Overview
Disorders of sugar, fat, and protein metabolism caused by insufficient and/or relatively insufficient insulin secretion in the body.
Typical symptoms include excessive thirst and drinking, polyuria, polyphagia, and weight loss.
The cause of the disease is not clear, but may be related to genetic, environmental and autoimmune factors.
It is mainly treated with a combination of drugs, dietary management and exercise.
Definition
Diabetes mellitus in children is a disorder of sugar, fat and protein metabolism caused by insufficient and/or relatively insufficient insulin secretion.
Types
Primary diabetes mellitus
Type 1 diabetes
Also known as insulin-dependent diabetes mellitus.
The vast majority of diabetes in children is type 1 diabetes.
Type 2 diabetes
Also known as non-insulin-dependent diabetes mellitus.
Type 2 diabetes is rare in children, with a rapidly increasing incidence in recent years.
Other types
Diabetes that occurs within the first 6 months of life is classified as neonatal diabetes.
It can be categorized as permanent neonatal diabetes and temporary neonatal diabetes.
Secondary Diabetes Mellitus
Secondary diabetes mellitus is mostly caused by a number of genetic syndromes and endocrine diseases.
Morbidity
Type 1 diabetes mellitus in children accounts for about 90% of the total number of all types of diabetes mellitus in childhood and is a major pediatric endocrine disease that endangers the health of children.
The incidence of type 2 diabetes in children and adolescents has risen sharply in recent years with the increase in childhood obesity.
The ages of 4-6 years and 10-14 years are the most common ages for type 1 diabetes mellitus in children.
Causes
Causes
The causes of diabetes in children are not yet clear, and they vary among different types of diabetes.
Type 1 diabetes
Type 1 diabetes is caused by an absolute lack of insulin secretion due to partial or total destruction of pancreatic β-cells as a result of immune damage.
It is caused by a combination of genetic and environmental factors and is a polygenic genetic disease.
On the basis of genetic susceptibility, viral infections (e.g., coxsackievirus), chemical toxins (e.g., ammonium nitrite), and certain components in the diet (e.g., alpha and beta casein in milk) trigger changes in the body’s immune function, which may lead to the development of type 1 diabetes.
Children with type 1 diabetes may have a variety of autoantibodies in their blood at the time of initial diagnosis, which have been shown to have a toxic effect on pancreatic islet cells in concert with complement and T-lymphocytes, thereby damaging pancreatic islet β-cells.
Type 2 diabetes
Type 2 diabetes is caused by insufficient insulin secretion by pancreatic β-cells or insensitivity of target cells to insulin (insulin resistance).
Type 2 diabetes has a clear familial predisposition.
Obesity, especially centripetal obesity, is an important factor in the development of type 2 diabetes in children.
Neonatal diabetes mellitus
An underlying single gene mutation is now considered to be the most common cause of neonatal diabetes.
The disease results from defective pancreatic β-cell function and maturation due to genetic mutations.
Secondary Diabetes Mellitus
Secondary to genetic syndromes such as trisomy 21, congenital ovarian insufficiency, etc.
Secondary to endocrine disorders such as Cushing’s syndrome, hyperthyroidism, etc.
Symptoms
Main Symptoms
Type 1 diabetes mellitus
Most children with type 1 diabetes mellitus have a rapid onset of the disease, typically characterized by excessive thirst and drinking, excessive urination, excessive food intake and weight loss, which are commonly referred to as the “three more and one less” symptoms.
Enuresis may occur due to increased nocturia.
Some older children have a slow onset of the disease, which is characterized by poor mental health, fatigue, and gradual weight loss.
The symptoms of polydipsia and polyuria in infants are not obvious and easily overlooked by parents.
Type 2 diabetes
Usually seen in obese children, the onset of overweight at the beginning of the disease, and later slowly lose weight.
The onset of the disease is more insidious, the child has a normal diet, most do not have or only have mild symptoms of polydipsia, polyuria, slight wasting or no change in weight, it is easy to be ignored and delayed diagnosis and treatment.
