This document provides information on diabetes including definitions, epidemiology, diagnosis, etiologic classifications, physiology, presentation, investigations, management, treatment, insulin types, and special considerations for pediatric diabetes. It defines diabetes as a metabolic disorder characterized by hyperglycemia caused by insulin deficiency or resistance. Key points include that type 1 diabetes is an autoimmune condition resulting in absolute insulin deficiency, while type 2 involves insulin resistance with relative deficiency. Diagnosis requires hyperglycemic symptoms and blood glucose criteria. Management involves a multidisciplinary team, medical treatment including insulin administration and nutrition management, and screening for acute and long-term complications.

1. Duhok Pediatrics
Diabetes center

2. Definition
• It’s a chronic metabolic disorder characterized
by hyperglycemia as a cardinal biochemical
feature, caused by deficiency of insulin or its
action, manifested by abnormal metabolism
of carbohydrates, protein and fat

3. Epidemiology
• Peaks of presentation occur in 2 age groups: at
5-7 yr of age (infectious) and at the time of
puberty (gonadal steroids ).
• Girls and boys are almost equally affected
• There is no apparent correlation with
socioeconomic status.

4. Incidence rates of type 1 diabetes mellitus by region and
country

5. Diagnosis of diabetes is made when:
• Symptoms +
• random BGL ≥ 11.1 mmol/L (≥200 mg/dl) (or)
• Fasting BGL ≥ 7mmol/L (≥ 126 mg/dl)

6. ETIOLOGIC CLASSIFICATIONS OF DIABETES MELLITUS
Type I diabetes: (β-cell destruction, usually leading to absolute insulin deficiency)
-Immune mediated.
-Idiopathic.
Type 2 diabetes: (may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly secretory defect with insulin resistance).
Other specific types :
Genetic defects of β-cell function:Chromosome 7, glucokinase (MODY2)
Genetic defects in insulin action:Rabson-Mendenhall syndrome
Diseases of the exocrine pancreas: Pancreatitis
Endocrinopathies: Cushing disease
Drug- or chemical-induced : Glucocorticoids
Infections:Cytomegalovirus
Uncommon forms of immune-mediated diabetes :Stiff-man” syndrome
Other genetic syndromes sometimes associated with diabetes :Down syndrome
Gestational diabetes mellitus
Neonatal diabetes mellitus

7. Physiology
• The main function of insulin are:
• 1. Reduce glucose by:
• ↓ gluconeogenesis
• ↓ glycogenolysis
• ↑ uptake of glucose by cell
• 2. Inhibit fat breakdown (lipolysis)
• 3. Inhibit protein breakdown (proteolysis)

8. Insulin deficiency will lead to:
1. Hyperglycemia: increase glucose→ osmotic
diuresis → polyuria → dehydration →
compensatory polydepsia.
2. Proteolysis: → weight loss → Polyphagia.
3. Lipolysis: ↑ free fatty acids and
accumulation of acetyl Co-A → Liver → keton
bodies → ketonemia → ketonuria &
Metabolic acidosis.

9. Presentation:
1. Although most symptoms are nonspecific
2. polyuria , polydepsia, Polyphagia & weight
loss.
3. Recurrent infection: skin or UTI.
4. Diabetic Ketoacidosis

10. Investigations:
• Blood glucose : Fasting glucose > 126 mg/dl &
Random > 200 mg/dl.
• HbA1c: (glycated haemoglobin) average over
the last 2-3 months. Measures amount of
glucose that attaches to haemoglobin, The
target HbA1c < 7.5% (58 mmol/mol).
• Ketone testing: either urine strips, or blood.
• Urine: glucosuria & Ketonuria if DKA
suspected.

11. Management
• Need team & Special diabetic Clinic?
• Medical: specialist
• Specialist Nurses:
• Dietitian.
• Psychologist
• Equipments: insulin, glucometer, Ketones
meter and good maintenance.
• Good follow up.

