Treatment of diabetes mellitus in children

The main task is to achieve and maintain stable compensation of the disease, and this is only possible with the use of a set of measures:

• diet;
• insulin therapy;
• patient education and self-monitoring;
• measured physical activity;
• prevention and treatment of late complications.

Diet for diabetes in children

The diet should be physiological and balanced in proteins, fats and carbohydrates to ensure normal growth and development rates. Features of the diet - exclusion of easily digestible carbohydrates (sugar, honey, wheat flour, white cereals). Necessary conditions;

• the use of products containing a sufficient amount of dietary fiber (rye flour, millet, oatmeal, buckwheat, vegetables, fruits), since dietary fiber helps reduce the absorption of glucose and total and low-density lipoproteins in the intestine;
• fixed distribution of carbohydrates during the day in terms of time and quantity, depending on the insulin received;
• equivalent replacement of products by carbohydrates in accordance with individual needs (one bread unit is 10 g of carbohydrates contained in the product);
• reducing the proportion of animal fats by increasing the proportion of polyunsaturated fats of plant origin.

The optimal content of nutrients in the daily diet: 55% carbohydrates, 30% fats, 15% proteins. The daily calorie distribution regimen includes three main meals and three additional meals (the so-called "snacks"). The main principle in striving to maintain normal glucose levels is to match the amount and time of intake of carbohydrate-containing products (bread units) with the dose of short-acting insulin administered. The daily requirement for bread units is determined by gender, age, level of physical activity and the family's eating habits and ranges from 9-10 for children under 3 years of age to 19-21 bread units for 18-year-old boys. The amount of insulin for each bread unit is determined based on individual sensitivity to insulin and differences in the digestion of various food components. The only way to determine this requirement is to study postprandial glycemia daily depending on the amount of carbohydrates eaten.

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Insulin therapy in children

There is no alternative to insulin therapy for patients with type 1 diabetes. The most widely used insulins today are human recombinant insulins. Insulin analogues are widely used in pediatric practice.

In childhood, the need for insulin is often higher than in adults, which is due to the greater severity of autoimmune processes, active growth of the child and high levels of counter-insular hormones during puberty. The dose of insulin varies depending on the age and duration of the disease. In 30-50% of cases, partial remission of the disease is observed in the first months. However, even with good compensation of carbohydrate metabolism in the first year of the disease (the so-called "honeymoon period" of diabetes mellitus), it is advisable to prescribe small doses of insulin in order to maintain residual insulin secretion for a longer period. Remission can last from 3 months to 1-2 years.

Types of insulin and their duration of action

Insulin drug

Beginning of action

Peak action, h

Duration of action, h

Short acting

Actrapid NM	0.5-1 h	1-3	6-8
Humulin R	0.5-1 h	1-3	6-8
Insuman Rapid	0.5	1-4	7-9

Medium duration of action

Protafan NM	1-2 hours	4-12	18-24
Humulin NPH	1-2 hours	4-12	17-22
Insuman basal	1 hour	3-4	11-20

Short-acting insulin analogs

Insulin lispro (Humalog)	0-15 min	1	3.5-4
Insulin aspart (NovoRapid)	0-15 min	1-3	3-5

Long-acting insulin analogs

Insulin glargine (Lantus)	1 hour	No	24-29
Insulin detemir (Levemir)	1 hour	No	Up to 24

After 5 years from the onset of diabetes, beta cells completely cease to function in most patients. Insulin therapy regimens provide for the use of prolonged-action drugs (basal insulin) in combination with short-acting drugs (insulin that imitates postalimentary secretion) during the day. The ratio of prolonged and short insulin is selected individually in accordance with the glucose levels in the blood plasma during the day.

