Introduction and Aim of the Study

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INTRODUCTION

iabetes mellitus (DM) is one of the most common chronic

diseases of childhood. It is a complex metabolic disorder,

due to resistance of insulin secretion by beta cells and is

characterized by altered homeostasis of carbohydrates, protein,

fat and metabolism )Guttman, 2009).

Diabetes is classified into two types, type 1 diabetes

(T1D) (insulin dependent diabetes mellitus [IDDM]) including

childhood onset diabetes, juvenile diabetes and insulin

dependent. This type is most common in the pediatric

population but can occur at any age (American Diabetes

Association [ADA], 2008;).

There is a worldwide increase in the incidence of T1D. It

affects approximately 1 in every 400-600 children and

adolescents in the United States of American (USA) develop

T1D (Guyatt et al., 2009). T1D accounts for 5 to 10 percent of

all diagnosed cases of diabetes mellitus (DM) in the USA (The

Centers for Disease Control and Prevention [CDC], 2008;

National Institute of Diabetes, Digestive & Kidney Disease

[NIDDKD], 2008;). While, Hanson et al., (2012) stated that the

number of pediatric population with T1DM is unknown,

although it is estimated that about 80, 000 children develop the

diseases each year globally.

D

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In Egypt, the prevalence of DM is 4.58% for the pediatric

population above 10 years and about 65% of deaths among

children with diabetes (Hanson et al., 2008).

The management of T1D is complex and intensive,

representing a substantial challenge for the family and for the

health system (Sullivan-Bolyai et al. 2003). Self-management

activities include multiple daily insulin injections or use of an

insulin pump, blood glucose monitoring several times daily,

regulation of dietary intake, regular physical activity, and

problem solving to correct unwanted blood glucose fluctuations

(ADA, 2008).

Nursing care of child with diabetes is complex rewarding

and challenging the successful recovery and rehabilitation of the

child is made possible with careful nursing assessment,

diagnoses, intervention and evaluation of all body systems

through follow-up care of child. The main role of pediatric nurse

is to do comprehensive assessment of the health problems and

health needs of the child and establish the goal to facilitate the

nursing intervention, provide preventive, curative and

rehabilitative care to child (Allen, 2010).

Childhood diabetes adversely affects health related

quality of life (HRQOL) of the pediatric patients and their

families. Diabetes imposes restrictions on physical, emotional

and social functioning of children and adolescents. One of the

Introduction and Aim of the Study

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international tools for assessment of HRQOL of children is the

Pediatric (Peds) QOL Inventory (El-Nagar , 2011)

Quality of life of the children with T1D is also affected by

numerous factors including medical factors are presented by

perceived difficulties in adherence regimen, complications,

duration and onset of disease. On other hand, the social factors

are also influence QOL (World Health Organization [WHO],

2006).

Significance of the Study:

Type 1 diabetes is currently the outstanding health

problem in developed as well as developing countries. It creates

increase family stress, requires constant adaptation by school age

children and the family member and poses challenge to nurse to

better understand meet the needs of these children and their

families. Therefore it is important to conduct this study to shed

light on QOL for school age children having T1D.

Introduction and Aim of the Study

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AIM OF THE STUDY

The study aims to assess QOL for school age children

with T1D.

Research Questions

1. What are the factors affecting the QOL of children with

T1D?

2. Is there a relationship between duration of illness and QOL

of children with T1D?

Review of Literature

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REVIEW OF LITERATURE

Definition of Diabetes

iabetes mellitus is a metabolic disorder characterized by a

raised blood glucose concentration either due to a

deficiency of insulin hormone or due to the presence of factors

opposing insulin action "insulin resistance" that means

hyperglycemia in spite of hyperinsulinemia (ADA, 2008).

Diabetes is a group of metabolic diseases characterized by

hyperglycemia resulting from defects in insulin secretion, insulin

action, or both. The chronic hyperglycemia of diabetes is

associated with long-term damage, dysfunction, and failure of

different organs, especially the eyes, kidneys, nerves, heart, and

blood vessels (ADA, 2008).

Classification of DM and Other Categories

of Glucose Regulation

Diabetes mellitus (DM) is divided into type1, type2,

gestational diabetes and other specific types related to genetic

defects of β cell function, diseases of endocrine pancreas,

infection and drug or chemical induced (Wagner et al., 2008).

The classification of DM is summarized in Table 1.

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Table (1): Classification of Diabetes

Type 1 diabetes* encompasses diabetes that is primarily a result of

pancreatic beta cell destruction (Figure 1) and is prone to ketoacidosis (KA).

This form includes cases due to an autoimmune process and those for which

the etiology of beta cell destruction is unknown.

Type 2 diabetes may range from predominant insulin resistance with

relative insulin deficiency to a predominant secretory defect with insulin

resistance.

Gestational diabetes mellitus refers to glucose intolerance with onset or first

recognition during pregnancy.

Includes latent autoimmune diabetes in adults (LADA); the term used to

describe the small number of people with apparent type 2 diabetes who

appear to have immune-mediated loss of pancreatic beta cells (WHO ,

2006).

