Care of Diabetes in Children & Adolescents

Dr. Zuhayer AhmedHMO

Dept. of EndocrinologyDMCH

Children

• Biologically, A child is generally a human between the stages of birth and puberty

• United Nations Convention on the Rights of the Child defines child as “a human being below the age of 18 years unless under the law applicable to the child, majority is attained earlier”

Adolescence

• A transitional stage of physical and psychological human development that generally occurs during the period from puberty to legal adulthood.

Why Special?• Changes in insulin sensitivity related to sexual

maturity and physical growth

• Ability to provide self care

• Supervision in child care and school

• Unique neurological vulnerability to hypoglycemia, hyperglycemia of DKA

Type 2 Diabetes Mellitus

• It is assumed that prevalence of T2DM under 20 years of age will quadruple in 40 years.

Testing Protocol in T2DM (< 18yrs)

• Asymptomatic Children:

–Overweight:–BMI > 85th percentile for age and sex–Weight for height > 85th percentile–Weight > 120% of ideal for height

• Any two of the following risk factors:

– Family history of T2DM– Race/Ethnicity– Signs of Insulin resistance or associated conditions– Maternal history of Diabetes or GDM

• Age of initiation:• At 10 years of age, or• At puberty, if puberty is earlier

• Checking should be done every 3 years

Suitable Tests

• Validity of HbA1c in the pediatric population under question

• OGTT and FPG more suitable

• For now, aside from rare instances like cystic fibrosis and hemoglobinopathies, HbA1c is recommended

Do not miss!!

• Blood Pressure measurement

• Fasting lipid panel

• Assessment of Albumin excretion

• Dilated eye examination

Type 1 Diabetes Mellitus

• 5-10% of all cases of Diabetes Mellitus

• 75% of all cases diagnosed as T1DM < 18 years of age

• Can be immune mediated or idiopathic

• Immune mediated variety was previously called “juvenile onset diabetes”

• The rate of ß-cell destruction is variable, being rapid in infants and children

• Children & adolescents may present with DKA more

Diagnosis

• According to ADA Criteria for Diagnosis of Diabetes

• Autoimmune Markers:• Islet cell autoantibodies• Autoantibodies to Insulin• Autoantibodies to GAD• Autoantibodies to ZnT8

• Early diagnosis may limit acute complications

• Extend long term endogenous insulin production if diagnosed early

Associated Autoimmune Conditions

–Thyroid disease:• TSH:– If normal, repeat every 1-2 years

• Anti-TPO and anti-TG Ab

–Autoimmune Gastritis:• S. B12 assay

• Celiac Disease:

• Anti tTG IgG• Anti Deamidated Gliadin IgG

Glycemic Goals

• HbA1c: <7.5%

• Before meals: 5.0-7.2 mmol/L

• Bedtime: 5.0-8.3 mmol/L

• Should be individualized

• Should consider long term benefits of A1c Control and risks of hypoglycemia

Remember!

• Attain low BG as safely as possible

• Stepwise goals

• Hypoglycemic unawareness (<6yrs)

• Near normalization of glucose levels more difficult to achieve in adolescents than in adults

To Avoid Hypoglycemia

• Insulin analogues

• Continuous Glucose Monitoring

• Low glucose suspend insulin pumps

• Education

Management of Blood Pressure

• High normal BP: (>90th percentile)• Dietary intervention• Exercise• Drugs (if no improvement for 3-6 months)

• Hypertension: (> 95th percentile)• ACE inhibitors• ARBs

• Goal:• Consistent BP < 90th percentile for age, sex and

height

Management of Dyslipidemia

• Obtain a Fasting Lipid Profile at or above 2 years of age:• If abnormal, monitor annually• If LDL <100 mg/dl, repeat every 5 years

• Initial Therapy:• Optimized glucose control•MNT (Medical Nutrition Therapy)

• After the age of 10 years:• LDL >160 mg/dl, or• LDL > 130 mg/dl and one or more CVD

risks

• Goal: • LDL <100 mg/dl

Smoking

• Discourage all sorts of smoking, including e-cigarettes

• Established risk factor of CVD

• Associated with onset of Albuminuria

Screening for Microvascular complications

• Nephropathy:• At least annually: (if diabetic for > 5

years)–Spot urine for ACR

• Creatinine clearance/ eGFR: – Initially once, then based on age, duration,

treatment etc.

• Retinopathy: (if diabetes 3-5 years)• Initial Dilated Eye Examination:–At 10 years of age, or–At the beginning of puberty

• Then, annual or bi-annually

• Neuropathy: (if Diabetes > 5yrs)

•Comprehensive Foot Examinations:–At 10 years of age, or–At the beginning of puberty

Education

• Diabetes Self-management Education and Support

• School and Child Care

• Medical Nutrition Therapy

• Psychosocial Issues

Monogenic Diabetes Syndromes• Diagnosed within first 6 months of life or

within 25 years• Strong family history but not typical of T2DM• Mild fasting hyperglycemia:

• 100-150 mg/dl (5.5-8.5 mmol/L)

• Diabetes with:• Negative Autoantibodies• No signs of Insulin resistance• No Obesity

Neonatal Diabetes

• Diagnosed in first 6 months of life

• Not typical of autoimmune T1DM

• Transient or Permanent

• Permanent form can be well managed with Sulfonylureas

Maturity-Onset Diabetes of the Young(MODY)

• Age below 25 years

• Inherited as Autosomal Dominant pattern

• Impaired insulin secretion

• Minimal or no defects in insulin action

Importance MDS

• To avoid suboptimal treatment regimens

• Unnecessary delay in diagnosing other family members