Diabetes describes a group of conditions with high blood glucose levels (hyperglycemia) caused by decreased insulin production, decreased effect of insulin, or both.
Typical symptoms at diagnosis include excessive thirst, excessive urination, and weight loss.
The diagnosis is based on symptoms and the results of urine and blood tests.
Treatment depends on the type of diabetes but includes insulin injections or other drugs and changes in diet, exercise, weight loss (if overweight).
The symptoms, diagnosis, and treatment of diabetes are similar in children and adults ( see Diabetes Mellitus (DM) Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more ). However, management of diabetes in children may be more complex. It must be tailored to the child’s physical and emotional maturity level and to constant variations in food intake, physical activity, and stress.
Diabetes is a disorder that affects the amount of sugar in the blood. There are many kinds of sugar. The white granules of table sugar are known as sucrose. Sucrose occurs naturally in sugar cane and sugar beets. Another kind of sugar, lactose, occurs in milk. Sucrose consists of two different simple sugars, glucose and fructose. Lactose consists of the simple sugars glucose and galactose. Sucrose and lactose must be broken down by the intestine into their simple sugars before they can be absorbed. Glucose is the main sugar the body uses for energy, so during and after absorption, most sugars are turned into glucose. Thus, when doctors talk about blood sugar, they are really talking about blood glucose.
Insulin is a hormone Endocrine Function The main function of endocrine glands is to secrete hormones directly into the bloodstream. Hormones are chemical substances that affect the activity of another part of the body (target site)... read more that is released by the pancreas Pancreas The pancreas is an organ that contains two types of glandular tissue: Pancreatic acini Islets of Langerhans (See also Overview of the Digestive System.) The acini produce digestive enzymes.... read more . Insulin controls the amount of glucose in the blood and allows glucose to move from the blood into the cells. Without a proper amount of insulin, glucose does not move into the cells and builds up in the blood. As glucose levels in the blood increase, glucose begins to appear in the urine. This glucose pulls more water into the urine, so people urinate more ( polyuria Excessive or Frequent Urination Most people urinate about 4 to 6 times a day, mostly in the daytime. Normally, adults pass between 3 cups (700 milliliters) and 3 quarts (3 liters) of urine a day. Excessive urination can refer... read more ) and thus become thirsty and drink more (polydipsia). Without insulin, electrolyte problems Overview of Electrolytes Well over half of the body's weight is made up of water. Doctors think about the body's water as being restricted to various spaces, called fluid compartments. The three main compartments are... read more and dehydration can develop. A lack of insulin also causes fat and protein to break down.
Types of Diabetes
The types of diabetes in children are similar to those in adults. The types include
Type 1 diabetes
Type 2 diabetes
Prediabetes is a condition in which blood glucose levels are too high to be considered normal but not high enough to be considered diabetes. Among children, prediabetes is more common among obese adolescents. It is temporary in over half of adolescents, but the remainder develop diabetes, especially those who continue to gain weight.
Type 1 diabetes
Type 1 diabetes occurs when the pancreas produces little or no insulin. Type 1 diabetes is the most common type among children, causing about two thirds of all cases of diabetes. It is one of the most common chronic childhood diseases. By age 18, 1 in 350 children has developed type 1 diabetes. The number of affected children has recently been increasing, particularly in children under age 5.
Type 1 diabetes can develop at any time during childhood, even during infancy, but it usually begins between ages 4 years and 6 years or between ages 10 years and 14 years.
In type 1 diabetes, the pancreas does not produce enough insulin because the immune system attacks and destroys the cells in the pancreas that make insulin (islet cells). Such an attack may be triggered by environmental factors in people who have inherited certain genes that make them susceptible to developing diabetes. These genes are more common among certain ethnic groups (such as Scandinavians and Sardinians). Close relatives of a person with type 1 diabetes are at increased risk of developing diabetes. Brothers and sisters have about a 4 to 8% risk and identical twins have a much greater 30 to 50% risk. The risk of diabetes for a child who has a parent with type 1 diabetes is about 10% if the father is affected and is about 4% if the mother is affected.
Children who have type 1 diabetes are at higher risk of some other disorders in which the body's immune system attacks itself ( autoimmune disorders Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers autoimmune disorders is not known. Symptoms vary depending on... read more ), particularly certain types of thyroid disease Overview of the Thyroid Gland The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that lies just under the skin below the Adam’s apple in the neck. The two halves (lobes) of the gland are connected... read more , and celiac disease Celiac Disease Celiac disease is a hereditary intolerance to gluten (a protein found in wheat, barley, and rye) that causes characteristic changes in the lining of the small intestine, resulting in malabsorption... read more .
