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Endocrinology 16. Diabetes Mellitus/Hypoglycemia Sources: WHO, Pocket book of hospital care for children, 2013; Eddleston et al, Oxford handbook of tropical medicine, 2008; Bugando Medical Centre, Paediatrics management guidelines, 2011. Definitions • Type I DM (diabetes mellitus) = insulin-­ dependent; pancreas produces little to no insulin • Type II DM = non-­ insulin-­ dependent; body resistant to insulin despite its presence • Malnutrition-­related DM = rare but can occur in young malnourished patients with protein deficiency; almost never present in diabetic ketoacidosis; frequently with very high insulin requirements Serum glucose for diagnosing diabetes mellitus: • Random: ≥11.1 mmol/L (≥200 mg/dL) • Fasting: ≥7 mmol/L (≥126 mg/dL) Clinical Manifestations • Polyuria • Nocturia 16. Diabetes Mellitus/Hypoglycemia 51 • Polydipsia • Weight loss • Weakness • Recent illness • Nausea/emesis • Altered mental status • Difficulty breathing • Abnormal/shallow breathing • Abdominal pain • Type II—obesity, acanthosis nigricans Investigations • History and physical exam • Pulse oximetry • Serum glucose • UA • *Blood gas • *Electrolytes • *Glycosylated hemoglobin • CXR if breathing problems Management • Inpatient for initial diagnosis and management • Insulin regimenºº Calculate daily total insulin needs: ~0.5 units/kg/dayºº Divide dose into two administration times of intermediate and short-­ acting insulin * → 2/3 of dose 15–30 minutes before breakfast as inter­ mediate insulin (Lente) * → 1/3 of dose 15–30 minutes before dinner as short-­ acting insulin (Actrapid) * Need to ensure patient regularly eats 2–3 meals every day * Ideal if also checking preprandial glucose and adjusting accordingly 52 Endocrinology • Routine follow-­ up in a diabetes clinic every 3 months: monitor blood pressure, weight, glucose levels (ideal if patient can monitor regularly at home as well); eye exam; evaluate feet; UA for albuminuria; *renal function tests • Lifestyle modifications for type II—diet and exercise Diabetic Ketoacidosis • Lack of insulin leads to hyperglycemia, which leads to buildup of acidotic ketones • Typically preceded by infection Diagnosis • Hyperglycemia • Ketonuria • *Serum acidosis either by bicarb (<15mmol/L) or blood gas (pH < 7.3) Management • Correct dehydration first • Slowly correct hyperglycemia, ketonuria, and acidosis with insulin and fluids. May need an insulin drip. Complications • Hypokalemia • aspiration • coma • seizures Hypoglycemia Etiologies Systemic infection, medication overdose/ingestion 16. Diabetes Mellitus/Hypoglycemia 53 Definition Glucose < 2.5 mmol/L or < 45 mg/dL Severe malnutrition = glucose < 3 mmol/L or < 54 mg/dL Clinical manifestations • Altered mental status • Seizures • Lethargy • Unconsciousness Treatment • 5ml/kg (or 2ml/kg if neonate) glucose/dextrose 10% via IV rapidly; repeat glucose test after 30 minutes to ensure it has improved • If difficulty obtaining IV access attempt IO access or as a last resort, try teaspoon of sugar under the tongue • If can take PO give glucose solution: 1 teaspoon of sugar mixed with 3 teaspoons of clean water • Maintenance therapy if patient unconscious: include dextrose 5% or 10% in IV fluids ...

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