12. Treatment
Insulin
Nutrition

13. Types of Insulin

14. Types of presentation
If newly diagnosed:
1. DKA: according to Guideline.
2. Only hyperglycemia.
Already diabetes on insulin therapy with:
1. DKA: according to Guideline.
2. Presence of ketonemia?
3. Only hyperglycemia? Not controlled?

15. 1. Diabetic Ketoacidosis (DKA):
• Occurs when there is profound insulin deficiency.
• It frequently occurs at diagnosis and also in
children and youth with diabetes if insulin is
omitted, or if insufficient insulin is given at times
of acute illness.
• The biochemical criteria for DKA are:
 Hyperglycaemia (blood glucose >11mmol/l
(~200 mg/dl))
 Venous pH <7.3 or bicarbonate <15 mmol/l
 Ketonaemia and ketonuria

16. Treatment

17. 2. New-Onset Diabetes without
Ketoacidosis
• Ideally, therapy can begin in the outpatient
setting, with diabetic team. (we prefer
admission).
• There are many Insulin regimens for
treatment with many advantages and
disadvantages
• We have to select one ??

18. Insulin regimens
A. Conventional Insulin therapy: Twice daily mixed Insulin.
B. Intensive Insulin therapy:
1. Basal – Bolus(3 Injections):
o 2 bolus of short acting before breakfast and lunch +
o Mixture of short acting and Intermediate acting at evening meal.
2. Basal – Bolus(3 +1 Injections):
o 3 bolus of short acting before breakfast + lunch + evening meal +
o Intermediate acting before bedtime.
3. Basal – Bolus(3 +1 Injections):
o 3 bolus of Rapid acting before breakfast + lunch + evening meal +
o Long acting before bedtime.
4. Basal – Bolus(3 +1 Injections):
o Long acting before bedtime.
o Rapid acting before meal according to Carbohydrate Counting
and Insulin Correction

19. 2. New-Onset Diabetes without Ketoacidosis
Insulin regimens
50% of the total daily dose Rapid -acting insulin
(NovoRapid Pen)
divided up between 3 pre-
meal boluses
50% of the total daily dose long-acting insulin
(Lantus® (insulin glargine
Pen)
single evening injection
Insulin requirements:
Start with 0.5 IU/kg/day
Pre-pubertal 0.7-1.0 IU/kg/day.
During puberty 1 and even up to 2 U/kg/day.
The correct dose of insulin is that which achieves the best glycaemic control

20. BLOOD GLUCOSE MONITORING
• Blood glucose monitoring should ideally be
carried out 4-6 times a day, however, this is
dependent on the availability of testing strips.
• Recommended target blood glucose levels:
Blood Glucose Targets for Most People with Diabetes
During the day 4.5-7mmol/l 80-125mg/dl
Overnight & pre breakfast 5.5 -8mmol/l 100-145 mg/dl

21. 3. Management of High Blood Glucose and
Ketones but not DKA
• Ketone testing: either urine strips, or blood.
• Should be performed:
 During illness with fever and/or vomiting.
 When blood glucose is above 14 mmol/l (250 mg/dl) in an
unwell child or
 when persistent blood glucose levels above 14 mmol/l (250
mg/dl) are present.
 When there is persistent polyuria with elevated blood
glucose, especially if abdominal pain or rapid breathing are
present.
 There is an immediate risk of ketoacidosis if the blood
ketone level is ≥ 3.0 mmol/l. Insulin treatment is needed
urgently. Consider medical evaluation of patient.

22. 3. Management of High Blood Glucose and Ketones but not DKA
blood
ketones
Results Action Follow up
0.1 – 1
mmol/l
acceptable No action
1- 3
mmol/l
• reduce it < 1
mmol/l
• Retest hourly.
10% of Total Daily Dose
( not more than 10 units)
Repeat dose after 2 hours if
ketones not < 1 mmol/l & the
glucose level > 250 mg/dl
(14mmol/l)
≥ 3.0
mmol/l.
•Risk of DKA?
reduce it < 1
mmol/l
•Retest hourly.
1/6 of Total Daily Dose
( not more than 15 units)
Repeat dose after 2 hours if
ketones not < 1 mmol/l & the
glucose level > 250 mg/dl
(14mmol/l)
Drink plenty of liquids that
contain no calories, for
example a glass of water
every thirty minutes
Try to identify the cause of
the high reading.