Type 2 diabetes
Type 2 diabetes occurs because the cells in the body do not respond adequately to insulin (called insulin resistance). Unlike in type 1 diabetes, the pancreas can still make insulin but cannot make enough insulin to overcome insulin resistance. This deficiency is often referred to as a relative insulin deficiency as opposed to the absolute deficiency seen in type 1 diabetes. Among children, type 2 diabetes occurs mainly in adolescents but is becoming increasingly common among overweight or obese younger children. Up until the 1990s, more than 95% of children who developed diabetes had type 1 diabetes, but now about one third of children newly diagnosed with diabetes have type 2 diabetes. Type 2 diabetes typically develops after puberty has begun. Although many children develop type 2 diabetes between 10 years and 14 years of age, the highest rate occurs during late adolescence, between 15 years and 19 years of age (see Obesity in Adolescents Obesity in Adolescents Obesity is defined as a body mass index (BMI) equal to or greater than the 95th percentile for age and gender. Although genetics and some disorders cause obesity, most adolescent obesity results... read more ). Compared to children with type 1 diabetes, children with type 2 diabetes are much more likely to have a first-degree relative with type 2 diabetes.
Did You Know...
The increase in childhood type 2 diabetes has been particularly prominent among Native Americans, blacks, Hispanics, Asian Americans, and Pacific Islanders.
Other children at higher risk of developing type 2 diabetes include those who
Are overweight (weigh more than 85% of children of similar age, sex, and height), particularly those who are obese (weigh more than 95% of children of similar age, sex, and height)
Have a parent, sibling, aunt, uncle, or grandparent who has type 2 diabetes (60 to 90%)
Have high blood pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more , high blood levels of lipids Dyslipidemia Dyslipidemia is a high level of lipids (cholesterol, triglycerides, or both) or a low high-density lipoprotein (HDL) cholesterol level. Lifestyle, genetics, disorders (such as low thyroid hormone... read more (fats), obstructive sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide... read more , dark and thick skinfolds on the nape of the neck (acanthosis nigricans), fatty liver, polycystic ovary syndrome Polycystic Ovary Syndrome (PCOS) Polycystic ovary syndrome is characterized by slight obesity, irregular or no menstrual periods, and symptoms caused by high levels of male hormones (androgens). It involves disruption of the... read more (PCOS), or a small-for-gestational-age birth weight Small-for-Gestational-Age (SGA) Newborn A newborn who weighs less than 90% of newborns of the same gestational age at birth (below the 10th percentile) is considered small for gestational age. Newborns may be small because their parents... read more
Have a mother who had diabetes during pregnancy ( gestational diabetes Gestational diabetes For women who have diabetes before they become pregnant, the risks of complications during pregnancy depend on how long diabetes has been present and whether complications of diabetes, such... read more ) or who has a history of diabetes
Are not physically active
Symptoms of Diabetes in Children and Adolescents
High blood glucose levels cause a variety of immediate symptoms and long-term complications.
Type 1 diabetes
Symptoms develop quickly in type 1 diabetes, usually over several days to weeks, and tend to appear in a typical pattern. High blood glucose levels cause the child to urinate excessively. Children may wet the bed or become unable to control their bladder during the day. Children who are not toilet-trained may have an increase in wet or heavy diapers. This fluid loss causes an increase in thirst and the consumption of fluids. About half of children lose weight and have impaired growth. Some children become dehydrated, resulting in weakness, fatigue, and a rapid pulse. Children may also have nausea and vomiting due to ketones (by-products of the breakdown of fat) in their blood. Vision may become blurred. If the symptoms are not recognized as being caused by diabetes and treated, children may develop diabetic ketoacidosis Diabetic ketoacidosis (DKA) Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more .
Type 2 diabetes
Many children do not have any symptoms, and doctors diagnose type 2 diabetes only when blood or urine tests are done for other reasons (such as during a physical before playing sports or going to camp). Symptoms in children with type 2 diabetes are milder than those in type 1 diabetes and develop more slowly. Parents may notice an increase in the child’s thirst and urination or only vague symptoms, such as fatigue. Children with type 2 diabetes are less likely to develop ketoacidosis or severe dehydration than those with type 1 diabetes.
Complications of Diabetes in Children and Adolescents
Diabetes can cause immediate complications and long-term complications. The most serious immediate complication is diabetic ketoacidosis.
