Endocrine Disease In
Childhood And Adolescence
Department of Endocrinology
Children’s Hospital
Fudan University
Email,shenshuixian@sina.com
luo_fh@163.com
Introduction
? Growth and growth disorders
? Adrenal disorders and sexual development
abnormalities
? Thyroid disorders
? Disorders of calcium and phosphorus
metabolism
? Diabetes mellitus and hypoglycemia
? Other disorders,obesity,autoimune
endocrinopathies,tumor,inborn metabolic
disease,water homeostasis,hypertension,et al,
Hypothalamus
Anterior pituitary Posterior pituitary
Bone growth
Breast
Ovary Testes
Adrenal
Thyroid
Diabetes Mellitus
in Childhood and Adolescent
Major objective
?To master pediatric diabetes diagnosis,
clinical presentation and therapy
Minor objectives:
?To be familiar with the etiology and
pathogenesis of pediatric diabetes
?To understand diabetes classification,clinical
findings,diagnosis and therapy
?To understand diabetic ketoacidosis diagnosis
and treatment
?To understand diabetic complications and
prevention
Definition
Diabetes mellitus is a metabolic disorder
of multiple etiology characterized by
chronic hyperglycemia due to defective
insulin secretion or insulin action or both.
Epidemiology of diabetes
Location（ Age<15yo） T1DM incidence (1/100000)
Finland 34
U.S.A, 14.6
Australia 14.4
Indonesia 2.53
Singapore 2.4
South Korea 1.86
New Zealand 1/1000
Japan 2.53（ 88－ 92yr）
Hang Kong 1.25
Tai Wan 1.5（ < 20y )
Beijing 0.94
Shanghai 0.83
Zuiyi 0.12
Guilin 0.30
Huhehaote 0.91
Nanjing 0.69
Hainan 0.29
I,Type 1 diabetes (?-cell destruction,usually
leading to absolute insulin deficiency)
A,Immune mediated T1A
B,Idiopathic T1B
II,Type 2 diabetes
American Diabetes Association,2004
Classification of diabetes mellitus
To be continued
Classification of diabetes mellitus
III,Other specific types
A,Genetic defects of ?-cell function
1,MODY 3, Chromosome 12,HNF-1?
2,MODY 2, Chromosome 7,glucokinase
3,MODY 1, Chromosome 20,HNF-4?
4,MODY4, Chromosome 13,insulin promoter
factor-1 (IPF-1)
5,MODY5,Chromosome 17,HNF-1 ?
6,MODY6, Chromosome 2,NeuroD1
7,Mitochondrial DNA
8,Others To be continued
Classification of diabetes mellitus
B,Genetic defects in insulin action
1,Type A insulin resistance
2,Leprechaunism
3,Rabson-Mendenhall syndrome
4,Lipoatrophic diabetes
5,Others
C,Disease of the exocrine pancreas
1,Pancreatitis
2,Trauma/pancreatectomy
3,Neoplasia
4,Cystic fibrosis
5,Hemochromatosis
6,Fibrocalculous pancreatopathy
7,Others To be continued
D,Endocrinopathies
1,Acromegaly
2,Cushing’s syndrome
3,Glucagonoma
4,Pheochromocytoma
5.Hyperthyroidism
6,Somatostatinoma
7,Aldosteronoma
8,Others
E,Drug or Chemical-induced
1,Vacor
2,Pentamidine
3,Nicotinic acid
4,Glucocorticoids
5,Thyroid hormone
6,Diazoxide
7.?-adrenergic agonists
8,Thiazides
9,Dilantin
10.?-interferon
11,L-Asparaginase
12,Others
Classification of diabetes mellitus
To be continued
Classification of diabetes mellitus
F,Infections
1,Congenital rubella
2,Cytomegalovirus
3,Others
G,Uncommon forms of immune-mediated diabetes
1.,Stiff-man” syndrome
2,Anti-insulin receptor antibodies
3,Others
To be continued
Classification of diabetes mellitus
H,Other genetic syndromes sometimes associated with diabetes
1.Down’s syndrome
2.Klinefelter’s syndrome
3,Turner’s syndrome
4.Wolfram’s syndrome
5.Friedreich’s ataxia
6,Huntington’s chorea
7,Laurence-Moon-Biedl syndrome
8,Myotonic dystrophy
9.Porphyria
10,Prader-Willi syndrome
11,Others
IV,Gestational diabetes mellitus (GDM)
Type 1 diabetes
in childhood and adolescence
Etiology & pathogenesis
Etiology & pathogenesis
Viral infection（ Coxsackie，
EBV,measles,mumps）
Milk proteins (lactoalbumin,
?－ casein,?- casein,
lactoglobulin)
Cow insulin
Autoantigens,GAD,IA-2,Insulin
Environment
Chemical agents
1.Aut
oim
mun
e
Etiology & pathogenesis
2.Genetics
?Monozygotic twins→IDDM (30－ 50％ )
?HLA DR3/DR4 →IDDM (70%)
?Aspartic acid on position 57 of HLA-DQ
? chain protective effect for T1DM
?Arginine on position 52 of HLA-DQ ?
