This document discusses diabetes mellitus type 1 (DM1) in children. It begins by outlining the types of diabetes and focuses on DM1. DM1 results from loss of pancreatic function and insulinopenia. It then discusses the presentation of diabetic ketoacidosis (DKA) in a 7-year-old patient from Saudi Arabia. The document reviews risk factors, genetic predispositions, diagnostic criteria and management of DM1 and DKA. Management involves rehydration, treating electrolyte imbalances, acidosis, hyperglycemia and monitoring for complications such as cerebral edema.

1. By: Hamza AlGhamdi

2. Our Roadmap….
Mazen DKA
Hamza
Diabetes
type I

3. DIABETES IN
CHILDREN

4. Types :
Other Types

5. Type I Type II
Insulinopenia Normal or High insulin
• Loss of pancreatic • Peripheral insulin
function resistance

6. TYPE I DM

7. Fatima ..
• 7 years old
• Saudi girl
• From Abha
• Came to OPD
• Found to have High blood glucose
on screening campaign
• Concerns about being Diabetic
• HOW TO APPROACH ???
is this common
presentation ??

8. History
• Risk Factors
• HLA •1/100.000 in China
•DR4-DQ8 •38/100.000 in Finland
•DR3-DQ2 •(2)
•IN 90% (1)
•DR15-DQ6 - protective
Genetic Geographic
predisposition. region
infections Dietary factors
•Congenital Rubella •Infant supplementation
•(3) with VitD may be
•Human Enterovirus protective (5)
•(4)
•We need further studies
to prove

9. DKA
History • Nausea and vomiting
• Abdominal pain
• Tachypnea
• Lethargy
Common
• Polyuria
• Polydipsia
• Age 5-15
• Weight loss
• Blurred vision
Uncommon
• Comma
• Vaginitis
• Incidental

10. Examination
General Skin Upper & Eye Others
•Look •Ulcers Lower limbs •Retinal •Complete whole
•Mental status •Rashes •Ulcers examination for body
•Vitals •Infections •Nails retinopathy examination
•Dehydration •Injection site •Neuropathy
•Growth •feet
parameters

11. RBG Random Blood Glucose
Diagnosis • RBG ≥ 200 mg/dL
Symptoms + one of the
following investigations:
FBG Fasting Blood Glucose
• FBG ≥ 126 mg/dL
OGTT Oral Glucose Tolerance test
• 2 –hours post OGTT ≥ 200 mg/dL
To confirm Dx, repeat the HbA1c Glycosylated Hb
test another time. • HbA1c ≥ 6.5%
Don’t forget to take Drug Hx

12. MANAGEMENT

13. Management
Insulin
Screening for
complications
Education and
Regular
psychosocial
Follow up
support
Long term
glycemic Monitoring
control
Diet

14. Management Goal
To keep Glucose
level as close to
normal as possible
More tight with
increased age!
Without inducing
Hypoglycemia

15. Types of insulin

16. Management
Basal Insulin
Initial dose :
0.5 – 1 units/kg/day
Honeymoon period ???
Premeal correction dose
Based on premeal glucose level
Amylin analogs
To reduce post prandial glucose level

17. Regemin
Long Acting Short acting
Glargin – once daily Regular – 3-3 times daily
NPH – twice daily
Detemir – twice daily
+ Lispro – premeal
Aspart – premeal
Glulisine – premeal

