what are the complications ,presentations ,features,management,

1. Its Complications
Childhood
Diabetes Mellitus
Prof. Dr. Saad S Al- Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@yahoo.com

2. Throughout the world, incidences of diabetes are on the
rise, and consequently so is diabetes amongst children
Most children are affected by type 1 diabetes in childhood
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Complications of DM Prof.Dr.Saad S Al Ani
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3. Number of children and young adults affected by type 2
diabetes is beginning to rise
Approximately 90% of young people with diabetes suffer
from type 1 and the number of patients who are children
varies from place to place
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4. A figure of 17 per 100,000 children developing diabetes
each year has been reported
As metabolic syndrome, obesity and bad diets spread, so
too have the first incidences of type 2 diabetes, previously
incredibly rare.
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5. How is diabetes caused in
children
The actual causes of the diabetic condition are little
understood
Inherited genetic characteristics are triggered by
environmental factors such as diet or exercise
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6. What symptoms do children
with diabetes exhibit
A number of symptoms may give early warning that diabetes
has developed
One or more of the following symptoms may be associated
with diabetes:
Thirst Tiredness Weight loss Frequent urination
Amongst children, specific symptoms may include:
Stomach aches Headaches Behavioral problems
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Complications of DM Prof.Dr.Saad S Al Ani
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7. What symptoms do children
with diabetes exhibit
(Cont.)
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8. How are children with diabetes
treated
The only certain method of treating diabetes in children is
insulin treatment
Because type 1 typically means that the vast majority
of islet cells have been destroyed and insufficient or
zero insulin can be produced,
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9. How are children with diabetes
treated
Fast-acting insulin will generally be administered during the
day, and nocturnal levels will be controlled by a slow-acting
dose
Insulin pumps are also common amongst children
Good glucose control is essential in the management of
all diabetics’ conditions.
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10. How are children with diabetes
treated
Treating type 2 diabetes in children depends entirely on how
far their condition has developed
An abrupt lifestyle change incorporating a healthier diet and
exercise at an early stage
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11. What can the parents of children with
diabetes do
Keeping a strict eye on the blood glucose levels
Avoiding lows and highs
Activity levels need to be closely monitored
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12. What can the parents of children with
diabetes do
Patients and their families alike should know that support is
available
Understanding how the disease affects the child, being
adaptable and patient, are essential to successfully
managing diabetes
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13. Childhood Diabetes
Mellitus
Complications
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Where
we
are?
13

14. Conclusions :One-fourth of girls with type 1 diabetes
scored above the cutoff for DEB and one-third reported
skipping their insulin dose entirely at least occasionally
after overeating. Both DEB and insulin restriction were
associated with poorer metabolic control, which may
increase the risk of serious late diabetes complications.
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15. The prevalence of type 2 diabetes mellitus and prediabetes in children
Abstract OBJECTIVE: To investigate the incident and prevalence of type 2 diabetes mellitus (T2DM) and
prediabetes in obese children in the last ten years. METHODS: The clinical data of hospitalized children with
newly diagnosed diabetes mellitus (DM) or obesity between October 2000 and September 2010 were
Conclusions: The prevalence rates of T1DM and T2DM
retrospectively studied. RESULTS: A total of 503 newly onset cases were diagnosed as DM in the past ten
years, of which 31 were diagnosed as T2DM. The prevalence of T2DM in the second five-year duration
increased significantly in the last 5 years. The prevalence of
increased significantly compared with that in the first five-year duration (0.18‰ vs 0.05‰; P<0.01). The
T2DM of type 1 diabetes mellitus (T1DM) and T2DM increased by 1.35 fold and 4.20 fold,
number of cases increased more significantly than T1DM. There was a
respectively in the second five-year duration. A total of 1301 obese patients received oral glucose tolerance
higher prevalence of prediabetes in obese children. Childhood
tests, and 29 cases were diagnosed with T2DM and 255 cases with prediabetes. Of the 255 cases of
obesity predicts a higher risk of T2DM and cardiovascular
prediabetes, 133 had dyslipidemia, 138 had non-alcoholic fatty liver disease and 53 had hypertension.
