儿童1型糖尿病的诊治与展望

doi:10.12372/jcp.2022.22e0411

摘要/Abstract

摘要：

儿童糖尿病主要为儿童1型糖尿病（T1DM）,根据我国大中城市的大样本纵向调查,其年发病率增幅约为世界平均增幅的3倍,5岁以下儿童增幅较高,提示我国儿童T1DM低龄化趋势。T1DM的病因机制复杂,遗传易感和环境因素促发是其发病的主要原因。年幼起病、长病程、血糖控制欠佳除导致糖尿病慢性并发症高发外,还影响患儿精神运动发育。药物治疗、血糖监测、健康教育、运动和营养管理是儿童T1DM良好血糖控制的根本举措。人工胰腺、干细胞胰岛分化与移植、免疫干预未来有可能从根本上改善未来T1DM的治疗和预后。

关键词: 1型糖尿病, 诊断, 治疗, 儿童

Abstract:

Type 1 diabetes mellitus (T1DM) is the major type of pediatric diabetes. According to the longitudinal epidemiology surveys in our national large metropolitans, the average annual incidence increasing rate is about three times higher that the average in the world, and the incidence increase in children under five years ranks the top, which indicates the younger trend of T1DM. The etiology and underlying mechanism of T1DM is complicated, with genetic susceptibility and environmental trigger factors as the main causes of T1DM. Early onset, long-term of disease course and poor glycemic control result in high incidence of chronic diabetic complications, and affect psychomotor development. Drug therapy, blood glucose monitoring, diabetes education, exercise and nutrition therapy are the fundamental measures for good glycemic control in pediatric T1DM. Artificial pancreas, stem cell islet differentiation and transplantation, and immune intervention may fundamentally improve the treatment and prognosis of T1DM in the future.

Key words: type 1 diabetes mellitus, diagnosis, therapy, child

罗飞宏. 儿童1型糖尿病的诊治与展望[J]. 临床儿科杂志, 2022, 40(5): 321-327.

LUO Feihong. Diagnosis, treatment and future of children type 1 diabetes mellitus[J]. Journal of Clinical Pediatrics, 2022, 40(5): 321-327.

图/表 2

表1

表2

美国糖尿病协会2022年度儿童糖尿病标准化管理指南[38]（节选）"

糖尿病自我管理教育与支持方面	建议T1DM患儿和父母/照料者定期接受糖尿病管理国家标准中的有关糖尿病个性化自我管理和支持方面的教育
营养治疗建议	建议对患有T1DM的儿童青少年进行个体化医学营养治疗,作为整体治疗计划的重要组成部分;监测碳水化合物摄入,无论是通过碳水化合物计数还是基于经验的估计, 都是优化血糖管理的关键组成部分建议由经验丰富的注册营养师进行诊断时的全面营养教育,并每年更新,以评估与体重状况和心血管疾病风险因素相关的热量和营养摄入是否合理,并告知宏量营养素的选择
体育活动和锻炼建议	建议T1DM患儿进行体育锻炼,目标是每天进行60分钟中到高强度的有氧运动,每周至少3天进行高强度肌肉和骨骼强化锻炼运动前、中和后,通过血糖仪或连续血糖监测进行频繁的血糖监测,预防和处理运动相关的低血糖和高血糖症青少年及其父母/照料者应在体育活动之前、期间和之后接受关于血糖目标和管理的教育,并根据计划体育活动的类型和强度进行个性化安排应教育青年及其父母/照料者在体育活动和锻炼期间、之后和夜间预防低血糖的策略, 包括锻炼前后膳食、加餐及相应胰岛素的调整
社会心理问题建议	在诊断和常规随访期间,评估可能影响糖尿病管理的心理社会问题和家庭压力,并向受过培训的、最好是有儿童糖尿病关联经验的心理健康专业人员转诊儿童糖尿病多学科团队应包含心理健康专业人员询问青少年和他们的父母/照顾者关于社会适应（同伴关系）和学校表现,以确定是否需要进一步的干预对10~12岁的T1DM进行饮食紊乱筛查

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参考文献 44

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自然病程	特点	诊断标准
阶段1	自身免疫血糖正常症状前	①多种胰岛自身抗体 ②无空腹血糖异常或糖耐量受损
阶段2	自身免疫血糖异常症状前	①胰岛自身抗体（通常为多个） ②糖调节异常：空腹血糖异常和/或糖耐量受损 ③空腹血糖5.6~6.9 mmol·L^-1 ④口服糖耐量试验2小时血糖 7.8~11.0 mmol/L ⑤HbA1C 39~47mmol·mol^-1或其增幅≥10%
阶段3	自身免疫明显的高血糖有临床症状	①自身抗体可能会缺失 ②符合糖尿病诊断标准