REFERAT PRESENTATION

Diabetes Mellitus on Children

Created by:
Khansadhia Supervised by:
Hasmaradana Mooiindie dr. Pulung Silalahi, Sp.A
1102014143

BHAYANGKARA TK.I RADEN SAID SUKANTO HOSPITAL

PERIODE 16 TH APRIL 2018– 30 TH JUNE 2018
FACULTY OF MEDICINE YARSI UNIVERSITY
1
PANCREAS ANATOMY

Main function:
• An exocrine function -> helps in
digestion
• An endocrine function ->
regulates blood sugar
 CELL TYPES IN PANCREATIC ISLETS
OF LANGERHANS

• Acini
• Langerhans
– A cell -> Glucagon
– B cell -> Insulin, C peptide,
proinsulin
– D cell -> Somatostatin
– PP/F cell -> Pancreatic polypeptide
GLUCOSE
→ CELL
• Passive diffusion
• Active transport
REGULATION
OF BLOOD
SUGAR
 DIABETES MELLITUS
Diabetes mellitus (DM) is a chronic disorder characterized by
carbohydrate metabolism, protein and fat disorders caused by both
absolute and / or relative insulin deficiency. Absolute insulin deficiency is
usually obtained in patients with type 1 diabetes mellitus. This is due to
progressive pancreatic b cell destruction so that insulin can not be
synthesized by the pancreas gland. Insulin deficiency is relatively found in
patients with type 2 diabetes because insulin use in the body is less
effective
DIABETES MELLITUS ON
CHILDREN
Type 1 diabetes mellitus (DMT1) is a
systemic defect the occurrence of glucose
metabolism disorder characterized by
hyperglycemia chronic. This condition is
caused by good pancreatic β cell damage
by autoimmune and idiopathic processes so
that the production of insulin is reduced
even stalled. Low insulin secretion results in
disturbance metabolism of carbohydrates,
fats, and proteins.
DIABETES MELLITUS ON
CHILDREN
Diabetes mellitus is a Caused by low insulin
group of metabolic levels due to pancreatic
diseases
beta cell destruction or
characterized by
insulin resistance.
hyperglycemia

Potentially disrupt children’s growth and development.

 EPIDEMIOLOGY
T1DM is common on children
rather than T2DM
<1980 new cases of type-1 DM
in children across Indonesia -
> <100 cases
By 2014 reaching >1,000 cases
(IDAI Data PP 2014).
T1DM T2DM
¾ of all cases of type-1 are
diagnosed on children <18 yrs
old.
 CLASSIFICATION
Type-1 DM

DIABETES
Monogenic DM

Type-2 DM
Exocrine pathology of
pancreas

Other specific
types Endocrine disease

Drugs

Genetic syndrome
 DEFINITION OF DM TYPE 1
Type 1 diabetes mellitus (T1DM) is the most common
chronic endocrine disease in children, in which pancreas
produces a little or no insulin.
With a very low incidence in the first months of life and
reaching its peak during puberty (10-15 years old is the
age group with the highest incidence at the time of onset).
 ETIOLOGY OF DM TYPE 1
• T1DM etiology’s theories
1.Genetics
2.Environmental
3.Autoimmune
PATOPHYSIOLOGY TYPE-1
DM
In type I diabetes, there are two forms with different pathophysiology.

Type IA, suspected genetic and Type IB is associated with a

environmental influences play a
major role for the occurrence of
pancreatic damage. HLA-DR4 is
found to have a very close
relationship with this
phenomenon.
primary autoimmune state in a group
of patients who also often exhibit
other autoimmune manifestations,
such as Hashimoto disease, Graves
disease, pernicious anemia, and
myasthenia gravis. This situation is
associated with HLA-DR3 antigen and
appears at about 30 - 50 years of age.

In type I diabetes, diabetes tend to occur

ketoacidosis
PATOPHYSIOLOGY
TYPE-2 DM
POLYPHAGIA
 GLYCOSURIA,
POLYURIA, POLYDIPSIA
 STAGE
Prediabetic Clinical Honeymoon Insulin
period manifestation period dependence
period period
• Asymptomatic • Almost 90% • The rest of the • The end of
• Insulin secretion beta cell was beta cells will T1DM stage
was decreased destroyed. work optimally • Patients will
• C-peptide  • Blood sugar  so insulin can be need insulin back
• Patient needs produced by our from outside the
insulin from the body itself. body for the rest
outside so that • Insulin from the of his life
blood glucose outside the body
can be uptake will be reduced,
into the cell but only
temporarily.
CLINICAL MANIFESTATION
 CLINICAL MANIFESTATION