Long-term complications are usually due to social and psychologic issues or to blood vessel problems. Although blood vessel problems take years to develop, the better the control of diabetes, the less likely that complications will ever occur.
Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis is present at the time of diagnosis in about one third of children with type 1 diabetes. Diabetic ketoacidosis is also common among children with known type 1 diabetes. It develops in about 1 to 10% of children with type 1 diabetes each year, usually because these children have not taken their insulin or are having problems with insulin delivery (for example, problems with their insulin pump Type 1 diabetes treatment Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more ). Diabetic ketoacidosis can also occur if children do not receive enough insulin during illness (when ill, children need more insulin). Without insulin, cells cannot use the glucose that is in the blood. Cells switch to a back-up mechanism to obtain energy and break down fat, producing compounds called ketones as by-products.
Ketones make the blood too acidic (ketoacidosis), causing nausea, vomiting, fatigue, and abdominal pain. The ketones make the child’s breath smell like nail polish remover. Breathing becomes deep and rapid as the body attempts to correct the blood’s acidity ( see Overview of Acid-Base Balance Overview of Acid-Base Balance An important property of blood is its degree of acidity or alkalinity. The acidity or alkalinity of any solution, including blood, is indicated on the pH scale. The pH scale, ranges from 0 ... read more ). Some children develop a headache and may become confused or less alert. These symptoms may be caused by accumulation of fluid in the brain (cerebral edema). Diabetic ketoacidosis can progress to coma and death. Children with diabetic ketoacidosis are also dehydrated and often have other chemical imbalances in the blood, such as abnormal levels of potassium and sodium.
Social and psychologic problems
Social and psychologic problems ( see Support Support Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more ) are very common among children with diabetes. Up to half of children develop depression, anxiety, or other psychologic problems ( see Overview of Mental Health Disorders in Children Overview of Mental Health Disorders in Children The treatment section for bipolar disorder has been extensively revised with separate treatment sections for mania and for depression. In addition, information has been added throughout to address... read more ). Because insulin can cause weight gain, eating disorders Overview of Eating Disorders Eating disorders involve a disturbance of eating or of behavior related to eating, typically including Changes in what or how much people eat Measures people take to prevent food from being... read more are a serious problem in adolescents, who sometimes skip their insulin doses to try to control their weight. Social and psychologic problems can affect children's ability to adhere to their diet and drug regimens, which means their blood glucose is poorly controlled.
Blood vessel problems
Diabetes eventually causes narrowing of small and large blood vessels. The narrowing can damage many different organs. Although the blood vessel narrowing starts to develop within a few years after diabetes begins, the organ damage usually does not become apparent until years later and is rarely present during childhood.
Damage to small blood vessels most often affects the eyes, kidneys, and the nerves. Damage to the blood vessels of the eyes can cause loss of vision ( diabetic retinopathy Diabetic Retinopathy Diabetic retinopathy is damage to the retina (the transparent, light-sensitive structure at the back of the eye) as a result of diabetes. Blood vessels in the retina can leak blood and fluid... read more ). Damage to the kidneys (called diabetic nephropathy Kidney damage in diabetes People with diabetes mellitus have many serious long-term complications that affect many areas of the body, particularly the blood vessels, nerves, eyes, and kidneys. (See also Diabetes Mellitus... read more ) can result in kidney failure. Damage to the nerves (called diabetic neuropathy Polyneuropathy Polyneuropathy is the simultaneous malfunction of many peripheral nerves throughout the body. Infections, toxins, drugs, cancers, nutritional deficiencies, diabetes, autoimmune disorders, and... read more ) can result in numbness, tingling, or burning pain in the arms and legs. These problems are more common among children who have type 2 diabetes than type 1 diabetes. These problems also may be present at the time of diagnosis or earlier in children who have type 2 diabetes.
Damage to large blood vessels most often involves the arteries to the heart and the brain. Narrowing of arteries to the heart can cause heart attack Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount... read more . Narrowing of arteries to the brain can cause stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more . Heart attack and stroke do not commonly occur during childhood.
Diagnosis of Diabetes in Children and Adolescents
Blood glucose tests
Hemoglobin A1C (glycosylated hemoglobin) test
Sometimes an oral glucose tolerance test
The diagnosis of diabetes is a two-part process. Doctors first determine whether children have diabetes and then determine the type. Children who appear to have complications also have other testing.
