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Diabetes in children.

INTRODUCTION

Diabetes mellitus (DM) is a chronic medical condition resulting in high levels of blood glucose. DM is caused by insufficient insulin production or insufficient sensitivity to insulin, or a mixture of both. Type 1 DM develops if the body cannot produce insulin. Insulin is a hormone that helps the glucose to enter the cells where it is used as fuel by the body. Type 1 DM is the most common type of diabetes seen in children but overall accounts for only 10 per cent of all people (i.e. children and adults) with DM (Diabetes UK, 2011). Type 2 DM develops when the insulin produced by the body is not working properly (insulin resistance) or not enough is being made.

Type 2 DM is associated with factors such as obesity, South Asian ethnicity and family history (Haines et al, 2007). Type 2 DM is thought to affect older people. However, type 2 DM is becoming increasingly common in children due to increasing obesity in children. This article will discuss Type 1 DM, the most common types seen in children and is referred to as diabetes in the rest of the article.

EPIDEMIOLOGY

Type 1 diabetes is one of the most common endocrine diseases in children. Worldwide, an estimated 65,000 children under 15 years old develop the disease each year, and the global incidence in children continues to increase at a rate of three per cent a year. There are about 29,000 children and young people with diabetes in the UK (Ali et al, 2009), out of which about 26,500 have Type 1 DM (Diabetes UK, 2011). The current incidence in the UK is around 26 in 100,000 per year. In a large UK general practice, a child with new diabetes will be seen about every two years (Ali et al, 2011).

CHILDREN WHO ARE AT INCREASED RISK OF DIABETES

Diabetes is a common health condition.

The chances of developing it may depend on a mixture of factors--genetic, lifestyle and environmental factors. Type 1 diabetes develops when the insulin-producing cells in the pancreas have been destroyed. No one knows for certain why these cells get damaged, but the most likely cause is the body having an abnormal reaction to the cells (an autoimmune condition). This may be triggered by viral or other infections (Craig et al, 2014). Children with some other autoimmune conditions such as coeliac disease and autoimmune hypothyroidism are also at higher risk of developing diabetes (NICE, 2004).

Genetics play a major risk for developing diabetes in children. The risk among children with type 1 DM in first-degree relatives is about 15 times higher than in the general population. The risk of developing diabetes in a child where a first-degree relative has type 1 DM is highlighted below (Diabetes UK, 2011).

* Mother: 2-4 per cent

* Father: 6-9 per cent

* Both parents: 30 per cent

* Sibling: 10 per cent

* Non-identical twin: 10-19 per cent

* Identical twin: 30-70 per cent.

CLINICAL PRESENTATION

Diabetes UK has launched the '4Ts' campaign which largely summarises the clinical symptoms of diabetes (Diabetes UK, 2015):

* Toilet: going to the toilet a lot, bed wetting by a previously dry child or heavier nappies in babies

* Thirsty: being really thirsty and not being able to quench the thirst

* Tired: feeling more tired than usual

* Thinner: losing weight or looking thinner than usual.

Polyuria and polydipsia are the main symptoms of diabetes in all age groups, occurring in up to three-quarters of school-aged children (Roche et al, 2005). However, these symptoms are not always mentioned initially and must be elicited by a proper history-taking. Nocturnal enuresis in a previously 'dry' child is the earliest symptom of diabetes in 89 per cent of children over the age of four years (Roche et al, 2005). Weight loss occurs in 50 per cent of those aged 10-14 years, but in only five per cent of children under two years (Williams et al, 2012). Lethargy occurs in 10-20 per cent of children of all ages. Constipation is an important symptom in the under-fives, occurring in around 10 per cent, secondary to chronic dehydration (Roche et al, 2005). Recurrent infections are uncommon as a presentation, occurring in only two per cent, although oral and vulval thrush has been reported more commonly (Diabetes UK, 2012).

DIAGNOSTIC DILEMMA IN DIABETES IN CHILDREN

The classic symptoms of diabetes may not be evident in children under two years and subtle and non-specific symptoms such as headache, constipation, oral and vulval thrush, abdominal pain, vomiting may be the presenting feature (Diabetes UK, 2012). It can be difficult to distinguish from other acute illnesses at the initial stages in younger children and therefore a high index of suspicion among health professionals is important. In older children and adolescents, polyuria and polydipsia usually predominate, but these symptoms can be misinterpreted by parents and schools or ignored by adolescents (Diabetes UK, 2012). High rates of misdiagnosis have also been found in children presenting with type 1 diabetes without diabetic ketoacidosis (DKA), with up to 86 per cent of children not diagnosed at first encounter (Usher-Smith et al, 2011).

