Insulin-dependent diabetes mellitus (type 1 diabetes mellitus, IDDM) is a complex endocrine disease with systemic metabolic abnormalities, and its treatment in children is comprehensive, including rational application of insulin, dietary therapy, physical exercise, monitoring of blood glucose, and enhanced education. There is a strong emphasis on there should be a team specialized in the treatment of diabetes. Long-term treatment and management of patients by endocrinologists, nurses, nutritionists and educators. The knowledge of diabetes is taught to the sick children and parents, so that they can participate in the treatment and management of diabetes, and thus the diabetes can be well controlled.
The overall goal of IDDM treatment is to achieve optimal “health” for the patient. Treatment must ensure that the following requirements are met.
(1) Clinical elimination of polyhydramnios, polyuria and polyphagia.
② Prevention of diabetic ketoacidosis.
(3) Avoid hypoglycemia.
④ Ensure that the affected child maintains normal growth and pubertal development.
⑤ Prevent the occurrence of obesity.
⑥ Early diagnosis of complications and concomitant diseases and timely treatment.
⑦ Understand the patient’s psychological disorders and emotional changes in a timely manner, and give moral support and assistance.
⑧ Prevent the occurrence of chronic complications.
1.Treatment of insulin
1.1 Insulin preparations and effects The insulins currently used are mainly porcine insulin and human insulin synthesized by recombinant DNA. There are three types of insulin: short-acting, medium-acting and long-acting, depending on the duration of action. The duration of action of various insulins after injection is shown in Table 1. medium-acting and short-acting mixed with general NPH is 7O%, Rj is 3O%, NPH: Ill should be 3:1.
1.2 Method of insulin application
Diabetic patients are first treated with Rj, the initial dose of 0.5 ~ 1.0 U/ks per day (0.513/l [g before the age of 5, 1.013/ks after the age of 5), calculate the amount of Rj throughout the day, divided into 4 times, subcutaneously injected 30 min before breakfast, lunch and dinner, and then injected once before going to bed at night (daily distribution of total insulin: 30% ~ 4JD% before breakfast, 20% ~ 30% before lunch %, 30% before dinner, 10% before bedtime). If NPH and Rj are mixed, RI 30% to 4JD%, NPH 60% to 70%, divided into 2 injections (before breakfast and before dinner). Short-acting only provides insulin after each meal, and its adjustment is to adjust the insulin before breakfast of the next day with the blood sugar and urine sugar after breakfast and before lunch of the previous day; adjust the amount of insulin before lunch of the next day with the blood sugar and urine sugar after lunch and before dinner, and so on. NPH and Rj injections before breakfast provide insulin after breakfast and lunch, and injections before dinner provide insulin after dinner to before breakfast of the next day, and should be adjusted according to the blood sugar and urine sugar of each If the blood glucose is high 2h after breakfast, the Rj before breakfast should be increased, if the blood glucose is high 2h after lunch, the NPH before breakfast should be increased or a small dose of Rj before lunch should be added. The adjustment of insulin is directly related to the time of insulin action, dose and the amount of food eaten at mealtime, which should be considered and analyzed accordingly before adjusting insulin dose or diet.
Table l Types of insulin and duration of action
Type of insulin Time of onset of action (h) Time of strongest action (h) Maintenance time (h)
Short-acting (RI) 0.5 3~4 6~9
Medium-acting (NPH) 1.5~2 4~12 18~24
Mixed (medium + long effect) 1.5 2~8 18~24
Long-acting(PZI) 3~4 14~20 24~36
1.3 Complications of insulin therapy
1.3.1 Hypoglycemia is very likely to occur in children with diabetes if the amount of insulin is too large or if they do not eat on time after using insulin, or after strenuous exercise. Mild hypoglycemia can often be relieved on its own, but the response of pancreatic glucagon to hypoglycemia is impaired in those who have been ill for a long time, and the response of adrenaline is also reduced, so the ability to recover from hypoglycemia is reduced and slow, and hypoglycemic convulsions are likely to occur. When hypoglycemia occurs in children with diabetes, additional meals or sugary drinks should be consumed in a timely manner.