Doctors suspect diabetes when children have typical symptoms or when a urine test done during a routine physical examination reveals glucose. The diagnosis is confirmed by measurement of the blood glucose level. Blood glucose levels can be measured in the morning before children eat (called the fasting glucose level) or without regard to meals (called the random glucose level). Children are considered to have diabetes if they have both typical symptoms of diabetes and a high blood glucose level. If the fasting glucose level is 126 milligrams per deciliter (mg/dL—7.0 mmol/L) or higher on 2 different occasions, children have diabetes. If the random glucose level is 200 mg/dL (11.1 mmol/L) or higher, children probably have diabetes and should have their fasting glucose level tested to confirm.
Doctors also measure the level of a protein in the blood called hemoglobin A1C (glycosylated hemoglobin). Hemoglobin is the red, oxygen-carrying substance within red blood cells Red Blood Cells The main components of blood include Plasma Red blood cells White blood cells Platelets read more . When blood is exposed to high blood glucose levels over a period of time, glucose attaches to the hemoglobin and forms hemoglobin A1C. Because hemoglobin A1C takes a relatively long time to form and to break down, levels change only over weeks to months rather than from minute to minute like blood glucose levels do. Hemoglobin A1C levels thus reflect blood glucose levels over a 2- to 3-month period of time. People whose hemoglobin A1C level is 6.5% or higher are considered to have diabetes. Hemoglobin A1C levels are more helpful in the diagnosis of type 2 diabetes in children who do not have typical symptoms.
Another kind of blood test called an oral glucose tolerance test may be done in children who have no symptoms or whose symptoms are mild or not typical. In this test, children fast, have a blood sample taken to determine the fasting glucose level, and then drink a special solution containing a large amount of glucose. Doctors then measure blood glucose levels 2 hours later. If the level is 200 mg/dL (11.1 mmol/L) or higher, children are considered to have diabetes. This test is similar to the test that pregnant women have to look for gestational diabetes Gestational diabetes For women who have diabetes before they become pregnant, the risks of complications during pregnancy depend on how long diabetes has been present and whether complications of diabetes, such... read more .
Diagnosing the type of diabetes
To help distinguish type 1 diabetes from type 2, doctors do blood tests that detect antibodies to various proteins produced by the insulin-producing cells in the pancreas. Such antibodies are usually present in children with type 1 diabetes and are rarely present in children with type 2 diabetes.
Testing after diagnosis
Children who are diagnosed with type 1 diabetes usually have other blood tests to look for autoimmune disorders such as celiac disease Diagnosis Celiac disease is a hereditary intolerance to gluten (a protein found in wheat, barley, and rye) that causes characteristic changes in the lining of the small intestine, resulting in malabsorption... read more and thyroid disease Thyroid function tests The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that lies just under the skin below the Adam’s apple in the neck. The two halves (lobes) of the gland are connected... read more . Doctors sometimes do tests to look for other problems such as a disorder of the adrenal glands ( Addison disease Adrenal Insufficiency In adrenal insufficiency, the adrenal glands do not produce enough adrenal hormones. Adrenal insufficiency may be caused by a disorder of the adrenal glands, a disorder of the pituitary gland... read more ), joint and muscle disorders (such as rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more ), and additional digestive tract disorders (such as inflammatory bowel disease Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more ).
Children who are diagnosed with type 2 diabetes have blood tests to determine how their liver and kidneys are functioning and urine tests. At diagnosis, children who have type 2 diabetes are also tested for other problems, such as high blood pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more , high blood levels of lipids Diagnosis Dyslipidemia is a high level of lipids (cholesterol, triglycerides, or both) or a low high-density lipoprotein (HDL) cholesterol level. Lifestyle, genetics, disorders (such as low thyroid hormone... read more (fats), and fatty liver Diagnosis Fatty liver is an abnormal accumulation of certain fats (triglycerides) inside liver cells. People with fatty liver may feel tired or have mild abdominal discomfort but otherwise have no symptoms... read more , because these problems are common among children with type 2 diabetes. Other tests are done depending on symptoms. For example, children with daytime sleepiness who snore are tested for obstructive sleep apnea Diagnosis Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide... read more and adolescent girls who are hairy and have acne or menstrual irregularities are tested for polycystic ovary syndrome Diagnosis Polycystic ovary syndrome is characterized by slight obesity, irregular or no menstrual periods, and symptoms caused by high levels of male hormones (androgens). It involves disruption of the... read more .