CONCLUSIONS: The prevalence rates of T1DM and T2DM increased significantly in the last 5 years. The
disease in the future.
prevalence of T2DM increased more significantly than T1DM. There was a higher prevalence of prediabetes in
obese children. Childhood obesity predicts a higher risk of T2DM and cardiovascular disease in the future.
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Complications of DM Prof.Dr.Saad S Al Ani
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16. J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96.
Subclinical metabolic abnormalities associated with
obesity in prepubertal Mexican schoolchildren
J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96.
Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican schoolchildren.
Romero JB, Briones E, Palacios GC, Castelán K.
Source
Departamento de Pediatría, Unidad Médica de Alta Especialidad, Hospital de Especialidades, Saltillo, Coahuila,
Mexico.
Abstract
Childhood obesity has increased to epidemic levels and is considered a public health problem due to its association
with a number of metabolic abnormalities, which are being detected at earlier stages of life. The objective was to
evaluate the association between the presence of subclinical metabolic abnormalities (SMA) and obesity in a sample of
pre-pubertal Mexican schoolchildren. Children of both sexes and 6 to 13 years old were questioned for signs of puberty,
In this sample of Mexican schoolchildren, obesity was groups were formed:
underwent anthropometric measurement and had their Body Mass Index (BMI) calculated. Twoassociated
those with obesity (case group) and those withof SMA, such as hyperinsulinism and
to a higher frequency normal weight paired by age and chosen randomly (control group).
Fasting insulin, glucose and cholesterol were measured. 92 children were included, 46 in each group, mean age 9.9 and
9.5 years old, impaired(p = 0.97). Aglucose, and to a family history ofthe case group: Fasting insulin
respectively fasting higher frequency of hyperinsulinism was found in DM
> 15 mU/ml, 75% vs. 21% (case group vs. control group, respectively); fasting glucose to insulin ratio < 6, 72% vs. 24%;
HOMA IR > 2.7, 83% vs. 14%; and decrease in QUICKI (< 0.3), 80% vs. 19% (p = 0.000). Hypercholesterolemia was 25%
vs. 15% (p = 0.22), impaired fasting glucose 28% vs. 8% (p = 0.01), and family history of diabetes mellitus (DM) 35% vs.
9% (OR = 5.6; 95% CI = 1.5-22.2; p = 0.002). In this sample of Mexican schoolchildren, obesity was associated to a
higher frequency of SMA, such as hyperinsulinism and impaired fasting glucose, and to a family history of DM.
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17. •
Korean Circ J. 2010 Mar;40(3):125-30. doi: 10.4070/kcj.2010.40.3.125. Epub 2010 Mar 24.
Left ventricular function in children and adolescents with type 1 diabetes mellitus.
Kim EH, Kim YH.
Source
Department of Pediatrics, Keimyung University School ofin children and adolescents with
Left ventricular function Medicine, Daegu, Korea.
Abstract
type 1 diabetes mellitus.
BACKGROUND AND OBJECTIVES:
Adult studies have reported that patients with diabetes mellitus (DM) show ultrastructural and functional myocardial
deterioration. The aim of this study was to assess whether cardiac functional deterioration can be detected in pediatric
patients with type I DM and whether or not a relatively short duration of DM and hyperglycemia influences cardiac
function.
