What is diabetes 1 5
What happens after the diagnosis
Type 1 diabetes mellitus is usually an autoimmune disease that is characterized by an absolute lack of insulin. The insulin-producing beta cells in the pancreas are completely destroyed in the course of the manifestation. Insulin deficiency syndrome develops with the typical signs of polyuria (frequent urination), polydipsia (excessive thirst), ketoacidosis and weight loss. The body can no longer meet the energy requirements of the cells due to the deteriorated intracellular glucose uptake. Therefore, more fat reserves are broken down for energy supply and body weight decreases.
The disease manifests itself considerably faster than type 2 diabetes mellitus, in which the manifestation lasts for years to decades. In most children, symptoms come on suddenly; 15 to 25 percent are admitted to hospital with a severe ketoacidotic metabolic imbalance. In the pharmacy, one should listen carefully if parents report the following symptoms in their child: exceptional thirst, urge to urinate, suddenly wetting again (at night), general weakness, fatigue during the day, headache combined with stomach pain, especially in the morning when getting up (this may be due to the formation of ketone bodies ), suddenly dry, itchy skin and sometimes significant weight loss (8 to 10 kg in three to four weeks).
These symptoms do not always appear together and are sometimes only mild. The acute phase can therefore drag on for weeks to months without being noticed. The pharmacy team should urgently recommend a visit to the pediatrician in the event of such symptoms or vague suspicions.
About 300,000 people in Germany suffer from type 1 diabetes. The disease can occur at any age. In 50 to 60 percent of patients it manifests itself in childhood or adolescence, in around 30 to 40 percent only after the age of 18. The peak of illness is in children aged five to eight.
During the summer vacation on a Mediterranean island, the five-year-old child was constantly thirsty. The parents didn't pay much attention to this, however, as it was hot and everyone drank a lot of water. But at home it went on and the child suddenly got wet at night, which hadn't happened in two years.
The next day the pediatrician determined a blood sugar of 350 mg / dl. The child and one parent were immediately admitted to a children's hospital with a diabetes-focused department. In the following 14 days, the child, parents, sibling and caring relatives (grandma, grandpa, aunt and others) learned what is initially important and how to act in an emergency.
Overall, the metabolic lapse was still "moderate". The child was not passed out; in severe cases the so-called manifestation coma can occur. The child had an HbA1c of 9.5 percent and could be normoglycemic again within 24 hours with a glucose infusion, potassium administration and insulin perfusor.
After the metabolic derailment was remedied by the careful slow titration of glucose, insulin and potassium, the intensified conventional insulin therapy (ICT) started immediately in the hospital. This was kept at home.
Several factors are now known that must come together. In the case of a genetic disposition, an event, for example a banal viral infection, can trigger the development of cellular and humoral immune phenomena. The organism produces T lymphocytes and autoantibodies against the islet cells. Immune-mediated inflammation of the islets of Langerhans (insulitis) occurs, resulting in the selective destruction of the insulin-producing beta cells.
Certain histocompatibility antigens are pathogenetically important. The human leukocyte antigens HLA-DR3 and -DR4 occur more frequently in type 1 diabetes. When the diagnosis is made, the blood is tested for these antigens.
The discrete antibodies can be detected in the blood in 90 to 95 percent of small patients at the time of manifestation:
- Islet cell antibodies (ICA),
- Glutamate decarboxylase antibodies (GADA),
- Tyrosine phosphatase IA2 antibody (IA2A) and
- Insulin autoantibodies (IAA).
Therefore, the blood is tested for these antibodies immediately after the diagnosis. Depending on the result, it is then clear whether it is a type 1 diabetes mellitus triggered by the autoimmune reaction or whether the causes must be searched further. If the immune reaction subsides after the phase of immune-induced insulitis, the antibodies are no longer sufficiently detectable. The autoantibodies gradually destroy the islet cells. The disease only becomes symptomatic when around 80 percent of the cells have been killed.
