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Diabetes Mellitus
A major chronic disease among children in US and increasing in numbers.
Type 1 and Type 2
Type 1
Childhood Diabetes or Insulin Dependent DM
Autoimmune disease + environmental factors Beta cells from pancreas are depleted (insulin producing)  
Clinical Manifestations of Type 1
Polyuria, polydipsia Constant hunger, eat and eat and not gain weight Recent weight loss, possible nausea and/or vomiting Fatigue, mood changes Ketoacidosis on initial presentation 30-40% Short duration of symptoms Hyperglycemia-excess sugars in body
What happens in Type 1?
1.  Spills sugars in urine, this changes the fluid balance between extracellar and intracellar. There are also large amounts of potassium and phosphate lost.(electrolyte depletion and dehydration) 2.  No glucose to use so to provide energy breakdown proteins and fats are used, which releases ketones. (metabolic acidosis)
Type 2
Adult onset or Non-insulin Dependent DM
An alteration occurs in the insulin receptors.  Body becomes resistant and/or impaired glucose secretion
Clinical Manifestations of Type 2
Polyuria, polydipsia Acanthosis Nigricans(darkening and thickening of the skin, change and color/texture of the skin) Obese, with possible weight loss Ketoacidosis on initial presentation 5-25%(up to 50% will develop)
Risk Factors for Type 2
Family hx of type 2
Intrauterine exposure to DM
Lack of exercise
Certain ethnicities (Indians
Management for All Diabetes Mellitus (DM)
Target blood sugar range (70-150mg/dl) Avoid using terms good blood sugar or bad blood sugar No food must be avoided, certain foods will however need extra insulin (Carbs 50-55%,protein 20-25%, fats 25-30%) Carbohydrate counting 1 unit of insulin =15 grams of carbs Hemoglobin A1C (glycosylate hemoglobin) Normally RBC carry trace of glucose(6-7%).  If serum glucose is greater than normal it attaches to hemoglobin protein.  Gives a better long term picture of glucose control.
Treatment of Diabetes Mellitus
Insulin Therapy (All Type I and some Type II) Note: NPH is moderate, peaking 4-5 hours later.  Not always good for kids because they have variation in activity.  JUST KNOW TYPE 1 NEEDS INSULIN Oral Medications (Some Type II) Diet Exercise
Hypoglycemic happens very fast…. While hyperglycemic takes time.  Hypoglycemic is much more of a problem.  KNOW: THE DIFFERENCE OF HYPOGLYCEMIA AND HYPERGLYCEMIA, THE SYMPTOMS. Hyper – you get thirsty, sleepy, bathroom a lot, think about symptoms you get when you have a big full meal.
Mild symptoms of Diabetes
Sweating/clammy skin
Moderate to severe symptoms of Diabetes
Irritability/Behavior changes
Extreme Tiredness
When is it treated?
When blood sugar is below 70 mg/l
Test 6-8 times a day
Keys to success in Diabetes
What could you do for a type 1 preschooler to keep their need for autonomy and control?
  • Diet choices – a kid at this age has lots of frequent meals
  • Ask them to help you gather supplies
  • Let them prick their finger
  • DON’T give them a lot of choices, give them two and don’t let them plunge till they are 5 or 6
What kind of dev challenges must be addressed for an adolescent with diabetes?
  • How to explain it to their friends
  • Self-care, where to do it and such
  • Know diet is like everyone else they just need to balance with coverage of insulin.
  • Their self-identity
  • Maintain their independence (don’t want them rebelling)
  • Drugs, alcohol, and tobacco, sex.
A teenager has figured out they can cheat all month and follow right carb count before doctor visit what test would show they haven't been following proper diet?
Test A1C
Newborn screening for Metabolic/Genetic Disorders
One of the best test presently available for picking up many disorders, but especially metabolic or endocrine
  • Need further testing to confirm
Using blood drops from newborns can detect many metabolic/genetic disorders
Which metabolic/genetic disorders could the newborn screening pick up?
  • PKU (phenylketonuria)
  • Galactosemia
  • Thyroid Disorders
  • Amino Acid Disorders
  • Organic acidemias
  • Fatty Acid Oxidation Disorders
  • Cystic Fibrosis
  • Sickle cell disease and other hemoglobinopathies
PKU (Phenylketonuria)
  • Autosomal recessive (1/4 and both parents may not know they (any defected gene)
  • tested w/ in 48 hours after birth: must have taken formula or breastfed!