∗ Includes latent autoimmune diabetes in adults (LADA); the term used to describe the small

number of people with apparent type 2 diabetes who appear to have immune-mediated loss of

pancreatic beta cells.

American Diabetes Association [ADA], (2012): Diagnosis and Classification of

Diabetes Mellitus. Diabetes Care; 35(suppl 1): S64- S71.

Website: http://www.nlm.nih.gov/medlineplus/ency/article/000305.htm

http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2012)

Type 1 diabetes can also define as T1DM is an

autoimmune disease that attacks and destroys the insulin-

producing beta cells of the pancreas. The pancreas then ceases to

produce insulin, a chemical hormone that is critical to survival

and needed to move glucose to the body‘s cells (NIDDKD,

2008).

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The Incidence

The incidence of Type 1 DM increased worldwide in the

closing decades of the 20th century, where the incidence of

T1DM is reported to be 8-10% pediatric population per year in

children aged <15 years. There are 215, 000 individuals <20

years of age with diabetes in the USA (CDC, 2008).

In Egypt, the prevalence rate of T1DM among school

children in Heliopolis district in Cairo was 1.09/1000 with male

predominance and in El Manyal district, the prevalence was

1.12/1000 school children with female predominance

(NIDDKD, 2008).

Etiological Classification of Diabetes Mellitus

The exact cause of T1D is unknown. T1D is a form

of DM that results from autoimmune destruction of insulin-

producing β cells of the pancreas (Figure 1). The subsequent

lack of insulin leads to increased blood and urine glucose.

T1D can be passed down through families. Furthermore the

child with T1D must rely on insulin medication for ever

(ADA, 2008).

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Figure (1): Autoimmune Destruction of Insulin-

Producing β of the Pancreas

Website: http://www.nlm.nih.gov/medlineplus/ency/article/000305.htm

http:// en. wikipedia. org/ wiki/ Diabetes_mellitus_type_2012

Type 1 Diabetes (ß-cell destruction, usually leading to

absolute insulin deficiency)

Type 1 Diabetes mellitus (T1DM) is a disease that is

subdivided into two groups: immune system mediated (type 1A)

and idiopathic (type 1B). Those with DM type 1B have

permanent insulin secretion deficiency by the pancreas, but no

development of autoimmunity (Hanson et al,2008). Since more

than 80% of pediatric patients with DM1 have the immune

system mediated form, the following physiological changes refer

to type 1A (ADA ;2011).

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Immune-Mediated Diabetes.

This form of diabetes accounts for only 5–10% of those

with diabetes, previously encompassed by the terms IDDM,

T1DM, or Juvenile-onset diabetes, results from a cellular-

mediated autoimmune destruction of the β-cells of the pancreas

(ADA, 2012). Markers of the immune destruction of the β-cell

include islet cell auto-antibodies (Figure 2), auto-antibodies to

insulin, auto-antibodies to gestation age diabetes GAD (GAD65)

and auto-antibodies to the tyrosine phosphatases IA-2 and IA-2β

(CDC 2008)

Baruchin, A., (2014): A Life-Changing Diagnosis: Type 1 Diabetes. Available at:

http://www.nytimes.com/health/guides/disease/type-1-diabetes/overview.

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In this form of diabetes, the rate of β-cell destruction is

quite variable, being rapid in infants and children and slow in

adults. Some pediatric patients, particularly children and

adolescents, may present with KA as the first manifestation of

the disease. Others have modest fasting hyperglycemia that can

rapidly change to severe hyperglycemia and KA in the presence

of infection or other stress (El Nagar 2011).

At this latter stage of the disease, there is little or no

insulin secretion, as manifested by low or undetectable levels of

plasma C-peptide. Immune-mediated diabetes commonly occurs

in childhood and adolescence, but it can occur at any age, even

in the 8th and 9

th decades of life (ADA, 2012).

Autoimmune destruction of β-cells has multiple genetic

predispositions and is also related to environmental factors that

are still poorly defined. Although pediatric patients are rarely

obese when they present with this type of diabetes, the presence

of obesity is not incompatible with the diagnosis. These pediatric

patients are also prone to other autoimmune disorders such as

Graves' disease, Hashimoto's thyroiditis, Addison's disease,

vitiligo, celiac sprue, autoimmune hepatitis, myasthenia gravis,

and pernicious anemia (WHO; 2013).

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Idiopathic Diabetes

Some forms of type 1 diabetes have unknown etiologies.

Some of these pediatric patients have permanent insulinopenia

and are prone to KA, but have no evidence of autoimmunity.

Although only a minority of pediatric patients with T1D fall into

this category, of those who do, most are of African or Asian

ancestry. This form of diabetes is strongly inherited, lacks

immunological evidence for β-cell autoimmunity, and is not

human leukocyte antigen (HLA) associated (ADA ;2012).

Figure 3 illustrates mechanism of β-cell destruction in T1DM.

In non-diabetic patients - immature dendritic cells (iDCs)

activate regulatory T-lymphocytes (Tregs), which induce

central tolerance → no ß-cell death (not shown on figure)

(WHO ,2013).