In these studies, common diagnostic errors included misinterpreting symptoms (such as polyuria misdiagnosed as urinary tract infection), exclusively focusing on one or more symptoms (such as oral candidiasis), and not performing appropriate investigations (such as blood glucose or urine tests) (Pawlowicz et al, 2008).

Between 10 and 70 per cent of these diagnosed children present in DKA, a metabolic derangement characterised by the triad of hyperglycaemia, acidosis, and ketonuria. In a Canadian study of 3,947 children with newly-diagnosed diabetes, 735 (18.6 per cent) presented with DKA, and this rate was highest among children aged [less than or equal to] 3 years; 39.7 per cent in comparison to 16.3 percent for children >3 years of age (Bui et al, 2010). Another study from the UK with 99 children, 27 out of 99 (27.2 per cent) presented in diabetic ketoacidosis (DKA) (Sundaram et al, 2009). The same UK study recorded a delay in diagnosis in 21 out of 99 (21.2 per cent) cases by >24 hours due to missed diagnosis at the local hospital (n=4) or by the general practitioner (n=7), arranging a fasting blood glucose test (n=9) and outpatient appointment requested via fax (n=1). Children presenting with DKA had symptoms for a mean of two weeks, up to a third had at least one medical consultation in the week before diagnosis, and misdiagnosis was associated with a threefold increase in DKA (Usher-Smith et al, 2011).

If ketoacidosis has already supervened, then the symptoms can include vomiting, deep sighing respiration, reduced conscious level, and abdominal pain. Because of these, DKA can be misdiagnosed as acute abdomen, possible severe gastroenteritis, acute asthma, or pneumonia if the parents are not asked about a history of polyuria and polydipsia. (Ali et al, 2011).

WHY DOES THIS MATTER?

Some children can develop dehydration and acidosis within 24 hours of first presentation of diabetes, and children under two years of age are at most risk. In a recent UK study, a higher proportion of children with delayed diagnosis presented with DKA in comparison to those with no delay in diagnosis (52 per cent compared to 21 per cent) (Sundaram et al, 2009). DKA is the leading cause of mortality and morbidity in children with type 1 diabetes; 10 children a year die from DKA in the UK. Most diabetes-related deaths are due to cerebral oedema, which is more common when DKA occurs at the onset of diabetes (Edge et al, 2009).

History and observation (weight loss, unexplained infections, thrush, etc) both play an important role in raising suspicion about diabetes in children. In cases where a health visitor or school nurse considers diabetes as a strong possibility, they need to inform the parents of the child and suggest immediate referral via their GP to be seen straight away in hospital by a paediatrician. This is to confirm the diagnosis of diabetes, make sure that they are not in DKA and to start treatment with insulin to prevent this serious complication.

DIAGNOSTICCRITERIAFORDIABETES IN CHILDHOOD AND ADOLESCENCE

Diagnostic criteria for diabetes are based on blood glucose measurements and the presence or absence of symptoms. Different methods can be used to diagnose diabetes and in the absence of unequivocal hyperglycaemia, blood glucose level must be confirmed by repeat testing.

The current criteria for diagnosis recommended by The American Diabetes Association (2014) and World Health Organization (2006) is either:

* A random (i.e. any time of day without regard to time since last meal) blood glucose level of >11 mmol/L, OR

* Fasting (i.e. no calorie intake for at least eight hours) plasma glucose >7.0 mmol/L.

If symptoms are present, urinary 'dipstick' testing for glycosuria and ketonuria, or measurement of glucose and ketones using a glucometer, provides a simple and sensitive screening tool. If the blood glucose level is elevated, then prompt referral to a centre with experience in managing children with diabetes is essential. Waiting another day specifically to confirm the hyperglycaemia in a fasting state is unnecessary, and if ketones are present in blood or urine, treatment needs to be urgently initiated as otherwise DKA can evolve rapidly (Craig et al, 2014; Diabetes UK, 2012). Finger prick blood glucose level (BGL) testing should not be used to diagnose diabetes and a confirmation through a laboratory BGL is essential (Craig et al, 2014).

Any child found to have high BGL by non-specialist staff or community health professionals should be assumed to have Type 1 diabetes and be referred to a multidisciplinary specialist paediatric diabetes team that has competencies needed to confirm diagnosis and to provide immediate care on the same day. The team consists of a paediatrician with interest in diabetes, paediatric diabetic specialist nurses (PDSN), dieticians, general practitioners and also, ideally, a psychologist (Husband, 2005; Diabetes UK, 2012). Specialist paediatric diabetes teams may consider other forms of diabetes where the diagnosis of diabetes remains unclear. If there is any doubt at all about the type of diabetes, the child should be presumed to have Type 1 diabetes and insulin therapy should be commenced (Diabetes UK, 2012).