chain increases susceptibility to DM
Antigen
Islet ?-cell
Genetic susceptibility Environmental factors
Monocyte,Phagocyte
Th1 cell
Phagocyte,NK,CTL
TNF-?,IL-1?
HLA-II
NO?
TNF-?
TNF-?
IFN-?
TNF-?,TNF-?,IFN-?
Oxygen free radical,NO?,
adhesion molecule,perforinOxygen free radical,NO?Fas?,Insulin?,growth
regeneration?,defense and
repair defect
? cell apoptosis
Pathophysiology
Insufficient insulin secretion
Decrease in glucose utilization Decreased metabolic
synthesis
Insufficient energy hyperglycemia
Polyphagia Glucosuria Osmotic diuresis Polyuria
Emaciation
Chronic dehydration
Thirst and Polydipsia
Clinical Features
? Weight loss
? Polyuria,polydipsia,
polyphagia
? Nocturia
Clinical Featrues
Common signs
? Flu-like symptoms
? Fatigue
? Blurry vision
? Urinary tract infection
? Weight loss of unknown reason
? Acute abdominal pain
? Nausea,vomiting,abdominal pain,
Kussmaul breathing,dehydration,
acidosis
? Lethargy,coma
Clinical Features
Associated
symptoms
Ketoacidosis
Complications
? Acute,Diabetic ketoacidosis
Hypoglycemia
Infection
Hyperosmolar nonketotic diabetic coma
? Subacute,Bone and joint abnormalities
Growth disorder
Puberty delay,learning disorder
? Chronic,Diabetic nephropathy
Diabetic retinopathy
Diabetic neuropathy
Diabetic Retinopathy and cataract
Diabetic nephropathy
Laboratory tests
? Serum,Glucose,electrolyte,BUN,creatinine,
calcium,magnesium,phosphorus,acetone,
lipid,venous blood gas (pH)
? Urine,urine glucose,ketone,protein
? HbA1c,reference range 4％～ 6％
? OGTT
? Autoantibodies,IAA GADAb ICA IA-2
? Islet function,glucagon stimulation test,
arginine c-peptide stimulation test
Diagnosis
1,Fasting blood glucose?7.0mmol / L（ at least
two times ) with diabetic signs and symptoms
2,Random blood glucose?11.1mmol / L
3,OGTT（ 2h） ?11.1mmol / L
One criteria needed for diagnosis.
