Alterations in Nutrition, Gastrointestinal, Metabolism and Endocrine

DIABETES MELLITUS is the absence of insulin secretion (type 1) or presence of peripheral insulin resistance (type 2).
RISK FACTORS:

o Overweight o Race or Ethnicity

: strong risk factor for type 2 diabetes in children
: the more fatty tissue, esp. inside & bet. the muscle &
skin around the abdomen, the more insulin-resistant
body cells become
o Inactivity
: less active, greater risk for type 2 diabetes
: Black, Hispanic, American-Indian, Asian-Americans are
more likely to develop type 2 DM
o Age and Sex
: many children develop type 2 DM in their early teens,
but it may occur at any age
: adolescent girls are more likely to develop type 2 DM

o Diet o Maternal Gestational Diabetes

: red meat, processed meat, & sugar-sweetened : children born to women who had gestational DM during
beverages are associated with higher risk for type 2 DM pregnancy have a higher risk of developing type 2 DM

o Family History o LBW / Preterm

: children's risk of type 2 DM increases if they have a
parent or sibling with the disease

DIAGNOSIS:

a. Random Blood Sampling

= ↑ 200 mg/dL or ↑ 11.1 mmol/L, along with symptoms, suggests diabetes

b. Glycosylated Hemoglobin (A1C) Test

= indicates a child's average blood sugar level for the past 3 months

TYPES:

1. Type 1 - a long-term (chronic) condition

- the child's body no longer produces insulin
- can develop at any time during infancy / childhood, but it usually begins bet. 4-6 y/o or 10-14 y/o
S&S:

o High levels of glucose in the blood & urine when tested o Blurred vision
o Unusual thirst o Nausea and vomiting
o Dehydration o Belly (abdominal) pain
o Frequent urination (a baby may need more diaper o Weakness and fatigue
changes, or a toilet-trained child may start wetting his or o Irritability and mood changes
her pants) o Serious diaper rash that does get better with treatment
o Extreme hunger but weight loss o Fruity breath and fast breathing
o Loss of appetite in younger children o Yeast infection in girls

DIAGNOSIS:

Fasting plasma glucose. The blood is tested after at least 8 hours of not eating.
Random plasma glucose. The blood is tested when there are symptoms of increased thirst, urination, and hunger.

TREATMENT:

- Daily injections of insulin

- Eating the right foods to manage blood glucose levels. This includes timing meals and counting carbohydrates.
- Exercise to lower blood sugar
 - Regular blood testing to check blood-glucose levels
- Regular urine testing to check ketone levels

COMPLICATIONS:

 Ketoacidosis
- ↑ blood sugar levels => body starts making ketones => ↑ risk for diabetic coma => loss of consciousness d/t brain swelling
- the brain swells because of the very high blood sugar levels

 Low blood sugar / Hypoglycemia / Insulin reaction --- occurs when blood glucose drops too low

 Tooth & Gum problems

 Skin & Foot problems
 Eye problems
 Kidney disease
 Nerve damage
 Heart & BV disease

** Symptoms develop quickly in type 1 diabetes, usually over several days to weeks, and tend to appear in a typical pattern.
** High blood glucose levels cause the child to urinate excessively.

** Children may wet the bed / become unable to control their bladder during the day.
** Children who are not toilet-trained may have an increase in wet or heavy diapers.
** This fluid loss causes an increase in thirst and the consumption of fluids.
** About half of children lose weight and have impaired growth.
** Some children become dehydrated, resulting in weakness, fatigue, and a rapid pulse.

** Children may also have nausea and vomiting due to ketones (by-products of the breakdown of fat) in their blood.
** Vision may become blurred.
** If the symptoms are not recognized as being caused by diabetes and treated, children may develop Type 2 DM.

2. Type 2 - a chronic disease that affects how the child's body processes sugar (glucose) for fuel
- w/o treatment, sugar builds up in the bloodstream & can lead to serious long-term consequences
- more common among adolescents adults, thus called “adult-onset diabetes”
S&S:

o Increased thirst, Frequent urination, Increased hunger, Frequent infection

o Fatigue
o Blurry vision
o Darkened areas of skin (neck, armpits, groin)
o Unintended weight loss (less common in children with type 2 than in children with type 1)

DIABETES SCREENING
- recommended for children who have started puberty, at least 10 y/o, are overweight or obese, & have at least one other
risk factor for type 2 diabetes

CAUSES:

- Family history
- Genetics
RISK FACTORS:

- Previously mentioned…
- Metabolic Syndrome
 : when conditions occur with obesity, they are assoc. with insulin resistance & can ^^ the risk of DM, <3 disease, Stroke.
: a combination of the following conditions is often called “metabolic syndrome”
: high BP, sugar, triglycerides
: low HDL
: large waist size

- Polycystic Ovary Syndrome (PCOS)

: affects young females after puberty
: d/t an imbalance of hormones resulting in weight gain, irregular menstruation, & excess facial and body hair
: often have problems with metabolism that can result in insulin resistance & type 2 diabetes

COMPLICATIONS:

 Stroke Eye disease --- including blindness Nerve damage

 High cholesterol Kidney disease Heart & BV disease

PREVENTION:

- Healthy lifestyle choices can help prevent type 2 diabetes in children.

- Eat healthy foods (low in fat & calories). Focus on fruits, vegetables, and whole grains. Strive for variety to prevent boredom.
- Get more physical activity. Encourage your child to become active. Sign up your child for a sports team or dance lessons.

** Many children do not have any symptoms, and doctors diagnose type 2 DM only when blood or urine tests are done for other
reasons (such as during a physical before playing sports or going to camp).
** Symptoms in children with type 2 diabetes are milder than those in type 1 & develop more slowly.
** Parents may notice an increase in the child’s thirst and urination or only vague symptoms, such as fatigue.
** Children with type 2 diabetes are less likely to develop ketoacidosis or severe dehydration than those with type 1 diabetes.

Complications of Diabetes in Children and Adolescents

Immediate Complications

- MOST SERIOUS: Diabetic Ketoacidosis

Long Term Complications

- Usually due to social and psychologic issues / due to blood vessel problems.
Although BV problems take years to develop, the better the control of diabetes, the less likely that complications will ever occur.

Values For Diabetes

- Fasting Glucose Level = helpful in diagnosing type 2 in children w/o typical s&s
= ↑ 126 mg/Dl or ↑ 7 mmol/L on 2 different occasions
- Oral Glucose Tolerance Test
- Random Glucose Level = done in children who have no symptoms or whose
= ↑ 200 mg/dL or ↑ 11.1 mmol/L symptoms are mild or not typical
= should have their fasting glucose level tested to confirm = children fast, have a blood sample taken to determine the
FGL, then drink a solution of a large amount of glucose
- Hemoglobin A1C Level = doctors then measure blood glucose levels 2 hours later
= ↑ 6.5% = diabetic if ↑ 200 mg/dL or ↑ 11.1 mmol/L
= this test is similar to the test that pregnant women take to
look for gestational diabetes

Management

- Metformin is the main drug given by orally for children and adolescents.
Started at a low dose then increased over several weeks. It can be taken with food to prevent nausea & abdominal pain.
- Liraglutide is an injectable drug given to type 2 DM children over 10 y/o.
It lowers hemoglobin A1C levels, reduce appetite, & promote weight loss.
It may be given w/ metformin only if hemoglobin A1C level is not in the target range.
Or it can be given instead of metformin to children who cannot tolerate that drug.

- Other drugs used for adults with type 2 DM may help some adolescents, but they are more expensive, and there is limited
evidence for their use in children.

- Insulin