In T1DM pediatric patients - DCs bind the ß-cell antigens

released from islets of Langerhans, and express major

histocompatibility complex (MHC)/HLA class I molecules.

These MHC molecules are recognized by CD8+T-cells →

release of cytotoxic cytokines (IFN-gamma and granzymes)

(WHO ,2013).

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Figure (3): Mechanism of β- Cell Destruction in DM1

Roncarolo, M.G. & Battagliam, M. (2007): Regulatory T-Cell Immunotherapy for

Tolerance to Self Antigens and Alloantigens in Humans. Nature Reviews; 7(8):

585- 598.

Immature dendritic cells (iDCs) internalize modified islet ß-

cell antigens, and migrate to pancreatic lymph nodes. DCs

mature during migration and express MHC Class II

molecules. The antigens are presented to CD4+ T-cells,

which then differentiate into CD4+ effector T-cells (Teff)

(ADA, 2012).

The activated CD4+Teff release pro-inflammatory cytokines,

such as IL-2, IL-12, IFN-gamma and TNF-alpha →

inflammatory response (insulitis). Pancreatic ß-cell apoptosis

is mainly mediated by IL-1 and tumor necrosis factor (TNF)

cytokines (Roncarolo & Battagliam, 2007). Etiologic

classification of DM is summarized in Table 2.

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Table (2): Etiologic Classification of DM

I. Type 1 diabetes (beta cell destruction, usually leading to absolute insulin deficiency)

A. Immune-mediated B. Idiopathic

II. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a

predominantly secretory defect with insulin resistance)

III. Other specific types

IV. Gestational diabetes mellitus

Genetic defects of betacell function • Chromosome 20, HNF-4alpha (MODY1) • Chromosome 7, glucokinase (MODY2) • Chromosome 12, HNF-1alpha (MODY3) • Chromosome 13, IPF-1 (MODY4) • Chromosome 17, HNF-1beta (MODY5) • Chromosome 2, NeuroD1 (MODY6) • Chromosome 2, KLF11 (MODY7) • Chromosome 9, CEL (MODY8) • Chromosome 7, PAX4 (MODY9) • Chromosome 11, INS (MODY10) • Chromosome 8, BLK (MODY11) • Mitochondrial DNA • Permanent neonatal diabetes • Transient neonatal diabetes • Others Genetic defects in insulin action • Leprechaunism • Lipoatrophic diabetes • Rabson-Mendenhall syndrome • Type A insulin resistance • Others Diseases of the exocrine pancreas • Cystic fibrosis • Fibrocalculouspancreatopathy • Hemochromatosis • Neoplasia • Pancreatitis • Trauma/pancreatectomy • Others Endocrinopathies • Acromegaly • Aldosteronoma • Cushing’s syndrome • Glucagonoma • Hyperthyroidism • Pheochromocytoma • Somatostatinoma • Others

Drug- or chemical-induced • Alpha-interferon • Atypical antipsychotics • Beta-adrenergic agonists • Diazoxide • Dilantin • Glucocorticoids • Highly Active Antiretroviral Therapy (HAART) • HMG CoA reductase inhibitors (statins) • Nicotinic acid • Pentamidine • Thiazides • Thyroid hormone • Vacor (rodenticide) • Others Infections • Congenital rubella • Cytomegalovirus • Others Uncommon forms of immune-mediated diabetes • Anti-insulin receptor antibodies • "Stiff-man" syndrome • Otherss Other genetic syndromes sometimes associated with

diabetes • Down syndrome • Friedreich ataxia • Huntington chorea • Klinefelter syndrome • Laurence-Moon-Bardet-Biedl syndrome • Myotonic dystrophy • Porphyria • Prader-Willi syndrome • Turner syndrome • Wolfram syndrome • Others

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American Diabetes Association [ADA], (2012): Diagnosis and Classification of Diabetes Mellitus. Diabetes Care; 35(suppl 1): S64- S71.

Clinical Manifestations

Diabetes Mellitus can present a wide variety of symptoms,

ranging from asymptomatic to profound ketosis and coma. The

typical symptoms of diabetes mellitus are three (polys) polyuria,

polydipsia, and polyphagia and in addition to undue fatigue,

excessive urination and thirst, unexplained weight loss,

hyperglycemia, and the excretion of glucose and ketones into

the blood and urine and there is nocturnal enuresis or diabetic

KA (El-Nagar 2011; Silverstein et al., 2011). Dryness of the

mouth, sensory disturbances of the lower extremities, blurred

vision, impotence in the male and menstrual irregularity and

pruits vulva in female (Wagner et al., 2008) The following

figure (4) clarifies signs and symptoms of T1DM.

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Figure (4): Main Symptoms of T1DM

Encyclopedia, (2013): Diabetes Mellitus Type 1. Available at: http://en.wikipedia.org/wiki/File:Main_symptoms_of_diabetes.

Website: http://www.theswanseye.co.uk/revision-notes/by-year/type-1-diabetes-mellitus/