MANAGEMENT

The medical treatment for type 1 DM is by subcutaneous insulin injections. There are different types of insulin commercially available with different onsets and durations of action. There are three main regimes for insulin treatment used in diabetes; however, regular BGL monitoring is required at home irrespective of the regime followed (NICE, 2004).

1. One, two or three insulin injections per day at fixed times: this regime relies on consistent meal habits but can be useful for children who will have problems injecting insulin at school lunchtime or if compliance is an issue.

2. Multiple daily injections: the patient has one or more injection per day of long-acting insulin but also injects short/rapid-acting insulin just before meals. This regime offers more flexibility with meal times but relies on good patient education and carbohydrate counting.

3. Continuous subcutaneous insulin infusion (also known as insulin pump therapy): Rapid/short-acting insulin is continuously infused and extra boluses can be given at mealtimes by pressing a button. This regime most closely mimics normal process by which insulin is secreted by the pancreas. Different rates can be set for different times of the day and even for different activities. However accurate carbohydrate counting and calculation of correction insulin doses is important. Insulin pump has shown to improve quality of life and improve glycaemic control. The pump has its own problems like rapid onset of diabetic ketoacidosis in case of pump failure. Therefore children and family should be assessed for motivation and education before a pump is recommended.

It is important to support the family not only in managing the medical aspects of diabetes, but to provide education and advice regarding diet, school meals, school trips, holidays, etc. (Sparud-Lundin et al, 2013). A written plan should be given outlining the management of diabetes at home and what to do when the child is unwell, misses a dose of insulin, or has been given an extra dose by mistake. Children and young people with type 1 DM should also be offered (NICE, 2004):

* Appropriate advice on diet, alcohol, smoking and exercise

* Influenza and pneumococcal immunisations

* Screening for coeliac disease, thyroid disease, retinopathy, microalbuminuria and blood pressure

* Annual foot care reviews.

COMMON MEDICAL PROBLEMS ASSOCIATED WITH DIABETES

Hypoglycaemia

Hypoglycaemia is the most common acute problem with diabetes. In a child with diabetes, hypoglycaemia is defined as a BSL of <4mmol/l. The risk of recurrent and severe hypoglycaemia causes significant anxiety and emotional morbidity for patients and families and is a limiting factor in achieving optimal glycaemic control.

Symptoms of hypoglycaemia include shakiness, pounding heart, and sweatiness, headache, drowsiness and difficulty in concentrating. In young children, behavioural changes such as irritability, agitation, quietness, and tantrums may be prominent. Common clinical precipitants for hypoglycaemia include: excessive insulin dosing, missed meals, exercise, sleep and alcohol ingestion in adolescents (Ly et al, 2014). Risk factors include young age, previous severe hypoglycaemic events, accidental insulin overdoses and reduced hypoglycaemia awareness (Ly et al, 2014). Most children and their families should be given a clear plan of how to manage any episode of hypoglycaemia.

Children, parents, schoolteachers, and other caregivers should be trained to recognise the early warning signs of hypoglycaemia and treat low blood glucose immediately and appropriately. Children and adolescents with diabetes should wear some form of identification or medic alert bracelet about their diabetes (Ly et al, 2014).

Diabetic ketoacidosis

DKA is a critical, life-threatening condition caused by prolonged raised blood glucose levels that requires immediate medical attention. DKA results from critical relative or absolute deficit of insulin, resulting in breakdown of fats as a fuel source and buildup of acid and ketones (breakdown product of fats) in the blood. Children can develop this condition at diagnosis, from long-term mismanagement of their diabetes or acutely during an inter-current illness. Recurrent DKA (high risk groups) may be seen in children with poor blood glucose control (due to missing doses of insulin), previous episodes of DKA, female gender (peri-pubertal or adolescent), psychiatric disorders including eating disorders, difficult or unstable family circumstances, limited access to medical services, and insulin pump therapy (chances of malfunctioning). A suspicion of DKA warrants urgent referral and management in the hospital (Wolfsdorf et al, 2014).

