Saturday, January 24, 2009

Diabetes in Children

Does diabetes occur in children ? Yes, but it is not as common as in adults and it is mostly not the same as in adults, so the treatment is very different in most cases.

Diabetes in children may be due to the following causes :

Type 1 Diabetes Mellitus – Occurs when the beta cells of the pancreas have been attacked by an autoimmune process ( cell-mediated immunity) and they are too few too produce sufficient insulin.

Type 2 Diabetes Mellitus – When the body is resistant to the effects of insulin, and the body fails to compensate by producing enough insulin to overcome the effects of this resistant state.
People who have had Type 2 diabetes for a long time often need insulin injections as well because the body is not only resistant to insulin but also no longer able to respond to oral medications Secondary diabetes – when the pancreas has been damaged due to another medical condition – for example, thalassemia major, effects of chemotherapy or surgery.

The approach to treatment of diabetes in children and teenagers is very different to that for adults because of the need to take into account issues of growth, puberty and adolescence, emotional development and matching the medication doses to the child’s timetable and CCA which need to be addressed at the same time as the diabetes. A children’s diabetes specialist ( a paediatric endocrinologist who specializes in diabetes ) is the better option to help provide the best care for the child with diabetes, or who is at risk for diabetes.

In adults with Type 2 diabetes, treatment is geared towards getting the body to make more insulin and make it work betterIn children with Type 1 diabetes, the body cannot make insulin any more, and the treatment is to replace the insulin in as natural a way as possibleEven when children develop Type 2 diabetes, they may need insulin right from the start as well, in addition to oral medications.

Some children may be at risk of diabetes but may not yet have diabetes or may only have impaired glucose tolerance ( prediabetes . Children and adult with prediabetes can go on to develop diabetes. Help is available to reduce the risk of progression to diabetes too, and it includes medication and lifestyle changes. Risk reduction strategies include helping pregnant women with diabetes achieve good blood glucose control in pregnancy and identifying high risk children for intervention as early as possible.

No matter what has caused the diabetes, treatment is geared towards :

1. Replacing the insulin needed to control blood glucose levels
2. Reducing the risks of hyperglycemia ( too high a sugar level in the blood ) and hypoglycemia ( too low a sugar level)
3. Allowing the person with diabetes to have as normal a life as possible .

Methods to achieve this include :

1. Insulin injections
2. Insulin pumps
3. Insulin sensitizers
4. Cholesterol lowering agents
5. Renalprotective medications6 Glucose monitoring

Maintaining a normal glucose level is important because high glucose levels lead to diabetes complications such as blindness, kidney failure, nerve damage, strokes and heart attacks as well as mood changes.Low blood glucose levels can lead to epileptic fits and lowered IQ. Research has shown that good glucose control can reduce by half, the rate of diabetes complications. Poorly controlled glucose , on the other hand can also give rise to stunted growth, delayed puberty, mood swings and poor performance in work and interpersonal relationships.

In the past, people with diabetes used to be on 2 insulin injections a day and had to accept a lot of restrictions on their lifestyle. Conventional insulin injections have many limitations. Even when the same dose is given each day, the amount of insulin released into the bloodstream can vary up to 55%, giving rise to high and low blood glucose levels when least expected. Conventional insulins also have a poor peak performance , which means that children with diabetes could not eat many favourite foods.

Nowadays, with newer insulin analogues such as Novorapid, Humalog, Detemir, Glargine / Lantus and so on, children with diabetes can eat a wider variety of foods and they no longer have to wait half an hour after their injections before they can start eating. With the newer insulins, the danger of having a very low glucose level is lowered.

In fact, with the new insulin pumps, the variation in the delivered insulin is only about 3% per day, compared to up to 55% variability in conventional insulins. With an insulin pump, the dose is infinitely variable, so that children active in sports and who have healthy appetites have much lower danger of highs and lows. Even quite young children can safely be put on an insulin pump, and many parents whose children are on an insulin pump tell of the great freedom and improved peace of mind which the pumps give them.

Whether the patient with diabetes is using insulin injections or using an insulin pump, it is useful to know what the blood glucose level is like so that dose adjustments can be made more accurately. While multiple daily finger pricks were the norm, new Continuous Glucose Monitoring Systems ( CGMS ), such as Medtronics’ Guardian Real-time system, can give blood glucose readings updated every 5 minutes for 3-5 days by having a small sensor inserted just under the skin. Besides being used in children and adults who want to have good control, CGMS is also useful for pregnancy diabetes patients who want to reduce the risk of complications in their unborn child.

Dr Warren Lee,
MBBS, M Med Paeds, FAMS, FRCP ( London ) , FRCPCH ( UK)
Senior Consultant Paediatrician and Paediatric Endocrinologist
Dr Warren Lee’s Paediatrics,
Growth and Diabetes Centre Pte Ltd