Primary prevention in studies
Since type 1 diabetes is a chronic disease with a gradual progression and the risk of the disease can be determined through screening, intensive research is being carried out into the possibilities of primary prevention. There are promising approaches if cow's milk protein is avoided in the first six to eight months of life. Studies have shown that the number of diseases in high-risk patients (positive detection of the relevant alleles in the screening) is lower than without intervention. The administration of nicotinamide or insulin in tablet form, on the other hand, has not shown any advantages in studies.
More recent studies check the effectiveness of insulin powder (given with food; Fr1da insulin intervention study) and the immunosuppressant abatacept (abatacept study). The studies included patients in whom at least two ICAs were detected, but diabetes is not yet manifest. One tries to "calm down" the beta cells or to minimize the immune reaction. Overall, all options for prevention are still at the stage of studies and not yet practiced.
The vast majority of patients still have a residual production of their own insulin at the time of diagnosis. Then, at the beginning of the disease, a good metabolic control can be achieved with relatively low doses of insulin, for example with meals. Often a very small amount of basal insulin (3 to 4 IU every twelve hours) must be taken in the first few weeks, which can be left out after a stabilization phase. This phase is known as the remission (Latin: remittere, to lead back) or honeymoon phase.
In the further course (from a few weeks to a maximum of two years), the need for insulin and the insulin dependence increase with the final drying up of the body's own insulin production.
Parents of children with diabetes often ask what causes the diabetes could have led to it and suspect vaccination as a trigger. In various studies, however, no connection could be clearly demonstrated (according to the Paul Ehrlich Institute, for example www.pei.de). The child should receive all vaccinations according to the current STIKO recommendations; there are no contraindications. In addition, a regular flu vaccination is strongly recommended.
Training begins in the hospital
After the diagnosis has been made, training for those involved begins immediately in the hospital. The focus is on the patient. The practical use of blood sugar measurement and insulin injections are practiced daily until the child can safely do both without outside help. For the interpretation of the blood sugar values and the correct calculation of the amount of insulin (fast-acting insulin), the support of parents and other caregivers is necessary for a long time.
During the inpatient stay, there are various topics that are discussed with both the child and the caregiver. In some cases, the instructions are given separately, as there is age-appropriate training material for children. The contents are usually taught in 1: 1 training courses in a child-friendly manner. It is about the following thematic blocks:
- Course of the disease, forms of insulin therapy, behavior in an emergency (hypoglycaemia and hyperglycaemia), hypoglycaemia perception, regular check-ups, for example of the eyes;
- Nutrition: calculation of the required amount of insulin, injection time, application of correction factors, optimal nutrition, handling sweets, eating in the restaurant;
- Life situations: influence of sport, school trips; in adolescents: diabetes and puberty, influence of alcohol / smoking; Application for severe disability, choice of profession, driver's license;
- psychological support for the family and, in the course of the illness, also for the patient alone.
After the hospital stay, regular care (at least once every three months) by a specialist in pediatric diabetology is necessary, who also addresses and deepens topics such as injection technology and blood sugar measurement. Further training documents can be downloaded as a pdf from the homepage of the Working Group for Pediatric Diabetology (AGPD, anchored in the German Diabetes Society, DDG, and the German Society for Pediatric and Adolescent Medicine, DGKJ).
Most common form of therapy: ICT
Intensified conventional therapy (ICT) is used when the body's need for insulin has to be replaced more or less completely. It is the most common form of therapy in type 1 and younger type 2 patients with the aim of achieving an almost normoglycemic metabolism. The therapy includes the administration of delayed insulin once or twice a day plus the need-based injection of fast-acting insulins.
The long-acting delay insulin covers the basic needs of the organism regardless of the carbohydrates consumed. This is essential for maintaining the protein and fat metabolism; therefore it is also known as basal insulin. The requirement is relatively fixed: the delay insulin is dosed correctly when the blood sugar level remains stable without carbohydrate intake. In this way, the right amount is determined during the inpatient stay.
