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  • Definition: Plasma glucose level that meets ADA criteria for DM (see table below)

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Normal mg/dL (mmol/L)

Impaired* mg/dL (mmol/L)

Diabetes Mellitus mg/dL (mmol/L)

Fasting plasma glucose

<100 (5.6)

100–125 (5.6–6.9)

≥126 (7)

2-h OGTT

<140 (7.8)

140–199 (7.8–11)

≥200 (11.1)

Random glucose

<200 (11.1)

≥200 (11.1)

≥200 (11.1) + classic symptoms

*Impaired glucose tolerance = prediabetes.

Asymptomatic criteria require confirmation on another day.

Classic symptoms include weight loss, polyuria, polydipsia ± polyphagia, lethargy, and vaginal yeast infection.

Adapted from Diabetes Care 2003;26(suppl):S1.

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Type I

Type 2

Age of onset

Variable

Pubertal

Classic symptoms

Days or weeks

Subacute or absent

Physical exam

Weight loss

Obese, acanthosis nigricans, features of PCOS

Predominant race

Caucasian

Non-caucasian

C-peptide level

Low

High

Autoantibodies

Positive

Negative

Ketoacidosis

Common, recurrent

Less common (∼1/3), very rarely recurrent

Adapted from Oski's Pediatrics: Principles & Practice, 4th ed. 2006:2115.

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  • Categories
    • Type 1 DM: ∼65% of pediatric patients with DM; 5% to 10% of adults with DM.
      • Mechanism: Absolute insulin deficiency caused by autoimmune β-cell destruction (∼90% of cases); idiopathic (∼10% of cases).
      • Presentation: Acute onset (<1 mo) of classic symptoms (weight loss, polyuria, polydipsia ± polyphagia, lethargy, or vaginal yeast infection); 25% present with DKA.
      • Diagnosis: See table “Diagnosing Diabetes Mellitus and Impaired Glucose Regulation.”
      • Screening: Not recommended (short asymptomatic period; no effective prevention).
    • Type 2 DM: ∼35% of pediatric patients with DM; 90% to 95% of adults with DM.
      • Mechanism: Insulin resistance and relative insulin deficiency.
      • Presentation: Usually subacute; many are asymptomatic, overweight (BMI >85%) or obese; absent or mild polyuria; acanthosis nigricans; glucosuria; usually no ketonuria.
      • Diagnosis: Establish hyperglycemia and then differentiate from type 1 (see table ” Characteristics Suggesting Type 1 versus Type 2 Diabetes Mellitus”).
      • Screening: See table “Recommendations For Type 2 Diabetes Mellitus Screening”.
      • Prevention: Avoid weight gain into the overweight or obese range. If overweight → weight loss and exercise (independent of weight loss) may delay, prevent, or reverse the course of Type 2 DM.

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Recommendations for Type 2 Diabetes Mellitus Screening*

Age >10 yr or onset of puberty (whichever is earlier) and overweight (BMI >85th percentile or >120% of IBW for height) and any two of the following:

  • Family history of type 2 DM in first- or second-degree relative
  • Non-European ethnicity
  • Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS)

*Screening should be done every 2 years.

Adapted from Pediatrics 2000;105:671.

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  • Secondary causes of DM: Genetic defects of β-cell function (formerly MODY; AD inheritance, multiple family members with hyperglycemia onset <25 yo), gestational DM, drug- induced (eg, L-aspariginase, steroids, tacrolimus, cyclosporine, β-blockers, phenytoin, protease inhibitors), diseases with pancreatic destruction (eg, CF, trauma, pancreatitis), infections (eg, rubella, CMV), genetic syndromes with insulin deficiency or resistance (eg, Down, Prader-Willi, Turner, Klinefelter syndromes).

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  • Inpatient management
    • DKA: See chapter 9 for DKA management.
    • New stable type 1 diabetic (not in DKA):
      • Criteria for admission to regular ward (vary by institution): Normal mental status, tolerating PO intake, and serum HCO3 ≥16 mEq/L (≤5 yo) or ≥12 mEq/L (>5 yo).
      • Orders: see table “Suggested Orders For The New Diabetic”.
      • Insulin management: See table ...

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