SUBJECTS AND METHODS:
CONCLUSION:
Forty-seven children and adolescents with DM and 38 healthy subjects (control group) were enrolled. Glycosylated
Patients with DM-induced complications, and left ventricular (LV) function as assessed using conventional the
hemoglobin (HbA1c), DM in childhood and early adolescence rarely have insight on and
unconventional echocardiography {tissue Doppler imaging (TDI) and vector velocity imaging (VVI)} were evaluated.
significance of DM, and their diet is difficult to control. An alteration of
RESULTS:
myocardial function induced by with may begin earlier than generally thought,
The conventional echocardiographic parameters,DM the exception of early peak mitral inflow velocity, the findings of
pulsed wave TDI at the annular level, and regional ventricular function by VVI, were not significantly different between
and groups. changes are accelerated when glycemic control is poor. We
the two theseUsing the conventional and unconventional indices of systolic and diastolic function, no significant
relationship was found between the duration of DM and the echocardiographic parameters. The deceleration time (DT)
recommend the early institution of close p=0.016, respectively).
and E'/A' had an inverse correlation with HbA1c (p=0.042 and observation of patients with diabetes for
CONCLUSION: in cardiac function, in addition to other diabetic complications
alterations
Patients with DM in childhood and early adolescence rarely have insight on the significance of DM, and their diet is
difficult to control. An alteration of myocardial function induced by DM may begin earlier than generally thought, and
these changes are accelerated when glycemic control is poor. We recommend the early institution of close observation
of patients with diabetes for alterations in cardiac function, in addition to other diabetic complications.
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18. J Res Med Sci. 2013 Feb;18(2):132-6.
Prevalence and related risk-factors of peripheral neuropathy in children with insulin-dependent diabetes mellitus.
Hasani N, Khosrawi S, Hashemipour M, Haghighatiyan M, Javdan Z, Taheri MH, Kelishadi R, Amini M, Barekatein R.
Source
Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran.
Abstract
BACKGROUND:
Diabetes mellitus (DM) is a common metabolic disorder that can cause various complications including, peripheral neuropathy
(PNP). Some possible risk-factors such as blood glucose level, hyperglycemia, duration of diabetes, and lipid profiles are
assumed to be important in diabetic PNP incidence. The aim of this study is to evaluate the prevalence and possible risk-factors of
PNP in children with insulin dependent DM.
MATERIALS AND METHODS:
Among diabetic children, 146 patients (up to 18-years old) were evaluated in this cross-sectional study. All patients were
examined for signs and symptoms of neuropathy and nerve conduction studies were performed. Blood level of glucose and lipid
profiles were also tested. The relation between variables was compared by independent t-test and logistic regression test.
RESULTS:
The mean age of diabetic children was 11.9 3.3 years whereas mean diabetes duration was 3.8 2.9 years. PNP was detected
in 40 patients (27.4%) that 62.5% of them have subclinical and 37.5% have clinical neuropathy. According to logistic regression
analysis, duration ofdiabetes was the most important factor in prevalence of PNP (5.7 3.5 and 3.1 2.5 years in patients with
and without neuropathy respectively, P < 0.001, 95% confidence interval [1.15-1.54]).
CONCLUSION:
As most of the patients had subclinical PN, neurological assessment is recommended to detect subclinical neuropathy in
asymptomatic type 1 diabetic children and it seems that the best way to prevent this complication is still rigid blood glucose control
and periodic evaluations.
Prevalence and related risk-factors of peripheral neuropathy
in children with insulin-dependent diabetes mellitus
CONCLUSION:
As most of the patients had subclinical PN, neurological assessment
is recommended to detect subclinical neuropathy in asymptomatic
type 1 diabetic children and it seems that the best way to prevent this
complication is still rigid blood glucose control and periodic
evaluations.
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19. PLoS One. 2013 Apr 10;8(4):e60057. doi: 10.1371/journal.pone.0060057. Print 2013.
Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with
and without diabetes in the U.S.
Suaya JA, Eisenberg DF, Fang C, Miller LG.
Source
GlaxoSmithKlineVaccines, Philadelphia, Pennsylvania, United States of America. Jose.2.Suaya@GSK.com
Abstract
INTRODUCTION:
Skin and soft tissue infections (SSTIs) are common infections occurring in ambulatory and inpatient settings. The extent
ofcomplications associated with these infections by diabetes status is not well established.