  • Body unable to break down the essential amino acid phenylalanine into tyrosine.
  • The high levels of PKU lead to disruption of cellular processes of myelination and protein synthesis
Complications of PKU
seizue disorcers and mental retardation
Treatment of PKU
  • Meats & dairy products avoided.
  • Special formulas such as lofenalae or minafen
  • Diet low in phenlalanine
  • Autosomal recessive
  • Unable to convert galactose to glucose
  • No milk or cheese products for life
  • Complications:  Liver disease, mental retardation, seizures, death if untreated
  • Downs babies are similar & many have this too
  • Females 2x risk
  • May be congenital (autosomal recessive)
    • Picked up with newborn screening
  • May be acquired
    • Picked up with blood test
Causes of Hypothyroidism
  • Lack of hormone
  • Feedback breakdown with central nervous system
  • Hypoplasia or aplasia of gland
Clinical Presentation for Infant for Hypothyroidism
  • Cretinoid features, hypotonia, bradycardia, cool extremities, difficulty feeding
Clinical Presentation for Child (not dx w/ newborn screening) for Hypothyroidism
  • Same as infant, also hair loss, decreased appetite but weight gain, goiter
Treatment for hypothyroidism
Medication for life and..
  • Make sure they are gaining weight
You don’t want them to have insomnia either
Metabolic/Endocrine not with Newborn Screening:
Diabetes Insipidus
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Growth Hormone Deficiency (Hypopituitarism)
Diabetes Insipidus
  • Hyposecretion of antidiuretic hormone (ADH) or vasopressin which produces uncontrolled diuresis
Causes of Diabetes Insipidus
Familial (rare), idiopathic, trauma, tumors, infection (meningitis), drugs (after chemo esp.)
Cardinal Signs of Diabetes Insipidus
  • Polyuria and polydipsia
    • Kids don’t want milk; they want water
Diagnosis of Diabetes Insipidus
  • Na serum levels high, K+ low
  • Urine specific gravity and osmolarity low
  • Fluids low, particles high
Care and treatment of Diabetes Insipidus
  • Restrict fluids and watch Specific Gravity
    • (DL & SIADH can flip flop really fast so restrict fluids!! Esp. w/ brain injury/trauma pts.
    • Check Na frequently !! if really high, can cause seizures.
    • Treated with vasopressin – kids that wet their bed may get this too! (older schoolage)
Syndrome of Inappropriate ANtidiuretic Hormone (SIADH)
  • Hypersecretion or release of vasopressin
  • Excess ADH causes filtered water to be reabsorbed from kidneys into central circulation
Causes of SIADH
  • Infection, tumors, CNS diseases/trauma, meds
Diagnosis of SIADH
  • Sodium serum levels low (watch output and intake for both DI and SIADH.
  • Urine specific gravity and osmolarity high
Symptoms of SIADH
Anorexia, nausea, vomiting and malaise often prior to severe symptoms such as seizures
Treatment of SIADH
  • Treated with fluid restrictions
    • NO ALBUMIN because fluid is already in the vascular system. 
    • May give diuretics
When NA is ascue, kids may become...
irritable or confused.
When is DI and SIADH permanent?
If they have it for weeks.
Why does it not initially become edemanous?
Because it is in the cardiac system (vascular)
Growth Hormone Deficiency (Hypopituitarism)
Pituitary gland not producing hormone for growth
Manifestations of Growth Hormone Deficiency (hypopituitarism)
  • Decreased linear growth
  • Bone mineral density decreased
  • Growth of all body tissues effected by inability to synthesis proteins  (decreased muscle mass, thin hair, poor skin quality)
  • Liver ineffective in metabolizing fat resulting in excessive subcutaneous fat and hypoglycemic
Children normal in size and weight at birth but changes in growth are noted when?
after 1 year (below the 3rd percentile on the growth chart)
Treatment of Growth Hormone Deficiency (Hypopituitarism)
Depends on cause
  • Synthetic growth hormone replacement therapy (later in life, at risk for brain tumors.)
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