Diabetes in children- what you need to know

Typically, diabetes diagnosis peaks in children aged 5 to 6 years and then again between the ages of 11 years to 13 years. While these are the peak age groups for diabetes, it can strike at any age. This form of diabetes is known as Type 1 Diabetes. It’s also called “juvenile diabetes” or “insulin-dependent diabetes”.

Type 1 diabetes is a very scary disease as it can come on quickly, and your perfectly healthy child could deteriorate into a critical state.

To understand the disease and appreciate what it means for a child and the parents, I asked the mom of one of my patients to provide us with their personal story. I honestly believe that parents need to know that there is light in this tunnel. Your child’s condition can be managed, and more importantly, parents can learn to recognise signs and symptoms that your child may be ill.

The mom writes:

“My daughter was diagnosed 2 months before her second birthday, at 1 year 10 months. She was a normal, healthy child. Two weeks before diagnosis, she caught a bad flu. We took her to a GP, but  2 weeks later she did not seem to have recovered. During this time, we also started noticing a sharp increase in her drinking water and her nappies were becoming soaked and were much heavier which initially seemed normal as she was drinking more.

I also noticed a change in the smell of her breath. I googled the symptoms, and together with the concern of the flu, I decided to take her to Dr Maraschin. When we ran the initial tests, and the indications on blood sugar levels were alarming; we were immediately booked into hospital where my daughter was in ICU for 3 days.

The diagnosis was a shock, but we knew nothing about Type 1 diabetes and had no idea of the tough road ahead. We spent the 3 days while she was in hospital trying to learn about the disease. We were introduced to our endocrinologist on discharge, who would ultimately help us manage the disease. We were educated us administering insulin and everything we needed to know about managing her disease. It was a scary journey initially with a lot of trial and error which was frustrating…but we trusted the process and the health professionals and managed to find our feet in the end.

Our daughter has just turned 6 and is managing well. She understands that she cannot always have anything she wants to eat at any time. We’ve chosen a path that allows her the occasional treat (like most children), but she understands that there are specific times for treats, and she has to have the patience to wait for her sugar levels to be at the right place to allow those treats.

We see our diabetic medical team every 3 months for check-ups. We’ve been very fortunate to be able to use the CGM (Continuous Glucose Monitor) that helps us track her sugar levels electronically, and that has helped us with peace of mind as parents of a young T1 child. My advice to parents with newly diagnosed children would be to be patient and not overwhelmed, and take it one day at a time. Eventually, you will find your feet and rhythm. Our kids take our cues; they will pull through comfortably if we are strong for them.”

As this child’s paediatrician, I can honestly say that she is extremely well-managed. She does not arrive at my door in crisis. I believe this is due to her parent’s attitude towards her health and their determination to ensure she leads a normal life.

For the sake of understanding, I will break down the story so that we can understand what the disease is, its symptoms, the dangers, how it is diagnosed and what management is necessary to care for a child with Type 1 diabetes.

What is Type 1 diabetes?

The pancreas is an organ in our body that plays a very important role in producing enzymes and various hormones, such as insulin. The enzymes break down food for our bodies to use. Insulin is involved in the regulation of sugar (glucose) metabolism. When the pancreas stops producing insulin or produces too little, the body cannot use sugar for energy. The sugar builds up in the bloodstream. Since the body cannot use the sugar, it passes out of the body in the urine, taking a lot of water with it. This is why our little patient was suddenly passing so much urine. This increased her thirst dramatically and is why she was drinking so much water.

What causes Type 1 diabetes?

We don’t know what the exact cause of Type 1 diabetes is. What scientists do know is that the body suddenly mistakes the insulin-producing cells (islet) for harmful bacteria or viruses. In other words, the child’s immune system starts to fight the good islet cells so that the pancreas stops producing insulin. Certainly, genetics and the environment have a role to play, but at this stage, we are not 100% sure of how or why.

What are the signs and symptoms of Type 1 diabetes?

1. Increases urination. Children who are already toilet trained may begin bedwetting. Our patient’s nappies were becoming soaked and heavy.
2. Increased thirst. Mom noticed a sharp increase in her drinking water.
3. Ketones on the breath. This is a strange, fruity smell. Mom noticed a change in the smell of her breath.
4. Irritability or change in behaviour.
5. Extreme hunger.
6. Fatigue, sleepiness.
7. Weight loss.
8. Flu-like symptoms. The GP had seen the little girl for flu, but she had not recovered two weeks later.

Why is type 1 diabetes dangerous?

When blood sugar levels are too high for too long, the body uses fat instead of sugar for energy. This causes acid (ketones) to build up in the blood. The state is known as diabetic ketoacidosis. A child with diabetic ketoacidosis will usually be highly dehydrated, confused, breathing fast and deeply, complaining of abdominal pain and nausea, and very sleepy. If the child does not receive urgent medical care, the high acid levels in the body will cause the body to shut down. The child becomes unconscious and may go into a diabetic coma due to swelling of the brain.

For this reason, I admitted our little patient to ICU. Her extremely high sugar levels, breathing issues and dehydration meant she was in diabetic ketoacidosis. I did not want to risk the symptoms progressing.

