Diabetes mellitus comprises the lack of insulin (Type 1) or peripheral insulin resistance (Type 2), which result in hyperglycemia. The early symptoms are related to the hyperglycemia and include polydipsia, polyphagia, polyuria and weight loss. The diagnosis is made by measuring the plasma glucose levels. Treatment depends on the type, but includes medications that reduce blood sugar levels, diet and physical activity.
(Diabetes mellitus (DM).)
Diabetes mellitus comprises the lack of insulin (Type 1) or peripheral insulin resistance (Type 2), which result in hyperglycemia. The early symptoms are related to the hyperglycemia and include polydipsia, polyphagia, polyuria and weight loss. The diagnosis is made by measuring the plasma glucose levels. Treatment depends on the type, but includes medications that reduce blood sugar levels, diet and physical activity. (Diabetes mellitus (DM).) The types of diabetes mellitus (DM) in children are similar to those in adults, but the psychosocial problems are different and can complicate treatment. Type 1 DM is the most common type in children, which is responsible for two thirds of new cases in children of all ethnic groups. He is one of the most common chronic diseases in childhood, occurring in 1 in 350 children up to the age of 18 years; the incidence has recently increased, especially in children <5 years. Although type 1 may occur in any age group, it is typically manifested at the age of 4 to 6 years and between 10 and 14 years. Type 2 DM who was once rare in children, has parallel to the increase in obesity in children: increased (obesity, children and obesity in adolescents) in its frequency. It manifests itself usually after puberty, with the highest rate between the ages of 15 and 19 years. Mono Gene forms of diabetes, formerly called "Maturity Onset Diabetes of Youth" (MODY) referred to are not considered as type 1 or type 2 (even if they are sometimes fäschlicherweise thought so) and are rare (1% to 4% of cases ). Prediabetes is the impaired glucose regulation, leading to intermediate glucose levels that are too high to be normal, but do not meet the criteria for diabetes. In obese adolescents of prediabetes can be temporarily continue (with a return to normal within 2 years at 60%) or diabetes, particularly among young people who persistently gain weight. Prediabetes is associated with the metabolic syndrome ((impaired blood glucose regulation, dyslipidemia, hypertension, obesity metabolic syndrome syndrome X)). Etiology There seems to be a familiar component for all types of DM in children, although the incidence and the mechanism vary. In diabetes type 1, the pancreas does not produce insulin due to autoimmune destruction of the pancreatic ?-cells. The destruction is probably triggered by environmental factors in genetically susceptible patients. Close relatives have an increased risk for DM, the total incidence of 10-13% (in 30 to 50% in identical twins). Children with diabetes type 1 are at increased risk of other autoimmune diseases, particularly thyroid disease and celiac disease. The inherited susceptibility to diabetes type 1 is determined by several genes (> 60 risk loci have been identified). Predisposing genes are more common in some populations. Thus, the higher prevalence of diabetes type 1 among certain ethnic groups (eg. B. Scandinavian, Sardinian) is explained. In diabetes type 2, the pancreas produces insulin, but there are varying degrees of Insulinresistez before and insulin secretion is not sufficient to cover the increased demand caused by insulin resistance (h d.. There is a relative insulin deficiency). The onset often occurs along with the height of the physiological pubertal insulin resistance, which can lead to symptoms of hyperglycemia in previously balanced youth. The cause is no autoimmune destruction of ?-cells, but a complex interaction of many genes and environmental factors, which differ between different populations and patients. Risk factors include obesity Ethnicity: Native American, dark frequently, Hispanic, Asian, Pacific Islands Positive family history (60 to 90% have a relative first or second-degree relative with diabetes type 2) Mono Gene forms of diabetes are caused by genetic defects autosomal dominant, caused, so that the patients are usually one or more affected family members. There is no insulin resistance or autoimmune destruction of ?