Type 1 diabetes mellitus is an autoimmune disease that involves destruction of the insulin-secreting cells of the pancreas, leading to impaired insulin secretion, high levels of glucose in the blood (hyperglycemia), and eventually insulin resistance.
Early symptoms are related to hyperglycemia and include excessive thirst, excessive hunger, excessive urination, and blurred vision.
Doctors diagnose type 1 diabetes by measuring blood sugar levels and by checking for evidence that the body's immune system is attacking the cells in the pancreas that produce insulin.
Children with type 1 diabetes need to monitor their blood sugar and take insulin.
After years, diabetes can damage blood vessels and increase the risk of heart attack, stroke, chronic kidney disease, and vision loss, as well as damage nerves and cause problems with the sense of touch. Keeping the blood sugar under good control can help prevent these complications.
Type 1 diabetes can develop at any time during childhood, even during infancy, but it usually begins between ages between ages 10 years and 14 years, or for some children between ages 4 years and 6 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 people with ancestry from certain countries (such as Nordic countries).
Close relatives of a person with type 1 diabetes are at increased risk of developing diabetes. Siblings have about a 6 to 7% risk, and identical twins have a more than 70% risk. The risk of diabetes for a child who has a parent with type 1 diabetes is about 6 to 9% if the father is affected and is about 1 to 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), particularly certain types of thyroid disease, and celiac disease.
Symptoms of Type 1 Diabetes in Children and Adolescents
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.
Because symptoms are not always recognized as being caused by diabetes and treated, many children develop a life-threatening disorder called diabetic ketoacidosis. This is the first sign of type 1 diabetes in nearly one-third of children.
Diagnosis of Type 1 Diabetes in Children and Adolescents
Blood glucose tests
Hemoglobin A1C (HbA1C) test
Antibody testing
Determination of diabetes type
The diagnosis of diabetes is a two-part process. In children with symptoms, doctors do blood tests to determine whether children have diabetes and then determine the type. Testing for diabetes-specific antibodies is an important part of identifying the type of diabetes. Hemoglobin A1c is also checked to get an idea of longer-term glucose control, since it reflects the blood glucose level over the preceding 3 months. Children who appear to have complications also have other testing.
As type 1 diabetes is being diagnosed, doctors can determine the stage. Type 1 diabetes progresses in stages:
Stage 1: Children have 2 or more diabetes-specific antibodies (antibodies are measured by blood tests) but have normal blood glucose levels and no symptoms of diabetes.
Stage 2: Children have 2 or more diabetes-specific antibodies, abnormal blood glucose levels, and usually no symptoms of diabetes.
Stage 3: Children have 2 or more diabetes-specific antibodies, high blood glucose levels, and symptoms of diabetes.
Stage 4: Children have established or long-standing type 1 diabetes.
Testing after diagnosis
Children who are diagnosed with type 1 diabetes also have other blood tests to look for other autoimmune disorders such as celiac disease and thyroid disease. These tests are done at diagnosis and every 1 to 2 years thereafter.
Doctors sometimes do tests to look for other problems such as a disorder of the adrenal glands (Addison disease), joint and muscle disorders (such as juvenile idiopathic arthritis), and additional digestive tract disorders (such as inflammatory bowel disease). These additional tests are usually done only if patients have symptoms that suggest a specific disorder.
Treatment of Type 1 Diabetes in Children and Adolescents
Diabetes education
Diet and exercise
InsulinInsulin
Diabetes education is an important part of diabetes management. Diabetes education often involves the child, the caregivers, a diabetes educator, the child's doctor or other clinician, and often a dietician.
In type 1 diabetes, parents and older children are taught how to gauge the carbohydrate content of food and to develop a meal plan. Most children with type 1 diabetes are able to maintain their usual eating patterns rather than following a rigid diet. 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 but may not be able to communicate symptoms of hypoglycemia to their parents.
Physical activity and exercise are encouraged, with education focusing on how to adjust and manage food intake and insulin doses, as well as how to recognize and treat hypoglycemia.
Insulin treatment
To control blood glucose, children with type 1 diabetes take injections of insulin. They always require To control blood glucose, children with type 1 diabetes take injections of insulin. They always requireinsulin because nothing else is effective.
When type 1 diabetes is first diagnosed, children are usually hospitalized. Children with type 1 diabetes are given fluids (to treat dehydration) when necessary, and insulin. Children who do not have diabetic ketoacidosis (DKA) at diagnosis typically receive 2 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.
After diagnosis, children 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) regimen using a basal-bolus regimen
Insulin pump therapy
Fixed forms of MDI regimen or premixed insulin regimen (less common)
Most children who have type 1 diabetes should be treated with MDI regimens or with insulin pump therapy.
A basal-bolus regimen is the preferred MDI regimen. This regimen involves taking one injection of a longer-acting insulin (basal dose) every day and then separate supplemental injections (bolus doses) of a short-acting is the preferred MDI regimen. This regimen involves taking one injection of a longer-acting insulin (basal dose) every day and then separate supplemental injections (bolus doses) of a short-actinginsulin 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 and how much is eaten.
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 that are given to correct a high blood glucose level are given as separate injections of rapid-acting 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 that are given to correct a high blood glucose level are given as separate injections of rapid-actinginsulin via the insulin pump.
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Insulin pump therapy is increasingly being used in children. Potential benefits include better glucose control, safety, and user satisfaction compared to MDI regimens. This therapy is preferred for younger children, such as toddlers and preschoolers, and overall offers an added degree of control to many children.
Fixed forms of MDI regimens are less commonly used. 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 typically receive a specific (fixed) amount of shorter-acting insulin before eating breakfast and dinner and a fixed dose of longer-acting insulin at bedtime.
Fixed regimens provide less flexibility, require a daily set schedule for meals, and have been largely replaced by basal-bolus regimens wherever possible.
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.: 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 and are not used as commonly except in some children whose nutritional intake is constant (such as some children fed through a feeding tube).
Insulin delivery methods
Insulin can be injected in several ways:
Vial and syringe
Insulin pen
Insulin pump
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 . 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 ofinsulin the syringe holds 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.
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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, even young children, are using 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, even young children, are usinginsulin pumps. 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 Continuous glucose monitoring (CGM) systems) 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.
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.
Screening and Prevention of Type 1 Diabetes in Children and Adolescents
Close relatives of people who have type 1 diabetes are at increased risk of diabetes and may be screened for the development of type 1 diabetes through monitoring of blood sugar and testing for diabetes-specific antibodies.
Delaying diabetes symptoms
Given the high rate of progression to stages of type 1 diabetes where people have symptoms and the prolonged period before symptoms are present, therapies have been studied in an effort to prevent or delay the start of type 1 diabetes (stage 3).
A monoclonal antibody, teplizumab, can be used to delay the start of type 1 diabetes in people 8 years of age and older who do not yet have symptoms of diabetes (A monoclonal antibody, teplizumab, can be used to delay the start of type 1 diabetes in people 8 years of age and older who do not yet have symptoms of diabetes (stage 2). Teplizumab may delay the start of symptoms of type 1 diabetes for about 2 years in some people. People are given an infusion of ). Teplizumab may delay the start of symptoms of type 1 diabetes for about 2 years in some people. People are given an infusion ofteplizumab once a day for 14 days. Side effects can include fever, nausea, fatigue, headaches and a decrease in white blood cells called lymphocytes (lymphopenia).
Screening and prevention of diabetes complications
Diabetes can cause immediate complications and long-term complications. Long-term complications are most often due to blood vessel disease. These complications may affect blood vessels in the eyes, kidneys, or feet.
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