(Clinical manifestation determination of T1DM and

T2DM.Greenspan basic and clinical physiology 8th ed.)
ANAMNESIS
 DIAGNOSIS
Polyuria, polydipsia, nocturia, enuresis,
polyphagia FPG  126 mg/dL
RPG 200 mg/ dL
Diagnosis Criteria of DM
by American Diabetes Association (ADA)

HbA1c >6.5% GD2PP > 200 mg/dL during a 75-g

oral glucose tolerance test
TYPE-1
DM VS
TYPE-2
DM
C-PEPTIDE
EXAMINATION
• C-Peptide examination was used to distinguish T1DM and
T2DM. It is a good indicator for beta cell function.
• Blood test done to find out how much insulin is produced.
• This test will be useful to determine whether you have type
1 or type 2 diabetes, or whether you suffer from insulin
resistance.
LABORATORY
EXAMINATION
Serum autoantibody detection
Islet cell autoantibodies (ICAs)
Glutamic acid decarboxylase
Insulin autoantibodies
Ketone
Urinalysis (Ketone, protein)
C-peptide
Hba1c (metabolic control)
INSULIN NUTRITION

TREATMENT

EDUCATION MONITORING EXERCISE

32
 INSULIN
• Absolute therapy should
be given to T1DM
• In the administration of
insulin to note the type of
insulin, insulin dose and
injection way
• Injection areas:
abdomen, upper arm and
lateral thighs
ULTRA SHORT ACTING INSULIN
(LISPRO, ASPALT, GLULISIN)
• Clear solution
• Onset 12-30 minutes
• Peak : 0,5 – 3 hr
• Duration : 3-5 hr
SHORT ACTING INSULIN
• REGULAR INSULIN
• Clear solution
• Onset 30-60 minutes
• Peak : 2-4 hr
• Duration : 5-8 hr
SHORT ACTING INSULIN
• Ketoacidosis
• Newly diagnosed
• Surgery
• Before meal
• Combination with intermediate acting insulin
(two times a day)
INTERMEDIATE ACTING INSULIN
(ISOPHANE/NPH, CRYSTALLINE ZINC
ASETATE)
• Suspension : Cloudy
• Onset : 2-4 hr
• Peak : 4-12 hr
• Duration : 12-24 hr
INTERMEDIATE ACTING INSULIN
• Regular life style
• Common use in diabetes
mellitus on children
• Neonates
BASAL INSULIN ANALOGUES
(GLARGINE, DETEMIR)
• Duration until 24 hr
• Glargine and Detemir :
peakless (basal insulin)
• Not recommended for
children < 6 years old
MIXED ACTING INSULIN
Combination :
Ultra short + intermediate acting insulin
OR
Short + intermediate acting insulin
DOSAGE
 METFORMIN
• Dosis metformin untuk anak-anak penderita diabetes tipe 2
• Dosis awal: 500 mg oral 1-2 kali sehari atau 850 mg sekali sehari. Dosis
dapat dinaikkan tiap 1 minggu sesuai toleransi
• Dosis maksimum: 2000 mg per hari, terbagi dalam 2-3 dosis
2. NUTRITION
• Diet in children with T1DM refers to
optimize children growth and
development
• Carbohydrates are the most influential
nutrients on blood glucose
• 90-100% of carbohydrates will be
converted into glucose within 15 to 60
minutes after meals
2. NUTRITION
• The number of caloric needs for children aged 1 year to age of
puberty can also be determined by the following formula:

The division of calories per 24 hours is given 3

times main meals and 3 times snacks as follows:
• 20% of breakfast.
• 10% of snacks.
• 25% of lunch.
• 10% of snacks.
• 25% of dinner.
• 10% of snacks.
EDUCATION
EDUCATION
MONITORING
 COMPLICATION
Ketoacidocis Hiperglikemik
Diabetic Hiperosmolar State
Glucose,a mmol/L (mg/dL) 13.9–33.3 (250–600) 33.3–66.6 (600–1200)
Sodium, meq/L 125–135 135–145
Potassiuma,b Normal to Normal
Magnesiuma Normal Normal
Chloridea Normal Normal
Phosphatea,b Normal Normal
Creatinine Slightly Moderately
Osmolality (mOsm/mL) 300–320 330–380
Plasma ketonesa ++++ +/–
Serum bicarbonate,a meq/L <15 meq/L Normal to slightly
Arterial pH 6.87.3 >7.3
Arterial PCO2,a mmHg 20–30 Normal
REFERENCE
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