-cells. The disease usually begins before the age of 25. Pathophysiology In diabetes type 1, the lack of insulin hyperglycemia and impaired glucose utilization in skeletal muscle caused. Muscle and fat are then broken up to supply energy. The fat loss produces ketones, which cause acidemia and sometimes significant, life-threatening acidosis (diabetic ketoacidosis [DKA] – diabetic ketoacidosis (DKA)). In diabetes type 2 enough insulin function is usually before to avoid DKA at diagnosis, but children can sometimes DKA (up to 25%) or less often (with a hyperglycemic hyperosmolan state HHS non ketotic hyperosmolar syndrome (NKHS)), in which a severe hyperosmolar dehydration occurs imagine. HHS occurs most often during stress or infection period, if the treatment is not observed, or if the glucose metabolism by drugs (eg. B. glucocorticoids) is further restricted. Other metabolic disorders associated with insulin resistance include dyslipidemia (leading to atherosclerosis atherosclerosis) hypertension (overview of hypertension) syndrome of PCOS (Polycystic ovary syndrome (PCOS)) Obstructive sleep apnea (Obstructive Sleep Apnea) Non-alcoholic steatohepatitis (fatty liver fatty liver) atherosclerosis begins in childhood and adolescence and increases the risk of cardiovascular disease significantly (atherosclerosis). In monogenic forms of DM the underlying defect of type depends. The most common types are caused by defects in transcription factors, which regulate the ?-cell function of the pancreas (z. B. hepatic nuclear factor 4-alpha [HNF-4 ?] and hepatic nuclear factor 1-alpha [HNF-1-?]). In these types of insulin secretion is impaired, but not absent, there is no insulin resistance and hyperglycemia worsens with age. Another type of monogenem diabetes is caused by a defect in the glucose sensor, glucokinase. In Glukokinasedefekten insulin secretion is normal, but the glucose levels are regulated at a higher setpoint, resulting in hyperglycemia of fasting, the minimally deteriorates with age. Tips and risks Despite the widespread misconception may occur DKA in children with diabetes type-2. Symptoms and signs In diabetes type 1 vary the initial manifestations of asymptomatic hyperglycemia to life-threatening DKA. However, children are most likely symptomatic hyperglycemia without acidosis with several days to weeks frequent urinary frequency, polydipsia and polyuria. Polyuria may manifest as nocturia, bedwetting or incontinence during the day; in children who are not yet accustomed to the toilet, the parents make any identified an increased frequency of wet or severe diapers. About half of the children as a result of increased catabolism weight loss and a compromised size growth. Fatigue, weakness, candida rash, blurred vision (due to the hyperosmolar state of the lens and the vitreous humor) and / or nausea and vomiting (due to ketosis) can also be initially present. In diabetes type 2, the children are often asymptomatic and her condition is probably observed only during a routine testing. However, some children present (despite widespread misconception) DKA with symptomatic hyperglycemia, or HHS. Complications DKA is common in patients with a known diabetes type 1; it annually develops in about 1 to 10% of patients, usually because they have not taken her insulin. Other risk factors for DKA include previous episodes of DKA, difficult social conditions, depression or other psychiatric disorders, intercurrent disease and the use of an insulin pump (due to a kinked or detached catheter, poor insulin absorption due to inflammation at the infusion site or pump malfunction). Doctors can help to minimize the effects of risk factors by educate, advise and support patients. Psychosocial problems are very common in children with diabetes and their families. Up to half of children depression, anxiety disorder or other psychological problems develop (overview of psychiatric disorders in childhood and adolescence). Eating disorders (Introduction to eating disorders) are a serious problem among young people, as