1.3.2 Chronic insulin overdose (Somogyi reaction) Chronic insulin overdose, especially medium-acting insulin overdose before dinner, is prone to hypoglycemia at 2 to 3 a.m. Hypoglycemia triggers an increase in the secretion of counter-regulatory hormones, which increases blood glucose and leads to hyperglycemia in the early morning, which is known as the hypo-hyperglycemic reaction, i.e. Somogyi reaction. If urine glucose is negative or weakly positive in the early morning, but urine ketone body is positive, it indicates nocturnal hypoglycemia, and blood glucose should be tested at 2-3 a.m., and insulin dosage before dinner or bedtime should be reduced.
1.3.3 Injection of local adipose tissue hypertrophy or atrophy can be prevented by circulating the injection by site.
1.3.4 Local or systemic allergic reactions A few children with skin injection localized erythema or urticaria. Allergic reactions can disappear in the course of continued medication, and those who still have allergic reactions can be desensitized or replaced with human insulin.
2.Dietary treatment
Diet therapy is one of the components of diabetes treatment. The diet for children with diabetes should be a planned diet rather than a restricted diet, because children should be supplied with sufficient calories and nutrition during the growth and development period. The calorie requirement = 1000 + age x (7O-100) kCal, the older the calorie used the smaller the calorie, also consider the wasting and obesity, the good and bad appetite and the amount of exercise. The distribution of food components should be 50% to 55% sugar, 30% fat, 15% to 20% protein, high protein for children under 3 years old, mainly animal protein, and vegetable oil for fat. The caloric distribution of the three meals is 1/5, 2/5 and 2/5, with a small amount (5%) set aside for snacks at each meal. The child should eat regularly and quantitatively.
3.Exercise therapy
Exercise is a necessary part of a child’s life for normal growth and development. Exercise is even more important for children with diabetes and is one of the treatment methods for diabetes. Exercise increases the sensitivity of muscles to insulin and increases the use of glucose, and it improves the composition of blood lipids and helps prevent the occurrence of cardiovascular diseases. Children with diabetes should participate in a certain amount of exercise regularly and quantitatively every day, and attention should be paid to adjusting the insulin dosage and diet arrangement when exercising to avoid hypoglycemia after exercise.
4.Treatment of diabetic ketoacidosis
4.1 Correct dehydration, acidosis and electrolyte disturbance start to give saline 20ml?ks a?h～ , first input saline for 1~2h, electrolyte result report then set the next step of infusion component addition. Usually saline or half-saline with potassium chloride (potassium added after urination) is used. Dehydration is generally calculated according to moderate dehydration, and the 24h input volume is calculated according to the standard of 8O-120ml/ks and then add the lost volume. The first 8h input half amount, the remaining amount in the last 16h input.
4.2 To correct hyperglycemia, small doses of insulin should be given by continuous intravenous drip, calculated as 0.1~0.15U?kg a?h for 3~4h. For infants and children under 4 years old, insulin should be given as 0.05U?ks a?h, added to 180~240ml of saline, maintained at the rate of 1ml per minute, and blood glucose should be measured once every 1~2h. Blood glucose should not fall too fast to avoid too much change in plasma osmolality and induce cerebral edema, and when blood glucose falls to 13.9mmol/L (250rag/alL), change to subcutaneous injection of 0.2~0.25U/ks, and stop intravenous insulin drip within 30rain. The insulin requirement is calculated as 0.5~1U/kg per day, divided into 4 subcutaneous injections, and later the insulin dosage is adjusted according to the blood glucose test.
4.3 Application of alkaline fluids The application of alkaline fluids in diabetic ketoacidosis should be strictly limited.