23. Exercise
• Regular exercise; improves glucoregulation by
increasing insulin receptor number.
• No form of exercise, including competitive sports,
should be forbidden to the diabetic child.
• In patients who are in poor metabolic control,
vigorous exercise may precipitate ketoacidosis
because of the exercise-induced increase in the
counter-regulatory hormones.
• A major complication of exercise in diabetic
patients is the presence of a hypoglycemic
reaction during or within hours after exercise.

24. • The major contributing factor to hypoglycemia
with exercise is an increased rate of absorption
of insulin from its injection site.
• In anticipation of vigorous exercise, additional
carbohydrate exchange may be taken before
exercise, and glucose should be available
during and after exercise.
• The total dose of insulin may be reduced by
about 10-15% on the day of the scheduled
exercise.
Exercise

25. Diet
• There are 3 main nutrients in foods—fats,
proteins, and carbohydrates.
• Fats: Fat typically doesn't break down into sugar ,
and in small amounts, it doesn't affect blood
glucose levels.
• Proteins: Protein doesn't affect blood glucose
unless the patient eat more than the body needs.
• Carbohydrates: Carbohydrates affect blood
glucose more than any other nutrient.

26. Diet
• The same total caloric intake as usual in
normal child is given with the same ratio
• 50% CHO
• 35% Fat
• 15% Proteins
• Number of meals is preferred to be three fixed
major with two snakes in between.

27. What is Carbohydrate (CHO) Counting?
• is a method of matching your insulin
requirements with the amount of
carbohydrate you eat and drink.
• It is an effective way of managing the
condition that, once mastered, will lead to
better blood glucose control, greater flexibility
and freedom of lifestyle.

28. To be successful using carbohydrate counting,
you need to:
• be motivated and able to take the time required
to improve diabetes management
• do simple arithmetic (add, subtract, multiply and
divide)
• understand insulin action
• read food labels
• count carbohydrates
• understand the relationship between
carbohydrate and insulin

31. Carbohydrate Counting and Insulin Correction
• adjusting insulin
• Calculate amount of carbohydrate that patient
eat.
• Think about activity/exercise
• Check blood glucose level.
• Ideally, the measurement after the meal should
be within 30-50 points or (2 mmol/l) of the pre-
meal levels. If it's not, need Carb Counting, Meal
Plans, and Insulin Adjustment?

32. • Insulin sensitivity :is how much 1 unit of rapid
acting insulin will generally lower your blood
glucose over 2 to 4 hours in a fasting or pre-meal
state.
• Insulin sensitivity: 100/Total daily units .
• Carbohydrate sensitivity : is a great way to
estimate how many grams of carbohydrate will
be covered by one unit of Rapid acting Insulin.
• Carbohydrate sensitivity: 500/ Total daily units
for adult

33. • Roughly according to Age the Insulin to CHO
ratio :
• Less than 5 years: 1unites /25 gm
• 5 to 8 years: 1unites /20 gm.
• 8 to 11 years: 1unites /15 gm.
• 11 to 18 years: 1unites /10 gm
AGE (yr)
TARGET
GLUCOSE
(mg/dL)
TOTAL DAILY
INSULIN
(U/kg/day)*
BASAL
INSULIN, % OF
TOTAL DAILY
DOSE
BOLUS INSULIN
Units Added
per 100 mg/dL
Above Target
Units Added
per 15 g at
Meal
0-5 100-200 0.6-0.7 25-30 0.50 0.50
5-12 80-150 0.7-1.0 40-50 0.75 0.75
12-18 80-130 1.0-1.2 40-50 1.0-2.0[‡] 1.0-2.0