Diagnostic criteria
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
Family history
Age
Gender
3%-5%
variable
F=M
74%-100%
>10yo
F>M
Asymptomatic Rare Common
Symptom
duration Days or weeks Weeks or months
Weight loss common common
To be continued
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
BMI at
diagnosis
Acanthosis
Hyperglycemia
?75th
percentile
No
variable
? 85th percentile
Common
variable
Ketosis and
ketonuria Common Common
Acidosis Common Moderately common
To be continued
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
HbA1c
Insulin or C-
peptide
Elevated
Low
Elevated
Normal or
elevated
Autoimmune
markers Common Uncommon
Differential diagnosis
? Renal glycosuria
? Secondary hepatic hyperglycemia 肝源性高
糖,Postprandial hyperglycemia,fasting
hypoglycemia
? Diabetes insipidus 尿崩症
? Hyperglycemia secondary to critical illness
Treatment
Dietary
management
Exercise
Drugs
BG
monitoring
Education
Type of Onset Peak Duration
Insulin（ h）
Short- acting
Regular ? hour 2-4 hours 4-8 hours
Humalog 10-15 min ?-1 hour 4 hour
Semilente 1-2 hours 2-5 hours 8-12 hours
Long-acting
NPH 2-4 hours 6-8 hours 12-15hours
Ultralente 4-6 hours 8-15 hours 15-18 hours
Lantus 2-4 hours 4-23 hours 24 hours
Premixed
NPH/Humalog 1-2 hours 6-12 hours 15-18hours
Times of insulin action
Management of insulin Therapy
30 '
br eak fa st
30 '
lu nch
30 '
di nn er
Bedtime
0.5 －
1.0 u/ k g/ d
RI( 30 ％ ) RI( 30 ％ ) RI( 30 ％ )
NPH or
Glargi ne
( 10 ％ )
NPH ＋ RI
（ 2 － 3:1 ）
60 ％ 40 ％
OR NPH +RI RI NPH
New onset patients
Insulin Management in Honeymoon
period
▲ Partial remission：
insulin < 0.5 u/kg /d
NPH＋ RI
PZI＋ RI
▲ Complete remission,2－ 3%
Continuing insulin therapy after remission
Insulin < 2 year 0.5u / kg / day
2－ 12 year 0.5-1.0 u / kg / day
adolescence 1.0-1.5 u / kg / day
Diabetes Control and Complications
Trial,DCCT
Intensive therapy：
1,3 or more insulin injection/d or insulin pump
2,four or more blood glucose determinations per
day
3,Careful attention to dietary intake
4,Frequent contact with health care provider
Results from DCCT
DCCT group
?Risk of retinopathy ↓76%
?Progress of retinopathy ↓54%
?Proliferative retinopathy ↓47%
?Risk of urinary ↓39%
protein≥40mg/24h
?Risk of urinary ↓54%
protein ≥300mg/24h
?Neuropathy ↓60%
Insulin Pen
Insulin Pump
Insulin dosage adjustment
Morning FBG? dinner/bedtime NPH ?
lunch BG ? Breakfast RI ?
dinner BG ? Breakfast NPH ?
bedtime BG ? dinner RI ?
（ If hypoglycemia,decrease insulin based on the above
schedule）
Hypoglycemia
Hypoglycemia Stress response?BG?
may affect mental development
Symptoms
Treatment Mild,food,coma,10％Dextrose,glucagon,0.5-1mg
Hunger,headache,nausea,fatigue,
diaphoresis,tachycardia,
seizure,coma
Chronic insulin excess
Nocturnal 2－ 3 Am BG ?
glucagon?adrenaline? glucocorticoid?
Glycogenolysis
肝糖原分解 ?
Gluconeogenesis
糖异生 ?
Morning BG ?
