Diabetes in children is a chronic condition that affects how your child’s body processes sugar (glucose). It’s important for parents to be aware of the signs and symptoms of diabetes in children, such as increased thirst, frequent urination, unexplained weight loss, and fatigue.
If you suspect your child may have diabetes, it’s important to see a doctor for proper diagnosis and management. Treatment for diabetes in children typically involves monitoring blood sugar levels, following a healthy diet, getting regular exercise, and possibly taking insulin.
Types of Diabetes
Diabetes mellitus is a condition that occurs when there is a lack of insulin secretion (type 1) or when there is resistance to insulin in the body (type 2), resulting in high levels of glucose in the blood. Initial signs are associated with high blood sugar and consist of increased thirst, excessive hunger, frequent urination, and weight loss. Diagnosis is based on the measurement of glucose levels in the blood. Treatment options differ depending on the type of diabetes but generally include medications to lower blood glucose levels, dietary adjustments, and physical activity.
The types of diabetes in children closely resemble those seen in adults, although there are variations in psychosocial challenges that can complicate treatment.
Common Types of Diabetes
Type 1 diabetes is the most prevalent form of diabetes in children, typically diagnosed between the ages of 4-6 or 10-14, and is increasing worldwide. On the other hand, Type 2 diabetes is on the rise in correlation with the increase in childhood obesity rates.
Monogenic forms of diabetes are rare conditions that do not fit into type 1 or type 2 categories. Prediabetes refers to impaired glucose regulation that has the potential to evolve into diabetes.
References
1. Maahs DM, et al. Studying the occurrence of type 1 diabetes.
2. Patterson CC, et al. Analyzing the trends in childhood type 1 diabetes in Europe.
3. Lawrence JM, et al. Investigating the prevalence of Type 1 and Type 2 Diabetes in Youth in the US.
4. Divers J, et al. Tracking the incidence of Type 1 and Type 2 Diabetes Among Young Individuals.
5. Pettitt DJ, et al. Estimating the prevalence of diabetes in American youth in 2009.
6. Liu LL, et al. Examining the ratio of overweight and obese youth with diabetes in the USA.
7. Shah AS, et al. Presenting the ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and teenagers.
Diagnosis and Genetics
Patients are classified as having either type 1 or type 2 diabetes based on their medical history and laboratory tests, although genetic and environmental factors are influential. Both types involve a progressive deterioration of beta-cell function leading to high blood sugar levels.
Genetic Risk Factors
In type 1 diabetes, a combination of genetic susceptibility and environmental triggers leads to the destruction of beta-cells due to an autoimmune response. In type 2 diabetes, inadequate insulin production and resistance to insulin cause elevated blood glucose levels.
Other Risk Factors
Risk factors for type 2 diabetes include ethnicity, family history, maternal diabetes history, and specific medications.
Monogenic Forms
Monogenic forms of diabetes are the result of genetic mutations inherited in an autosomal dominant pattern, typically manifesting before the age of 25.
Additional Information:
Type 1 diabetes is often diagnosed in children and young adults, while type 2 diabetes is more common in older adults, especially those who are overweight or obese.
Diet and exercise play a crucial role in managing both types of diabetes and can help improve insulin sensitivity and blood sugar control.
Regular monitoring of blood glucose levels and A1C levels is important for managing diabetes and preventing complications such as heart disease, kidney disease, and nerve damage.
References
1. Steck AK, Rewers MJ. Analyzing the genetic aspects of type 1 diabetes.
2. Libman I, et al. Detailing the ISPAD Clinical Practice Consensus Guidelines 2022: Definition, epidemiology, and classification of diabetes in minors and teens.
3. Tryggestad JB, Willi SM. Discussing the complications and comorbidities of T2DM in adolescents.
Metabolic Effects
In type 1 diabetes, the absence of insulin leads to high blood sugar and fat breakdown, resulting in diabetic ketoacidosis (DKA). Type 2 diabetes is characterized by inadequate insulin function that cannot prevent DKA, although symptoms are usually less severe. Metabolic complications are present in both types.
Monogenic diabetes can be attributed to defects in transcription factors like HNF-4-α or HNF-1-α, affecting insulin secretion without resistance. Another form stems from a malfunction in the glucose sensor, glucokinase, causing fasting hyperglycemia. Diabetic ketoacidosis may also occur in children with type 2 diabetes.
