Childhood Diabetes: Insulin Dependent Diabetes Mellitus in Children
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Loading ...Childhood Diabetes (DM), earlier known as juvenile inset type of diabetes now called as IDDM or insulin dependent diabetes mellitus, affecting children and young adults below 18 yrs.
Risk factors of diabetes in children
Genetic factors - they are divided into
- Gestational Diabetes Mellitus (DM)
- Impaired glucose tolerance (in obese and non-obese children)
- Genetic factors associated with B cell dysfunction and insulin resistance.
IDDM is a polygenic disorder. The major locus is HLA (human leukocyte antigen) region short arm of chromosome 6. This locus is referred to as IDDM.
- Environmental factors - they are relatively low in numbers. Viral infection in-utero is consistent with observation that incidence of IDDM increased in children with congenital rubella. IgM antibodies against Coxsackie’s virus have been found in 25-30% of new cases, suggesting recent infection.
- Dietary factors - a positive association between IDDM, high protein intake and frequency of consumption of foods containing nitrosamine is seen in close control studies.
Pathogenesis
- Auto-immunity - islets of newly diagnosed persons show histological picture of marked mononuclear cell infiltration around islets.
- Islets cell antibodies (ICA) - they are present in 80% cases of children at the time of diagnosis. Long term follow up has shown that family members with ICA are at increased risk of progression to DM.
- B cell destruction - this process is slow with patchy histological appearance in newly diagnosed persons. Clinical onset of diabetes does not occur until 90% of cells have been destroyed.
Clinically - children with complaints of polyuria, intense thirst, nocturia, polyphagia, weight loss, weakness, lassitude, leg cramps and leg cramps. Some children have a stormy onset and seek medical aid for first time with symptoms of ketoacidosis, such as persistent enuresis, abdominal pain, vomiting, dehydration, prostration, drowsiness and even coma. Characteristic features of IDDM include:
- Severe insulin deficiency.
- Abrupt onset of severe symptoms.
- Tendency to ketoacidosis.
- Dependence on exogenous insulin to sustain life.
Complications of diabetes in Children:
- Acute: ketoacidosis, coma and lactic acidosis.
- Sub-acute: infection either bacterial or fungal involving skin mucosa, soft tissue, lungs (tuberculosis) and urinary tract infection.
- Chronic: arteriosclerosis, retinopathy, polyneuropathy, diabetic neuropathy, delayed development of secondary sexual characters.
Diagnosis - through urine sugar and blood sugar level examination and oral glucose tolerance test.
Management - main line management includes diet and insulin.
Aims of managing diabetes in children:
- To maintain ideal body weight essential to preserve optimal insulin sensitivity.
- To maintain long term nutritional balance for normal growth and development in children.
- To time meal and snacks to prevent wide swings in BSL especially because these persons have to be managed with insulin.
- To maintain BSL and avoid complications.
Total calorie intake should be according to ideal body weight (IBW) of child, calculated as IBW (in kgs) = (height in cms -100) x 0.9
Children need baseline calories of 1000, plus 100 calories (for girls) and 125 calories (for boys) per year of age up to 12 yrs.
Distribution of total calories into various nutrients is:
- Carbohydrate - 60 to 65% of total calories
- Proteins-15 to 20% of total calories
- Fats-15 to 25% of total calories
Carbohydrates supply 4 cal/gm of cereals, roots and pulses rich in complex carbohydrates are preferred and diet with low glycaemic index are preferred.
Proteins – most amino acids are glucogenic. They decrease glucagon secretion as well. It supplies 4 cal per gram. Its intake must be restricted in diabetic nephropathy.
Fats supply 9 cal per gram. It must not exceed 20% of total calorie intake.
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