The dose of the delay insulin is not or only slightly varied. If necessary, it can be increased, for example in the case of febrile infections, or decreased, for example during prolonged physical activity such as on a skiing holiday.
In addition, normal insulin boluses or fast-acting insulin analogues are administered preprandially - each adapted to the current blood sugar level and the carbohydrate or bread units (KE or BE) to be consumed. The E: KE ratio is used to denote the insulin units that have to be supplied in order to lower the blood sugar to the starting range after 1 KE. An example: An E: KE ratio of 2: 1 means that 2 IU of normal insulin are required for 1 KE.
Structured training for children and parents is a prerequisite for the safe use of ICT. The metabolism is checked at least four to five times a day before meals, before going to bed, immediately after getting up and, if possible, once a month at around 3 a.m. At the beginning of the therapy, it is strongly recommended to check the blood sugar every night between 2 and 3 o'clock (when the insulin requirement is lowest) and to correct it if necessary. In children, it can take several months to find the right amount of basal insulin. In addition, there is the initial remission phase, which is why measurements should be carried out at night for a longer period of time.
ICT in children and adolescents requires close control and constant adjustment. In return, it offers the greatest possible flexibility in the daily routine. The composition, amount and time of meals can be freely chosen and the insulin dose can be adapted to the physical activity.
Insulin pump therapy (CSII) is a special form of ICT. An insulin pump only delivers fast-acting insulin analogues into the body in two independent rates.
The basal rate (corresponds to the delay insulin) is supplied continuously. The dose is programmed in and delivered automatically, for example 0.8 units per hour. It can be varied every hour, for example to control the dawn phenomenon, and temporarily reduced or increased if necessary. Furthermore, special profiles can be programmed for different stress situations, for example on weekends or for sporting competitions.
During meals, boluses are called up and delivered at the push of a button according to the currently measured blood sugar and the KE to be recorded.
The early morning hyperglycaemia is partly due to the early morning release of cortisol and growth hormone, which act as contrainsulinary hormones. This results in an increased need for insulin in the morning hours. The dawn phenomenon is exacerbated by the flattening of the effect of the delay insulin administered the night before in ICT. The release kinetics of the delayed insulin do not match the insulin requirements in the early morning hours.
Therapeutically, one tries to see whether a later administration (not before 10 p.m.) of the delay insulin reduces the phenomenon. If this is unsuccessful, a delayed insulin with very uniform release kinetics, for example long-acting insulin analogs, is chosen. The dawn phenomenon occurs mainly in people with type 1 diabetes and especially during puberty (fluctuating hormone levels).
The CSII is primarily used in people with type 1 diabetes, when the ICT cannot achieve a satisfactory metabolic level or when a pronounced dawn phenomenon occurs (box). The insulin pump also offers an alternative for very young children (one to four years of age), because they cannot say exactly how much they want to eat before a meal. Parents or carers can then trigger the appropriate bolus after the meal. With the insulin pump, even the very low need for basal insulin can be precisely dosed.
The CSII is also used when there is a tendency to severe and recurrent hypoglycaemia and hypoglycaemia-impaired perception. The CSII is particularly advantageous in connection with a continuous glucose measurement (CGM).
Measure and document blood sugar
A close check of the blood sugar (BG) as well as the documentation of the measurement results and the associated parameters such as recorded KE, bolus size, correction units and basal rate in the "diabetic diary" are decisive for a good metabolic management. There are also appropriately structured diaries with an adapted layout and symbols for younger children.
The documentation of all parameters is used to provide a better overview when optimizing therapy, for example when adjusting the E: KE ratio or the basal rate, but also to provide evidence of the safe handling of the therapy. With some measuring devices, in addition to the BG values, other parameters, for example KE or bolus, can be saved and printed out using the software on the PC. Some manufacturers also offer electronic diaries as apps for smartphones.
Most measuring devices show the blood sugar behavior in capillary whole blood in a measuring range of 20 to 500 mg / dl (according to the ISO standard). Trend indicators show values that are too high or too low. Such trend indicators are set as individual upper and lower limits for blood sugar. The software then uses statistical methods to determine whether the blood sugar values develop outside the personally defined upper and lower limits. With some devices, the beta-ketone body measurement is also possible.