It is easy to overlook and delay the diagnosis and treatment of diabetes mellitus. Children are often found to have elevated blood glucose by chance, or only after they have developed complications.
Some children have signs of acanthosis nigricans, which can be seen on the back of the neck, armpits, skin folds, or elbow sockets, where the skin is darkened, rough, and has papillary projections.
Neonatal Diabetes
Neonatal diabetes mellitus is characterized by “three more and one less” symptoms, often accompanied by developmental delay.
Complications
Diabetic ketoacidosis
Diabetic ketoacidosis is the most common acute complication in children with type 1 diabetes mellitus, which is often triggered by acute infections and sudden interruption of insulin therapy.
Some children with diabetes mellitus are in ketoacidosis at the time of diagnosis, which is characterized by nausea, vomiting, abdominal pain, joint or muscle pain, lethargy, and deep, rapid breathing with the odor of rotten apples.
Diabetic nephropathy
Kidney damage occurs in a chronic diabetic state.
Children may present with symptoms such as foamy urine and edema.
Diabetic retinopathy
A blinding eye disease characterized by abnormal retinal microcirculation.
With the progression of the disease, children may have different degrees of vision loss, visual distortion, and so on, and in severe cases, blindness may occur.
Diabetic neuropathy
Peripheral neuropathy is the most common.
Children may have abnormal sensation in the limbs, loss of pain, temperature and vibration sensation.
Consultation
Department of Medicine
Pediatrics
If your child has excessive drinking, excessive urination, increased appetite but weight loss, or generalized weakness, you should consult a doctor promptly.
Endocrinology
If your child has any of the above symptoms, you can also visit the endocrinology department of a specialized children’s hospital.
Emergency Medicine
If your child develops symptoms such as deep, rapid breathing with the odor of rotten apples, depression, or even coma, vomiting, or abdominal pain, parents should call “120” or go to the emergency department immediately.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of information, common problems
Tips for seeking medical treatment
Parents should keep a detailed record of the symptoms your child has experienced, as well as the time of onset and changes in symptoms, so that the doctor can understand his or her condition.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Has the child felt thirsty a lot recently? Has there been an increase in water intake? What is the approximate amount of water he/she drinks each day?
Has the child recently experienced increased urination at night or sudden onset of bedwetting?
Has the child recently become hungry or eaten too much? For how long?
Has there been a recent change in weight (e.g., in the last six months)? How many pounds has he or she gained or lost?
Has the child recently been frequently tired and uninspired?
Medical History Checklist
Does the child have any family members with diabetes?
Has the child had any recent viral infectious diseases?
Is the child obese or overweight?
Does the child have a condition such as trisomy 21, congenital ovarian insufficiency, Cushing’s syndrome, or hyperthyroidism?
Checklist
Test results from the last 6 months, which can be brought with you to the doctor’s office
Laboratory tests: urine test, blood glucose, oral glucose tolerance test, glycosylated hemoglobin
Medication List
Medication for the last 3 months, bring along the box or package if you have one
Metformin
Insulin
Diagnosis
Basis of diagnosis
medical history
Family history of diabetes.
Recent viral infectious disease.
Presence of obesity or overweight.
History of disorders such as trisomy 21, congenital ovarian insufficiency, Cushing’s syndrome, and hyperthyroidism.
Clinical manifestations
Symptoms
Typical symptoms in children are excessive thirst and drinking, polyuria, polyphagia, and weight loss.
Physical signs
Some children have no positive signs on physical examination except weight loss and emaciation.
In some children, the skin on the back of the neck, armpits, skin folds, or elbow sockets is darkened, rough, and has papillary projections.
Laboratory Tests
Urinalysis
Including urine sugar, urine ketone bodies, urine protein, etc., which can help early detection of diabetic ketoacidosis, diabetic nephropathy and other complications.
Urine glucose can indirectly reflect the status of blood glucose control in diabetic patients, and is usually positive.
Positive urine ketone bodies suggest diabetic ketosis or ketoacidosis.
