University of Toronto - Faculty of Medicine

 

Author
The revision of this chapter was prepared by Kusiel Perlman, MD, FRCPC

Diabetes Mellitus (DM) is the most common endocrine disease and one of the most frequently encountered chronic disorders in childhood and adolescence.

 

Type 1 Diabetes Mellitus

• Accounts for most cases in children and teens. Incidence in Canada ranges from 9-25 new cases/100,000 population/year.
• Prevalence is about 1/400-500 school aged children.
• Usually present with a brief history of classic symptoms of polyuria, polydipsia, fatigue and weight loss. Less frequently has a more prolonged onset of weeks to month.
• Risk of delayed diagnosis when it is assumed that a baby who has wet diapers and drinking well is not too sick.
• Tachypnea of ketoacidosis must not be confused with bronchiolitis, a common respiratory disorder in children.
• Untreated type 1 diabetes in children may progress rapidly to ketoacidosis, a life-threatening situation.

Type 2 Diabetes Mellitus

• Accounts for a small, but steadily increasing number of youth with DM.
• The incidence is about 1.5 children per year for 100,000 children 0-18 years.
• Prevalence varies with ethnicity of clinic population.
• More likely to be from a high-risk group such as Aboriginal Canadians, African-, Asian- or Hispanic-Canadians.
• Obesity may play a role in the expression of type 2 diabetes in susceptible youth.

Maturity-Onset Diabetes of the Young (MODY)

• Relatively uncommon.
• Strong family history suggestive of an autosomal dominant pattern of inheritance.
• Tend to be lean.

Other

• DM may be secondary to other diseases such as cystic fibrosis or thalassemia major (iron overload from blood transfusions) or an effect (transient or permanent) of drug administration such as corticosteroids.

 

• If diabetes is suspected (classic symptoms) do a urine check in the office. Glycosuria with or without ketonuria suggests the need for immediate referral.
• Classic symptoms of hyperglycemia with a random (non-fasting) capillary blood or venous plasma glucose concentration > 11.1 mmol/L, with or without ketonuria confirms the diagnosis.
• A glucose tolerance test is seldom necessary to establish the diagnosis of type 1 diabetes.

 

• Similar to those of adults with type 1 diabetes but need to consider impact of diabetes on (1) physical growth and psychological development, and (2) the functioning of the child-family unit.
• Youngsters are at greater risk for hypoglycemia and ketoacidosis: intercurrent illness is more frequent, food intake and activity patterns are often erratic.
• Families require expert teaching and support in dealing with such situations.

 

• Refer to a pediatric diabetes health care team for initial stabilization and family education.
• Detailed history and physical. Assess developmental stage of the child, emotional impact of diagnosis and specific needs of child and family.
• Laboratory investigations to confirm the diagnosis and to determine the fluid and electrolyte/acid-base status of the child.

 

• The pediatric diabetes team (physician, diabetes nurse, dietitian, behavioral specialist) should provide initial and ongoing education, care and support to the child or adolescent and family.
• Unless the child is in diabetic ketoacidosis (DKA), or there are major psychosocial problems or there are concerns regarding family follow-up, whenever possible, treatment and "survival skill education" should be initiated in an outpatient diabetes care setting.
• Regardless of the child's age or level of independence, both parents, when available, need to be encouraged to remain involved in the diabetes education and home management.

 

Diet

• Meal plan is individualized for each child.
• Emphasis on (i) healthy eating as per Canada's Food Guide to Healthy Eating, (ii) regular meal and snack times (iii) consistent amounts of carbohydrate, (iv) lower glycemic index foods (as per the new Canadian Clinical Practice Guidelines) and (v) satisfaction.
• Takes into account factors such as individual family meal times and food preferences, school routines, special occasions and growth spurts.
• Individuals on continuous subcutaneous insulin pumps and MDI should be taught carbohydrate counting to facilitate the adjustment of their insulin dose. This allows for more flexibility in dietary intake based on individual insulin to carbohydrate ratios.

Insulin

• Essential for all children with Type 1 DM.
• Three injections per day generally prescribed: intermediate (NPH) and rapid acting insulin pre-breakfast, rapid insulin pre-supper and intermediate or long acting insulin at bedtime. After initial stabilization, the insulin requirement may decrease transiently ("honeymoon period"). Occasionally it is necessary to discontinue the supper and/or the bedtime injection for a short period.
• The use of pre-meal rapid insulin with once daily long acting insulin and the use of insulin pumps are options that increasing numbers of young people are choosing to achieve good metabolic control.
• Families need to know how to recognize the need for a change in insulin dose or infusion rate and how to respond.
• Need to individualize insulin dosage, timing and frequency.
• The use of insulin to carbohydrate ratios to determine the pre-meal insulin dose and sensitivity factors or insulin correction factors for the timely correction, with rapid insulin, of high or low blood glucose levels is often recommended and is being used by many families of children with type 1 diabetes.(See Section 4.8 for further explanation of bolus calculation).

Exercise

• Although exercise should be encouraged for good health, it does not need to be prescribed in children with type 1 diabetes.
• Encourage them to participate in their usual exercise/activities with appropriate adjustments in food and insulin to prevent hypoglycemia.