Management,Decrease insulin dosage
Somogyi phenomena
Dietary management
Calorie requirement＝ 1000+(age-2)× 100 (kcal)
Sugar 55－ 60％
Lipid 25－ 30％
Protein 15－ 20％
Calorie assignment,Breakfast 2 / 10
Lunch 3 / 10,Dinner 3 / 10
Snack,afternoon 1/10
before bedtime 1/10
Exercise
?Recommended,ball games,swimming,
running
?Not recommended, climbing,diving
?Regular aerobic exercise at least 25 minutes
daily
?Warning,snack before exercise to avoid
hypoglycemia
Blood Glucose Monitoring
Ideal blood glucose control (mmol/l)
?Fasting BG 3.9-6.1
?Postprandial BG 4.4-7.8
?HgbA1c <6.05%
Diabetic Education
Members,Physician,Nurse,Dietician,patients,
parents
Objectives,Nature and harm of diabetes,
food menu,
exercise,BG measurements,
urinary ketone and glucose test,
foot care,hypoglycemia
prevention
Methods,seminar,counseling,hot line
telephone,broadcasting,telephone,
camp
Diabetic ketoacidosis
(DKA)
Definition of DKA
? pH <7.30
? Glucosuria and ketonuria
? Hyperglycemia
? Bicarbonate <15mmol/l
? Clinical dehydration >5%
? With or without mental status change
DKA pathogenesis
insufficient insulin secretion
Glucose use ? insulin counter regulatory hormone?
lipolysis? glycogenolysis ? gluconeogenesis
Free fatty acid? hyperglycemia
Oxidation CoA Acetoacetate
?－ hydroxybutyrate
DKA management
1,Fluid Rehydration
Fluids requirement=deficit+maintenace
Deficit=estimated%dehydration x weight
Maintenance fluids,
Age (yo) Weight (kg) Fluids (ml/kg/24 hr)
<1 3-9 80
1-5 10-19 70
6-9 20-29 60
10-14 30-50 50
>15 >50 35
DKA management
2,Insulin
Initiated intravenously at continuous
dosage of 0.1 units/kg/hour
3,Glucose
Glucose 4-5% added to 0.45% (or 0.9%)
saline after BG falls to 12-15 mmol/l
DKA management
4,Potassium
Supplement potassium deficit with
KCl 40 mmol to each liter of saline
after insulin/fluids are given.
5,Bicarbonate
Only given when pH <7.10 at a
calculated dosage of 5% NaHCO3
(ml) = weight x 0.2 x BE
Childhood And Adolescence
Department of Endocrinology
Children’s Hospital
Fudan University
Email,shenshuixian@sina.com
luo_fh@163.com
Introduction
? Growth and growth disorders
? Adrenal disorders and sexual development
abnormalities
? Thyroid disorders
? Disorders of calcium and phosphorus
metabolism
? Diabetes mellitus and hypoglycemia
? Other disorders,obesity,autoimune
endocrinopathies,tumor,inborn metabolic
disease,water homeostasis,hypertension,et al,
Hypothalamus
Anterior pituitary Posterior pituitary
Bone growth
Breast
Ovary Testes
Adrenal
Thyroid
Diabetes Mellitus
in Childhood and Adolescent
Major objective
?To master pediatric diabetes diagnosis,
clinical presentation and therapy
Minor objectives:
?To be familiar with the etiology and
pathogenesis of pediatric diabetes
?To understand diabetes classification,clinical
findings,diagnosis and therapy
?To understand diabetic ketoacidosis diagnosis
and treatment
?To understand diabetic complications and
prevention
Definition
Diabetes mellitus is a metabolic disorder
of multiple etiology characterized by
chronic hyperglycemia due to defective
insulin secretion or insulin action or both.
Epidemiology of diabetes
Location（ Age<15yo） T1DM incidence (1/100000)
Finland 34
U.S.A, 14.6
Australia 14.4
Indonesia 2.53
Singapore 2.4
South Korea 1.86
New Zealand 1/1000
Japan 2.53（ 88－ 92yr）
Hang Kong 1.25
Tai Wan 1.5（ < 20y )
Beijing 0.94
Shanghai 0.83
Zuiyi 0.12
Guilin 0.30
Huhehaote 0.91
Nanjing 0.69
Hainan 0.29
I,Type 1 diabetes (?-cell destruction,usually
leading to absolute insulin deficiency)
A,Immune mediated T1A
B,Idiopathic T1B
II,Type 2 diabetes
American Diabetes Association,2004
Classification of diabetes mellitus
To be continued
Classification of diabetes mellitus
III,Other specific types
A,Genetic defects of ?-cell function
1,MODY 3, Chromosome 12,HNF-1?
