Makindo Medical Notes

Related Subjects:Sick Neonate |APGAR Scoring |Approach to Assessing Sick Child |Sick Child with Acute Gastroenteritis |Sick Child with Respiratory Distress |Sick child Diabetes Mellitus Type 1 and DKA

💉 Type 1 Diabetes Mellitus (T1DM) is a chronic autoimmune condition caused by destruction of pancreatic β-cells ➝ absolute insulin deficiency ➝ persistent hyperglycaemia. Around 25% of children present in Diabetic Ketoacidosis (DKA) at first diagnosis 🚨.

📖 About

• Autoimmune destruction of insulin-producing β-cells in the pancreas.
• Usually presents in childhood or adolescence, though can occur at any age.
• Requires lifelong insulin therapy.

🧬 Aetiology

• Insulin produced by islets of Langerhans (β-cells).
• Autoantibodies (e.g. anti-GAD, anti-islet cell) target β-cells, leading to progressive destruction.
• Genetic predisposition (HLA types), with environmental triggers (viral infections, toxins) thought to play a role.

🩺 Clinical Features

• Classic triad: Polyuria 🚽, Polydipsia 💧, Weight loss ⚖️.
• Vomiting, lethargy, and dehydration in severe cases.
• Nocturnal enuresis (bedwetting) may be a presenting sign.
• Recurrent candida infections can be a clue.
• 25% present in DKA (abdominal pain, vomiting, Kussmaul breathing, acetone breath).

🧪 Investigations

• Blood glucose: Random ≥11.1 mmol/L with symptoms is diagnostic.
• Ketones: Urine or blood ketones (raised in DKA).
• HbA1c: Chronic hyperglycaemia marker (≥48 mmol/mol).
• Blood gas: Metabolic acidosis in DKA (pH <7.3, HCO₃⁻ <15).
• Autoantibodies: Anti-GAD, anti-islet cell (autoimmune confirmation).
• Screen for coeliac and thyroid disease (autoimmune associations).

💊 General Management of T1DM

• Education 👨‍👩‍👧: Self-monitoring of glucose, insulin administration, sick-day rules.
• Insulin therapy:
  • Basal-bolus: Long-acting insulin once daily + rapid insulin with meals.
  • Pump therapy: Subcutaneous infusion in selected children; risks: infection, pump failure.
• Diet & lifestyle: Carbohydrate counting, healthy diet, regular exercise.

🚨 Paediatric Diabetic Ketoacidosis (DKA) Management

⚠️ Cerebral oedema is the most feared complication in paediatric DKA. Always monitor neurological status closely. Treat promptly with mannitol 20% (2.5 mL/kg IV over 10 min) or 3% hypertonic saline (5 mL/kg IV over 10–15 min) if suspected.

🩺 Stepwise Management

• 1️⃣ ABC & Monitoring
  • Airway, Breathing, Circulation ➝ stabilise.
  • Continuous monitoring: HR, BP, SpO₂, GCS, neuro obs hourly.
  • Cardiac monitor (risk of arrhythmia if K⁺ deranged).
• 2️⃣ IV Access & Bloods
  • Venous gas (pH, bicarbonate, ketones).
  • FBC, U&E, glucose, lactate.
  • Urinalysis for ketones.
• 3️⃣ Fluids 💧
  • Correct dehydration slowly over 48 h (avoid cerebral oedema).
  • Use 0.9% saline ± 5% dextrose when BG <14 mmol/L.
  • Resus if shocked: 10 mL/kg 0.9% saline over 10–15 min (repeat once if needed).
• 4️⃣ Insulin 💉
  • Start 1–2 h after fluids have begun.
  • Continuous IV infusion at 0.05–0.1 units/kg/hr.
  • Aim: fall in glucose 2–5 mmol/L/hr.
• 5️⃣ Potassium ⚡
  • Total body K⁺ depleted even if serum appears normal/high.
  • Add KCl once child is voiding and serum K⁺ <6 mmol/L.
  • Typical: 20 mmol KCl per 500 mL bag.
• 6️⃣ Ongoing Care
  • Hourly BG; 2–4 hourly VBG & electrolytes.
  • Strict fluid balance (catheterise if necessary).
  • Watch for headache, bradycardia, ↓GCS ➝ suspect cerebral oedema.
• 7️⃣ Transition to SC Insulin
  • When ketones cleared, child well, eating & drinking.
  • Overlap IV infusion with first SC dose by 30–60 min.

📚 References

• UK Paediatric DKA Guidelines (BSUH, 2020)
• NICE NG17: Type 1 diabetes in children and young people