Positive urine protein suggests possible secondary damage to the kidneys.
Blood glucose measurement and oral glucose tolerance test
Blood glucose values help in the diagnosis of the disease and elevated blood glucose is the main basis for diagnosis.
Oral glucose tolerance test is used in children with normal or high limit of normal fasting blood glucose, higher than normal postprandial blood glucose and occasional positive urine glucose. Before the test, strenuous exercise and mental stress should be avoided, and drugs affecting glucose metabolism, such as dihydroketorolac and salicylic acid, should be discontinued.
Glycated hemoglobin
That is, HbA1c, can understand the status of blood sugar control in children with diabetes in the past 2 to 3 months.
Normal HbA1c <7%, well-treated diabetic children should be <7.5%, HbA1c 7.5% to 9% suggests that the disease control is general, such as >9% indicates that the blood glucose control is not ideal.
Blood insulin and C-peptide
Blood insulin and C-peptide can reflect the function of insulin secretion by endogenous pancreatic β-cells, which is not affected by external insulin injection, and can help to classify diabetes mellitus.
Children with type 2 diabetes often have C-peptide >1.5 ng/mL, whereas children with type 1 diabetes often have <0.5 ng/mL.
Islet Cell Autoantibodies
Islet cell antibodies (ICA), insulin autoantibodies (IAA), and glutamic acid decarboxylase antibodies (GAD) can be used to differentiate between type 1 and type 2 diabetes.
Tests are mostly negative in children with type 2 diabetes; they are often positive in children with type 1 diabetes.
Diagnostic Criteria
Diabetes mellitus is diagnosed in children when one of the following four criteria is met:
Fasting blood glucose ≥ 7.0 mmol/L.
Glucose ≥11.1 mmol/L 2 hours after oral glucose tolerance load.
Glycated hemoglobin ≥ 6.5%.
The “three more and one less” symptoms of diabetes mellitus and random blood glucose ≥11.1mmol/L.
Differential Diagnosis
Pediatric hyperthyroidism
Similarities: Both children may present with excessive drinking and eating with weight loss.
Differences: Children with hyperthyroidism may also have fever, excessive sweating, palpitations, proptosis, etc., and have normal blood glucose and urinary glucose quantification.
Pediatric Uremic Disease
Similarity: Both children may have excessive drinking and urination.
Differences: Children with diabetes mellitus have negative blood glucose and urine glucose, while children with diabetes mellitus have positive blood glucose and urine glucose.
Identification of type 1 diabetes and type 2 diabetes mellitus
Differential indicators of type 1 diabetes mellitus type 2 diabetes mellitus
Age of onset any age, high prevalence at 4 to 6 and 10 to 14 years of age mostly seen in older children
Age of onset
Any age, with a high prevalence between 4-6 and 10-14 years of age
Most common in older children
Family history Usually no family history Often family history is present
Family history
Usually no family history
Often family history
Mode of onset Rapid onset usually slow
Mode of onset
Sharp onset
Usually slow
Symptoms Drinking more, urinating more, eating more, weight loss, fatigue Noticeable symptoms Mild or asymptomatic
Symptoms
Drinking more, urinating more, eating more, losing weight, noticeable fatigue
Symptoms are mild or asymptomatic
Nutritional status Normal weight or lethargy Obese or overweight
Nutritional status
Normal weight or lethargy
Obese or overweight
Insulin pathologic changes with insulitis, beta cell destruction without
Insulin pathologic changes
With insulitis, beta cell destruction
No
Immunologic markers detectable autoantibodies mostly no autoantibodies positive
Immunologic markers
Autoantibodies detectable
Mostly autoantibody positive
Treatment
The treatment of diabetes mellitus in children is aimed at eliminating symptoms, stabilizing blood glucose in the target range, maintaining normal growth and development, and preventing and controlling various comorbidities.
The principle of treatment is comprehensive treatment, based on self-monitoring, choosing the appropriate drug treatment program and dietary management, exercise therapy and so on, in order to achieve satisfactory results.
