treatment of type 1 diabetes in child : The types of diabetes mellitus (diabetes) in children are similar to those in adults, but the psychosocial problems are different and can complicate treatment.
Type 1 diabetes is the most common type in children, accounting for two-thirds of new cases in children of all ethnic groups. It is one of the most common chronic diseases of childhood, occurring in 1 in 350 18-year-olds; the incidence has recently been increasing, especially in children <5 years. Although type 1 can occur at any age, it usually manifests between the ages of 4 and 6 or between 10 and 14 years.
Type 2 diabetes, once rare in children, has been increasing in frequency in parallel with the rise in childhood obesity (see Obesity in Children). It usually manifests after puberty, with the highest rate between the ages of 15 and 19 (see also Obesity in Adolescents).
Monogenic forms of diabetes, formerly known as young-onset to maturity, are not considered type 1 or type 2 (although they are sometimes confused with them) and are rare (1-4% of cases).
Prediabetes is impaired glucose regulation that results in intermediate glucose levels that are too high to be normal, but do not meet the criteria for diabetes. In adolescents with obesity, prediabetes can be transient (with reversion to normality in 2 years in 60%) or progress to diabetes, especially in adolescents who persistently gain weight. Prediabetes is associated with the metabolic syndrome (impaired glucose regulation, dyslipidemia, hypertension, obesity).
There appears to be a familiar component to all types of diabetes in children, although the incidence and mechanism vary.
In type 1 diabetes, the pancreas does not produce insulin due to an autoimmune destruction of pancreatic beta cells, which can be triggered by environmental exposure in individuals with genetic predisposition. Close relatives have a higher risk of diabetes (about 15 times higher risk than the general population), with an overall incidence of 4 to 8% (30 to 50% in monozygotic twins). Children with type 1 diabetes are at increased risk for other autoimmune disorders, particularly thyroid disease and celiac disease. Inherited susceptibility to type 1 diabetes is determined by multiple genes (> 60 risk loci have been identified). Susceptibility genes are more common in some populations and account for the higher prevalence of type 1 diabetes in certain ethnic groups (eg, Scandinavians, Sardinians).
In type 2 diabetes, the pancreas produces insulin, but there are varying degrees of insulin resistance, and insulin secretion is insufficient to meet the increased demand caused by insulin resistance (ie, there is relative insulin deficiency). Onset usually coincides with the physiological insulin resistance peak of puberty, which can lead to symptoms of hyperglycemia in previously compensated adolescents. The cause is not the autoimmune destruction of beta cells but a complex interaction between many genes and environmental factors, which differ between different populations and patients. Risk factors include
- Native American, Black, Hispanic, Asian American, and Pacific Islander
- Positive family history (60-90% have a 1st or 2nd degree relative with type 2 diabetes)
Monogenic forms of diabetes are caused by genetic defects that are inherited in an autosomal dominant pattern, so patients often have one or more affected family members. There is no insulin resistance or autoimmune beta cell destruction. The entity usually appears before the age of 25.
In type 1 diabetes, a lack of insulin causes hyperglycemia and impaired glucose utilization in skeletal muscle. Muscle and fat are then broken down to provide energy. The breakdown of fats produces ketones, which cause acidemia and sometimes major life-threatening acidosis (diabetic ketoacidosis).
In type 2 diabetes, there is usually enough insulin function to prevent diabetic ketoacidosis at diagnosis, but children can sometimes present with diabetic ketoacidosis (up to 25%) or, less commonly, with a hyperosmolar state hyperglycemic (HHE), in which severe hyperosmolar dehydration occurs. HE occurs most often during a period of stress or infection, with non-adherence to therapeutic regimens, or when glucose metabolism is further impaired by drugs (eg, corticosteroids). Other metabolic disorders associated with insulin resistance may be present at the time of type 2 diabetes diagnosis and include
- Dyslipidemia (leading to atherosclerosis)
- Polycystic ovary syndrome
- Obstructive sleep apnea
- Nonalcoholic steatohepatitis (fatty liver)
Atherosclerosis begins in childhood and adolescence and greatly increases the risk of cardiovascular disease.