However, the measuring accuracy of the devices is usually overestimated. The deviation from the laboratory method and between the devices can be 15 to 20 percent. This is also allowed by the ISO standard. Therefore, one should not change the blood sugar measuring device constantly. The replacement device must of course be the same device (cave test strips). The devices should usually be calibrated (using a calibration strip, chip or code) or they automatically calibrate when the test strip is inserted.
Continuous glucose measurement (CGM) is new and not yet listed in the service catalog of all health insurances. The devices continuously measure the glucose values in the intercellular fluid of the subcutaneous tissue by means of sensors, for example in the upper arm (exchange after about 14 days) and transmit the values electronically to a reader. With the help of the curve diagrams shown, the glucose courses (upward and downward trends) can be observed day and night and quickly corrected therapeutically.
Since the glucose value in the intercellular fluid does not exactly correspond to the value in the capillary blood, the blood sugar is measured and documented four to five times a day for about a week and the respective value of the CGM is noted. This is how the difference can be determined. As a result, the patient and parents can more reliably assess where the real value lies.
CGM systems are now approved for children from the age of four (example: freestyle libre®). As a rule, the costs are still borne by the patient; some statutory health insurances (GKV) cover at least some of the costs.
Acute complication hypoglycaemia
Hypoglycaemia is the most common acute complication during insulin treatment. By definition, hypoglycaemia is present when plasma glucose falls below 50 mg / dl. There are several degrees of severity (table).Mild hypoglycaemia is expected on average once a week under conventional therapy (CT) with mixed insulin and twice a week under ICT. A total of 2000 to 4000 hypoglycaemias in life with diabetes and insulin.
|mild, light||Weakness, tremors, sweating, confusion, restlessness||no impairment of activity|
|moderate, medium difficulty||Weakness, tremors, sweating, confusion, restlessness||pronounced symptoms, but still reactive|
|heavy||clouded consciousness, loss of consciousness, coma, convulsions||in need of external help|
Severe hyperglycaemia, on the other hand, rarely occurs as an acute situation because it develops over hours. However, if the blood sugar is checked at least every four hours, one can counteract this with quickly acting insulin.
If the blood sugar drops, adrenergic symptoms in the form of tremors, sweating, restlessness, tingling around the mouth, palpitations and cravings appear. The body's adrenaline-induced alarm and warning system is responsible for this. After the training, even small children can subjectively notice the adrenergic symptoms well. However, very young children often cannot articulate this clearly.
If there is a cerebral undersupply of glucose in the further course, so-called neuroglucopenic symptoms take the place of the adrenergic symptoms. Older children and young people can still partially register these; but no longer respond adequately. The symptoms are expressed, for example, in blurred vision, agitation, aggressiveness, restlessness, slurred speech and nightmares. In the worst case, hypoglycemia leads to unconsciousness within 10 to 20 minutes, which can be accompanied by convulsions. Pareses and hemiplegia are also possible.
The perception of hypoglycaemia, i.e. the occurrence and noticing of adrenergic symptoms, is particularly clear in the case of a sudden drop in blood sugar starting from a high level, for example from 300 to 160 mg / dl. A consistently low blood sugar level or frequent hypoglycaemia lead to a decrease in the perception of hypoglycaemia. With increasing duration of diabetes, the ability to counter-regulate hormones (glucagon) irreversibly decreases.
Measures against hypoglycemia
In the case of mild to moderate hypoglycemia (table), the patient is given one or better two KE in the form of rapidly absorbable carbohydrates such as glucose, Coca-Cola or fruit juice. Because of the gastroparesis that exists during hypoglycaemia and because of the faster absorption, grape sugar should be supplied in liquid form or with water if possible. Diet products such as Diet Coke or diet chocolate are contraindicated; Protein and fat-rich foods such as milk or chocolate are unsuitable.