Dietary management
Children with diabetes mellitus are in the period of growth and development, calorie intake should not be strictly restricted, and their needs should be met.
Calories
Children’s energy intake should follow the principle of “total control”, and the daily calorie requirement (kcal) is 1000+[age×(70-100)].
The coefficients in the formula can be chosen in relation to age: 100 for <3 years old, 90 for 3-6 years old, 80 for 7-10 years old, and 70 for >10 years old.
Children with diabetes at diagnosis need to replenish weight loss from catabolism prior to onset of the disease; higher energy intake is possible if appetite is good, but should be reduced when weight is regained.
For overweight and obese children with type 2 diabetes, it is recommended that energy intake be reduced to aid weight loss while maintaining a healthy dietary profile (but should not be less than 800 kcal/day).
Food composition and proportions
The total daily energy intake should be distributed as follows: 50% to 55% carbohydrates, 25% to 35% fat and 15% to 20% protein.
The protein component should be slightly higher in children under 3 years of age, more than half of which should be animal protein, with poultry, fish, and a variety of lean meats being the more desirable sources of animal protein.
It is recommended that carbohydrates come from low glycemic index (GI) foods such as whole wheat (whole grain) flour, buckwheat, black rice, corn, etc., as well as vegetables, fruits, legumes and dairy products.
Fats should be based on vegetable oils containing polyvalent unsaturated fatty acids.
Daily meals should be timed and the amount of food eaten should be fixed over a period of time.
Exercise
Exercise
Aerobic exercise increases cardiorespiratory fitness and muscle strength and improves muscle insulin sensitivity in children with diabetes.
Moderate aerobic exercise includes brisk walking on level ground, jogging, cycling, swimming, climbing stairs, jumping rope, playing ball games, hiking and so on.
Children with more than moderate obesity or poor physical strength can choose walking, gymnastics and other small exercise programs at the beginning, and then gradually increase the amount of exercise.
Children with mild obesity can choose fast walking, jogging, jumping rope, dancing, playing table tennis, cycling and other programs.
Exercise intensity
The pulse rate can be used to measure the exercise intensity of the child, gradual progress, avoid strenuous exercise.
During aerobic exercise, the pulse rate should reach 60% to 75% of the maximum heart rate, which can be calculated by the formula, i.e. pulse rate = (220 – age) × (60% to 75%).
Exercise time
The child should consistently exercise for at least 30 minutes per day, preferably up to 60 minutes per day of moderate-intensity exercise.
Weight control can be achieved by completing at least 5 days of moderate intensity exercise per week.
Precautions
Children should choose to exercise 0.5 to 1.0 hours after meals to prevent hypoglycemia.
Warm up and slow down the recovery activities before and after exercise for 5 to 10 minutes.
Carry drinks and food with the child during exercise in case of emergency.
When exercising for more than 30 minutes, carbohydrate food should also be supplemented appropriately to prevent delayed hypoglycemia.
If children experience symptoms of hypoglycemia such as panic, sweating, or shaking hands during exercise, they should stop exercising immediately, rest in place, and eat some of the food they carry with them.
Medication
Children need to be careful when using medication. When using medication, the doctor will choose the right form and exact dosage for children of different ages, so parents should not give medication to their children on their own.
Metformin
Metformin is the first line of treatment for type 2 diabetes in children.
If the child is metabolically stable (HbA1c <9% and random blood glucose <13.9 mmol/L and asymptomatic), treatment should be initiated with metformin.
The most common adverse reactions are gastrointestinal reactions such as transient nausea, vomiting, and diarrhea, which are largely tolerated by children. Prolonged administration of metformin may lead to vitamin B12 deficiency and regular monitoring of vitamin B12 levels should be considered.
Insulin
Treatment Options
Insulin rapidly improves metabolic abnormalities and protects pancreatic beta cell function.
Insulin is the key to successful treatment of diabetes in children, and treatment needs to be individualized. The choice of regimen will be based on the child’s age, duration of disease, lifestyle, and previous health status.