COMPLICATIONS OF DIABETES

Complications of diabetes tend to develop in older age groups but NICE recommends that children and young people with type 1 DM are offered screening for coeliac disease, thyroid disease, retinopathy and microalbuminuria (protein loss in urine) (NICE 2004). Persistently high blood sugar levels can lead to serious problems, including heart disease and kidney disorders. The complications of DM seen in young diabetics are usually related to poor compliance, issues with injections, weight issues and bullying or peer pressure (NICE 2004).

The Royal College of Paediatrics and Child Health (RCPCH) looked at figures from young people's diabetes units across England and Wales in 2013-14. Just 16 per cent underwent all seven annual health checks that are recommended to monitor their blood sugar control and any complications.

The figures suggest (RCPCH, 2015):

* More than 27 per cent of young people had high blood pressure--putting them at risk of heart disease

* Some 7 per cent had markers of future kidney disease

* Over 14 per cent had early signs of eye disease--putting them at risk of blindness in later years

* More than 25 per cent were classed as obese.

SICK DAY RULES

The diabetes care team should provide clear guidance to patients and their families on how to manage diabetes during inter-current illnesses with vomiting or fever and such education should be repeated periodically to avoid the complications of--ketoacidosis, dehydration, uncontrolled or symptomatic hyperglycaemia, and hypoglycaemia.

The Five General Sick Day Diabetes Management Principles (Brink et al, 2014) are:

* More frequent blood glucose and ketone (urine or blood) monitoring

* Do NOT stop insulin

* Monitor and maintain salt and water balance

* Treat the underlying precipitating illness

* Sick day guidelines including insulin adjustment should be taught soon after diagnosis and reviewed at least annually with patients and family members with a goal of minimising and/or avoiding DKA and similarly minimising and/or avoiding illness associated hypoglycaemia.

HOW CAN COMMUNITY PRACTITIONERSSUPPORTCHILDREN WITH DIABETES?

Diabetes is a life-long medical condition with potential for serious complications. Community practitioners play an important role in helping to identify children who may have diabetes and prompting rapid blood glucose testing and referral. Community practitioners also have an important role in the paediatric diabetes care team, in helping ensure continuity of care for these children and appropriate support and education. We have outlined a few suggestions as to how community practitioners can help children with diabetes, drawn up from the available literature and our experience in managing children with diabetes (Ali et al, 2011; Williams et al, 2012; Sparud-Lundin et al, 2013; NICE, 2004, Diabetes UK, 2012):

1. Use the 4T's to help recognise children early with common features of diabetes

2. High level of suspicion in young children less than two years of age with non-specific symptoms and atypical presentations

3. Arrange prompt blood glucose testing for diagnosing diabetes

4. Ensure children with suspected diabetes are referred on the same day to paediatric diabetes team

5. Help ensure ongoing management in terms of insulin injections and healthy diet in the school environment

6. Recognise symptoms of hypoglycaemia and ketoacidosis and is able to treat emergencies and transfer child to hospital for further management.

7. Provide leaflets and offer information about support groups to the patient and family.

References

Ali K, Harnden A, Edge JA (2011) Type 1 diabetes in children. BMJ 2011;342:d294

American Diabetes Association (2014) Diagnosis and classification of diabetes mellitus. Diabetes Care 2014: 37 (Suppl. 1): S81-S90.

Brink S, Joel D, Laffel L, Lee WWR, Olsen B, Phelan H, Hanas R(2014). Sick day management in children and adolescents with diabetes. Pediatric Diabetes. 15 (Suppl. 20): 193-202.

Bui H, To T, Stein R, Fung K, Daneman D (2010). Is diabetic ketoacidosis at disease onset a result of missed diagnosis? J Pediatr 156(3):472-7.

Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC (2014). Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatric Diabetes. 15 (20): 4-17.

Diabetes UK (2011). Diabetes in the UK 2011/2012: Key statistics on diabetes. December 2011. Available from: http://www. diabetes.org.uk/documents/reports/diabetes-in-the-uk-2011-12. pdf

Diabetes UK (2015). Do you know the 4Ts of the Type 1 Diabetes? Available at: http://www.diabetes.org.uk/Get_ involved/Campaigning/Our-campaigns/4-Ts-campaign/

Diabetes UK (2012). Early diagnosis of children with Type 1 diabetes. Available at: https://www.diabetes.org.uk/Documents/ Position%20statements/diabetes-uk-position-statement-early-diagnosis-type-1-children-0513.pdf

Edge JA, Ford-Adams ME, Dunger DB (1999). Causes of death in children with insulin dependent diabetes 1990-1996. Arch Dis Child 81(4):318-23.

Haines L, Wan KC, Lynn R, Barrett TG, Shield JP (2007). Rising incidence of type 2 diabetes in children in the UK. Diabetes Care 30 (5):1097-101.

