Diabetes in childhood

Question 1

Which hormones maintain blood glucose homeostasis?

Answer 1

glucagon
insulin

Question 2

Diabetes bloods diagnosis cut offs

Answer 2

fasting >7
2 hours post OGTT >11
random glucose + symptoms >11

Question 3

Symptoms of diabetes

Answer 3

polydipsia
polyuria
tired
weight loss

Question 4

2 types of monogenic diabetes mellitus

Answer 4

neonatal diabetes mellitus
MODY

Question 5

Describe MODY

Answer 5

young age at onset (<25y)
autosomal dominant
family history
absence of signs of insulin resistance (obesity, acanthosis nigricans)
little/no insulin requirement 5 years after diagnosis
stimulated c-peptide >200 pmol/L

Question 6

T1DM autoantobodies

Answer 6

GAD65
ICA
IA2
ZnT8

Question 7

Advantages of insulin pumps

Answer 7

delivers insulin in more physiological way
can improve diabetes control
lessens risk of hypoglycaemia
fewer injections/needles

Question 8

Disadvantages of insulin pumps

Answer 8

intensive therapy, can be hard work
pump failure
not everyone wants visible sign of diabetes
concerns over wearing pump during sport
risk of skin infection at cannula site
expensive

Question 9

Short term complications of diabetes

Answer 9

DKA
hypoglycaemia
hyperglycaemia

Question 10

DKA diagnostic criteria

Answer 10

BM >11 mmol/L
ketonaemia > mmol/L
acidosis: pH<7.3, HCO3<15mmol/L

Question 11

DKA triggers

Answer 11

8Is:
Infection (pancreatitis, pneumonia, UTI)
Infarction (MI)
Infraction (non-compliance with therapy)
infant (pregnancy)
ischaemic (CVA)
illegal (cocaine)
Iatrogenic (steroids etc)
Idiopathic (new onset T1DM)

Question 12

Mild DKA cut offs

Answer 12

pH 7.2-7.3
HCO3 15

Question 13

Moderate DKA cut offs

Answer 13

pH 7.1-7.2
HCO3 10

Question 14

Severe DKA cutoffs

Answer 14

pH <=7.1
HCO3<=5

Question 15

SPIDER mnemonic for DKA treatment

Answer 15

saline
potassium
insulin
dextrose: with insulin
eat nothing: NBM
reason: find underlying cause + treat

Question 16

DKA management

Answer 16

IV fluids 1h before insulin
0.9% saline with 40mmol/L KCl

once glucose drops to 12mmol/L change to 0.9%/5 dextrose saline with KCl added

novorapid: 50 units in 50ml normal saline
run at 0.1 units/kg/hour

Question 17

Complications of DKA

Answer 17

cerebral oedema
hypoglycaemia
hypokalaemia

Question 18

Risk factors for cerebral oedema in DKA

Answer 18

children<5
new onset diabetes
late presentation (longer symptoms, more acidic pH)
administration of large amounts of fluids
hypotonic fluid administration
early administration of insulin
administration of sodium bicarbonate
bolusing IV insulin

Question 19

Clinical features of cerebral oedema

Answer 19

headache
drowsiness
incontinence
vomiting
decreased level of consciousness
bradycardia
rising BP
decreasing oxygen sats
CNS signs (abnormal pupil responses, abnormal posturing)

Question 20

Cerebral oedema treatment

Answer 20

mannitol 0.5g to 1.5g /kg (=2.5-7.5ml/kg 20% mannitol) over 30 mins
3% saline

Question 21

Cushing’s triad

Answer 21

suggestive of raised ICP

decreased resp rate
decreased heart rate
increased systolic BP

Question 22

Chronic complications of diabetes

Answer 22

microvascular:
- retinopathy
- nephropathy
- neuropathy

macrovascular:
- cerebrovascular disease
- cardiovascular disease
- peripheral vascular disease

Question 23

When can a newly-diagnosed T1DM patient leave hospital?

Answer 23

able to do injections + blood glucose monitoring
basic dietary advice - carb counting
hypoglycaemia management
ketone monitoring if sugar levels high

Question 24

Advice to give about hypoglycaemia treatment

Answer 24

conscious: 10g fast carbohydrate followed by starchy snack

conscious but uncooperative = glucogel followed by starchy snack

unconscious = glucagon IM then starchy snack if possible + hospital

Question 25

Signs and symptoms of hypoglycaemia

Answer 25

hunger coma anxiety abdominal pain headache palpitations weakness abnormal cry blurred vision fainting dizziness confusion convulsions irritability

Question 26

MODY inheritance

Answer 26

monogenic autosomal dominant

Question 27

What does MDI stand for with regards to diabetes management?

Answer 27

multiple daily injections

Question 28

How to calculate total daily dose if insulin

Answer 28

0.75 units/kg (0.5 units/kg if <5y)

Question 29

What long-acting insulin analogues are used in children?

Answer 29

tresiba for >2y levemir for <2y

Question 30

How to calculate dose of tresiba (long-acting insulin) for children

Answer 30

30% of total daily dose (TDD) [TDD = 0.75 U/kg]

Question 31

What rules dictate the insulin:carb ratios in children? How is this used?

Answer 31

300 rule for <5y 400 rule for 5-11y 500 rule for >11y eg. child age 6 years, 20kg insulin:carb ratio = 400/TDD = 400/15 = 27 1:27 1 unit novorapid covers 27 carbs

Question 32

What is correction factor and how is this calculated in children?

Answer 32

based on 100 rule 20kg 6y old child correction factor = 100/TDD = 100/15 = 7 1:7 1 unit novorapid will bring blood glucose down 7 mmol/L

Question 33

Ideal pre-meal blood glucose for diabetics

Answer 33

4-7mmol/L

Question 34

Degree of dehydration in mild or moderate DKA

Answer 34

5% dehydration

Question 35

Degree of dehydration in severe DKA

Answer 35

10% dehydration

Question 36

Why might potassium initially be high in DKA?

Answer 36

due to dehydration replace potassium if levels are normal or low as insulin will drive it lower if high --> monitor

Question 37

When can fixed rate insulin infusion be stopped in DKA?

Answer 37

when ketonaemia has resolved if ketonaemia still present, continue insulin even if glucose levels have normalised

Question 38

What observations should be done for patients in DKA?

Answer 38

hourly neuro obs monitoring for signs of cerebral oedema (particularly hypertension and bradycardia)