Diabetes Mellitus

Question 1

What is Type 1 Diabetes Mellitus?

Answer 1

Total insulin deficiency due to autoimmune destruction of pancreatic beta cells.

Question 2

What is type 2 Diabetes Mellitus?

Answer 2

Insulin resistance followed later by beta cell failure

Question 3

What are possible environmental causes for type 1 diabetes?

Answer 3

• Enteroviral infections
• Diet
  
  • Cow’s milk proteins
  • Overnutrition

Question 4

What are the symptoms/signs of diabetes mellitus?

Answer 4

Most common (usually for only a few weeks before presenting):

• Polydipsia
• Polyuria
• Weight loss

Less common:

• Secondary enuresis
• Skin sepsis
• Candida and other infections

Question 5

What is secondary enuresis?

Answer 5

Child did have bladder control at night for a period of at least 6 months, but lost that control and now wets the bed again.

Question 6

How is the diagnosis of a symptomatic child confirmed?

Answer 6

• Random blood glucose > 11.1 mmol/L or fasting BG > 7 mmol/L
• Glycosuria
• Ketosis

Question 7

When should type 2 diabetes be suspected?

Answer 7

• Family Hx
• Severely obese child
• Signs of insulin resistance
  
  • Acanthosis Nigricans
  • Skin tags
  • PCOS phenotype (in teenage girls)

Question 8

What is seen in this image?

Answer 8

Acanthosis Nigricans = Velvety dark skin on the neck or armpits

Question 9

What is the initial management for a patient presenting with DKA?

Answer 9

Urgent hospital admission and treatment (inc. fluid and insulin)

Question 10

What education is provided to the newly diagnosed child and their parents?

Answer 10

• Basic understanding of the pathophysiology
• Injection of insulin (Technique & sites)
• Blood glucose (Finger prick) monitoring
• Healthy diet & ‘Carb counting’
• Encourage exercise (with adjustment of diet and insulin)
• ‘Sick-day rules’ to prevent ketoacidosis
• Recognition and treatment of hypoglycaemia & hyperglycaemia/DKA
• Where to get 24hr advice (from team)
• Where to access support from voluntary services
• Psychological impact of life-long condition.

Question 11

How is diabetes typically managed in children?

Answer 11

Either with:

• Continuous subcutaneous insulin pump
• Multiple daily injections (‘basal-bolus’) with rapid-acting insulin (e.g. novorapid) before each meal (bolus) and long-acting insulin (e.g. Glargine) in the evening/before breakfast (basal).

Question 12

What is the concentration of all insulin used in the UK in children?

Answer 12

100 units/ml (U-100)

Question 13

What is ‘carb counting’?

Answer 13

A method of calculating likely insulin requirement by estimating the amount of carb in food, while taking into account the pre-meal sugar level and post-meal exercise pattern.

Question 14

What is the pre-meal blood sugar target?

Answer 14

4 - 7 mmol/L

Question 15

What factors increase blood glucose levels?

Answer 15

• Insufficient insulin
• Food (esp carbs)
• Illness
• Menstruation
• Growth hormone
• Corticosteroids
• Sex hormones at puberty
• Stress

Question 16

What factors decrease blood glucose levels?

Answer 16

• Insulin
• Exercise
• Alcohol
• Some drugs
• Marked anxiety/excitement
• Hot weather

Question 17

What is the target HbA1c in diabetes?

Answer 17

< 48mmol/mol (6.5%)

Question 18

What is HbA1c and why is it useful to monitor in diabetes?

Answer 18

It is glycated haemoglobin and is used to identify average plasma glucose concentation.

Helpful guide of overall diabetes control over previous 6-12 weeks - should be checked at least 4 times a year.

Question 19

When can HbA1c levels be misleading?

Answer 19

If RBC lifespan is reduced (e.g. sickle cell anaemia) or if HbA molecule is abnormal (e.g. thalassaemia).

Question 20

What are the common symptoms of hypoglycaemia?

Answer 20

• Hunger
• Tummy ache
• Sweatiness
• ‘Wobbly feeling’ in legs
• Pallor
• Irritability & ‘unreasonable behaviour’
• Seizures & coma (when untreated/unrecognised)

Question 21

What blood glucose values indicate hypoglycaemia?

Answer 21

< 4 mmol/L

Question 22

What can happen with frequent episodes of hypoglycaemia?

Answer 22

The patient can lose awareness of the symptoms.

Question 23

How is a ‘hypo’ treated at an early stage?

Answer 23

• Glucose tablets
• Sugary drink (e.g. lucozade)

Question 24

How is a ‘hypo’ managed when the patient can’t cooperate?

Answer 24

Oral glucose gels (e.g. glucogel) are useful because absorbed by buccal mucosa.

Question 25

How should severe hypoglycaemia be managed at home/school?

Answer 25

Glucagon injection kit (provided to parents and school)

Question 26

How should hypoglycaemia in an unconscious child be managed in hospital?

Answer 26

IV glucose

Question 27

What are the symptoms/signs of diabetic ketoacidosis?

Answer 27

• Smell of acetone on breath
• Vomiting
• Dehydration
• Abdo pain
• Hyperventilation due to acidosis (Kussmaul breathing)
• Hypovolaemic shock
• Drowsiness
• Coma & death

Question 28

What are essential early investigations in DKA?

Answer 28

• Blood glucose > 11.1 mmol/L
• Blood ketones > 3 mmol/L
• U&Es (Possibility of dehydration)
• Blood gas analysis (Severe metabolic acidosis)
• Blood and urine cultures (Infection precipitating cause)
• ECG (T-wave changes of hypokalaemia)
• Weight (compare with recent clinic weight to ascertain level of dehydration)