In monogenic forms of diabetes, the underlying defect depends on the type. The most common types are caused by defects in transcription factors that regulate beta cell function of the pancreas (eg, hepatic nuclear factor 4-alpha [HNF-4-alpha], hepatic nuclear factor 1-alpha [ HNF-1-alpha]). In these types, insulin secretion is impaired but not absent, there is no insulin resistance, and hyperglycemia worsens with age. Another type of monogenic diabetes is caused by a defect in the glucose sensor, glucokinase. With glucokinase defects, insulin secretion is normal, but glucose levels are regulated at a higher set point, causing fasting hyperglycemia that minimally worsens with age.
Signs and symptoms
In type 1 diabetes, the initial manifestations range from asymptomatic hyperglycemia to life-threatening diabetic ketoacidosis. However, more commonly, children have symptomatic hyperglycemia without acidosis, with several days to weeks of frequency, polydipsia, and polyuria. Polyuria can manifest as nocturia, enuresis, or daytime incontinence; In children who do not control toilet bowls, parents may notice an increase in the frequency of wet or heavy diapers. About half of children have weight loss as a result of increased blood sugar catabolism and also have impaired growth. Fatigue, weakness, Candida rashes, blurred vision (due to hyperosmolar state of the lens and vitreous humor), or nausea and vomiting (due to ketonemia) may also be present initially.
In type 2 diabetes, children are often asymptomatic and their disease can be detected in a systematic evaluation. However, some children present with symptomatic hyperglycemia, EHH, or, despite the common misconception, diabetic ketoacidosis.
Complications of diabetes in children
Diabetic ketoacidosis is common among patients with known type 1 diabetes; it develops in about 1 to 10% of patients each year, usually because they have not received their insulin. Other risk factors for diabetic ketoacidosis include previous episodes of diabetic ketoacidosis, difficult social circumstances, depression or other psychiatric disorders, intercurrent illnesses, and use of an insulin pump (due to a kinked or dislodged catheter, poor insulin absorption due to infusion site inflammation, or pump malfunction). Doctors can help minimize the effect of risk factors through education, counseling, and support.
Psychosocial problems are very common among children with diabetes and their families. Up to half of children develop depression, anxiety, or other psychological problems. Eating disorders are a serious problem in teens, who also sometimes miss insulin doses in an effort to control weight. Psychosocial problems can also lead to poor glycemic control by affecting children’s ability to adhere to their dietary or drug regimens. Social workers and mental health professionals (as part of a multidisciplinary team) can help identify and mitigate the psychosocial causes of poor glycemic control.
Vascular complications are seldom clinically evident in childhood. However, early pathological changes and functional abnormalities may be present within a few years after onset of disease in type 1 diabetes; poor long-term glycemic control is the most important risk factor for the development of vascular complications. Microvascular complications include diabetic nephropathy, retinopathy, and neuropathy. Microvascular complications are more common among children with type 2 diabetes than with type 1 diabetes, and in type 2 diabetes they may be present at the time of diagnosis or appear earlier in the course of the disease. Although neuropathy is more common in children who have had diabetes for a long period (≥ 5 years) and poor control (glycosylated Hb [HbA1C]> 10%), it can occur in young children who have had diabetes for a short duration and good control. Macrovascular complications are coronary artery disease, peripheral vascular disease, and stroke.
- Fasting plasma glucose ≥ 126 mg / dL (≥ 7.0 mmol / L)
- Random glucose concentration> 200 mg / dL (≥ 11.1 mmol / L)
- Glycated hemoglobin (HbA1C) ≥ 6.5%
- Sometimes oral glucose tolerance test
(Para recomendaciones sobre el diagnostico, véanse también the American Diabetes Association’s standards in medical care in diabetes and the International Society for Pediatric and Adolescent Diabetes’ (ISPAD) guidelines for type 2 diabetes in children and adolescents.)
Diagnosis of diabetes in children
Diagnosis of diabetes and prediabetes is similar to that of adults, generally using random or fasting plasma glucose concentrations or HbA1C levels, and depends on the presence or absence of symptoms (see Diagnostic Criteria for diabetes mellitus and impaired glucose regulation). Diabetes can be diagnosed with the presence of classic diabetes symptoms and blood glucose measurements. Blood glucose measurements (glucose are random samples of plasma ≥ 200 mg / dL [≥ 11.1 mmol / L] or fasting plasma glucose ≥ 126 mg / dL [≥ 7 mmol / L]; fasting is defined such as no caloric intake for 8 h).