they sometimes also skip insulin doses as part of their effort to control their weight. Psychosocial problems may also result in a bad glyzämischen control by limiting the ability of children to stick to their diet and medication plans. Social workers and experts in mental health (as part of a multidisciplinary team) can help to identify the psychosocial causes of poor glyzämische control and alleviate. Vascular complications are rare clinically evident in childhood. However, early pathological changes and functional abnormalities may possibly be a few years after the outbreak of the disease. Among the microvascular complications include diabetic nephropathy, retinopathy and neuropathy (diabetes mellitus (DM): Complications). Among the macrovascular complications include coronary artery disease, peripheral vascular disease and stroke. Although neuropathy in children who have diabetes for a long time (? 5 years) had and (glycosylated hemoglobin [HbA1c]> 10%) have poor control, is more common, it can also occur in young children who have diabetes for a short time had and have good control. Diagnostic fasting glucose levels in plasma ? 126 mg / dL (? 7.0 mmol / l) Any glucose levels ? 200 mg / dL (? 11.1 mmol / l) Glycated Hb (HbA1c) ? 6.5% Sometimes oral glucose tolerance test diagnosis of diabetes Diagnosis diabetes and pre-diabetes is similar to that in adults, typically by fasting or random glucose levels in the plasma and / or HbA1c levels are used, and it depends on the presence or absence of symptoms (see table: Diagnostic criteria for diabetes mellitus and abnormal glucose metabolism ). Diabetes can (with presence of the classic symptoms of diabetes and blood glucose measurements random plasma glucose ? 200 mg / dl [? 11.1 mmol / l] or fasting glucose in plasma ? 126 mg / dl [? 7.0 mmol / l]; sobriety is as defined 8 hours without caloric intake) to be diagnosed. An oral glucose tolerance test is not necessary and should not be performed if diabetes can be diagnosed through other criteria. If necessary, the test using 1.75 g should / kg (maximum 75 g) are carried out in water of dissolved glucose. The test may be helpful in children without symptoms or with mild or atypical symptoms and into cases of suspected or type 2 diabetes monogenem. The HbA1c test is more useful in general to diagnose diabetes type 2, and hyperglycemia should be confirmed. Diagnostic criteria for diabetes mellitus and abnormal glucose metabolism, impaired glucose metabolism method normal diabetes FPG (mg / dL [mmol / l]) <100 (<5.6) 100-125 (5.6 to 6.9) ? 126 (? 7, 0) OGTT (mg / dl [mmol / l]) <140 (<7.7) 140-199 (7.7 to 11.0) ? 200 (? 11.1) HbA1c (%) <5.7 5.7 to 6.4 6.5 ? PFG = Sober plasma glucose value; HbA1c = glycosylated hemoglobin; OGTT = oral glucose tolerance test, 2-h glucose levels. Initial evaluation and testing in patients suspected of that they have diabetes, but do not appear sick, the initial testing should include a simple metabolic panel including electrolytes and glucose, and a urinalysis. In sick patients, the testing also includes a venous or arterial blood gas, liver function tests and calcium, magnesium, and Kaliu- Hämatokritspiegel.Diagnose of diabetes type Additional tests should be performed to confirm the type of diabetes, including C-peptide and insulin levels (if not already treated with insulin) HbA1c levels (if not already) tests for autoantibodies to pancreatic islet cell proteins autoantibodies include glutamic acid decarboxylase, insulin, insulinoma-associated protein and zinc transporter ZnT8. More than 90% of patients with newly diagnosed diabetes type 1 have ? 