Prevention of Diabetes in Children and Adolescents
Because prompt measures (such as dietary changes, an increase in physical activity, and weight loss) may help prevent or delay the start of type 2 diabetes, children at risk of type 2 diabetes Type 2 diabetes Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more should be screened with a blood test that measures the hemoglobin A1C levels. This test should first be done when children are 10 years old or when puberty starts (if puberty occurred at a younger age) and should be repeated every 3 years.
Some risk factors for type 2 diabetes can be prevented. For example, children who are obese should lose weight, and all children should get regular exercise (see Nutrition and exercise Nutrition and exercise Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more ).
Nothing can be done to prevent type 1 diabetes.
Treatment of Diabetes in Children and Adolescents
Nutrition and exercise
For type 1 diabetes, injections of insulin
For type 2 diabetes, metformin by mouth and sometimes injections of insulin or liraglutide
The main goal of diabetes treatment is to keep blood glucose levels as close to the normal range as can be done safely. However, no treatment completely maintains blood glucose at normal levels. When people try very hard to keep blood glucose levels normal, they increase the risk that their blood glucose levels will sometimes become too low. Low blood glucose is called hypoglycemia Hypoglycemia Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more and can be dangerous.
Nutrition and exercise
Children with either type of diabetes need to
Make healthy food choices
Lose weight if overweight
General nutritional management and education are particularly important for all children with diabetes. Dietary recommendations for children with diabetes are based on healthy eating recommendations for all children and aim to maintain ideal body weight and optimal growth and to prevent short-term and long-term complications of diabetes.
All children should eat regularly and not skip meals. Although most dietary regimens allow some flexibility in carbohydrate intake and meal times, having meals and scheduled snacks at about the same time each day and that contain similar amounts of carbohydrates is important for optimal glucose control. Because carbohydrates in food are turned into glucose by the body, variations in carbohydrate intake cause variations in blood glucose levels.
Choosing healthy foods can help control blood glucose and protect heart health. Children should focus on eating fruits and vegetables, whole grains, and high-fiber foods (for example, foods that have at least 3 grams fiber or more per serving). Food should not contain many highly processed (refined) carbohydrates Carbohydrates, Proteins, and Fats Carbohydrates, proteins, and fats are the main types of macronutrients in food (nutrients that are required daily in large quantities). They supply 90% of the dry weight of the diet and 100%... read more , particularly candy, baked goods (such as cookies, donuts, and pastries), and sugary drinks. Children should have no more than 4 to 8 ounces of 100% fruit juice per day. They should avoid regular soda, sweetened iced tea, lemonade, fruit punch, and sports drinks altogether. Children also should avoid foods with saturated fats Kinds of fat Carbohydrates, proteins, and fats are the main types of macronutrients in food (nutrients that are required daily in large quantities). They supply 90% of the dry weight of the diet and 100%... read more , such as baked goods, snack foods (such as potato chips and corn tortilla chips), deep-fried foods (such as french fries), and fast food. Some of these foods may still contain trans fats Kinds of fat , common ingredients in certain commercial foods, which are being removed because they have been shown to be associated with an increased risk of heart disease.
In type 1 diabetes, parents and older children are taught how to gauge the carbohydrate content of food and to develop a meal plan. In most children with type 1 diabetes, food intake is not rigidly specified and is based on the child's usual eating patterns and insulin doses are matched to actual carbohydrate intake. Infants and preschool-aged children present a particular challenge to parents because they do not eat consistent amounts of food and because they may develop hypoglycemia Hypoglycemia Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more but may not be able to communicate symptoms of hypoglycemia to their parents.
In type 2 diabetes, lifestyle modifications focus on weight in the majority of children. Steps to improve the diet and manage food intake include eliminating sugary drinks, controlling portion size, switching to low-fat foods, and increasing fiber by eating more fruits and vegetables.
Regular exercise is important because it improves glucose control and makes it easier to lose weight. Because vigorous exercise can cause a significant drop in blood glucose, some children with type 1 diabetes may need to consume some extra carbohydrates before and/or during a workout.
Children with diabetic ketoacidosis Diabetic Ketoacidosis Diabetic ketoacidosis is an acute complication of diabetes that occurs mostly in type 1 diabetes mellitus. Symptoms of diabetic ketoacidosis include nausea, vomiting, abdominal pain, and a characteristic... read more (DKA) are usually treated in an intensive care unit. They often require fluids given by vein (intravenously) to correct dehydration. They often also need intravenous potassium solutions to correct low potassium levels. Children often require intravenous insulin during DKA.