An oral glucose tolerance test is not necessary and should not be done if diabetes can be diagnosed by other criteria. When necessary, the test should be done using 1.75 g / kg (maximum 75 g) of glucose dissolved in water. The test may be helpful in children with no symptoms, or with mild or atypical symptoms, and may be helpful in suspected cases of type 2 or monogenic diabetes. The HbA1C criterion is generally more useful for the diagnosis of type 2 diabetes, and hyperglycemia must be confirmed.
Initial evaluation and testing
For patients in whom diabetes is suspected but who do not appear ill, the initial test should include a basic metabolic panel, including electrolytes and glucose, and urinalysis. For sick patients, tests also include venous and arterial blood gases, liver tests, and calcium, magnesium, phosphorus, and hematocrit levels.
Diagnosis of type of diabetes
Additional tests should be done to confirm the type of diabetes, including
- C-peptide and insulin concentrations (if you are not already treated with insulin)
- HbA1C concentrations (if not already done)
- Autoantibody tests against pancreatic islet cell proteins
Autoantibodies include against glutamic acid decarboxylase, insulin, insulinoma-associated protein, and zinc transporter ZnT8. More than 90% of newly diagnosed type 1 diabetes patients have ≥ 1 of these autoantibodies, while the absence of antibodies strongly suggests type 2 diabetes. However, about 10-20% of children with the diabetes phenotype Type 2 have autoantibodies and are reclassified as Type 1 diabetes, as these children are more likely to require insulin therapy and are at higher risk of developing other autoimmune diseases.
It is important to recognize monogenic diabetes because treatment differs from type 1 diabetes and type 2 diabetes. The diagnosis should be considered in children with a strong family history of diabetes, but who lack the typical characteristics of type 2 diabetes. ; that is, they have only mild fasting hyperglycemia (between 100 and 150 mg / dL [5.55 to 8.32 mmol / L]) or postprandial, are young and not obese, and have no autoantibodies or signs of insulin resistance (eg, acanthosis nigricans). Genetic tests are available to confirm monogenic diabetes. This test is important because some types of monogenic diabetes can progress with age.
Tests for complications and other disorders
Patients with type 1 diabetes should be evaluated for other autoimmune diseases by measuring celiac disease antibodies (see Celiac Disease: Diagnosis), thyrotropin, thyroxine, and thyroid antibodies (see Thyroid Function Overview: Laboratory Tests for assess thyroid function). Other autoimmune disorders, such as primary adrenal insufficiency (Addison’s disease), rheumatologic disease (eg, rheumatoid arthritis, systemic lupus erythematosus, psoriasis), other gastrointestinal disorders (eg, inflammatory bowel disease, autoimmune hepatitis), and disease of the skin (eg, vitiligo), can also occur in children with type 1 diabetes, but does not require screening tests.
Patients with type 2 diabetes should have liver tests, a fasting lipid profile, and a urine microalbuminuria: creatinine ratio at the time of diagnosis, since these children (unlike people with type 1 diabetes, who develop complications over many years) often have comorbidities, such as fatty liver, hyperlipidemia, and hypertension, at the time of diagnosis. In children with clinical findings suggestive of complications, the following should also be evaluated:
- Obesity: test for nonalcoholic steatohepatitis
- Daytime Sleepiness or Snoring: Test for Obstructive Sleep Apnea
- Hirsutism, acne, or menstrual irregularities: test for polycystic ovary syndrome
Screening for diabetes Asymptomatic children (≤ 18 years) who are at risk should be screened for type 2 diabetes or prediabetes by measuring HbA1C. This test should be done first at age 10 or early in puberty, if puberty occurred at a younger age, and should be repeated every 3 years.
Children at risk include those who are overweight (body mass index> 85th percentile for age and sex or weight for height> 85th percentile) and who have 2 of the following:
- Positive family history of type 2 diabetes in a first or second degree relative
- Native American, Black, Hispanic, Asian American, and Pacific Islander
- Signs of insulin resistance or conditions associated with insulin resistance (eg, acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or low-for-gestational age birth weight)
- Gestational diabetes or a maternal history of diabetes