Panel consisted of Dr Ehsan Assad, Dr Mehboob Ashraf, Dr Arshad Javiad Sh &
Dr Saleem A Rana.
Transient Hypoglycaemia present in newborns of daibetic Mothers.
If mother is not known diabetic then large weight babies (Macrosomia) along with hypoglycaemia shall raise the suspicion. If mother is known diabetic then attending physician shall be alive to the possibility of hypoglycaemia in such newborns. Glucose crosses placental barrier. Hyperglycaemia of mother stimulates pancreas of foetus and so foetus is having hyperinsulinaemia. After birth this continues for some hours due to hyperplasia of Beta iselet cells. These raised levels of insulin produce hypoglycaemia.
Symptoms and Signs: This happens in first 6 hours. (Hypocalcemic convultions occur at 24 hours after birth). These babies are gittery, irritable. Tachycardia, sweating may be present. They can have tremors or even convultions. Weight depends upon that gestational age when mother develops DM.If it is in first trimester than due to placental insufficiency baby may be low weight.
Management: Start early feeding.
Juvenile Diabetes Mellitus (Type 1, IDDM)
Incidence: Figures of local population are not available. Western figures can be qouted to have some idea. In general population it is 1:5000,in population at increased risk it is upto 1:500.In first degree relatives it may be upto 15 %. Genetics is not involved in a clearly defined pattern. Although its association with certain HLA types (e.g. D3, D4) is well known. Overall incidence is increasing.
Age of Onset: DM presents usually few years after birth.That time is required to let Beta Islet Cells be sufficiently damaged. Usual age of presentation is around 10 years.
Life Expectancy: Complications are bound to occur. Average life expectancy is about 30 years at the age of first presentation. Add 30 to the age when it is first diagnosed.
Etiology: Autoimmune mechanisms are responsible. Autoantibodies to Beta iselet Cells can be detected in majority of patients at the time of presentation or even before this. Later on these disappear.
Clinical Manifestations: Some of the commener presenations are followings. These shall raise the index of suspision.
q DKA.This is the most common presentation. There are several precipitating factors like infections, any kind of stress including emotional stress. Stress of severe weather like severe winter can precipitate DKA.
q Classical triad of polydypsia, polyuria and polyphagia.
q Repeated infections
q Growth Failure
q Lethargy
q Clumsy habits
q Abdominal pain with vomiting, sometimes leading to laprotomy.
q Delayed onset of puberty
All these behaviours should necessitate BGL estimation.
Diagnosis: You have to suspect it before you can diagnose it.
q 2 hour post prandial > 11 mmol /l (198 mgs/dl)
q Demonstrated on two different days confirms the diagnosis.
Management:
It is different than in adults. First priority is provision of adequate types and amount of calories. Second is decision about physical acitivity. Insulin has to keep BGL normal with these two preconditions. Schedule of diet, exercise and insulin amount and timing has to be very tight. Patient and parents have to be educated again and again. Without this education and understanding on the part of patient and parents management can never succeed. Any disturbance in any of these three aspects can push the bittle BGL in one or the other direction.
1. Diet
2. Physical Activity
3. Corresponding requirement of insulin.
Monitoring: Rather than having one or two readings, it is better to have 6 readings 4 hourly in 24 hours on anyone day to see how BGL is behaving on any specific regime.
Arranged Hypoglycaemia: Hypoglycaemia is an essential part of the education. It is bound to occur once in a while in tightly controled patient. Patient shall be trained to recognise the symptoms at the earliest. We arrange one episode of hypoglycaemia before discharging him. (Please describes the method.4 units I/V?)
Honeymoon Period: Many patients have a normal period after initial presentation is managed. They no longer need insulin. Please note this period is only for short duration. Patient is bound to present again with DM and then he will need insulin daily thereafter.
Managing Insulin Requirments: (Have I taken the correct notes?) Patient usualy are managed at amounts equal to 0.5-1.5 units/Kg of body weight. Any random amount can be started and later on titrated. Or we can calculate from 0.5 units/kg of body weight. Initialy it has to be regular. Four doses are ideal. On first day 1/3rd of total dose can be given. Second day two thirds can be given. Later on amount should be titrated according to BGL.Three doses 30 minutes before each meal and fourth one at bedtime.
Once control has been achieved NPH and Regular can be combined and twice a day regime can be tried.2/3 NPH and 1/3 Regular.
Management of DKA: (I apologise I could not take proper notes due to the haste)
There is considerable water and electrolytes deficit. Conitnous monitoring for these is required. Insulin shall be given continously until blood glucose is < 250 mgs/dl. Rough estimate of fluid loss can be made by body weight. It is approximately 10-15 % of body weight.
One year old or 10 kg body wt = Deficit is 1 litre
Above 10 kg = 0.5 litres /Kg?
¼ shall be given as N Saline in first 6 hours
Next ¼ should be N/2 N.saline to be given over next 6 hours.
Then remaining ½ of deficit should be given as N/2 over next 12 hours.
Once blood glucose is less than 250 mgs then 5 % dextrose in water and N/5 shall be combined in equal amounts to be given slowly to fullfil the remaining requirments.
Sodium Bicarbonate: Usually 1 meq /kg body weight is enough. Total amount is given withen ½ - 1 hour in separate infusion. It shall not be given continously or slowly otherwise it can lead to Paradoxical Acidosis and get lost in the expired air.