Teplizumab therapy, an anti-CD3 monoclonal antibody, is a treatment that can postpone the onset of type 1 diabetes in individuals aged ≥ 8 years with preclinical diabetes. This therapy consists of a 14-day regimen of daily IV infusions.
Type 2 diabetes management
To manage type 2 diabetes effectively, lifestyle changes such as adopting a better diet and increasing physical activity are crucial.
Meal plan and exercise
In the case of type 2 diabetes, it is recommended to encourage weight loss to improve insulin sensitivity. For children between 3 and 13 years old, a formula can be used to calculate calorie requirements: 1000 calories + (100 x child’s age in years).
Steps to improve diet, control caloric intake, and enhance physical activity include:
- Eliminating sugary beverages and refined sugars
- Discouraging skipping meals and promoting regular family meals
- Avoiding constant snacking
- Monitoring portion sizes
- Restricting high-fat, high-calorie foods
- Increasing fiber intake through more fruits and vegetables
- Raising physical activity levels to at least 60 minutes of moderate to vigorous exercise on a minimum of 3 days per week
- Limits screen time
Pharmacologic treatment
Insulin therapy is initiated in children with severe type 1 diabetes (HbA1C > 8.5% or with DKA) using glargine, detemir, or premixed insulin.
If there is no acidosis present, metformin is usually introduced simultaneously.
Metformin is often the initial oral antihyperglycemic medication given. It should be started at a low dose, increased gradually, and taken with food to reduce gastrointestinal side effects.
Liraglutide, extended-release exenatide, and dulaglutide are GLP-1 receptor agonists that can help reduce HbA1C levels in children over the age of 10 with type 2 diabetes.
Liraglutide is administered daily through injection, while extended-release exenatide, dulaglutide, and semaglutide are given as weekly subcutaneous injections, which may improve patient compliance. These medications promote weight loss, potentially through delayed gastric emptying and appetite reduction. They are gradually adjusted to treatment doses over weeks to minimize gastrointestinal side effects, particularly nausea and vomiting. GLP-1 agonists can be used if metformin is not well-tolerated or added if HbA1C target levels are not reached with metformin alone within 3 months. They may be prescribed before insulin initiation due to their weight loss and glycemic control benefits.
Empagliflozin, an SGLT2 inhibitor, can be used for children over the age of 10 with type 2 diabetes. SGLT2 inhibitors function by blocking the reabsorption of sodium and glucose in the kidneys, leading to increased renal glucose excretion and lower blood glucose levels in type 2 diabetes. These medications are not recommended for patients with end-stage renal disease or on dialysis as they can raise the risk of DKA. Adverse effects may include a higher incidence of urinary tract and genital yeast infections.
Glycemic control and HbA1C target levels
Similar to type 1 diabetes, target fasting glucose levels in type 2 diabetes can vary based on the treatment, glycemic control, and available resources.
Children and teenagers may self-monitor their blood glucose levels at different frequencies depending on their therapy, glucose levels, and control. Monitoring frequency may increase if targets are not met, during illness, or when experiencing symptoms of hypo or hyperglycemia. Some individuals may opt for CGM systems similar to those with type 1 diabetes for monitoring.
HbA1C target levels for type 2 diabetes in children and teenagers are akin to those for type 1 diabetes. Regular monitoring may be essential for youngsters with suboptimal control or those on insulin therapy.
Children with type 2 diabetes who do not meet targets may require intensified therapy like insulin or GLP-1 receptor agonists.
Target glucose levels may be set lower to reduce the risk of complications while lowering the risk of hypoglycemia in most children with type 2 diabetes.
Monogenic diabetes management
Management of monogenic diabetes is tailored individually based on the subtype.
The glucokinase subtype usually does not necessitate treatment due to its low long-term risk.
Individuals with hepatic nuclear factor 4-alpha and hepatic nuclear factor 1-alpha subtypes may respond well to sulfonylureas or eventually need insulin. Other oral hypoglycemic medications such as metformin are often ineffective.
Screening for complications of diabetes
DKA is prevalent in type 1 diabetes due to missed insulin doses, social situations, or mental health concerns. Healthcare providers can assist by offering education and support.
Mental health problems are common in children with diabetes and can affect treatment adherence. Social workers and mental health professionals can address these issues.
Vascular complications are rare in childhood but could develop in type 1 diabetes with prolonged inadequate glycemic control. Microvascular and macrovascular issues may include nephropathy, retinopathy, neuropathy, coronary artery disease, and stroke.
Complications are regularly screened based on the type of diabetes, with further testing if problems are detected.