METHODS:
Using a very large repository database, we examined medical and pharmacy claims of individuals aged 0-64 between 2005 and
2010 enrolled in U.S. health plans. Diabetes, SSTIs, and SSTI-associated complications were identified by ICD-9 codes. SSTIs
were stratified by clinical category and setting of initial diagnosis.
RESULTS:
We identified 2,227,401 SSTI episodes, 10% of which occurred in diabetic individuals. Most SSTIs were initially diagnosed in
ambulatory settings independent from diabetes status. Abscess/cellulitis was the more common SSTI group in diabetic and nondiabetic individuals (66% and 59%, respectively). There were differences in the frequencies of SSTI categories between diabetic
and non-diabetic individuals (p<0.01). Among SSTIs diagnosed in ambulatory settings, the SSTI-associated complication rate was
over five times higher in people with diabetes than in people withoutdiabetes (4.9% vs. 0.8%, p<0.01) and SSTI-associated
hospitalizations were 4.9% and 1.1% in patients with and without diabetes, respectively. Among SSTIs diagnosed in the inpatient
setting, bacteremia/endocarditis/septicemia/sepsis was the most common associated complication occurring in 25% and 16% of
SSTIs in patients with and without diabetes, respectively (p<0.01).
CONCLUSIONS:
Among persons with SSTIs, we found SSTI-associated complications were five times higher and SSTI-associated hospitalizations
were four times higher, in patients with diabetes compared to those without diabetes. SSTI prevention efforts in individuals
with diabetes may have significant impact on morbidity and healthcare resource utilization.
Skin and soft tissue infections and associated complications among
commercially insured patients aged 0-64 years with and
without diabetes in the U.S.
CNCLUSIONS
Among persons with SSTIs, we found SSTI-associated complications were
five times higher and SSTI-associated hospitalizations were four times
higher, in patients with diabetes compared to those without diabetes. SSTI
prevention efforts in individuals with diabetes may have significant impact on
morbidity and healthcare resource utilization
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Complications of DM Prof.Dr.Saad S Al Ani
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20. Diabetologia
Diabetologia. 2013 May;56(5):995-1003. doi: 10.1007/s00125-013-2850-z. Epub 2013 Feb 7.
Diabetic ketoacidosis at the onset of type 1 diabetes is associated with future HbA1c levels.
Fredheim S, Johannesen J, Johansen A, Lyngsøe L, Rida H, Andersen ML, Lauridsen MH, Hertz B, Birkebæk NH, Olsen
B, Mortensen HB, Svensson J; Danish Society for Diabetes in Childhood and Adolescence.
Source
Department of Paediatrics, Herlev Hospital, Arkaden, Turkisvej 14, DK 2730 Herlev, Denmark. sirifredheim@dadlnet.dk
Abstract
AIMS/HYPOTHESIS:
We investigated the long-term impact of diabetic ketoacidosis (DKA) at onset on metabolic regulation and residual beta cell
function in a Danish population with type 1 diabetes.
METHODS:
The study is based on data from DanDiabKids, a Danish national diabetes register for children. The register provides clinical and
biochemical data on patients with type 1 diabetes diagnosed in 1996-2009 and then followed-up until 1 January 2012. Repeatedmeasurement models were used as statistical methods.
RESULTS:
The study population comprised 2,964 children <18 years. The prevalence of DKA at diagnosis was 17.9%. Of the total subjects,
8.3% had mild, 7.9% had moderate and 1.7% had severe DKA. DKA (moderate and severe) was associated with increased
HbA1c (%) levels (0.24; 95% CI 0.11, 0.36; p = 0.0003) and increased insulin dose-adjusted HbA1c (IDAA1c, 0.51; 95% CI 0.31,
0.70; p < 0.0001) during follow-up, after adjustment for covariates. Children without a family history of diabetes were more likely to
present with DKA (19.2% vs 8.8%, p < 0.0001); however, thesechildren had a lower HbA1c (%) level over time (-0.35; 95% CI 0.46, -0.24; p < 0.0001). Continuous subcutaneous insulin infusion (CSII) was associated with a long-term reduction in HbA1c,
changing the effect of DKA, after adjustment for covariates (p < 0.0001).
