Diabetes Mellitus Pada Anak Kuliah
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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%