DM1

Autoimmune destruction of pancreatice b-cells

o Insulin def and hyperglycemia
Highest prevelance amongst caucausians
children
PRESENTATION
Classic, DKA or Incidental
CLASSIC
o Polyuria and polydipsia more likely than
polyphagia
DKA
o will experience DKA
o Usually have the classic symptoms plus
loss of appetite, nausea, and vomiting
when acidosis develops
o Kussumaul respiration to compensate for
acidosis
Incidental
o No overt findings (vulvovaginal candida)

DIAGNOSIS
Differentiate btwn T1 and T2
o T2 after puberty
o T2 w/ obesity, acanthosis nigracans
o T2 5x more likely to have 1st degree family
member associated
 o T2 higher amongst Native American,
Hispanic, AA not whites
Both T1 and T2 can have DKA (same Rx)
Diseases that cause damage to pancrese(CF)
can get T1
Drugs like Tacrolimus, cyclosporine,
glucocorticoid and chemo drugs all can lead to
DM

TREATMENT
Every child diagnosed with T1 should be
evaluated by pediatric endocrinologist, nurse
educator, dietician, social worker, child life
specialist, and
mental health professional
Learn how to check glucose
Optimal diabetes management is to get into
euglycemic range
 TDD=.5 to 1 unit/ kg per day (prepubertal
lower, pubertal higher)
3 goals
o 1 facilitate metabolism and storage
Insulin is given in proportion to the
amount of carbs ingestd (1 unit
insulin/10 grams carbs)
Rule of 500
o Normalize hyperglycemia
Rule of 1800
o Maintiain euglycemai during fasting
Long acting inculin given to maintain
insulin during fasting
Honeymoon phase initial treatment can lead
to hypoglycemia because still little use of b-
cells
Basal bolus is where rapid acting insulin given
with meals and long acting insulin to provide a
steady amount of insulin w/ little to no peak
between meals.
Short and intermediated can be used to
decrease number of daily injections mixed
split-reuqire ptn to eat same amount and
same time each day
Benefit of basal bolus= greater flexibility for
when meals and snacks eaten.


DKA
Glucose >200mg/dl, pH< 7.3 and bicarb
<15mmol/l
Med noncompliance most freq cause
Most 5-10% dehydrated
First Fluid andn electrolyte replace ment, then
hyperglycemeia and ketoacidosis and if need
be cerebral edema.
Assess Hr, rr, BP neuro signs, capillary glucose
leves hourly
 Asses hyperkalemia (peaked T waved, widened
QRS complex) and hypokalemia( flattened t
waves, st depress and u waves)
Look for cerebral edema b4 and during dka rx.
o Usually happens with 4-12hrs during rx.
o Look for 2 major or 1 maj/2minor
o Diagnosed clinically(not ct)

Rx. Mannitol (.25 to 1 g/kg) or 3% saline given

over 30 mins at 5 to10 ml/kg
FLUID and Electrolyte
Initial rehydration at bolus of 10 to20 ml/kg
isotonic saline over 1-2 hrs.
 o Careful rehydrating too quickly(cerebral
edema)
Following initial fluid give fluids evenly over 48
hrs and can be switched to .45% saline after 4-
5 hrs(Nsaline=hyperchloremic metabolic
acidosis)
o It should equal the sum of
1500/ml/m^2/day)
o Once potassium is determine and urine
output add potassium(40meq/L)

INSulin
After 1-2 hr of fluids rehydration, give .1to.2
units/kg per hr(not to quick because cerebral
edema)
Ideal rate is to drop glucose 50-100mg/dL per
hr(hyperglycemia corrects before acidosis)
Can add 5% dextrose to IV fluid once gluc level
beneath 300mg/dl then 10% beneath 200mg/dl
Slowly continue infusion until (Ph >7.3 or
bicarb >17mmol/L) and ptn can tolerate oral
intake of fluids
BICARBONATE
Only under <7 pH ( causes cerebral edema)
then stop at 7.1
THINGS TO LOOK FOR WHEN Rx DKA
Management
4 or more test /day best for glycemic control
HbA1c is great because glucose irreversibly
binds to blood whose life span is 3 months
Insulin pumps great way to monitor insulin
without frequent injections plus it can monitor
dawn phenomenon (cortisol and gH over
night inc glucose)
 Watch for hypoglycemia(,70mg/dl) which is
very common (tremor, tachycardia, anxiety,
hunger, weakness; severe hypogly=seizures
and dysarrythmias)
15gram glucose tablets/ check level/ if not over
100mg/dl add another 15 grams repeat. Family
should be taught to inject glucagon(.5 to 1.mg)
in case of loss of consciousness
Exercise can induce hypoglycemia so ptn
needs to check before during and after exercise
(100-120mg/dl is goal)
Sick days can lead to hyperglycemia and needs
strict control

COMPLICATIONS
Look out for autoimmune thyroiditis and celiac
disease in ptns
Nephropathy(gross proteinuria and end stage
renal disease) check nmicroalbiumina every
year kids older than 10 w/ diabetes past 5
years
Retinopathy (eye check after 10 years old w/
diabetes 3-5 years)
Diabetec neuropathy (every year after puberty)
Atherosclerotic disease much earlier with

Diabetics(necessitating tight glycemic