2,MODY 2, Chromosome 7,glucokinase
3,MODY 1, Chromosome 20,HNF-4?
4,MODY4, Chromosome 13,insulin promoter
factor-1 (IPF-1)
5,MODY5,Chromosome 17,HNF-1 ?
6,MODY6, Chromosome 2,NeuroD1
7,Mitochondrial DNA
8,Others To be continued
Classification of diabetes mellitus
B,Genetic defects in insulin action
1,Type A insulin resistance
2,Leprechaunism
3,Rabson-Mendenhall syndrome
4,Lipoatrophic diabetes
5,Others
C,Disease of the exocrine pancreas
1,Pancreatitis
2,Trauma/pancreatectomy
3,Neoplasia
4,Cystic fibrosis
5,Hemochromatosis
6,Fibrocalculous pancreatopathy
7,Others To be continued
D,Endocrinopathies
1,Acromegaly
2,Cushing’s syndrome
3,Glucagonoma
4,Pheochromocytoma
5.Hyperthyroidism
6,Somatostatinoma
7,Aldosteronoma
8,Others
E,Drug or Chemical-induced
1,Vacor
2,Pentamidine
3,Nicotinic acid
4,Glucocorticoids
5,Thyroid hormone
6,Diazoxide
7.?-adrenergic agonists
8,Thiazides
9,Dilantin
10.?-interferon
11,L-Asparaginase
12,Others
Classification of diabetes mellitus
To be continued
Classification of diabetes mellitus
F,Infections
1,Congenital rubella
2,Cytomegalovirus
3,Others
G,Uncommon forms of immune-mediated diabetes
1.,Stiff-man” syndrome
2,Anti-insulin receptor antibodies
3,Others
To be continued
Classification of diabetes mellitus
H,Other genetic syndromes sometimes associated with diabetes
1.Down’s syndrome
2.Klinefelter’s syndrome
3,Turner’s syndrome
4.Wolfram’s syndrome
5.Friedreich’s ataxia
6,Huntington’s chorea
7,Laurence-Moon-Biedl syndrome
8,Myotonic dystrophy
9.Porphyria
10,Prader-Willi syndrome
11,Others
IV,Gestational diabetes mellitus (GDM)
Type 1 diabetes
in childhood and adolescence
Etiology & pathogenesis
Etiology & pathogenesis
Viral infection（ Coxsackie，
EBV,measles,mumps）
Milk proteins (lactoalbumin,
?－ casein,?- casein,
lactoglobulin)
Cow insulin
Autoantigens,GAD,IA-2,Insulin
Environment
Chemical agents
1.Aut
oim
mun
e
Etiology & pathogenesis
2.Genetics
?Monozygotic twins→IDDM (30－ 50％ )
?HLA DR3/DR4 →IDDM (70%)
?Aspartic acid on position 57 of HLA-DQ
? chain protective effect for T1DM
?Arginine on position 52 of HLA-DQ ?
chain increases susceptibility to DM
Antigen
Islet ?-cell
Genetic susceptibility Environmental factors
Monocyte,Phagocyte
Th1 cell
Phagocyte,NK,CTL
TNF-?,IL-1?
HLA-II
NO?
TNF-?
TNF-?
IFN-?
TNF-?,TNF-?,IFN-?