CONCLUSIONS/INTERPRETATION:
DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c
and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta
cell function, changing the effect of DKA at onset in our population.
Diabetic ketoacidosis at the onset of type 1 diabetes is associated
with future HbA1c levels
CONCLUSIONS/INTERPRETATION:
DKA at diagnosis was associated with poor long-term metabolic
regulation and residual beta cell function as assessed by HbA1c and
IDAA1c, respectively; however, CSII treatment was associated with
improvement in glycaemic regulation and residual beta cell function,
changing the effect of DKA at onset in our population.
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21. Emergency Medicine Clinics of North America
Volume 31, Issue 3,
August 2013, Pages 755–773
Pediatric Emergency Medicine
Emerg Med Clin North Am. 2013 Aug;31(3):755-73. doi: 10.1016/j.emc.2013.05.004.
Epub 2013 Jul 6.
Diabetic ketoacidosis in the pediatric emergency department.
Olivieri L, Chasm R.
Diabetic ketoacidosis in the pediatric emergency department
Source
Department of Emergency Medicine, University of Maryland Medical Center, 110
South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
Abstract
Despite many advances, the incidence of pediatric-onset diabetes and diabetic
ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic
pediatric illnesses and, along with DKA, is associated with significant cost and
morbidity. DKA a patient has prolongedstate hallmarked by dehydration andif
when is a complicated metabolic or multiple courses of DKA or
electrolyte disturbances. Treatmentcerebralfluid resuscitation with can be
DKA is complicatedconstant monitoring for the results insulin andDKA is
by involves edema, cerebral edema. When
electrolyte replacement under
devastating.
recognized and treated immediately, the prognosis is excellent. However, when a
patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral
edema, the results can be devastating.
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22. Diabetes
Mellitus
Its Complications
http://thediabeteschallenge.org/
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23. 11/30/2013
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24. Acute
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25. Diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is an acute and
dangerous complication of diabetes mellitus
DKA is always a medical emergency and requires medical
attention
Ketoacidosis is much more common in type 1 diabetes
than type 2
http://eatingacademy.com
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26. Diabetic ketoacidosis
(cont.)
Low insulin levels cause the liver to turn fatty acid
to ketone
Elevated levels of ketone bodies in the blood
decrease the blood's pH, leading to DKA
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27. Diabetic ketoacidosis
(cont.)
On presentation at hospital, the patient in DKA is
typically dehydrated, and breathing rapidly and
deeply
Abdominal pain is common and may be severe
The level of consciousness is typically normal until
late in the process, when lethargy may progress to
coma
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28. Diabetic ketoacidosis
(cont.)
Ketoacidosis can easily become severe enough to
cause hypotension, shock, and death
Urine analysis will reveal:
Significant levels of ketone bodies
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29. Diabetic ketoacidosis
(cont.)
Prompt, proper treatment usually results in full
recovery
Death can result from:
Inadequate or delayed treatment
Complications (e.g., brain edema).
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30. Hyperglycemia hyperosmolar
state
Hyperosmolar nonketotic state (HNS) is an acute
complication sharing many symptoms with DKA,
but an entirely different origin and different
treatment.
It is more common in type 2 diabetes than type 1
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31. Hyperglycemia hyperosmolar
state
(cont.)
Blood glucose levels
above 300 mg/dl
(16 mmol/L))
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Water is
osmotically drawn
out of cells into
the blood
Complications of DM Prof.Dr.Saad S Al Ani
Kidneys
eventually begin
to dump glucose
into the urine
31

32. Hyperglycemia hyperosmolar
state
(cont.)