Husband A (2005) The role of the paediatric interdisciplinary diabetes team in the care of children and adolescents with diabetes. Paediatr Child Health 10(1): 17.

Ly TT, Maahs DM, Rewers A, Dunger D, Oduwole A, Jones TW (2014). ISPAD Clinical Practice Consensus Guidelines--Hypoglycemia: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatric Diabetes. 15 (20): 180-192.

NICE CG15 [NICE (2004)]. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Available from : http://www.nice.org.uk/guidance/cg15

Pawlowicz M, Birkholz D, Niedzwiecki M, Balcerska A (2008) Difficulties or mistakes in diagnosing type 1 diabetes in children? The consequences of delayed diagnosis. Pediatr Endocrinol Diabetes Metab 14(1):7-12

RCPCH (2015) National Paediatric Diabetes Audit Report 2013-2014. Available from: http://www.rcpch.ac.uk/system/files/ protected/page/2014%20NPDA%20Report%201%202014%20 FINAL.pdf

Roche EF, Menon A, Gill D, Hoey H (2005). Clinical presentation of type 1 diabetes. Pediatr Diabetes. 6(2):75-8.

Sparud-Lundin C, Hallstrom I, Erlandsson LK (2013). Challenges, strategies, and gender relations among parents of children recently diagnosed with type 1 diabetes. J Fam Nurs. 19(2):249-73.

Sundaram PC, Day E, Kirk JM (2009) Delayed diagnosis in type 1 diabetes mellitus. Arch Dis Child 94(2):151-2.

Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM (2011). Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 343:d4092.

Williams G, Paul SP, Hicks S (2012). Diabetes in children. Adjusting to normal life as a diabetic. J Fam Health Care 22(6):16-7, 19-22.

Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R (2014). A Consensus Statement from the International Society for Pediatric and Adolescent Diabetes: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes. 15 (20): 154-179

World Health Organisation (2006) Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia: Report of a WHO/IDF Consultation. Geneva, Switzerland: World Health Organisation.

DR SUJATA EDATE

Locum Consultant in Paediatrics, Frimley Park

Hospital, London

DR RACHELDEBONO

General Practice Specialty Trainee Year 1,

Royal United Hospital, Bath

DR SIBA PROSAD PAUL

Specialty Trainee Year 8 in Paediatrics, Bristol

Royal Hospital for Children

CPD Questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. Type 1 diabetes (Insulin dependent diabetes) is

A. More common in children

B. Common in adults

C. Never occurs in children

D. None of the above

2. Type 2 diabetes

A. Becoming increasingly common in children

B. Seen in overweight children

C. Known to affect South Asian and African children

D. All of the above

3. A common symptom of diabetes is

A. Polyuria and polydipsia

B. Lethargy

C. Weight loss

D. All of the above

4. Diagnostic criteria for diabetes is

A. Presence of '4Ts'

B. Blood glucose >11 mmol/L.

C. Urinary 'dipstick' testing for glycosuria and ketonuria

D. All of the above

5. Which of the following statements regarding diabetic ketoacidosis in children are true?

A. Is a serious life-threatening medical emergency

B. Can occur due to malfunctioning or blocked insulin pump

C. Warrants urgent referral and management in the hospital

D. All of the above

6. Hypoglycaemia in diabetic children

A. Defined as a blood sugar <4mmol/l

B. Community practitioners (e.g. school nurses) should be able to recognise symptoms

C. Not a life threatening complication in diabetic children

D. Both A and B are correct

7. General Sick Day Diabetes Management Principles include

A. More frequent blood glucose and ketone (urine or blood) monitoring.

B. Do not stop insulin

C. Monitor and maintain salt and water balance

D. All of the above

8. Complications of long-standing diabetes include

A. High blood pressure with risk of heart disease

B. Kidney disease

C. Retinopathy and blindness.

D. All of the above

9. The role of the school in managing children with diabetes is mainly to

A. Ensure availability of suitable meals

B. Suitable place to inject insulin injections for diabetic children

C. Recognise signs of hypoglycaemia and treat it

D. All of the above

10. Community practitioners can play an important role for children with diabetes ...

A. By diagnosing diabetes in children and making a referral to specialist services on the same day

B. Supporting children in the community post diagnosis

C. Help local schools support children with diabetes and educate the staff about how to manage emergencies

D. All of the above
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Author:Edate, Sujata; Debono, Rachel; Paul, Siba Prosad
Publication:Community Practitioner
Article Type:Disease/Disorder overview
Date:Jul 1, 2015
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