Oxygen free radical,NO?,
adhesion molecule,perforinOxygen free radical,NO?Fas?,Insulin?,growth
regeneration?,defense and
repair defect
? cell apoptosis
Pathophysiology
Insufficient insulin secretion
Decrease in glucose utilization Decreased metabolic
synthesis
Insufficient energy hyperglycemia
Polyphagia Glucosuria Osmotic diuresis Polyuria
Emaciation
Chronic dehydration
Thirst and Polydipsia
Clinical Features
? Weight loss
? Polyuria,polydipsia,
polyphagia
? Nocturia
Clinical Featrues
Common signs
? Flu-like symptoms
? Fatigue
? Blurry vision
? Urinary tract infection
? Weight loss of unknown reason
? Acute abdominal pain
? Nausea,vomiting,abdominal pain,
Kussmaul breathing,dehydration,
acidosis
? Lethargy,coma
Clinical Features
Associated
symptoms
Ketoacidosis
Complications
? Acute,Diabetic ketoacidosis
Hypoglycemia
Infection
Hyperosmolar nonketotic diabetic coma
? Subacute,Bone and joint abnormalities
Growth disorder
Puberty delay,learning disorder
? Chronic,Diabetic nephropathy
Diabetic retinopathy
Diabetic neuropathy
Diabetic Retinopathy and cataract
Diabetic nephropathy
Laboratory tests
? Serum,Glucose,electrolyte,BUN,creatinine,
calcium,magnesium,phosphorus,acetone,
lipid,venous blood gas (pH)
? Urine,urine glucose,ketone,protein
? HbA1c,reference range 4％～ 6％
? OGTT
? Autoantibodies,IAA GADAb ICA IA-2
? Islet function,glucagon stimulation test,
arginine c-peptide stimulation test
Diagnosis
1,Fasting blood glucose?7.0mmol / L（ at least
two times ) with diabetic signs and symptoms
2,Random blood glucose?11.1mmol / L
3,OGTT（ 2h） ?11.1mmol / L
One criteria needed for diagnosis.
Diagnostic criteria
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
Family history
Age
Gender
3%-5%
variable
F=M
74%-100%
>10yo
F>M
Asymptomatic Rare Common
Symptom
duration Days or weeks Weeks or months
Weight loss common common
To be continued
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
BMI at
diagnosis
Acanthosis
Hyperglycemia
?75th
percentile
No
variable
? 85th percentile
Common
variable
Ketosis and
ketonuria Common Common
Acidosis Common Moderately common
To be continued
Differentiating type 1 from type 2 diabetes in
children and adolescents
Characteristic Type 1 Type 2
HbA1c
Insulin or C-
peptide
Elevated
Low
Elevated
Normal or
elevated
Autoimmune
markers Common Uncommon
Differential diagnosis
? Renal glycosuria
? Secondary hepatic hyperglycemia 肝源性高
糖,Postprandial hyperglycemia,fasting
hypoglycemia
? Diabetes insipidus 尿崩症
? Hyperglycemia secondary to critical illness
Treatment
Dietary
management
Exercise
Drugs
BG
monitoring
Education
Type of Onset Peak Duration
Insulin（ h）
Short- acting
Regular ? hour 2-4 hours 4-8 hours
Humalog 10-15 min ?-1 hour 4 hour
Semilente 1-2 hours 2-5 hours 8-12 hours
Long-acting
NPH 2-4 hours 6-8 hours 12-15hours
Ultralente 4-6 hours 8-15 hours 15-18 hours
Lantus 2-4 hours 4-23 hours 24 hours
Premixed
NPH/Humalog 1-2 hours 6-12 hours 15-18hours
Times of insulin action
Management of insulin Therapy
30 '
br eak fa st
30 '
lu nch
30 '
di nn er
Bedtime
0.5 －
1.0 u/ k g/ d
RI( 30 ％ ) RI( 30 ％ ) RI( 30 ％ )
NPH or
Glargi ne
( 10 ％ )
NPH ＋ RI
（ 2 － 3:1 ）
60 ％ 40 ％
OR NPH +RI RI NPH
New onset patients
Insulin Management in Honeymoon
period
▲ Partial remission：
insulin < 0.5 u/kg /d
NPH＋ RI
PZI＋ RI
▲ Complete remission,2－ 3%
Continuing insulin therapy after remission
Insulin < 2 year 0.5u / kg / day
2－ 12 year 0.5-1.0 u / kg / day
adolescence 1.0-1.5 u / kg / day
Diabetes Control and Complications
Trial,DCCT
Intensive therapy：
1,3 or more insulin injection/d or insulin pump
2,four or more blood glucose determinations per
day
3,Careful attention to dietary intake
4,Frequent contact with health care provider
Results from DCCT
DCCT group
?Risk of retinopathy ↓76%
?Progress of retinopathy ↓54%
?Proliferative retinopathy ↓47%
?Risk of urinary ↓39%
protein≥40mg/24h
?Risk of urinary ↓54%
protein ≥300mg/24h
?Neuropathy ↓60%
Insulin Pen
Insulin Pump
Insulin dosage adjustment
Morning FBG? dinner/bedtime NPH ?
