Childhood diabetes: A malady everyone needs to know about.

Wondering if a child can have diabetes?? Continue reading this story to precisely understand what childhood diabetes means.

At 9 pm that night, the on-duty nurse called me up to inform the arrival of John (name changed), who was brought by his parents to seek consultation. His parents had seen the pediatrician that evening, as they felt the child was urinating more frequently than ever for the last 1 week.

The reports were here, in front of me and it read a blood sugar of 387 mg/dl. The child was playful and happily smiling at me.

After listening to what the parents had recently noticed in the child and examining him, I uttered, “Going by the symptoms and the blood tests, your child has diabetes mellitus. We will have to start him on insulin”

“Doctor, he is just 3 years old, how can he have diabetes?!”, yelled the father….

For many of you, diabetes is a disease of the adulthood. As a matter of fact, diabetes mellitus can occur at any age, though there exists considerable difference between childhood and adult onset diabetes.

Diabetes mellitus, “sugar” as the common man calls it, is a condition characterised by a persistent increase in the blood glucose (sugar) values (hyperglycemia) beyond the normal range. Normally, the blood glucose levels (BGL) at any random time of a day varies anywhere in the range of 70 to 200 mg/dl.

Broadly diabetes mellitus is of two main categories:

– Type 1 diabetes mellitus (T1DM): previously called insulin dependent diabetes mellitus.

– Type 2 diabetes (T2DM)

Apart from these, there are other rare specific forms like the monogenic diabetes (neonatal diabetes, maturity onset diabetes of young), secondary diabetes (post chronic pancreatitis, drug induced and others.

In this blog post, my focus lies on type 1 diabetes only

The American Diabetes Association has laid down the following criteria for the diagnosis of diabetes mellitus. This applies to diagnosis of both type 1 and type 2 diabetes.

  1. Symptoms of diabetes, along with a random BGL of 200 mg/dl or more.

or

  • A fasting BGL of 126 mg/dl or more (fasting of 8 hours).

or

  • Post 2-hour oral glucose tolerance test (OGTT) showing a BGL of 200 mg/dl or more. The doctor decides when this test should be done and provides the specific instructions for carrying it out.

or

  • HbA1c (glycosylated hemoglobin) of 6.5% or more.

My grandfather had T2DM, but I remember he used to take oral tablets, not insulin!”  the mother said frowning at me.

I calmed her down and said, “I understand your concern. But your child has type 1 diabetes, while what your grandpa had was type 2 diabetes.”

How is that different doctor?”, she anxiously asked and I went on

“T1DM differs from T2DM not just in the age of onset, but also in its causation, treatment and educational approaches.  

T1DM generally develops during childhood and adolescence; it is due to insulin deficiency and hence, insulin is the only currently available treatment.

T2DM typically occurs in the adults. Nevertheless, with the modern sedentary lifestyle, there is a rising occurence of T2DM in adolescents and young adults. This is seen mainly in obese individuals and is due to insulin resistance, meaning despite adequate amounts of insulin, the fat body does not respond to insulin.  Hence, insulin sensitizers given as oral medicines are effective in the treatment apart from lifestyle adjustments. Insulin deficiency may develop in the later stages of T2DM when insulin may be added to the treatment.”

The parents looked on as the nurse administered the first shot of insulin.

“Is it essential to give him insulin? Can we not do without it? Look, my child is in pain”, the mom questioned as she consoled the child.

“No. Insulin is absolutely essential for his survival, and yes, he will need these injections all his life, until the future gives us other treatment options. The prick of the injection is new to the child and you as well. Give yourself some time and you will see the child will get used to it.”

The parents were now eager to know more and I explained:  

The interplay of insulin and blood glucose.

“Human beings require energy to stay alive. Let’s now look at the microscopic level. The human body is nothing but a well organised collection of minute structures called “cells”. When each cell of the body produces energy, the body as a whole functions in harmony.

The food we eat serves as the source of this energy. Food, made up of carbohydrates, proteins, fats eventually get digested and broken down into “glucose” in our digestive system. This glucose is then transported from the intestines through the blood, which then delivers the glucose to each cell of the body.

The role played by insulin.

Insulin is a hormone produced by the beta cells of the pancreas. Its level increases when we eat food. Insulin acts on the various cells of the body like skeletal muscles, fat, brain etc and facilitates the entry of the glucose into these cells.

In simple terms, insulin acts as a gatekeeper at the door of each cell and opens the door for glucose to enter into the cell, where energy is produced.

The gist is that insulin levels rise with intake of food and fall in fasting state. Insulin decreases the blood glucose levels by enabling the body to make use of the glucose. This way, insulin, along with certain other hormones maintain the blood glucose within a normal range.

The distressed parents handed over John to his aunt to feed him dinner and sat down across my table. I could see a bundle of emotions of fear, guilt, agony, curiosity reflecting on their faces.

How did this happen to my child doctor? He was all good until a week ago. He doesn’t eat too many chocolates as well!” the father shot the next question at me.

“T1DM is an autoimmune condition. The immune system is a defence system that protects the body from the invasion by harmful organisms like the bacteria, viruses etc. It is so designed to differentiate between the cells of the body and the invading foreign organisms.

In autoimmune disease, this mechanism fails and the immune system attacks the normal cells of the body. The body then produces what we call the auto antibodies which fight against and destroy the cells of the body.