To prevent the development of DKA and minimize the need for hospitalization, children and families should use ketone test strips to check for ketones in blood or urine. Blood testing may be preferred in younger children and in others in whom it is difficult to obtain a urine sample, those who have frequent episodes of DKA, and insulin pump users. Ketone testing should be done whenever children become ill (regardless of the blood glucose level) or when the blood glucose is high. High ketone levels may indicate DKA, especially if children also have abdominal pain, vomiting, drowsiness, or rapid breathing.
Type 1 diabetes treatment
To control blood glucose, children with type 1 diabetes take injections of insulin.
When type 1 diabetes is first diagnosed, children are usually hospitalized. Children with type 1 diabetes are given fluids (to treat dehydration) and insulin. They always require insulin because nothing else is effective. Children who do not have DKA at diagnosis typically receive two or more daily injections of insulin. Insulin treatment is usually begun in the hospital so that blood glucose levels can be tested often and doctors can change insulin dosage in response. Less commonly, treatment is started at a regular doctor visit.
Once children are released from the hospital, they must take insulin regularly. Doctors work with children and their family to determine which insulin regimen is best.
There are several types of insulin regimens:
Multiple daily injections (MDI) regimens (most commonly a basal–bolus insulin regimen)
Insulin pump regimens
Premixed insulin regimens
Most children who have type 1 diabetes should be treated with MDI regimens or with insulin pump therapy.
With MDI regimens, a basal–bolus insulin regimen is preferred. This regimen involves taking one or two injections of a longer-acting insulin (basal dose) every day and then separate supplemental injections (bolus dose) of a short-acting insulin immediately before meals. Each bolus dose can be different depending on how much food the child is going to eat or what the blood glucose level is at that time.
An advantage of the basal-bolus regimen is that it allows for flexibility as to when meals are eaten.
If a basal-bolus regimen is not an option (for example, if adequate supervision is not available, such as when an adult is not available to give injections at school or daycare), fixed forms of MDI regimens can be an option. In these regimens, children receive a specific (fixed) amount of both longer-acting and shorter-acting insulin before eating breakfast and dinner and a fixed dose of longer-acting at bedtime. Fixed regimens provide less flexibility, require a daily set schedule for meals, and have been largely replaced by basal-bolus regimens.
In insulin pump therapy, the basal dose of insulin is delivered through a small, flexible tube (catheter) that is left in the skin. Supplemental boluses that are given at mealtime or to correct a high blood glucose level are given as separate injections of rapid-acting insulin using a needle or by using the insulin pump.
Premixed insulin regimens use a fixed mixture of two forms of insulin: one that works quickly and lasts for only a few hours, and one that takes longer to work but lasts longer. The usual ratios of insulin are 70/30 (70% longer-acting and 30% shorter-acting) or 75/25. Children are given one injection at breakfast and one at dinner.
An advantage of premixed regimens is that they require fewer injections and are easier to manage. However, premixed regimens have less flexibility with respect to timing and amount of meals and cannot be adjusted as frequently. Thus, these regimens do not control blood glucose levels as well as other regimens.
Insulin delivery methods
Insulin can be injected in several ways:
Vial and syringe
Some children use a vial and syringe. In this method, each dose of insulin is drawn up into a syringe from a vial and is injected under the skin, usually in the arm, thigh, or abdominal wall. Small syringes with very thin needles make the injections nearly painless. The amount of insulin the syringe will hold varies depending on the amount of insulin needed per injection. Young children often use syringes with 1/2 unit markings to allow for smaller adjustments in the doses of insulin to be used.
An insulin pen, is a convenient way for many children to carry and use insulin, especially for children who take several injections a day outside the home. The pen contains a cartridge that holds enough insulin for several doses. The dose delivered on each injection is adjusted by turning the top of the pen.
Another device is an insulin pump, which automatically pumps insulin continuously from a reservoir through a catheter that is left in the skin. The catheter site must be changed every 2 to 3 days. More and more children are using insulin pumps, even young children. The pump more closely mimics the way the body normally delivers insulin. Pumps are programmed to release small doses of insulin continuously over 24 hours (called the basal dose) and can be triggered manually to deliver extra insulin (called the bolus dose) with meals or to treat high blood glucose. Unlike other methods, insulin pumps use only short-acting insulin. Children do not need longer-acting insulin because they are continually receiving a small amount of insulin in the basal dose. The pump can be programmed to give different amounts of insulin at different times of day and night.
Insulin pumps may be used with continuous glucose monitoring systems ( see Monitoring diabetes treatment Monitoring diabetes treatment ) to better track trends in blood glucose throughout the day. Newer insulin pumps have been developed that combine insulin pump therapy with continuous glucose monitoring systems in one device.