lunch BG ? Breakfast RI ?
dinner BG ? Breakfast NPH ?
bedtime BG ? dinner RI ?
（ If hypoglycemia,decrease insulin based on the above
schedule）
Hypoglycemia
Hypoglycemia Stress response?BG?
may affect mental development
Symptoms
Treatment Mild,food,coma,10％Dextrose,glucagon,0.5-1mg
Hunger,headache,nausea,fatigue,
diaphoresis,tachycardia,
seizure,coma
Chronic insulin excess
Nocturnal 2－ 3 Am BG ?
glucagon?adrenaline? glucocorticoid?
Glycogenolysis
肝糖原分解 ?
Gluconeogenesis
糖异生 ?
Morning BG ?
Management,Decrease insulin dosage
Somogyi phenomena
Dietary management
Calorie requirement＝ 1000+(age-2)× 100 (kcal)
Sugar 55－ 60％
Lipid 25－ 30％
Protein 15－ 20％
Calorie assignment,Breakfast 2 / 10
Lunch 3 / 10,Dinner 3 / 10
Snack,afternoon 1/10
before bedtime 1/10
Exercise
?Recommended,ball games,swimming,
running
?Not recommended, climbing,diving
?Regular aerobic exercise at least 25 minutes
daily
?Warning,snack before exercise to avoid
hypoglycemia
Blood Glucose Monitoring
Ideal blood glucose control (mmol/l)
?Fasting BG 3.9-6.1
?Postprandial BG 4.4-7.8
?HgbA1c <6.05%
Diabetic Education
Members,Physician,Nurse,Dietician,patients,
parents
Objectives,Nature and harm of diabetes,
food menu,
exercise,BG measurements,
urinary ketone and glucose test,
foot care,hypoglycemia
prevention
Methods,seminar,counseling,hot line
telephone,broadcasting,telephone,
camp
Diabetic ketoacidosis
(DKA)
Definition of DKA
? pH <7.30
? Glucosuria and ketonuria
? Hyperglycemia
? Bicarbonate <15mmol/l
? Clinical dehydration >5%
? With or without mental status change
DKA pathogenesis
insufficient insulin secretion
Glucose use ? insulin counter regulatory hormone?
lipolysis? glycogenolysis ? gluconeogenesis
Free fatty acid? hyperglycemia
Oxidation CoA Acetoacetate
?－ hydroxybutyrate
DKA management
1,Fluid Rehydration
Fluids requirement=deficit+maintenace
Deficit=estimated%dehydration x weight
Maintenance fluids,
Age (yo) Weight (kg) Fluids (ml/kg/24 hr)
<1 3-9 80
1-5 10-19 70
6-9 20-29 60
10-14 30-50 50
>15 >50 35
DKA management
2,Insulin
Initiated intravenously at continuous
dosage of 0.1 units/kg/hour
3,Glucose
Glucose 4-5% added to 0.45% (or 0.9%)
saline after BG falls to 12-15 mmol/l
DKA management
4,Potassium
Supplement potassium deficit with
KCl 40 mmol to each liter of saline
after insulin/fluids are given.
5,Bicarbonate
Only given when pH <7.10 at a
calculated dosage of 5% NaHCO3
(ml) = weight x 0.2 x BE
