Children and adolescents also not spared from diabetes

KUALA LUMPUR: “What? Children have diabetes too?” exclaimed Hassan (not his real name) when told that his fouryear-old daughter, Siti (not her real name), has diabetes.

“There is no diabetes in our family,” he told the doctor.

Hassan has the wrong impression that only adults suffer from diabetes. The truth is that children and adolescents too are not spared from the disease.

In fact, diabetes is one of the most common chronic diseases of childhood and can occur in children of any age, including toddlers and infants.

It is estimated that currently, there are more than one million children with diabetes worldwide and this number keeps increasing at a rate of three to five per cent annually. It may be a bit comforting to Hassan to know that Siti is not the only child having the disease. Type 1 diabetes in children There are two major types of diabetes in children, type 1 and type 2. Type 1 diabetes – traditionally the more common – usually occurs in children between the ages of four and 15. Presentation Siti’s symptoms are typical of type 1 diabetes presentation in children (see below). She was well two weeks ago, then one day she started complaining of always being hungry and thirsty and passing urine frequently (and in a few occasions, she also experienced bed-wetting). Her parents also noted that she seemed to be more irritable and in spite of her good appetite, was losing weight and looking tired.

Her parents took her to the hospital when they noticed that she was not her usual self as she was looking lethargic and weak with laboured breathing. Common presentation of Type 1 diabetes Excessive thirst Frequent passing (large amount) of urine Extreme hunger (younger children may have loss of appetite) Weight loss (in spite of good appetite) Weakness and fatigue Pain in the abdominal Being irritable Nausea and vomiting Having fruity- smelling breath and rapid breathing

On admission to the hospital, Siti’s blood glucose was very high (26.8 mmol/l) and she had ketones in her urine. Further investigations confirmed that she was suffering from diabetic ketoacidosis – a serious complication of type 1 diabetes, which if not treated early and effectively, may lead to death. Causes While the exact cause of type 1 diabetes is not known, it is believed that in most children, the body immune system attacks and destroys beta cells that produce insulin in the pancreas. The process may be triggered by certain (common) viral infections. Early introduction of cow’s milk or cereal to the baby’s diet may also increase the risk.

Genetics may play a role (as autoimmune conditions tend to run in families), but type 1 diabetes can occur without a family history (as in Siti’s case).

Insulin is essential in bringing in sugar (glucose) from the blood circulation into the body cells to be used as energy. As the beta cells are destroyed by the autoimmune process, children with type 1 diabetes produce little or no insulin at all. Because of this lack of insulin, glucose accumulates in the child’s bloodstream, causing hyperglycaemia ( high blood glucose level).

The persistently high blood glucose level, if not controlled, would lead to the acute (for example, blurring of vision, ketoacidosis) and chronic complications of diabetes such as kidney damage (nephropathy), nerve damage (neuropathy), eye damage (retinopathy) and others. Treatment of type 1 diabetes Because a child with type 1 diabetes has little or no insulin, he/she must have daily insulin injections to keep the blood glucose within the normal ranges (to live). The child must also be educated on appropriate food intake (especially carbohydrates and sugars) and encouraged to be physically active (with regular exercise) to make the body more sensitive to the action of insulin.

Blood glucose levels will have to be checked regularly using a portable glucometer (and urine ketones, when indicated). The parents will have to give the insulin injections and carry out the tests initially (when the child is small) but the child must be taught to take care of himself/herself when he/ she is older.

Siti is now seven years old and is coping well with her diabetes. She administers her own insulin injections and does regular blood glucose (and occasionally urine ketone) testing. She enjoys schooling with the encouragement of her teachers and friends who are aware of her diabetes. Type 1 diabetes: Prognosis good if diabetes is managed well Research is ongoing to find ways to prevent or cure type 1 diabetes. Sadly, to date, it is not possible to prevent or cure the disease.

Nonetheless, effective treatment is available to manage diabetes type 1: Insulin has to be given daily, ideally to mimic the physiologic insulin release in healthy individuals.

This would entail at least four injections a day: a fast- acting insulin before each of the three main meals to cover for blood glucose rise after the meal and another injection of long- acting insulin at bedtime to provide background insulin. Children may be prescribed an insulin pump, thus eliminating the need for the multiple daily injections.