For some children, the pump offers an added degree of control, whereas others find wearing the pump inconvenient or develop sores or infections at the catheter site. Children must rotate their injection and pump sites to avoid developing lipohypertrophy. Lipohypertrophy is an accumulation of fatty lumps of tissue under the skin. The lumps occur at injection sites that have been overused for insulin and can cause blood glucose levels to vary because they can prevent insulin from being absorbed consistently.
Type 2 diabetes treatment
Children with type 2 diabetes usually are not treated in the hospital unless the diabetes is severe. Usually they are given drugs to lower blood glucose levels (antihyperglycemic drugs) at a regular doctor's office visit. Children with severe diabetes may need to be hospitalized to start insulin treatment. Less commonly, children with type 2 diabetes develop severe dehydration or, as in type 1 diabetes, DKA.
Metformin is the main drug given by mouth (orally) for children and adolescents. It is started at a low dose and often increased over several weeks to higher doses. It can be taken with food to prevent nausea and abdominal pain.
Liraglutide is an injectable drug that can be given to children over 10 years of age who have type 2 diabetes. Liraglutide may lower hemoglobin A1C levels and may also reduce appetite and promote weight loss. It may be given to children who are taking metformin but whose hemoglobin A1C level is not in the target range or it can be given instead of metformin to children who cannot tolerate that drug.
Other drugs used for adults with type 2 diabetes may help some adolescents, but they are more expensive, and there is limited evidence for their use in children.
Insulin is given to children who are hospitalized. Insulin can often be stopped after several weeks once glucose levels return to normal after treatment with metformin. Children whose type 2 diabetes is not controlled by metformin and/or liraglutide need to take insulin. About half of adolescents with type 2 diabetes ultimately require insulin.
A few children who lose weight, improve their diet, and exercise regularly may be able to stop taking the drugs.
Low blood glucose ( hypoglycemia Hypoglycemia Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more ) occurs when too much insulin or too much of an antihyperglycemic drug is taken or when the child does not eat regularly or exercises vigorously for a long period of time. Warning symptoms include confusion or other abnormal behavior, and children often appear pale and/or sweaty.
To treat hypoglycemia, children are given sugar in any form, such as glucose tablets, hard candies, glucose gel, or a sweet drink, such as a glass of fruit juice. If children are unable to eat or drink (for example, because they are confused, disoriented, are having a seizure, or are unconscious), an injection of glucagon is given. If untreated, severe hypoglycemia causes weakness, confusion, and even coma or death.
In adults, adolescents, and older children, episodes of hypoglycemia rarely cause long-term problems. However, frequent episodes of hypoglycemia in children younger than 5 years of age may impair intellectual development. Also, young children may not be aware of the warning symptoms of hypoglycemia. To minimize the possibility of hypoglycemia, doctors and parents monitor young children with diabetes particularly closely and use a slightly higher target range for their blood glucose level. Continuous glucose monitoring systems Monitoring diabetes treatment can help children because they sound an alarm when glucose falls below a specified range.
Monitoring diabetes treatment
The frequency of monitoring depends on the type of diabetes.
In type 1 diabetes, blood glucose levels may need to be checked up to 6 to 10 times per day and should be measured before all meals and before a bedtime snack. A fingerstick glucose test is most often used to monitor blood glucose. Most blood glucose monitoring devices (glucose meters) use a drop of blood obtained by pricking a fingertip (fingerstick) with a small implement called a lancet. The lancet holds a tiny needle that can be jabbed into the finger or placed in a spring-loaded device that easily and quickly pierces the skin. The drop is placed on a test strip and the test strip is read by a machine. The machine reports the result on a digital display. Because exercise can lower glucose levels for up to 24 hours, glucose should be measured more frequently on days children exercise or are more active. Sometimes levels need to be measured during the night.
Continuous glucose monitoring (CGM) systems use a small glucose sensor placed under the skin. The sensor measures blood glucose levels every 1 to 5 minutes, 24 hours a day. Some CGM systems must be calibrated daily with fingerstick blood glucose levels, but other systems do not require calibration. They transmit real-time results of blood glucose levels wirelessly to a device that may be built into an insulin pump or to a wireless monitor that can be worn on a belt. The systems also record results for the doctor to review. Alarms on CGM systems can be set to sound when blood glucose levels drop too low or climb too high, so the devices can help people quickly identify worrisome changes in blood glucose that they can treat right away. Use of CGM devices may help lower hemoglobin A1C levels. Although CGM devices can be used with any insulin regimen, they are typically worn by insulin pump users.