If a child with Type 1 diabetes is not managed correctly, it can affect the major organs. These complications include:

1. Heart and blood vessel disease – Diabetes damages blood vessels, which may mean that the blood vessels become narrow and blood pressure increases. This increases the risk of heart disease and stroke later in life.
2. Kidney damage – The kidneys have tiny vessels that filter waste from the blood. If these vessels are affected, then the child’s kidneys will not work as they should. Toxins build up in the body, and the kidneys may go into failure. This will ultimately mean that the sufferer requires dialysis.
3. Nerve damage – This happens over a long period of time. Since excess sugar affects the walls of the vessels, the child’s nerves aren’t nourished as they should be, and nerve damage will result. The early signs may include tingling, numbness, burning or pain. Most often, this is felt in the hands and feet first.
4. Damage to the eyes – As with the other organs, damage to the vessels of the retina in the eye will lead to sight issues in the child.
5. Osteoporosis – This is a condition which affects the strength of the bones. Diabetes decreases the amount of minerals in the bone, and this will, in turn, lead to osteoporosis later in life. This places the person at risk for fractures of the bones.

How is Type 1 diabetes diagnosed?

The first step is to get a history on the child. By the time a child arrives in my rooms, parents are usually concerned about the amount of fluid the child is taking in and how often the child needs to wee. Our little patient’s parents had Googled some of her symptoms and were concerned about the “flu” that had not resolved.

1. Urine – If the child is well enough, I will get a urine sample and use a dipstick to do an initial check of the urine. I will be looking for glucose (sugar) in the urine. We mentioned that glucose is passed out of the body in the urine. I will also look for Ketones. Remember, this is the acid found in the urine if the body uses fat instead of sugar for energy. If any of these is present, then there is definitely a need for further investigation.
2. Blood tests – Blood tests are necessary to establish the level of sugar in the blood stream. An acceptable level for a child 6 to 12 years of age is from 5.0 to 10.0 mmol/L (90 to 180 mg/dL). Your doctor will be concerned with higher levels than this, especially if your child hasn’t just eaten.

How is Type 1 diabetes managed?

I have specifically used the term managed here, as Type 1 diabetes does not have a cure at the moment.

I love our mom’s explanation on how she manages her daughter’s condition. She includes all the steps in effective management of a Type 1 Diabetic:

1. Checking blood sugar levels. Our little patient has a CGM device (Continuous Glucose Monitoring). This device has a sensor that can measure the blood sugar levels every 5 minutes. It can report the value directly to the parent’s cell phone. Other patients may need to prick their finger before each meal and again before bedtime to check the levels.
2. Taking insulin – Our little patient does have insulin injections to ensure that she is able to use the glucose in her bloodstream for energy. All type 1 diabetics need insulin. The amount is adjusted according to the blood sugar levels at the time. You will be guided on what your child requires to maintain blood sugar levels. Insulin can either be injected, or an insulin pump may be used. If a pump is being used then a little tube is placed just under the skin, and insulin is continuously injected at the required amount.
3. Eating a healthy, balanced diet ensures that the carbohydrates are controlled. Our mom explained that her daughter understands that she cannot eat what she wants at any time, but treats are allowed.
4. Exercise – Being active makes insulin work better. It also builds strong muscles and bones and controls blood sugar levels. This is all critical in a diabetic child. Your child also wants to feel normal, so please allow your child to participate in all sorts of physical activities.
5. Have a team – After I discharged my little patient from hospital, the family was introduced to their endocrinology team. This is a group of professionals trained to look after diabetes. They educate the parents, provide support, and monitor the child’s well-being. As mom says, they see their team every 3 months, and all is going well. It has been 4 years since diagnosis, so this is wonderful to hear.

Conclusion

Throughout this article, I have referred to Type 1 diabetes. Type 2 is usually associated with adults and has traditionally been known as “Adult-onset diabetes”. Unfortunately, our modern lifestyles are having a significant impact on our children’s health. Children are struggling more and more with obesity and spend way too much time on the couch. Due to this, a growing number of children, from as young as 10 years of age that, are developing Type 2 diabetes. The symptoms are similar to those in Type 1 but come on more gradually. Other signs may include darkened areas of skin, especially around the neck or in the armpits. This is scary, and parents need to see the urgency in making decisions about food choices. I know the kitchen isn’t the favourite family gathering spot, but cooking a healthy meal together is now becoming a matter of life and death. We owe it to our children.

To those parents who have to deal with a Type 1 diabetic, take the advice of our mom: “My advice to parents with newly diagnosed children would be to be patient and not overwhelmed, and take it one day at a time. Eventually, you will find your feet and rhythm. Our kids take our cues; they will pull through comfortably if we are strong for them.”

References:

https://emedicine.medscape.com/article/907111-overview
https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/diagnosis-treatment
https://www.childrenshospital.org/conditions/type-1-diabetes
https://www.aboutkidshealth.ca/
https://medlineplus.gov/lab-tests/glucose-in-urine-test
https://www.choa.org/parent-resources/diabetes/checking-blood-glucose-in-kids
https://medlineplus.gov/ency/patientinstructions
https://www.sciencedirect.com/science/article/abs/pii/S1530891X21001658
https://link.springer.com/article/10.1007/s00125-019-05075-6