In T1DM, the autoimmunity selectively targets and destroys the beta cells of the pancreas, which produce insulin, thus leading to insulin deficiency. It does not develop due to eating chocolates”.

So, Type 1 diabetes = no insulin = no gatekeeper to open the door, so glucose does not enter the cells and effectively, no energy is produced. On the other hand, glucose accumulates in the blood, thus increasing the blood glucose levels.

The mother was puzzled, “What lead to this autoimmunity in my child doctor?”

“The cause of the autoimmunity is not certainly known. However, studies implicate autoimmunity is triggered by a complex interaction between the genetic makeup of a child and environmental factors like viral infections, nutrition in early life. However, despite ongoing research, we have not reached to a stage where we can prevent the child from developing overt diabetes, even if we identify him/her to have increased T1DM genetic risk”.

“Doctor, when did John develop diabetes? I saw he urinated too often and drank litres of water only since last week. Did we fail to recognise his symptoms earlier?” asked John’s mother.

“I cannot exactly tell you when it all started. But certainly, he didn’t have it since birth.

The symptoms appear gradually and it’s not unusual for parents to overlook them. They may often be there for few weeks until they become so severe that you may suddenly notice that something is wrong with the child. Not infrequently, any mild illness like common cold may aggravate the pre-existing symptoms.  But it is important that you learn all the ways the child may present, so that you can spread the word.

Diabetes classically has the following symptoms:

  1. Polyuria ie child urinates frequently than before. Waking up at night to urinate or resumption of bedwetting.
  2. Polydipsia: More urine leads to more thirst.
  3. Polyphagia: Excessive hunger. Waking up at night, asking for food.
  4. Loss of weight: Despite excess appetite, child loses weight or may fail to gain weight.
  5. Tiredness: Some children report that they can no longer play for the length of time they used to.
  6. Some parents also report ants to the urine of the child.
  7. Blurring of vision
  8. Repeated skin infections or infections in the genital area (private parts).
  9. Reduced school performance.
  10. If the above symptoms are not timely recognised, the child may unfortunately end up in a very sick state, with difficulty in respiration, vomiting, pain abdomen which is called Diabetic ketoacidosis (DKA).

A combination of some or all of these features should alert you to see a doctor, who may then order tests like urine and blood glucose examination”.

The parents looked at each other and spoke, “Yes doctor, I realise my child had most of these features for last few weeks, we dint think it was abnormal”.

 “But, are you sure my child has T1DM. Should my child be thoroughly investigated?” the father promptly asked.

“T1DM is the most common type of diabetes in children. In western countries, >90% of children with diabetes have T1DM. So, it is not necessary to carry out any tests for autoantibodies or imaging scans of the pancreas.

Only if the diabetes develops too early (in the first year of life), or if the child is obese, or has unusual associated symptoms or an unusual family history, then the doctor may ask for additional tests.

However, we will get a HbA1c, a thyroid profile and tests to screen for celiac disease (gluten allergy) for your child, as these autoimmune diseases frequently co-occur with T1DM”, I said.

After listening and understanding the facts about T1DM, the mother looked at the child who was peacefully asleep. She then looked at me and spoke in a trembling voice, “Doctor, are you sure there is no alternative to the insulin injections? I have never held a syringe in my hand. How will I be able to administer injections to my baby?”

I took a deep breath, smiled and answered, “Trust me, no doctor would prefer to prescribe an injection to a child if he/she had another option.

You’ve mothered this baby and you will certainly be able to inject the doses to him, better than anyone else.”

The father spoke in agreement – “Doctor, we will do it, together, for our child. Please guide us what other care is required”.

I was elated by the father’s readiness to be a part of the care for the child. I said, “You need not worry. The diabetic team consisting of the pediatric endocrinologist, the diabetic education nurse, the dietitian will educate you how to inject the insulin and all other entities.

Insulin is the mainstay of treatment, but there are certain other aspects that need equal attention.

Self-monitoring of blood glucose (SMBG): Every child should own a glucometer kit for monitoring and charting the blood glucose levels multiple times a day (at least 4 times). This is absolutely essential to have a better glycaemic control as it guides the dosage of insulin, food intake on a daily basis and long-term adjustment of insulin doses.

Medical nutrition therapy: The diet needs to be taken care of, in terms of its quantity and the quality, the timing and the amount of food in relation to insulin.

Physical activity and play: Like any other child, your child can continue to play, but certain precautions are essential to prevent his sugars going haywire. Physical activity of any desired kind ensures the fitness of body and mind, builds up the self-esteem, social interaction and promotes active lifestyle. Particularly, in a child with T1DM, exercise helps improve the insulin sensitivity and achieve better glycaemic control.

Attitude of the family: Participation of all immediate family members in the care of the child and sharing of tasks makes life much less challenging. Parents should not be too apprehensive, over vigilant and strict to scare away the child nor too lenient and uninvolved that they know nothing about the child’s diabetes. A balanced approach ensures a smooth and better glycaemic control.

Together, we shall make it easy”, I concluded.

John’s parents greeted me with thanks. They now seemed much relaxed, confident and eager to learn more about insulin, injection technique, diet etc.

The story takes a pause here. Thank you for reading till the end.

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More such stories await you.!!

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