher fasting insulin and lower insulin sensitivityfasting insulin and lower insulin sensitivity

Screening (ADA recomendation)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 toleranceImpaired glucose tolerance

Increased incidence of impaired glucose Increased incidence of impaired glucose tolerance in obesity clinic populationtolerance in obesity clinic population

25% of obese children (aged 4-10yrs)25% of obese children (aged 4-10yrs)21 % of obese adolescents (aged11-18 yrs) 21 % of obese adolescents (aged11-18 yrs)

Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, Savoye M, Rieger V, Taksali S, Barbetta G, Allen K, Savoye M, Rieger V, Taksali S, Barbetta G, Sherwin RS, Caprio S: Prevalence of impaired glucose Sherwin RS, Caprio S: Prevalence of impaired glucose tolerance among children and adolescents with marked tolerance among children and adolescents with marked obesity. obesity. N Engl J MedN Engl J Med 346:802–810, 2002 346:802–810, 2002

Diagnosis criteriaDiagnosis criteria

Diabetes mellitusDiabetes mellitus1. Symptom DM + Glucose random > 200 mg/dl1. Symptom DM + Glucose random > 200 mg/dl2. Fasting blood glucose > 125 mg/dl2. Fasting blood glucose > 125 mg/dl2. Blood glucose, 2 hr OGTT > 200 mg/dl2. Blood glucose, 2 hr OGTT > 200 mg/dl

PrediabetesPrediabetes1. Gula darah puasa terganggu (> 11O & <125)1. Gula darah puasa terganggu (> 11O & <125)2. Toleransi glukosa terganggu (> 140 mg/dl & < 2. Toleransi glukosa terganggu (> 140 mg/dl & <

> 200 mg/dl)> 200 mg/dl)

Treatment of Type 2 DMTreatment of Type 2 DM

Lifestyle changesLifestyle changes Pharmaceutical therapyPharmaceutical therapy

BiguanidesBiguanidesSulfonylureasSulfonylureasMeglitinide Meglitinide ThiazolidenedionesThiazolidenediones

Monitoring for complicationsMonitoring for complications Hypertension and hyperlipidemia treatmentHypertension and hyperlipidemia treatment

Nutrisi treatmentNutrisi treatment

Children or adolescent calori requirement Children or adolescent calori requirement

Carbohydrat : 55%-60%Carbohydrat : 55%-60%Protein : 10-20%Protein : 10-20%FatFat : 30% : 30%