1 of these autoantibodies, while the absence of antibodies strongly suggesting diabetes type-2. However, about 10 to 20% of children with diabetes type 2 phenotype autoantibodies and be reclassified as diabetes type 1, because such children rather need insulin therapy and a higher risk have to develop other autoimmune diseases. It is important to recognize monogenic diabetes, because the treatment of diabetes type 1 and diabetes type 2 is different. The diagnosis should in children with a strong family history of diabetes, but do not have the typical features of diabetes type 2, are considered; This means that they only have fasting light (100 to 150 mg / dl) or postprandial hyperglycemia, are young and not obese and do not have autoantibodies or signs of insulin resistance (z. B. acanthosis nigricans). Genetic tests are to confirm monogenem diabetes available. These studies are important because some types of monogenic diabetes können.Tests progress with age complications and other diseases patients with diabetes type 1 should be tested for other autoimmune diseases by celiac antibodies (celiac disease: diagnosis), thyroid stimulating hormone, thyroxine, and thyroid antibodies (representation of the thyroid function: laboratory tests of thyroid function) are measured. In patients with diabetes type 2, liver function tests, fasting lipid profile and urine microalbumin should: be conducted creatinine ratio at the time of diagnosis because these children (as opposed to those with diabetes type 1, in which complications for many years often develop) in the diagnosis of concomitant diseases such as fatty liver, hyperlipidemia and hypertension have. Children, the clinical findings have that suggest complications should also be tested for: Obesity: Test on nonalcoholic steatohepatitis daytime sleepiness or snoring Test for obstructive sleep apnea hirsutism, acne or menstrual irregularities Test for polycystic ovary syndrome therapy diet and exercise for diabetes type 1: insulin For diabetes type 2: metformin and sometimes insulin intensive education and treatment in childhood and adolescence may contribute to the treatment goals, to normalize blood sugar levels, while the number of episodes of hypoglycaemia minimized and the onset and progression of complications is prevented or delayed, to achieve. Lifestyle changes lifestyle changes that are beneficial for all patients include Regular Eating consistent amounts Limited intake of refined carbohydrates and saturated fats increase physical activity In general, the term should be avoided in favor of diet food plan or healthy food choices. The focus is on selecting a diet that is healthy for the heart and low in cholesterol and saturated fats. In diabetes type 1, the popularity of basal-bolus therapy and the use of carbohydrate counting has (parents estimate the amount of carbohydrates in an upcoming meal and use this amount to calculate the preprandiale dose of insulin) changed the eating plan strategies. In this flexible approach, the food intake is not strictly defined. Instead, the eating plans based on the usual eating habits of the child and not on a theoretically optimal nutrition, is the unlikely they will be met by the child, and the insulin dose is adjusted to the actual carbohydrate intake. Insulin: carbohydrate ratio is individualized, but changes with age. A good rule of thumb for different age groups of birth to 5 years: 1 unit of insulin per 30 g carbohydrates 6 to 12 years: 1 unit of insulin per 15 g carbohydrates adolescence: 1 unit of insulin per 8 to 10 g carbohydrates In diabetes type 2 should patients are encouraged to lose weight and thereby increase their insulin sensitivity. A good rule of thumb for determining the amount of calories needed by a child aged 3 to 13 years old, is 1000 calories + (100 x child's age in years). Simple steps to improve the diet and manage your calorie intake include eliminating sugary drinks discouragement, meals omit avoid slow-finished food throughout the day control of portion sizes switching to low-fat foods increase the fiber intake by including more fruits and vegetables are ingested insulin therapies for diabetes type 1 insulin is the cornerstone of treatment of diabetes type -1. The insulin formulations available are similar to those used in adults (see table: onset, maximum value and duration of action of human insulin preparations *). Insulin should be administered before meals, except in young children whose income is difficult to predict at a given meal. The dosage requirements vary with the age, activity level, the puberty stage and time elapsed since the initial diagnosis. Within a few weeks after the initial diagnosis, many patients have a temporary decrease in their insulin requirements due to the remaining ?