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33. Hyperglycemia hyperosmolar
state
(cont.)
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34. Hyperglycemia hyperosmolar
state
(cont.)
Urgent medical treatment is necessary, commonly
beginning with fluid volume replacement.
Lethargy may ultimately progress to a coma
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Complications of DM Prof.Dr.Saad S Al Ani
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35. Hypoglycemia
Hypoglycemia, or abnormally low blood glucose,
is an acute complication of several diabetes
treatments
In patients with diabetes, this may be caused by
several factors such as:
Too much or incorrectly timed insulin
Too much or incorrectly timed exercise
Not enough food
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36. Hypoglycemia
(cont.)
The patient may become agitated, sweaty, weak,
and have many symptoms of sympathetic
activation of the autonomic nervous system
resulting in feelings akin to dread and immobilized
panic.
Consciousness can be altered or even lost in
extreme cases, leading to coma, seizures, or even
brain damage and death
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37. Hypoglycemia
(cont.)
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38. Hypoglycemia
(cont.)
In most cases, hypoglycemia is treated with
sugary drinks or food
In severe cases, an injection of glucagon or an
intravenous infusion of dextrose is used for
treatment, but usually only if the person is
unconscious
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39. Diabetic coma
Diabetic coma is a medical emergency in which
a person with diabetes mellitus is comatose
(unconscious) because of one of the acute
complications of diabetes:
1.Severe diabetic hypoglycemia
2.Diabetic ketoacidosis
3.Hyperosmolar nonketotic coma
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40. Chronic
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41. Microangiopathy
The damage to small blood vessels leads to a
microangiopathy, which can cause one or more
of the following:
1.Diabetic cardiomyopathy
leading to diastolic dysfunction and eventually
heart failure.
2.Diabetic nephropathy
can lead to chronic renal failure, eventually
requiring dialysis.
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42. Microangiopathy (cont.)
3. Diabetic neuropathy
usually in a 'glove and stocking' distribution
starting with the feet but potentially in other
nerves, later often fingers and hands
4.Diabetic retinopathy
can lead to severe vision loss or blindness.
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43. Macrovascular diseases
They are not common in children as in adults
Macrovascular disease leads to cardiovascular
disease, to which accelerated atherosclerosis is a
contributor:
1.Coronary artery disease, leading to angina or
myocardial infarction ("heart attack")
2.Diabetic myonecrosis ('muscle wasting')
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44. Macrovascular diseases
(cont.)
3.Peripheral vascular disease, which contributes to
intermittent claudication (exertion-related leg and
foot pain) as well as diabetic foot
4.Stroke (mainly the ischemic type)
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45. Complications
and poor control
Type 1 diabetes rarely results in retinopathy and
nephropathy within the first five years, but kidney damage
and eye diseases have been found to be more common
amongst those with poor control.
Risks of diabetes complications climb once HbA1c levels
exceed 9%, and again increase significantly above 12%..
Type 2 diabetes may often result in vascular complications
such as heart attacks, stroke and problems with circulation
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46. Complications
and poor control
By closely controlling
Blood sugar levels
Blood pressure and cholesterol
People with diabetes can help lower their risk of diabetes
complications.
A lifestyle involving:
a good diet
regular exercise
no smoking
Can also help to reverse diabetes complication risks.
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47. References
1. "Diabetes Complications". Diabetes.co.uk. Retrieved 22 November 2012.
2. http://emedicine.medscape.com
3.Romero JB. Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican
schoolchildren. J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96.
1. http://www.nlm.nih.gov
2. http://www.cdc.gov/diabetes
3. http://www.uptodate.com
4. http://care.diabetesjournals.org
5. http://www.global-sci.org/cjcp
6. http://www.degruyter.com/view/j/jpem
7. http://www.koreancircj.kr
8. http://journals.mui.ac.ir/jrms
9. http://www.plosone.org
,
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48. 11/30/2013
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49. 11/30/2013
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