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Diabetes in Children

Rahul is 6 years old. His mother found that he had been losing weight. He was getting up at night for urination several times. One fine day he was brought to emergency department with breathlessness. On evaluation we found that his sugar was 452 mg/dl and he had urine ketones positive. He was started on insulin. His mother has several questions to ask.

1. Why did Rahul get diabetes?
Diabetes typically seen in children in type I diabetes. In this type of diabetes insulin producing beta cells are destroyed by auto-immune process and there is absolute deficiency of insulin. They require insulin for their survival.

Nowadays, type II diabetes is also seen in children. In current situation around 8-10% of children may suffer from type II diabetes. These children are typically obese and they have family history of type II diabetes.

There are other types of diabetes also seen in children like Malnutrition related diabetes (MRDM), syndromic diabetes, Neonatal diabetes.

2. What all lab tests are needed?
We need to check Blood sugars, Urine ketones, S. Electrolytes, Blood count. As per the recommendations from ADA we should also do TSH, Anti-TPO antibody and TTGA.

We should also do USG to check any abnormalities in pancreas.

3. Does he require admission in hospital?
Typically to start insulin in a new case needs admission. Diabetes education is imparted during the admission. Insulin injection techniques and monitoring is taught.

In case of Diabetic ketoacidosis, admission is must. It is treated with IV fluids and IV insulin. They need frequent blood testing till the time they are out of DKA.

4. What are the targets for control in children?
Targets are similar to adults. However, it is difficult to achieve HbA1c of 7%. Hence, most of the guideline recommend to 7.5-8% should be fine. Once child grows up and understand the disease better, control can be tightened.

5. What should be the frequency of monitoring?
In the initial phase daily sugar testing is must. Once they achieve good control then we should monitor blood sugar at least 2 days in a week. They should check FBS, Pre-Lunch BS, Pre-dinner BS and Post-dinner BS. HbA1c should be tested once in three months.

6. When should we start monitoring for chronic complications?
5 years, after the onset of diabetes a regular annual monitoring for eyes, kidneys, heart and nerves should be done.

7. Insulin injsites, types of insulin?
There are different types of insulin and insulin analogs. Newer insulin have better profile in term of sugar control. Nowadays, these insulin are preferred. These include Insulin aspart, glulisine, lispro which are short acting analogs. Detemir and glargine are long acting analogs.

Preferred injection sites are abdomen and thigh. Site should be changed on regular basis. Injecting at same site can lead to lipodystrohy which look cosmetically bad.

8. Are insulin delivery devices useful in children?
Insulin delivery devices like pen and pump are useful in children. Pen devices give the ease of injection with minimal pain. Patients on basal-bolus regimen are frequently using pen devices.

Insulin Pump is newer and expensive modality in treating these patients. It helps in achieving better control with lesser risk of hypoglycemia. A proper training is must for all the patient and parent who whish to be put on pump.

9. Why are oral tablets not effective in children?
In type I diabetes beta cells of pancreas are destroyed completely, hence, there is no scope of insulin production from with in. Tablets are suppose to stimulate pancrease and make mor e insulin. Since, pancreas is already weak and unable to make any more insulin, so tablets are not at all useful.

10. Artificial pancreas/pancreatic transplant
One of the promising treatment modality is to transplant beta cells. It is a highly specialized process. Beta cells from the donar are injected into patients liver, which have capacity to make insulin. This procedure is done only at selected centres in the World. Currently, it is not available in India.

11. Youngest child treated

We have treated youngest child of 3 months with insulin. Hence, there is no need to worry about insulin if used properly.