Children with type 1 diabetes also have to test their blood glucose levels, up to seven or eight times each day; and test their urine for ketones.

The blood glucose test can be performed using a glucometer and strips. But, recently, a patch device has been made available to measure blood glucose continuously (for up to 14 days), eliminating the need for multiple daily finger-pricks.

And prototypes of “artificial pancreas”, which automatically release insulin based on blood glucose feedback, have been developed, eliminating the need for frequent manual insulin adjustment (and injections) and blood glucose testing.

The good news is that, with good control, children with type 1 diabetes can expect to lead a long and healthy life, free of complications. However, while this is possible, making it a reality needs serious commitment from all stakeholders – the parents, child, teachers and friends – and with full support from the healthcare team. T-1 Club @ Diabetes Resource Centre In an effort to help children with diabetes and their caretakers to cope with the life-long disease, the National Diabetes Institute (NADI) has formed the T-1 Club at its resource centre in Klang.

The club holds regular gettogethers for the children and their parents to learn and share experiences on the best ways to manage diabetes. Regular outings and diabetes camps are also arranged while glucometers and test strips are given free to eligible children. Membership is free. Type 2 diabetes in children Daniel’s (not his real name) story is not the same as Siti’s. Daniel was diagnosed with diabetes when he was 12 years old after a routine blood test at school. He had no symptoms and his parents too were shocked when told of the diagnosis. Presentation Type 2 diabetes classically occurs in older people, 40 years and above. But the condition is now more frequently seen in younger people who are in their 20s and 30s (and as young as four to six years).

And most of them do not know that they have diabetes until they are tested, as reported in the National Health and Morbidity Study 2017.

Typical for children with type 2 diabetes, Daniel was obese for his age. He was not active physically, spending most of his free time with his iPad or playing video games. His mother developed diabetes when she was pregnant with Daniel. Causes Type 2 diabetes is also influenced by genetic and environmental (lifestyle) factors (see below). As in adults, type 2 diabetes in children is thought to be due to insulin resistance, made worse by being overweight or obese and physically inactive. Risk factors of Type 2 diabetes in children Positive family history of diabetes in parent(s); mother had diabetes during her pregnancy (gestational diabetes). Low birth weight or high birth weight. Overweight/Obese overeating). Not active physically. Presence of dark skin patches over neck, abdomen, elbows (acantosis nigricans). Associated with polycystic ovary syndrome (in girls). Has other features of insulin resistance, for example, high blood pressure, abnormal cholesterol levels. (due to Treatment In contrast to type 1, most often in children, type 2 diabetes can be managed with lifestyle adjustment including limiting food intake, increasing physical activity and doing regular exercise and reducing the excess weight.

Oral anti-diabetic agents such as metformin or sulfonylurea may be prescribed by the doctor if lifestyle adjustments are not sufficient to control blood glucose (to normal levels).

Medications to lower high cholesterol and blood pressure levels may also need to be prescribed when indicated, to reduce complications, especially to the heart and kidneys. Conclusion: Reducing risk of diabetes in our children While presently there is no effective means to prevent type 1 diabetes in our children, we can still take steps to reduce the risk.

As studies have shown that the risk is increased with bottled (cow’s milk) feeding or early introduction of solid foods in the diet, we may want to encourage breastfeeding in our children (and for a longer period before introducing solid foods).

For type 2 diabetes, the issue seems clearer: we must make sure that our children take to healthy and balanced diets and be physically active. Children should also not be overfed to the extent of them becoming overweight or obese.

The belief that a “chubby baby is a healthy baby” should be discarded as “chubby” babies have been shown to end up being fat teenagers and obese adults. And, obesity is a strong risk factor for diabetes and other chronic diseases.

Studies have suggested that the (metabolic) health of a baby is determined from the time he/she is in the womb. As such, it is also important that women who are (or intending to become) pregnant adopt a healthy lifestyle and pay due attention to healthy and balanced nutrition.

They should also be active physically and avoid unhealthy habits, such as smoking or drinking alcohol. You owe this to your unborn baby to prevent him/ her from getting chronic diseases, including diabetes.

Emeritus Professor Datuk Dr Mustaffa Embong is consultant diabetologist at the National Diabetes Institute ( NADI). — Bernama