19. HYPOGLYCEMIA?

20. THANK YOU

21. References
• 1- Gillespie, K. M. (2006). Type 1 diabetes: pathogenesis and prevention. CMAJ : Canadian Medical
Association journal = journal de l’Association medicale canadienne, 175(2), 165-70.
doi:10.1503/cmaj.060244
• 2- Onkamo, P., Väänänen, S., Karvonen, M., & Tuomilehto, J. (1999). Worldwide increase in incidence of
Type I diabetes--the analysis of the data on published incidence trends. Diabetologia, 42(12), 1395-403.
doi:10.1007/s001250051309
• 3- Ginsberg-Fellner, F., Witt, M. E., Fedun, B., Taub, F., Dobersen, M. J., McEvoy, R. C., Cooper, L. Z., et al.
(n.d.). Diabetes mellitus and autoimmunity in patients with the congenital rubella syndrome. Reviews of
infectious diseases, 7 Suppl 1, S170-6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3890104
• 4- Hober, D., & Sauter, P. (2010). Pathogenesis of type 1 diabetes mellitus: interplay between enterovirus
and host. Nature reviews. Endocrinology, 6(5), 279-89. doi:10.1038/nrendo.2010.27
• 5- Hyppönen, E., Läärä, E., Reunanen, A., Järvelin, M. R., & Virtanen, S. M. (2001). Intake of vitamin D and
risk of type 1 diabetes: a birth-cohort study. Lancet, 358(9292), 1500-3. doi:10.1016/S0140-6736(01)06580-
1

22. DKA

23. • Othman, 6yrs old Saudi boy from Abha
• Known case of DM type I
Meet our patient
• Came to ER complaining of :
• Fatigue and malaise
• Nausea/vomiting
• Abdominal pain
• On Examination:
Altered mental status
Tachycardia
Tachypnea or hyperventilation (Kussmaul respirations)
low blood pressure
Increased capillary refill time
Poor perfusion
Lethargy and weakness
Fever
Acetone odor

24. Investigations :
Serum glucose
• -Hyperglycemia (>200 mg/dl).
ABG
• -Acidosis (arterial pH < 7.25).
Urinalysis
• -Ketosis (+ve in urine /serum).
ABG
• -Serum HCO3 (<15 mEq/l).

25. Hyperglycemia
DKA
ketosis Acidosis

26. Causes
New-onset DM1.
Known DM1 if :
- Insulin injectionsare omitted.
- Stress (infections/surgery ).

27. Management
Electrolytes
Acidosis
Hyperglycemia
Rehydration
ABC

28. Dehydration
[1] IV fluid bolus of glucose-
free isotonic solution
(NS/ringer`s lactate).
[2] The remaining fluid deficit
+ maintenance fluid:
-replaced SLOWELY over 36-
48 hours.
* To avoid rapid shifts in serum osmolality:
 start with 0.9% NaCl
Then replaced by 0.45% NaCl.

29. Management
Electrolytes
Acidosis
Hyperglycemia
Rehydration
ABC

30. Hyperglycemia:
[1] Fast-acting IV insulin (0.1U/kg/hour).
[2] If serum glucose <300 mg/dl , add glucose to IV fluid.
Acidosis:
* Insulin  increase glucose uptake.
 decrease FFAs production.
* Avoid HCO3 unless sever acidosis (pH < 7.0).

31. Management
Electrolytes
Acidosis
Hyperglycemia
Rehydration
ABC

32. Electrolytes imbalance:
* potassium should be added to IV fluid , ONLY if
adequate urine output is shown.
(50% KCl & 50% KPo) at 20-40 mEq/L.
Monitoring:
[1] Flow-sheet.
[2] repeat serum glucose every hour.
[3] neurologic & mental status.

33. Cerebral edema.
Complications
CVA.
ATN è ARF.
Pancreatitis.
Arrhythmia.
Bowel ischemia.
Pulmonary edema.
Peripheral edema.

34. Cerebral edema
* 1-5%.
* 20-80% mortality rate.
* pathogenesis: osmolar shift  increase
intracellular compartment fluid & cell swelling.
* 6-12 hours after therapy.
* signs & symptoms:
1- sever headache.
2- bradycardia, HTN, apnea.
3- dilated pupil, papilledema.
4- seizure.

35. Treatment of cerebral edema :
[1] IV Mannitol.
[2] Endotracheal intubation &
hyperventilation.

36. That’s all
THANK YOU