Treatment of diabetes in children

The main task is to achieve and maintain a sustainable compensation of the disease, and this is possible only when using a set of measures:

• diet;
• insulin therapy;
• patient education and self-control;
• dosed physical exercise;
• prevention and treatment of late complications.

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 - the exclusion of easily assimilated carbohydrates (sugar, honey, wheat flour, white cereals). The necessary conditions;

• the use of products containing a sufficient number of dietary fiber (rye flour, millet, oatmeal, buckwheat, vegetables, fruits), since dietary fibers contribute to a decrease in the absorption of glucose and lipoproteins of general and low density in the intestine;
• fixed in time and quantity distribution of carbohydrates during the day, depending on the insulin received;
• the equivalent replacement of products by carbohydrates in accordance with individual needs (one unit of bread is 10 grams of carbohydrates contained in the product);
• decrease in the proportion of fats of animal origin due to the increase in polyunsaturated fats of vegetable origin.

Optimal nutrient content in the daily diet: 55% carbohydrates, 30% fat, 15% protein. The mode of distribution of daily caloric content includes three main meals and three additional meals (so-called "snacks"). The basic principle in striving to maintain a normal level of glucose is the coordination of the amount and timing of intake of carbohydrate-containing products (bread units) with a short-acting insulin dose. The daily need for bread units is determined by gender, age, degree of physical activity and eating habits of the family and ranges from 9-10 in children up to 3 years of age to 19-21 bread units in boys 18 years of age. The amount of insulin per unit of bread is determined, based on individual sensitivity to insulin, differences in the digestion of various food components. The only way to determine this need is a daily study of postprandial glycemia, depending on the amount of carbohydrates eaten.

[1], [2], [3], [4], [5]

Insulin therapy in children

For patients with type 1 diabetes mellitus, there is no alternative to insulin therapy. The most widely used insulin is human recombinant. Analogues of insulin were 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, the active growth of the child and the high level of contrinulsory 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 "honey period" diabetes mellitus), it is advisable to administer 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 and duration of insulin

The preparation of insulin

Start of action

Peak of action, h

Duration of action, h

Short action

Actrapid NM	0,5-1 hours	1-3	6-8
Humulin R	0,5-1 hours	1-3	6-8
Insuman Rapid	0.5	1-4	7-9

Average duration of action

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

Analogues of short-acting insulin

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

Analogues of long-acting insulin

Insulin Glargine (Lantus)	1 h	No	24-29
Insulin Detemir (Leewemir)	1 h	No	Up to 24

After 5 years from the onset of diabetes in most patients, beta cells completely stop functioning. Schemes of insulin therapy include the use of extended-acting drugs (basal insulin) in combination with short-acting drugs (insulin simulating post-secretory secretion) during the day. The ratio of prolonged and short insulin is selected individually in accordance with the glucose level in the blood plasma during the day.

Basic regimens of insulin therapy

• 2 injections of insulin per day: before breakfast 2/3 of the daily dose and before dinner 2/3 of the daily dose - a combination of short-acting insulin and insulin of average duration of action. And, 1/3 of the dose of each injection of insulin should be a short-acting insulin, and 2/3 - an insulin of average duration of action.
• 3 insulin injections during the day - a combination of short-acting insulin and insulin of average duration of action before breakfast (40-50% of the daily dose), short-acting insulin injection before dinner (10-15% of the daily dose) and insulin injection of average duration of action before bedtime 40% of the daily dose).
• Basis bolus insulin therapy - 1-2 long-acting insulin injections or long-acting insulin analogues before breakfast and before bedtime (30-40% of the daily dose) and short-acting insulin injections before main meals in accordance with blood sugar and planned meals.
• Introduction of insulin using a continuous subcutaneous injection system ("insulin pump"). In the "pump" insulin analogs of ultrashort action are used. In accordance with the given program, basal insulin is injected at a certain rate through a catheter connected subcutaneously. "Nutritional" insulin is administered immediately before meals by changing the rate of its administration. The dose is selected individually. The catheter changes on average once every three days.

Complication of insulin therapy - hypoglycemia - lowering the blood glucose level below 3 mmol / l, developing with the introduction of an excessive dose of insulin, or with a reduced intake of glucose into the body, as well as an increased glucose consumption during physical exertion. Hypoglycemia occurs suddenly or within a few minutes. The first symptoms of hypoglycemia are caused by the activation of the sympathoadrenal system in response to a decrease in blood glucose level - limb tremor, tachycardia, cold sweat, weakness, hunger, abdominal pain. Then, because of the decrease in glucose in the cerebrospinal fluid, there are unmotivated crying, aggressiveness, agitation, alternating drowsiness, aphasia, local or general tonic-clonic convulsions, loss of consciousness.

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

[6], [7]

Self-monitoring

Conducting self-monitoring means not only determining the sugar content in the blood with an individual glucometer, but also correcting the dose of insulin depending on the level of glycemia, changes in diet, exercise. Training in self-monitoring of patients and their parents is carried out in schools "Diabetes" according to specially developed training programs.

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

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

Treatment of diabetic ketoacidosis

• Patients with stages I and II of diabetic ketoacidosis before the start of infusion therapy (and at stage III after improvement) make a cleansing enema.
• Rehydration therapy regardless of the stage of diabetic ketoacidosis begins with intravenous administration of 0.9% sodium chloride, with glycemia below 14 mmol / l inject 5% glucose solution with insulin (for 5 g of dry glucose substance - 1 unit of insulin).
• Correction of the level of potassium in the blood is necessary from the second hour of treatment with insulin. The initial dose of 7.5% KCL is 0.3 ml Dxgxh). In the subsequent it is necessary to maintain the level of potassium in the blood in the range of 4-5 mmol / l. The introduction of potassium drugs is stopped when it is in the serum above 6 mmol / l.
• The volume of infusion solutions is calculated taking into account the physiological needs, severity of dehydration and pathological losses. Because of the risk of overloading the volume and causing cerebral edema, the fluid should be administered cautiously: the first hour - 20 ml / kg, the second hour - 10 ml / kg, the 3rd hour and then - 5 ml / kg. The maximum amount of liquid injected during the first 24 hours should not exceed 4 l / m ^{2 of} the body surface.
• Small doses of short-acting insulin should be administered intravenously as a continuous infusion. Insulin can not be mixed with injected fluids, but must be administered separately at a rate of 0.1 U / (kghh). The goal is to reduce the glucose level by no more than 4-5 mmol / L per hour, as a faster decrease leads to 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 with a persistent blood pH below 7.1.
• The need for symptomatic therapy is determined individually.