Nursing Insights: Defeating Pediatric Diabetes

Pediatric Diabetes

Diabetes diagnoses are increasing among U.S. children. 

The American Diabetes Association estimates that around 210,000 Americans under age 20 have been diagnosed with diabetes; a number that represents 0.25% of that population. 

While factors such as genetics, family history, physical inactivity and belly fat apparently play a role, the exact causes of type 2 diabetes are unknown. What we do know is that type 2 diabetes affects nearly every major organ in a child’s body, including the blood vessels, nerves, eyes and kidneys. The disease’s long-term complications, such as high blood pressure, high cholesterol, heart and blood vessel disease, stroke, blindness and kidney disease, can be disabling and even life-threatening.

We asked experts to weigh in on how to mitigate these risk factors, explain the differences between pediatric diabetes and adult-onset diabetes, how to spot the symptoms of pediatric diabetes and what treatment should include. 

Making important distinctions

Pediatric diabetes generally refers to type 1 diabetes, and is the most common form of diabetes in children and adolescents, says Fran Cogen, MD, CDE, director of the childhood and adolescent diabetes program at Children’s National Hospital in Washington, D.C.

Type 1 diabetes, she explains, is caused by the autoimmune destruction of the islet cells in the pancreas that are responsible for insulin production. 

“Due to the loss of these cells, children with type 1 diabetes are unable to produce their own insulin, resulting in high blood sugar levels,” says Cogen, noting that adults may also develop type 1 diabetes later in life. 

However, an increasing number of children and adolescents are developing type 2 diabetes, in which the child (or adult) is still able to produce their own insulin, but their body is resistant or unable to use insulin effectively, she says. 

“Because of these differences, people with type 1 diabetes are usually insulin-dependent, whereas those with type 2 diabetes are treated with oral agents and may also need to eventually be treated with insulin.” 

While we usually think of children developing type 1 diabetes, more kids are developing type 2 diabetes, as childhood obesity continues to increase, says Jill Brodsky, MD, MBA, FAAP, associate medical director and chair of pediatrics, pediatric gastroenterology, pediatric endocrinology and pediatric neurology at CareMount Medical in Poughkeepsie, N.Y.

“Children can have type 2 diabetes, and, sadly, as kids have become heavier in weight, more kids are developing type 2 diabetes.”

“Type 2 diabetes starts as a disorder of excess insulin. When we are obese, our body must make extra insulin because the extra weight makes us insulin resistant,” says Brodsky, adding that patients with type 2 diabetes initially over-produce insulin.

“But, over time, their pancreas cannot keep up with that demand, and, therefore, they develop an insulin insufficiency. Patients with Type 2 diabetes can often be treated with a variety of oral therapies that improve insulin sensitivity and non-insulin injectable therapies, for several years, before they become reliant on insulin-therapy.”

Seeing the warning signs

Some common signs in children who develop new onset diabetes include increased thirst, urination, changes in energy level and weight loss, with younger children possibly developing diaper rashes as well.

Healthcare providers can identify these symptoms when interviewing patients at annual exams, and completing a review of systems,” says Cogen. 

“Children with new-onset diabetes may also initially present to the emergency department with diabetic ketoacidosis (DKA), due to elevated blood glucose, resulting in the development of ketones and high acid levels in the blood.

“The symptoms of DKA include abdominal pain, nausea, vomiting, dehydration and fatigue,” continues Cogen. “Healthcare professionals should pay attention to those symptoms and also monitor for increased heart rate and respiratory rate, changes in blood pressure.”

Patients with DKA might even present in an altered mental status, she says, which constitutes an emergency and requires immediate treatment and hospitalization. 

“In summary, a child who presents with any of these symptoms and an elevated blood glucose level or glucose in the urine should immediately make clinicians suspect pediatric diabetes.” 

Pediatric diabetes patients might also experience new-onset nocturia, adds Brodsky. 

“Many elementary-aged kids will start having bedwetting accidents when they were previously dry at night. This is usually an alarming symptom for parents that prompts them to bring their child to the doctor,” she says, adding that the late stages of the presentation will likely also include lethargy, listlessness and an inability to wake up the child. 

“This is a catastrophic warning sign that diabetes can be present.” 

Ensuring effective diabetes treatment

Insulin therapy is the mainstay of treatment for type 1 diabetes in children and adolescents. 

This is the key that enables glucose to enter the cells in the body to provide energy, says Cogen. 

“Because the amount of insulin administered is dependent on blood glucose levels, children with diabetes are required to closely monitor the blood sugars by a glucose meter or a continuous glucose sensor,” she says, noting that diabetes education is essential for the child and family, in order to teach the necessary skills to manage diabetes. 

“Most diabetes teams include healthcare providers, certified diabetes educators and dieticians, as well as a psychosocial team, in order to provide multidisciplinary care to families. Maintaining appropriate blood glucose control has been shown to have long-term benefits in preventing the vascular complications of diabetes, including kidney damage, retinopathy and cardiovascular disease,” says Cogen, adding that yearly lab work and eye exams are conducted to monitor and/or prevent any developing complications. 

Monitoring for the development of associated autoimmune diseases such as thyroid, celiac and juvenile rheumatoid arthritis is part of routine care for type 1 diabetic patients, says Cogen, who also recommends that children receive immunizations such as the flu and pneumococcal vaccine if appropriate. 

There are other technologies available to help them monitor their blood glucose levels, says Brodsky. 

Traditionally, this was done through finger stick glucose levels where patients would prick their finger six-to-eight times a day to understand blood sugar levels at that point in time. 

“Now, we have technologies available called continuous glucose monitoring systems (CGM) that allow us to have minute-to-minute data on the current blood glucose number, but also trend information on where their number has been and where it is headed,” she says. “This allows the patient to make better treatment-related decisions to prevent extreme highs and lows in his or her blood sugar levels.

Insulin can be taken by injection or through an insulin pump, with the dose based on the blood sugar level at the time the dose is administered, the composition of the food they are consuming for that meal or snack, and any anticipated physical activity that is in-process or anticipated, says Brodsky, who also stresses the importance of having an adult oversee the process for children and adolescents. 

“It is a fairly complex decision-making process that most children, until their later years of high school, need an adult to co-manage to be as successful as possible.”

 

References

  1. National Institutes of Health, 2017. Accessed Oct. 26, 2020. 

[https://www.nih.gov/news-events/news-releases/rates-new-diagnosed-cases-type-1-type-2-diabetes-rise-among-children-teens]

  1. American Diabetes Association, 2020. Accessed Oct. 26, 2020. 

[https:// https://www.diabetes.org/resources/statistics/statistics-about-diabetes#:~:text=Diabetes%20in%20youth,5%2C800%20with%20type%202%20diabetes.]

  1. The Mayo Clinic, 2020. Accessed Oct. 29, 2020. 

[https://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/symptoms-causes/syc-20355318]

  1. Centers for Disease Control and Prevention, 2018. Accessed Oct. 28, 2020.

[https://www.cdc.gov/healthyschools/obesity/index.htm

  1. International Society for Pediatric and Adolescent Diabetes, 2020. Accessed Oct. 27, 2020. 

[https://www.ispad.org/page/Chapter9Insulintreatmentinchildren_and_adolescentswithdiabetes]  

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