-cell function (honeymoon phase). The honeymoon phase may last from several months to two years, after which the insulin requirements typically range from 0.7 to 1 unit / kg / day. During puberty, the patients need to address (up to 1.5 units / kg / day) of insulin resistance by the increased pubertal hormonal levels higher doses. Among the forms of insulin therapy basal-bolus therapy includes therapy with multiple daily injections (MDI therapy) Premixed insulin therapies A basic bolus therapy is typically preferred. In this therapy, the children receive a daily baseline dose of insulin, which is then supplemented with doses of short-acting insulin before each meal, based on the expected carbohydrate intake and the measured glucose levels. The basal dose can be considered a one-time daily injections (sometimes every 12 hours for younger children) of a long-acting insulin (glargine or detemir) or as a continuous infusion of short-acting insulin (usually aspart or lispro) using an insulin pump, which insulin administered continuously over a placed under the skin catheter take place. The supplemental boluses be administered as separate injections rapid-acting insulin or insulin pump. Glargin- or detemir injections are typically administered at dinner or before bedtime and may not be mixed with short-acting insulin. The basal dose helps to keep blood sugar levels between meals and at night in the normal range. The use of an insulin pump to administer the basal dose allows for maximum flexibility; the pump can be programmed so that they are administered different amounts at different times during the day and at night. A basal-bolus therapy may is not an option when there is no adequate supervision is available, especially when no adult is available to administer injections during the day at school or daycare. An MDI therapy can be used when a basal-bolus therapy is not an option (for. Example, because the family needed a simpler therapy, the child or the parents have a needle phobia, injections for lunch not in school or daycare can be administered). In this therapy, the children usually get neutral protamine Hagedorn (NPH) - insulin before breakfast and dinner and at bedtime and get short-acting insulin before breakfast and dinner. Because NPH and short-acting insulin can be mixed, this therapy has fewer injections than the basal-bolus therapy and is possibly preferred by younger children. However, this therapy offers less flexibility and requires a fixed daily schedule for meals and snack times. Premixed insulin therapies use preparations of 70/30 (70% insulin aspart protamine / 30% conventional insulin) or 75/25 (75% insulin lispro protamine / 25% insulin lispro). Premixed therapies are not a good choice, but are easier and can improve compliance because they require fewer injections. with two-thirds of the total daily dose is given at breakfast and one third for dinner children be administered two times a day fixed doses. However Premixed therapies provide much less flexibility in terms of timing and quantity of meals and are less accurate than other therapies because of the fixed ratios. Doctors should apply the intensive management program to which the children and keep their families in order to maximize glycemic control and thus the risk for long-term vascular complications verringern.Glukose- and HbA 1c -Zielwerte for diabetes type 1 target values ??for glucose in plasma (see table: glucose and HbA1c target values) are set to weigh the need to normalize blood sugar levels with the risk of hypoglycemia. Patients should try to have ? 50% of the blood sugar levels in the normal range (70 to 180 mg / dl [3,9 to 10 mmol / l]) and <10% below this range according to honeymoon phase. HbA1c targets were earlier for younger children is higher (<8.5%), but lately a target of <7.5% for all patients <18 years been recommended to the damage caused by prolonged hyperglycemia in childhood to reduce. However, many children and teens do not reach this target. Increased frequency of self monitoring of blood glucose is associated with improved HbA1c levels because the patients to be better able to adjust the insulin for their meals, they have an improved ability to correct hyperglycemic values ??and therefore are potentially