Overview of Diabetes Mellitus in Children and Adolescents

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 adolescents with obesity. It is temporary in some adolescents, but the remainder develop diabetes, especially those who continue to gain weight.

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 19, 1 in 450 children has developed type 1 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 of it to overcome insulin resistance. This deficiency is often referred to as a relative insulin deficiency as opposed to the absolute deficiency that occurs in type 1 diabetes.

Monogenic forms of diabetes are caused by genetic defects that affect the function of cells of the pancreas that make insulin, the action of insulin, or the parts of the cells that make energy. Monogenic forms of diabetes are not considered type 1 or type 2 and are uncommon. Monogenic forms of diabetes are not caused by an autoimmune reaction or by inflammation in the pancreas.

Children who have siblings or parents with type 1 diabetes may be screened for the disease.

Children who have overweight and have at least one additional risk factor (family history of type 2 diabetes or a mother with gestational diabetes, high blood pressure, abnormal cholesterol levels, polycystic ovary syndrome, or low birth weight) are screened for type 2 diabetes beginning at age 10 years.

Doctors suspect diabetes when children have typical symptoms or when a screening test suggests the presence of diabetes. To confirm the diagnosis, doctors measure blood glucose levels.

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 symptoms and a fasting glucose level of 126 mg/dL (7.0 mmol/L) or higher. If the random glucose level is 200 mg/dL (11.1 mmol/L) or higher, especially when there are symptoms of high or low blood sugar, children probably have diabetes but should have their fasting glucose level tested to confirm.

Doctors also measure the level of a protein in the blood called hemoglobin A1c (HbA1C). Hemoglobin is the red, oxygen-carrying substance within red blood cells. When blood is exposed to high blood glucose levels over a period of time, glucose attaches to the hemoglobin and forms HbA1C. Because HbA1C 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. HbA1C levels thus reflect blood glucose levels over a 2- to 3-month period of time. Children whose HbA1C level is 6.5% or higher are considered to have diabetes. HbA1C levels are especially helpful for diagnosing 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.

Lab Test

Hemoglobin A1C (HbA1c) Test

To help distinguish type 1 diabetes from type 2, doctors do blood tests that detect antibodies to various proteins made by the insulin-producing cells in the pancreas. Antibodies are important to fight off foreign substances such as germs, but sometimes antibodies attack normal cells. In the case of diabetes, cells that make insulin and other chemicals related to insulin are examples of normal cells that can be attacked. Such antibodies are usually present in children with type 1 diabetes and are rarely present in children with type 2 diabetes. Type 1 diabetes is an example of an autoimmune disorder, in which antibodies attack the normal cells.

Type 1 diabetes progresses in stages so after type 1 diabetes is diagnosed, doctors determine the stage based on the blood glucose level, symptoms, and the presence of antibodies.

Children who are diagnosed with diabetes also need testing to look for other problems that often occur in people with diabetes.

Children with diabetes and their caregivers often participate in intensive diabetes education programs. These programs are recommended to help children and their families manage their disease and meet their treatment goals. The programs cover all aspects of managing and living with diabetes.

Children with either type of diabetes need to:

• Eat regular, consistent meals and snacks

• Limit intake of refined carbohydrates and saturated fats

• Exercise regularly

• Work toward a healthy 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. Nutrition therapy, including the services of a dietician when possible, is helpful.

All children should eat regularly and not skip meals. An individualized meal plan that accounts for food preferences and a child's activity level is important. 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.

Although general healthy eating guidelines are the same for children with type 1 and type 2 diabetes, people with type 1 diabetes may focus more on counting carbohydrates and a consistent diet, while people with type 2 diabetes often focus on weight loss.

The mainstay of medication treatment for type 1 diabetes is insulin.The mainstay of medication treatment for type 1 diabetes is insulin.

Both oral and injectable antihyperglycemic medications (which prevent high blood sugar or lower blood sugar), as well as insulin, are often used in children with type 2 diabetes. Children with disorders that increase their risk of heart disease may also take other medications such as angiotensin-converting enzyme inhibitors or Both oral and injectable antihyperglycemic medications (which prevent high blood sugar or lower blood sugar), as well as insulin, are often used in children with type 2 diabetes. Children with disorders that increase their risk of heart disease may also take other medications such as angiotensin-converting enzyme inhibitors orangiotensin II receptor blockers.

The frequency of monitoring depends on the type of diabetes.

Options for monitoring include intermittent self-monitoring, using fingerstick glucose tests, or continuous glucose monitors, which are worn continuously.

In type 1 diabetes, people should use self-monitoring to measure blood glucose levels before all meals, before a bedtime snack, during illness, and if children have symptoms of low blood glucose (hypoglycemia) or high blood glucose (hyperglycemia). It may be necessary to check blood glucose levels 6 to 10 times per day as glucose control is being established. Self-monitoring with 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 (glucometer). 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.