Some examples: 1 KE corresponds to 2.5 Dextro-energy® flakes or six pieces of glucose or 100 ml of juice or cola. One tube of Jubin® (40 g glucose-sucrose solution) corresponds to 2.6 KE.
In the event of severe hypoglycaemia that requires external help, the following immediate measures apply:
- Keep airways free,
- stable side position,
- never give fluids to an unconscious person (risk of aspiration),
- If available: Inject an ampoule of glucagon into the subcutaneous fat tissue or into the muscles, for example in the abdomen, arm, buttocks or leg,
- Call an emergency doctor,
- When the patient wakes up: immediately give two to three CUs quickly and two to three CUs slowly to absorb absorbable carbohydrates such as bread in order to avoid slipping into hypoglycaemia again,
- After waking up: close blood sugar tests for four to six hours.
Glucagon mobilizes the sugar reserves in the body (primarily in the liver) within about ten minutes. This increases blood sugar by around 20 to 30 mg / dl. Usually this is enough to supply the brain with enough glucose so that the person concerned comes to.
Glucagon is produced in the alpha cells of the pancreas and is the strongest hormonal antagonist of insulin. The finished drug GlucaGen® HypoKit can be stored for a maximum of 18 months at room temperature. In the case of severe hypoglycaemia, it can also be injected subcutaneously by laypersons. Therefore, expired kits should not be thrown away; they can be used as demo and exercise material for companions and friends. After consultation, approval and training, a HypoKit can be deposited together with glucose in the school or kindergarten.
What's next in school?
In order for children with type 1 diabetes to be able to attend kindergarten and school like all other children, educators and teachers must be well informed. For them, diabetes advisors and diabetologists sometimes offer several hours of training while the child is in hospital. There are also events in the school for teachers and classmates.
When the child goes back to school, there is security for everyone involved if a parent accompanies them during the first few days of school and, if necessary, with lunchtime care. If lunch is used in the after-school care center or kindergarten, you need food tables (for example from diabetes clinics) and a scale. In the first few days, parents should at least give advice over the phone to help calculate the correct amount of insulin to be injected. The caterer also provides the KE content per serving of lunch on request. Lunchtime care is only possible if the child can inject himself or operate the insulin pump safely.
Many PE teachers are trained to deal with emergencies. In order to avoid hypoglycaemia in sports as much as possible, the child has to measure their blood sugar directly before sports class. It should have a value of at least 150 mg / dl. The following applies:
- no sport if the blood sugar is below 150 mg / dl;
- If necessary, increase blood sugar by adding suitable carbohydrates ("sports apple") and check it again.
- measure blood sugar before, possibly during and after exercise,
- Eat additional BE before, during and after exercise, depending on the type of sport and load (duration),
- possibly reduce the insulin dose,
- always take glucose with you to exercise.
On the first class trip after the diagnosis, a parent is very welcome as an accompanying person. If this is not possible, the accompanying teachers must be well trained and ready to take on this responsibility. Because this is of course also associated with the fact that the basal insulin is correctly injected late in the evening and the blood sugar is checked directly beforehand.
Stay with friends
If an overnight stay with friends is due, the child must already have a certain degree of confidence in dealing with diabetes. The parents and the child friend should know what to do in an emergency and be able to help with blood sugar measurements. This gives security and allows diabetes to become "normal".
The more children who are friends are included, the more likely they are to recognize when the sick child is not doing well and hypoglycemia is on the horizon. You should have glucose with you and then help measure your blood sugar.
You should discuss with the host parents which foods should be included in the insulin calculation and thus weighed up. It is also helpful not to leave sweets standing around openly. Nuts of all kinds are a good alternative to snacking.
If the "usual diet" at children's parties in the form of ice cream, cake, lemonade and sweets cannot be avoided, the child should inject an approximately appropriate (lower) amount of insulin and check the blood sugar level every hour. Slightly higher values are acceptable for a few hours. The child can go along quite easily and there is no risk of hypoglycaemia.
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