Main modes of insulin therapy

• 2 insulin injections per day: 2/3 of the daily dose before breakfast and 2/3 of the daily dose before dinner - a combination of short-acting and medium-acting insulin. Moreover, 1/3 of the dose of each insulin injection should be short-acting insulin, and 2/3 - medium-acting insulin.
• 3 insulin injections during the day - a combination of short-acting and intermediate-acting insulin before breakfast (40-50% of the daily dose), an injection of short-acting insulin before dinner (10-15% of the daily dose) and an injection of intermediate-acting insulin before bed (40% of the daily dose).
• Basal-bolus insulin therapy - 1-2 injections of medium-acting insulin or long-acting insulin analogs before breakfast and before bedtime (30-40% of the daily dose) and injections of short-acting insulin before main meals in accordance with blood sugar levels and planned meals.
• Insulin administration using a continuous subcutaneous administration system (an "insulin pump"). The "pump" uses ultra-short-acting insulin analogues. Basal insulin is administered at a certain rate through a subcutaneously connected catheter according to a given program. "Food" insulin is administered immediately before meals by changing the rate of its administration. The dose is selected individually. The catheter is changed on average once every three days.

Complication of insulin therapy - hypoglycemia - a decrease in the blood glucose level below 3 mmol / l, developing when an excessive dose of insulin is administered, or with a reduced intake of glucose into the body, as well as with increased glucose consumption during physical activity. Hypoglycemia occurs suddenly or within a few minutes. The first symptoms of hypoglycemia are due to the activation of the sympathoadrenal system in response to a decrease in blood glucose levels - tremors of the limbs, tachycardia, the appearance of cold sweat, weakness, hunger, abdominal pain. Then, due to a decrease in glucose content in the cerebrospinal fluid, unmotivated crying, aggression, agitation replacing drowsiness, aphasia, local or general tonic-clonic seizures, loss of consciousness appear.

If the child is conscious, it is necessary to give him sweet tea or any product containing carbohydrates. In case of severe hypoglycemia with loss of consciousness, an intramuscular injection of glucagon is indicated (Glucagen HypoKit, 1 mg). If the patient's weight is less than 25 kg, the dose of glucagon administered is 0.5 mg. If the patient's weight is more than 25 kg, the dose of glucagon is 1 mg. In case of persistent hypoglycemia, a glucose solution is administered intravenously.

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Self-control

Self-monitoring means not only determining the blood sugar level using an individual glucometer, but also adjusting the insulin dose depending on the glycemia level, changes in nutrition, and physical activity. Patients and their parents are taught the principles of self-monitoring in Diabetes schools using specially developed training programs.

Control of disease compensation is carried out by determining glycosylated hemoglobin - a fraction of hemoglobin, the level of which reflects the total glucose content in the blood over the past 6 weeks. The criterion for good compensation of diabetes mellitus 1 is glycosylated hemoglobin figures of 7-8%. The target value for children and adolescents is 7.6%.

Determination of ketone bodies in urine is very important and mandatory in case of concomitant diseases or the presence of constant hyperglycemia.

Treatment of diabetic ketoacidosis

• A patient with stages I and II of diabetic ketoacidosis is given a cleansing enema before infusion therapy (and in stage III after the condition improves).
• Rehydration therapy, regardless of the stage of diabetic ketoacidosis, begins with intravenous administration of 0.9% sodium chloride; if glycemia is below 14 mmol/l, a 5% glucose solution with insulin is administered (for 5 g of dry glucose matter - 1 U of insulin).
• Correction of the potassium level in the blood is necessary from the second hour of insulin treatment. The initial dose of 7.5% KCL is 0.3 ml/kg h. Subsequently, it is necessary to maintain the potassium level in the blood within 4-5 mmol/l. The administration of potassium preparations is stopped when its content in the blood serum is above 6 mmol/l.
• The volume of infusion solutions is calculated taking into account the physiological need, the severity of dehydration and pathological losses. Due to the risk of volume overload and the development of cerebral edema, the fluid should be administered carefully: 1st hour - 20 ml/kg, 2nd hour - 10 ml/kg, 3rd hour and further - 5 ml/kg. The maximum amount of fluid administered during the first 24 hours should not exceed 4 l/m2 ^of body surface.
• Small doses of short-acting insulin should be administered intravenously as a continuous infusion. Insulin should not be mixed with the administered fluids, but should be administered separately at a rate of 0.1 units/(kg h). The goal is to reduce glucose levels by no more than 4-5 mmol/l per hour, since a more rapid decrease entails the development of cerebral edema.
• Correction of metabolic acidosis with 4% sodium bicarbonate solution is performed no earlier than 4 hours from the start of therapy if the blood pH remains below 7.1.
• The need for symptomatic therapy is determined individually.