34. Example
• 15 years old with DM on 25 units Lantus and 8 Novorapid at
meal times.
• Prelaunch RBS= 10 mmol/l ≈ 180 mg/dl
• She planned to eat Potato for lunch (50 g Carbohydrate)?
• How much Insulin?
• Target BG 4.5-7 ≈ 6 (110 mg/dl) , so need to reduce it by 70
mg/dl
• Total daily insulin= 50/day
• Insulin sensitivity: 100/Total daily units =100/50=2 it mean
1 unit will drop BG by 2 mmol (35 mg/dl) therefore will
need 2 units.
• Carbohydrate sensitivity: 500/ Total daily units =500/50=10
, so need 1 unit for every 10 g. potato is appoximatily 50 g,
therefore need to take 5 units to cover food.
• Total 7 units.

35. • Note: In general these 3 factors will aid in
estimating correct mealtime does of
insulin(rapid acting insulin )
1. Check blood glucose
2. Estimate amount of carbohydrate about to
be eaten.
3. Consider any exercise done before this meal
or any exercise after meal.

36. Expert meter

37. Patient Education

38. Family Education

39. Dietary Education

41. Nurse Advices & Education

42. Nurse Advices & Education

43. Psychological support & Education

44. Screening for complications and associated
conditions
• height and weight & state of injection sites at
each clinic visit.
• Thyroid disease & coeliac disease at diagnosis
and annually.
• annual foot care reviews.
• Regular dental and eye examinations every 2
years.
• from the age of 12 years: blood pressure,
retinopathy, microalbuminuria & S.Creatinine.

45. • The following complications, although rare,
should be considered at clinic visits:
• juvenile cataracts
• necrobiosis lipoidica
• Addison's disease.
• Routine screening for elevated blood lipid
levels and/or neurological function is not
recommended for children and young people
with type 1 diabetes.
Screening for complications and associated conditions

46. Special consideration
• Partial Remission or Honeymoon Phase in
Type 1 Diabetes
• Somogi Phenomena
• Dawn Phenomena.
• Management of DM during Infection.

47. Partial Remission or Honeymoon
Phase in Type 1 Diabetes
• Insulin requirements can decrease transiently following
initiation of insulin treatment.
• This has been defined as insulin requirements of less
than 0.5 units per kg of body weight per day with an
HbA1c < 7%.
• Ketoacidosis at presentation and at a young age reduce
the likelihood of a remission phase.
• It is important to advise the family of the transient
nature of the honeymoon phase to avoid the false
hope that the diabetes is spontaneously disappearing.
• Treatment by reduce the dose of Insulin Accordingly.

48. • In children with High dose of Insulin at Night
(Long acting) develop late night(3-4 a.m)
Hypoglycemia Counter regulatory hormon
will increase Early morning Hyperglycemia.
• Treatment: Reduce the dose of Long acting
Insulin at Night .
Somogyi Phenomenon

49. • In children with Normal dose of Insulin at
Night & Normal midnight glucose
(Normoglycemia), Counter regulatory
hormone may normally increase Early
morning Hyperglycemia.
• Treatment: Increase the dose of Long acting
Insulin at Night .
Dawn Phenomenon

50. • Infection may precipitate hyperglycemia or
DKA.
• Mild infection should be treated + increase
the dose of Insulin by 10 – 15%.
• Sever infection necessitate hospitalization.
Management during Infection

51. Important information
• Do not shake the insulin as this damages the
insulin?
• After first usage, an insulin vial should be
discarded after 3 months if kept at 2-8 C or 4
weeks if kept at room temperature.
• Intermediate-acting and short-acting/rapid-
acting insulin, can be combined in one
Syringe.
• Use 4mm needle for injection of Insulin SC.

52. THANKS FOR YOUR
Attention

53. Dundee

54. Dundee

55. Ninewell Hospital

57. Tayside Children's Hospital