Complications of Diabetes in Children and Adolescents

Hypoglycemia is low blood glucose that occurs when too much insulin or too much of an antihyperglycemic medication 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. 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 allow a slightly higher target range for their blood glucose level. Continuous glucose monitoring systems can help children because these systems sound an alarm when glucose falls below a specified range.

DKA is present at the time of diagnosis in nearly one-third of children with type 1 diabetes, and sometimes is present at the time of diagnosis in children with type 2 diabetes.

DKA is also common among children with previously diagnosed 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. DKA also can develop in children who have had previous episodes of it, are facing difficult social circumstances, or are depressed or having other mental health issues, which may impact how they manage their diabetes. Problems with DKA is also common among children with previously diagnosed 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. DKA also can develop in children who have had previous episodes of it, are facing difficult social circumstances, or are depressed or having other mental health issues, which may impact how they manage their diabetes. Problems withinsulin delivery (for example, problems with their insulin pump) can rapidly lead to DKA. DKA 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). Eventually 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 (DKA) is usually treated in an intensive care unit. Children with DKA are also dehydrated and often have other chemical imbalances in the blood, such as abnormal levels of potassium and sodium. They 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. DKA, when untreated, can progress to coma and death.

Diabetic ketoacidosis can often be prevented using sick day management, a program of giving extra fluid and insulin during a period of illness and monitoring for ketones. 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.

Urine Ketone Test Strip

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DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Another condition with similar symptoms to DKA is called hyperosmolar hyperglycemic state. This is more common in adolescents and adults with type 2 diabetes, and also requires hospital treatment.

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 as a result of diabetes (called diabetic retinopathy) can cause loss of vision. Damage to the kidneys can result in kidney failure. Damage to the nerves 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. Changes to blood vessels in children with diabetes may contribute to high blood pressure. Narrowing of arteries to the heart can cause heart attack. Narrowing of arteries to the brain can cause stroke. Heart attack and stroke do not commonly occur during childhood but can occur later in life.

Mental health issues (see Support) are common among children with diabetes. Up to half of children develop depression, anxiety, or other psychological issues (see Overview of Mental Health Disorders Children and Adolescents).

Because insulin can cause weight gain, eating disorders are a serious problem in adolescents, who sometimes skip their insulin doses to try to control their weight.

Mental health problems can affect children's ability to follow their meal plan and medication regimens, which means their blood glucose is poorly controlled.