It is mainly used in children with randomized blood glucose of 13.9 mmol/L and/or HbA1c of 8.5% or more, diabetic ketoacidosis or metabolic instability.
Insulin therapy should be initiated as soon as possible in children with first-onset type 1 diabetes, and those with positive urine ketones should be given insulin within 6 hours.
Common treatment regimens are multiple daily insulin injections and continuous subcutaneous insulin injections (i.e., insulin pump therapy).
Types of insulin
Insulin currently available for the treatment of diabetes mellitus in children include rapid-acting insulin analogs (e.g., Mentholatum insulin, Lysostaphin), long-acting insulin analogs (e.g., Glucagon insulin, Ditropan insulin), and short-acting insulin (e.g., recombinant human insulin), and so on.
Precautions for use
Hypoglycemia is likely to occur if insulin dosage is too large, or if insulin is used without regular food intake; once it occurs, glucose should be given orally or by injection immediately.
Opened vials of insulin or insulin refills can be stored at room temperature (within 1 month after opening and not beyond the shelf life).
Unopened bottles of insulin or insulin refills should be stored at 2 to 8°C, never frozen, protected from heat or sunlight, and protected from shock.
Disease education
Parents of children with diabetes should have a full understanding of childhood diabetes and how to formulate the child’s diet and exercise program, how to monitor blood glucose, and how to prevent, recognize and deal with hypoglycemia.
Psychological education should be provided to children with diabetes to help them build up confidence, so that they can adhere to a regular life and treatment, and strengthen regular follow-up review.
Prognosis
Cure
Children with type 1 and type 2 diabetes mellitus cannot yet be completely cured, but if blood glucose is well controlled, the progression of the disease can be slowed down, and children can live and study as normal children, with no major impact on life expectancy and quality of life.
If blood glucose is poorly controlled, it may lead to a variety of complications and even be life-threatening.
Transient neonatal diabetes mellitus resolves or disappears on its own after the neonatal period, but about half of the patients will reproduce in childhood or adolescence.
Hazards
Diabetic ketoacidosis is an acute complication of diabetes mellitus in children and can be life-threatening if not treated promptly.
Children with long-term poor blood glucose control may develop diabetic retinopathy, diabetic nephropathy and many other complications, jeopardizing the healthy growth of children.
Daily
Daily Management
Dietary management
Eat regularly according to the doctor’s advice or the diet plan formulated by the dietitian.
Eating should be regular and quantitative.
Balanced diet and dietary control should be based on the principles of maintaining normal body weight, reducing fluctuation of blood glucose and maintaining normal blood lipids, and avoiding excessive restriction of diet.
Encourage the intake of a variety of fiber-rich foods, especially vegetables, fruits, beans, potatoes, whole grains rich in soluble fiber.
It is recommended that children should consume 80-120g of fish (except fried fish) once or twice a week.
Children can choose low-sugar or sugar-free foods with added sweeteners (e.g. xylitol) to improve the sweetness and taste of food, but care should be taken to identify the type and content of sweeteners.
Parents can assist in calculating the carbohydrate content and glycemic index of food through cell phone software and nutrition labels.
Life management
Parents should administer medication to the child as prescribed by the doctor and should not reduce or stop the medication without authorization.
Parents should monitor the child’s food intake and should not allow him/her to eat at will.
Parents should train the child to develop good hygiene habits and keep the mouth and skin clean.
Ensure that the child has enough sleep and do not put too much pressure on the child to avoid prolonged mental stress.
Parents should be positive and optimistic in assisting the child’s treatment and help the child to build up confidence in overcoming the disease.
Disease monitoring
Blood Glucose Monitoring
Fingertip blood glucose monitoring
Children with first-onset diabetes need strict blood glucose monitoring, which should be done 7 times a day, before three meals, 2 hours after three meals and before bedtime.
Children with stabilized disease can reduce the number of measurements as appropriate, taking turns to measure at different times of the day to reduce pain.