Monitoring

• Check blood glucose (BG) before each meal, before bedtime snack and occasionally at 3 AM.
• Individuals on insulin pumps may also require some post-meal blood glucose checks.
• Target levels for pre-meal blood glucose should be individualized e.g.
       6 - 12 mmol/L for infants and toddlers
       4 - 10 mmol/L for school age children
       4 - 8 mmol/L for teens
       4 - 7 mmol/L for those choosing intensive diabetes therapy
• Expect fluctuations in blood glucose levels.
• Ensure families are clear about goals, know how to interpret results and how to make changes accordingly.
• Urine ketones should be checked if blood glucose levels are persistently high and during intercurrent illness.
• Glycosylated hemoglobin (A1C): Measure every 3 to 4 months to track ongoing metabolic control. Attempt to achieve the best possible levels for the age and stage of the child. The family should be informed of the result. Aim to achieve levels below 8.5% (non-diabetic range ~4.0 - 6.0%) in children < 6 years of age, < 8% in children 6-12, and <7% in adolescents.

Psychosocial Issues

• The diagnosis of diabetes and the associated lifestyle changes invariably have a significant impact on the child and family.
• Good metabolic control depends on a healthy psychosocial environment. Strengths and barriers need to be identified and addressed.
• Medical social workers or psychologists have an important role in assessment and counseling.

 

• Telephone access to members of team for support and advice as required.
• 24 hour support for diabetes emergencies i.e. illness and severe hypoglycemia.
• Anticipatory guidance and access to education programs to meet the developmental needs of the child/family.
• Integrated approach with the diabetes health care team every 3 to 4 months to assess blood glucose control, monitor growth and development, review the meal plan and engage in problem solving.
• A1C levels and a blood glucose home meter/lab comparison at each visit.
• Blood lipids and thyroid function tests, 6 months post diagnosis.
• Thyroid function tests every two years unless antibody positive or on thyroid replacement therapy: in which case every 6-12 months.
• Annual measurement of fasting lipids in children <10 years of age if there is another risk factor such as family history; otherwise at 12 and 17 years of age.
• Annual eye examinations commencing at 15 years of age with diabetes of >5 years -duration and annual urinary albumin to creatinine ratio commencing at 12 years of age and > 5 years duration of diabetes.

 

• Mild, occasional hypoglycemia that can be easily recognized and treated is to be expected and represents an acceptable risk.
• More severe hypoglycemia (defined by coma, confusion, or need for help from another individual) is to be avoided wherever possible (see Chapter 12).

 

• Infections are more common in children than adults and may upset diabetes control. More frequent blood glucose and urine ketone monitoring (every 4 hours around the clock), insulin dose adjustment, fluid and calorie provision as well as treatment of the underlying disorder are important components of care (See Chapter 14).
• Access to 24 hour telephone support for illness management is essential in reducing emergency room visits and diabetes related crisis.

 

• DKA at diagnosis can be prevented by public awareness campaigns to recognize the early symptoms of diabetes.
• The principles of management of DKA (diabetic ketoacidosis) are similar in children and adults, namely reversal of dehydration and acidosis, and provision of insulin and electrolyte replacement. However, pediatric protocols should be employed.
• Intravenous fluids and insulin infusions are calculated on a per weight basis. In general, DKA management is initiated with 7-10 ml/kg of normal saline over the first hour, followed by 3.5-5 ml/kg/hour thereafter.
• Avoidance of excessive fluid infusion and hypotonic solutions may be important in avoiding complications of DKA such as cerebral edema.
• Intravenous insulin infusions (0.1 unit/kg/hour), plus potassium replacement are other essential components of care.
• Do not administer an IV bolus of insulin.
• The insulin infusion should not be started until one hour after starting IV fluid replacement.
• There is no need for bicarbonate administration if pH > 6.9.
• The cause of DKA in a child with established diabetes should be identified and addressed to prevent further episodes.
• Recurrent DKA in children and adolescents is invariably a result of insulin omission. When this occurs, a responsible adult must be identified who will inject insulin, while psychosocial stressors are examined.

 

• The treatment of youth with type 2 diabetes is often difficult, with very little data to support a specific treatment approach. In general, management is similar to that in adults with type 2 diabetes.
• Some children with type 2 diabetes present with severe hyperglycemia and metabolic instability and must be treated with insulin initially, however may be switched to oral antihyperglycemic agents once glucose levels are sufficiently improved.
• There is very little data available on the use of thiazolidinediones in children and therefore their standard use in the pediatric population is not recommended.
• Metformin may be beneficial, especially in the overweight individual.

References

1. Daneman D, Perlman K. Diabetes mellitus in childhood and adolescence. In Conn's Current Therapy 1999;Rakel RE (ed) 548-5.
2. Curtis J, Hamilton J, Beck C, Frank M, Daneman D. Diagnosis and short-term clinical consequences of diabetes in children and adolescents. In Evidence-Based Diabetes Care, Gerstein H, Haynes B (editors). BC Decker, Hamilton-London, 2001;107-23.
3. Ontario Program for Optimal Therapeutics. Ontario guidelines for the pharmacotherapeutic management of diabetes mellitus. June 2000.
4. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32(suppl 1):S150-.
5. Emergency Guidelines for Managing the Child with Type 1 Diabetes; Ontario MOHLTC 2008.