The so-called artificial pancreas (a closed-loop insulin delivery system) for children 14 years old and older has been approved by the Food and Drug Administration. Artificial pancreas systems monitor glucose levels using a CGM sensor. They automatically provide the right amount of insulin using an insulin pump and sophisticated computer algorithms that are on a smartphone or similar device. These systems help to more tightly control insulin dosing and limit episodes where blood levels of insulin are too high or too low.
In type 2 diabetes, blood glucose levels should be measured regularly but typically less often than in type 1 diabetes. Several factors determine the frequency of self-monitoring, including children's glucose levels between meals and after eating. The frequency of monitoring should increase if children do not have good control of their glucose, during illness, or when symptoms of hypoglycemia or hyperglycemia are felt. Once glucose is controlled, home testing is limited to a few between-meal and after-meal blood glucose measurements per week.
Once experience is gained, parents and many children can adjust the insulin dose as needed to achieve the best control. In general, by 10 years of age, children start to become interested in testing their own blood glucose levels and injecting insulin themselves. Parents should encourage this independence but make sure the child is being responsible. Doctors teach most children how to adjust their insulin dosage in accordance with the patterns of their home blood glucose records.
Children with either type of diabetes typically see their doctor several times a year. The doctor evaluates their growth and development, reviews blood glucose records that a family member keeps, provides guidance and counseling about nutrition, and measures glycosylated hemoglobin levels (hemoglobin A1C— see Diagnosing diabetes Diagnosing diabetes ). The doctor usually screens for long-term complications of diabetes Complications Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more by measuring protein in the urine, doing tests to determine how the thyroid gland is functioning ( thyroid function tests Thyroid function tests The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that lies just under the skin below the Adam’s apple in the neck. The two halves (lobes) of the gland are connected... read more ), doing tests to look for nerve damage, and doing eye examinations. Screening tests may be done once a year or every other year.
Children with diabetes should carry or wear medical identification (such as a bracelet or tag) to alert emergency care providers to the presence of diabetes. This information allows providers to start life-saving treatment quickly, especially in the case of injury or change in mental status.
Some children with diabetes do very well and control their diabetes without undue effort or conflict. In others, diabetes becomes a constant source of stress within the family, and control of the condition deteriorates. Adolescents in particular often find it difficult to follow the prescribed treatment regimen given the demands on their schedule and the limitations on their freedom that arise from diabetes. An adolescent benefits if the doctor considers the adolescent’s desired schedule and activities and takes a flexible approach to problem solving by working with the adolescent rather than imposing solutions.
Did You Know...
Adolescents with diabetes
Adolescents may have particular problems controlling their blood glucose levels because of
Hormonal changes during puberty: These changes affect how the body responds to insulin. As a result, higher doses are usually needed during this time.
Adolescent lifestyle: Peer pressure, increased activities, erratic schedules, concern about body image, or eating disorders may interfere with the prescribed treatment regimen, particularly their meal plan.
Experimentation with alcohol, cigarettes, and illicit drugs: Adolescents who experiment with these substances may neglect their treatment regimen and may be at greater risk of complications of diabetes (such as hypoglycemia and DKA).
Conflicts with parents and other authority figures: Such conflicts may make adolescents less willing to follow their treatment regimen.
Thus, some adolescents need a parent or another adult to recognize these issues and give them the opportunity to discuss problems with a health care practitioner. The practitioner can help make sure adolescents remain appropriately focused on keeping their blood glucose levels under control. Parents and health care practitioners should encourage adolescents to check their blood glucose levels frequently.
Emotional issues affect children with diabetes and their families ( see Social and psychologic problems Social and psychologic problems ). The realization that they have a lifelong condition may cause some children to become sad or angry, and sometimes even deny that they have an illness. A doctor, psychologist, or counselor needs to address these emotions to secure the child’s cooperation in adhering to the required regimen of meal plan, physical activity, blood glucose testing, and drugs. Failure to resolve these issues can lead to difficulties controlling blood glucose.
Summer camps for children with diabetes allow these children to share their experiences with one another while learning how to become personally more responsible for their condition.
For the treatment of diabetes, the child’s primary care doctor usually enlists the aid of a team of other professionals, possibly including a pediatric endocrinologist, dietitian, diabetes educator, social worker, or psychologist. Family support groups may also help. The doctor may provide parents with information to bring to school so that school personnel understand their roles.