able to recognize hypoglycemia earlier, which prevents over-correction (ie, excessive carbohydrate intake to treat hypoglycemia, resulting in hyperglycemia). Treatment goals should be individualized based on patient age, duration of diabetes, comorbidities and psychosocial circumstances. The risk of hypoglycemia in children who are not aware of hypoglycemia or do not have the maturity to recognize the symptoms of hypoglycemia, restricts aggressive attempts to achieve the treatment goals. Glucose and HbA1c target values ??blood test ideal goal Optimum target Suboptimal target high-risk target self Continuous monitoring of blood glucose (mg / dl [mmol / l]) in the morning fasting 65-100 (3.6 to 5.6) 70-145 (4-8) > 145 (> 8)> 162 (> 9) Postprandial 80-126 (4.5-7.0) 90-180 (5-10) 180-250 (10-14)> 250 (> 14) Bedtime 80-100 (4,0-5,6) 120-180 (6,7-10) <75 or> 162 (<4.2 or> 9) <80 or> 200 (<4.4 or> 11) at night 65-100 (3,6-5,6) 80-162 (4,5-9) <75 or> 162 (<4.2 or> 9) <80 or> 200 (<4.4 or> 11) HbA1C (%) – <6.5 <7.5 7.5-9.0> 9.0 HbA1c = glycosylated hemoglobin. Adapted from Rewers MJ, Pillay K, de Beaufort C, et al: Assessment and monitoring of glycemic control in children and adolescents with diabetes. Pediatric Diabetes 15 (supplement 20): S102-S114, 2014. Management of complications of diabetes type 1 hypoglycemia (hypoglycemia) is a critical but common complication in children who are treated with intensive insulin therapy. Most children have several light hypoglycemia episodes per week and treat it yourself with 15 grams of fast-acting carbohydrates (eg. As 118 ml [4 oz] juice, grape sugar, candy, graham crackers or glucose gel). Severe hypoglycemia, which is defined as an episode requiring the assistance of another person in the administration of carbohydrate or glucagon occurs every year at about 30% of children and most will have experienced such an episode until the age of 18 years , Oral carbohydrates can be attempted, but glucagon 1 mg i.m. is usually used when symptoms prevent Neuroglycopenic (z. B. behavioral changes, confusion, difficulty thinking) eating or drinking. If left untreated, severe hypoglycemia can cause seizures or even coma or death. Real-time continuous glucose monitoring devices can help children with a lack of awareness of hypoglycemia, because they trigger an alarm if the glucose falls below a specified area or when the glucose decreases rapidly (diabetes in children and adolescents: monitoring of glucose and HbA 1C level) , Ketonurie/Ketonämie wird am häufigsten durch eine interkurrente Krankheit verursacht, kann aber auch aus einer unzureichenden Einnahme von Insulin oder fehlenden Dosen resultieren und kann eine Warnung vor drohender DKA sein. Weil die Früherkennung von Ketonen entscheidend dafür ist, das Fortschreiten zur DKA zu verhindern und die Notwendigkeit einer Einweisung in die Notaufnahme zu minimieren, sollte Kindern und ihren Familien beigebracht werden, im Urin oder im Kapillarblut mit Keton-Teststreifen auf Ketone zu prüfen. Blut-Keton-Tests können bevorzugt werden bei jüngeren Kindern, denjenigen mit rezidivierender DKA und Anwendern von Insulinpumpen oder wenn eine Urinprobe schwierig zu erhalten ist. Keton-Tests sollten immer dann durchgeführt werden, wenn das Kind krank wird (unabhängig vom Blutzuckerspiegel) oder wenn der Blutzuckerspiegel hoch ist (typischerweise > 240 mg/dl [13,3 mmol/l]). Das Vorliegen mittlerer oder hoher Urin-Keton-Spiegel oder Blut-Keton-Spiegel > 1,5 mmol/l kann auf DKA hindeuten, vor allem, wenn die Kinder ebenfalls Bauchschmerzen, Erbrechen, Benommenheit oder eine schnelle Atmung haben. Geringe Urin-Keton-Spiegel oder Blut-Keton-Spiegel zwischen 0,6 und 1,5 mmol/l müssen ebenfalls behandelt werden. Wenn Ketone vorliegen, erhalten die Kinder zusätzliches kurzwirksames Insulin, typischerweise 10 bis 20% der Gesamttagesdosis alle 2 bis 3 Stunden, bis sich die Ketone auflösen. Zudem sollte auch zusätzliche Flüssigkeit gegeben werden, um Dehydrierung zu verhindern. Dieses Programm der Messung von Ketonen und der Gabe zusätzlicher Flüssigkeit und zusätzlichen Insulins während der Krankheit und/oder Hyperglykämie wird als “sick-day management” bezeichnet. Eltern sollten angewiesen werden, ihren Arzt anzurufen