In type 2 diabetes, blood glucose levels monitored with self-monitoring 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 to at least 3 times a day 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. The transition to having children and adolescents perform their own glucose monitoring and medication administration, at first with supervision and then independently, depends up on the child's developmental maturity and skill level. Doctors, diabetes educators, and the rest of the care team work with children and families to help them encourage independence in a safe and responsible way.Once experience is gained, parents and many children can adjust the insulin dose as needed to achieve the best control. The transition to having children and adolescents perform their own glucose monitoring and medication administration, at first with supervision and then independently, depends up on the child's developmental maturity and skill level. Doctors, diabetes educators, and the rest of the care team work with children and families to help them encourage independence in a safe and responsible way.

Parents should use a journal, app, spreadsheet, smart meter, or cloud-based program to keep detailed daily records of all factors that can affect control of blood glucose, including blood glucose levels, timing and amount of insulin doses, carbohydrate intake, physical activity, and any other relevant factors (for example, illness, late snack, or a missed insulin dose).

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 parent keeps or that are captured by a monitoring device, provides guidance and counseling about nutrition, and measures glycosylated hemoglobin levels (hemoglobin A1C). The doctor usually screens for long-term complications of diabetes by measuring protein in the urine, doing tests to determine how the thyroid gland is functioning (thyroid function tests), doing tests to look for nerve damage, and doing eye examinations. Screening tests may be done once a year or at other intervals.

Continuous glucose monitoring (CGM) systems are a common method of monitoring blood glucose levels and replace routine self-monitoring of blood glucose for some children. In CGM systems, a small glucose sensor placed under the skin measures blood glucose levels every 1 to 5 minutes, 24 hours a day. The sensor transmits real-time results of blood glucose levels wirelessly to a device that may be built into an insulin pump, to a wireless monitor that can be worn on a belt, or to a smartphone or smartwatch app. 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 with type 1 diabetes quickly identify worrisome changes in blood glucose that they can treat right away. Use of CGM devices may help lower HbA1C levels.

Continuous Glucose Monitor

Image

Dragoljub/stock.adobe.com

Two types of CGM systems are currently available: real-time CGM and intermittently scanned CGM.

Real-time CGM can be used in children 2 years of age and older. This type of system automatically transmits a continuous stream of glucose data to the user in real time, provides alerts and active alarms, and also transmits glucose data to a receiver, smartwatch, or smartphone. Real-time CGM should be done as close to daily as possible for maximum benefit.

Intermittently scanned CGM can be used in children 4 years of age and older. This type of system provides the same type of glucose data as real-time CGM but requires the user to purposely scan the sensor to obtain information. Many intermittently scanned CGM systems have optional alerts and alarms. Intermittently scanned CGM should be done frequently, at least once every 8 hours.

Children who use a CGM device, of either type, need to be able to measure blood glucose with a fingerstick to calibrate their monitor and to verify glucose readings if they do not match their symptoms.

Although CGM devices can be used with any insulin regimen, they are typically worn by Although CGM devices can be used with any insulin regimen, they are typically worn byinsulin pump users. When used in conjunction with an insulin pump, the combination is known as sensor-augmented pump therapy.

Other CGM systems are integrated with a pump and can also lower the insulin dose if blood glucose drops too low. This integration can reduce the number of episodes where blood glucose drops too low, even when compared to sensor-augmented pump therapy.

Closed-loop insulin pumps can be used in children 2 years of age and older. They automatically provide the right amount of insulin by using sophisticated computer algorithms that are on a smartphone or similar device and link a CGM sensor to an insulin pump to determine blood glucose levels and control insulin delivery. Closed-loop systems are not completely automated because they require users to manually provide insulin for meals and snacks and make adjustments for exercise. These systems help to more tightly control insulin dosing and limit episodes where blood levels of insulin are too high or too low. A fully automated closed-loop system, sometimes known as an artificial pancreas, is not yet commercially available.

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 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 and challenges: Peer pressure, increased activities, erratic schedules, concern about body image, or eating disorders may interfere with the prescribed treatment regimen, particularly their meal plan and attention to glycemic control.

• 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 professional. A health care professional can help make sure adolescents remain appropriately focused on keeping their blood glucose levels under control. Parents and health care professionals should partner with adolescents to help them with glucose monitoring and treatment.

Adolescents benefit if the doctor and family consider their desired schedule, activities, and food choices and take a flexible approach to problem solving by working with the adolescent rather than imposing solutions.

Mental health problems affect children with diabetes and their families. 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. Parents can look for a doctor, psychologist, or counselor who can address these emotions and help the child adhere to the required regimen of meal plan, physical activity, blood glucose testing, and medications. Untreated mental health problems 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 more personally responsible for their condition, in a physically active setting.

For the treatment of diabetes, the child’s primary care doctor 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.