An autoimmune disease, in which people with a genetic predisposition generate anti-islet cell antibodies in response to uncertain environmental stimuli. The risk of IDDM in a monozygotic twin is 35%, so the genetics account for less than half of the explanation! The risk to a sibling is 5%. Scotland & Scandinavia have a high incidence - cause?
Diabetes NSF/NICE guideline 15 - transition clinics, specialist nurse with max 100 patients, dietician at clinic, easy access to psych/chirop, screening for retinopathy, microalbuminuria, hypertension from 12yrs, screening for coeliac/thyroid 3 yearly, register, guidelines, audit.
Specialist clinics had better HbA1cs (PMID 15941771, Arch 2005). Aim for HbA1c under 7.5% (59mmol/mol) without frequent disabling hypoglycaemia (aim for under 6.5 (48mmol/mol) if other risk factors for arterial disease).
Any of:
Normal HbA1c is 4.8-6.7% (20-42 mmol/mol). Ethnic differences exist, with higher HbA1c values seen in South Asians despite normal fasting/postprandial glucose values.
See Prescribing under Practical.
Different regimens possible:
Choice is based on how parents/child feel about doing injections, the convenience of doing injections during the school day, and flexibility. The QDS regimen offers the most flexibility in terms of timing meals and meal sizes. Also the one that approximates best with endogenous secretion.
HbA1c target 7-7.5% (53-59mmol/mol), equivalent to 3/4 of sugars being normal (4-10). But without frequent disabling hypoglycaemia.
So aim for most blood sugar results to be in the target range of 4-10 mmol/l. If three blood sugar results in a row, at the same time of day, are not in the target range then consider the following:
Note that on discharge home after initial diagnosis, there is often a decrease in the amount of insulin needed, as activity in hospital tends to be less than at home. There is also a honeymoon effect, where close attention to diet and some residual endogenous secretion may make insulin unnecessary! Transient, though.
If none of the above are a problem, adjust insulin dose:
Paleness, Mood Swings, Bad Tempered, Hunger, Tiredness, Shaky, Jelly/Tired Legs, Lack of Concentration. 1-2 mild hypos per week acceptable. Sugar level irrelevant - judge clinically. Important to find cause (NB alcohol) to alleviate fear.
Give 10g of fast acting (sugary) carbohydrate:
and follow this up with a biscuit or bread or fruit.
Place child in the recovery position. Give Glucagon Injection (0.5-1mg). Squirt some Hypostop Gel between your child’s teeth and cheek. 5ml/kg 10% dextrose IV.
Check a Blood Sugar - make sure there's no Hypostop on the hands. Once he/she starts to come round, eg opening eyes or speaking, give a little more Hypostop. When sitting, give half a cup of Lucozade.
Vomiting can occur after a severe hypo - wait for a few minutes then give something else sugary.
The child will feel ill and want to sleep due to the shock of the incident. Ensure he/she has some longer lasting carbohydrate eg 2 Digestive biscuits or a sandwich, before being allowed to sleep to avoid the blood sugar dropping again.
No standard definition, but typically glucose >11mmol/L, with pH <7.3 and/or bicarb <15. Associated with glycosuria and ketonuria. It is unusual but possible to present with near normal glucose values. Usual triggers are inadequate insulin, and/or intercurrent illness.
See DKA page.
Don't order diabetic meal, may not be enough carbohydrate. Split up supplies in case a bag goes missing. If the time difference is more than three hours, then change insulin regimen. Instead of normal insulin, give CLEAR insulin - add up the number of units of insulin you normally take and then divide this by 4. Give every six hours (Travel dose). On the day of travel, do not take normal insulin. Take TRAVEL DOSE every 6 hours before food starting at normal breakfast injection time. This will normally fit quite well with airline meal plans. 1 hour earlier or later will not make any difference provided insulin is taken immediately before food.
If your blood sugar is more than 16 mmol/l, then give an extra quarter of TRAVEL DOSE. If meals are later than normal, swap around your late snack and meal carbohydrate allowances. If meals are delayed, have a snack at the right time then the rest of your carbohydrate allowance when the meal is ready.
In children with IDDM, prevalence of microalbuminuria is 25% at 10yrs, 50% at 20 yrs. HbA1c is a strong predictor, with hazard ratio of 1.39 for each 1% increase. Not clear if there is a threshold value, but the best controlled group (<8.5%, 70mmol/mol) were not protected (15% risk at 20yrs). A Finnish study suggested a lower risk of end stage renal disease in patients diagnosed before age 5 but others have not found a clear difference between onset in adulthood or in childhood. Amercian Diabetes Association recommends target HbA1c 7.5% (59mmol/mol) in teenagers, 8% (64mmol/mol) in children, 8.5% (70mmol/mol) in toddlers. Glucose variability may be important. No data on ACE inhibitors in adolescents with diabetic nephropathy.
Childhood type 2 diabetes (25 cases in UK) is often confused with Monogenic Maturity Onset Diabetes of the young (MODY), a single gene disorder without insulin resistance or obesity. Patients with MODY have endogenous insulin secretion, are usually not insulin dependent or prone to ketoacidosis. In white children MODY comprises 50% of non-type 1 diabetes, but is rarely found in non-whites.
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