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Type 1 Diabetes is one of the most common endocrine diseases seen in young children. According to the Indian Journal of Endocrinology and Metabolism, the incidence of Type 1 Diabetes mellitus (T1DM) is also on the rise like Type 2 Diabetes, even though not in the same proportion, but still with a trend of 3-5 per cent increase/year.
Type 1 Diabetes is an autoimmune condition, where the immune system (the body's natural defence against infection and illness) mistakes the cells in your pancreas as harmful and attacks them. In Type 1 Diabetes, the pancreas (a small gland behind the stomach) doesn't produce any insulin the hormone that regulates blood glucose levels. This is why it's also sometimes called insulin-dependent diabetes.
If the amount of glucose in the blood is too high, it can, over time, seriously damage the body's organs.
Type 1 Diabetes is generally caused due to environmental factors. It can be either viral or different infection or different environmental toxins. It is still unclear what cause Type 1 Diabetes. But, yes we are seeing more number of patients with Type 1 Diabetes.
Diabetes occurring in a new born child is called neonatal Diabetes. The main feature of neonatal Diabetes is that it is seen in a baby under the age of 6 months, and this is where it's different from Type 1, as Type 1 doesn't affect anyone under 6 months. It is caused by a change in a gene which affects insulin production. This means that levels of blood glucose (sugar) in the body rise very high. Every year I come across one to two cases of neonatal Diabetes. There are two types of neonatal Diabetes - transient and permanent.
Transient neonatal Diabetes doesn't last forever and usually resolves before the age of 12 months. But it usually recurs later on in life, generally during the teenage years. It accounts for 50-60 per cent of all cases. Permanent neonatal Diabetes, lasts forever and accounts for 40-50 per cent of all cases.
Around 50 per cent of people with neonatal Diabetes don't need insulin and can be treated with a tablet called Glibenclamide. These people have a change in the KCNJ11 or ABCC8 gene and need higher doses of Glibenclamide than would be used to treat Type 2 Diabetes. As well as controlling blood glucose levels, Glibenclamide can also improve the symptoms of developmental delay. It's important to know if your child has neonatal diabetes to make sure they're getting the right treatment and advice (e.g. stopping insulin).
The only treatment for Type 1 Diabetes is insulin. In children with Type 1 Diabetes rapid-acting/regular and long acting insulin is required. So it can be either rapid acting and regular insulin preparation or a basal insulin with rapid acting insulin as pre-meal insulin along with basal insulin more preferable. In toddlers, we tend to give fast acting insulins. This insulin has an added advantage that it can be given after they eat; since their eating habits are unpredictable
The dose and regime for each child is different and there is an approximate dose e.g., for a smaller child 0.5-1 unit per kg per day but even that needs titration.
Normally, in Type 1 Diabetes you have to
monitor your blood sugar levels every day (at least 4-6 readings) so that we can analyze a trend. Once the trend is recognized the doses are then adjusted, but still monitoring of blood sugar levels have to be done more meticulously than a person with Type 2 Diabetes.
Insulin pump therapy is officially called “Continuous Subcutaneous Insulin Infusion” (CSII) and closely imitates the natural
action of the pancreas, providing a constant supply of insulin to the body and extra doses as needed in a patient with Type 1 Diabetes. It is now the gold standard of therapy for insulin dependent Diabetes, especially in children.
An insulin pump can help you manage your Diabetes. By using an insulin pump, you can match your insulin to your lifestyle, rather than getting an insulin injection and matching your life to how the insulin is working. CSII is better than injections as it gives more flexibility in terms of dietary pattern. It also reduces the need for multiple injections. Since insulin is going in the body continuously it is also more physiological.
When you work closely with your Diabetes
care team, insulin pumps can help you keep your blood glucose levels within your target ranges. People of all ages with Type 1 Diabetes use insulin pumps and people with Type 2 Diabetes have started to use them as well. Although insulin pumps can aid in controlling blood sugar levels, frequent testing by needle pricks is a must. Pumps that can monitor a patient's blood glucose levels and release insulin accordingly are being developed they are called the closed loop systems or artificial pancreas. However, they have not yet been approved for clinical use.
Insulin pumps are considered the gold standard of Diabetes therapy and are making their way in India as well. People of all ages use the pump. Currently my youngest patient with an insulin pump is 6 years old. Also, note that for young kids, it's the parents who manage the Diabetes, regardless of whether the child is on injection therapy or pump therapy.
Insulin pumps deliver rapid- or short-acting insulin 24 hours a day through a catheter placed under the skin. Your insulin doses are separated into:
• Basal rates - Basal insulin is delivered continuously over 24 hours, and keeps your blood glucose levels in range between meals and overnight. Often, you program different amounts of insulin at different times of the day and night.• Bolus doses to cover carbohydrate in meals - When you eat, you use buttons on the insulin pump to give additional insulin called a bolus. You take a bolus to cover the carbohydrate in each meal or snack. If you eat more than you planned, you can simply program a larger bolus of insulin to cover it.
• Correction or supplemental doses - You also take a bolus to treat high blood glucose levels. If you have high blood glucose levels before you eat, you give a correction or supplemental bolus of insulin to bring it back to your target range.
• Local reactions such as swelling and redness and kinking of the plastic tubing can be annoying but usually they are well tolerated.
• Pumps are much more expensive to buy and a bit more expensive to maintain. However managing your diet and activity is better with a pump as it gives you more flexibility.
• Diabetic ketoacidosis - If for any reason the insulin pump stops working and alarm fails; and the patient also does not monitor sugar and ketone bodies during this time then ketoacidosis can develop. This is rare.
• Hypoglycaemia - Again these are caused by technical errors or lack of monitoring on part of the family. Also during physical activity if the patient does not take away pump or does not eat in between, hypoglycemia can develop.
Unlike Type 2 Diabetes, Type 1 is always symptomatic within a short duration. In Type 2 Diabetes, the onset of the disease starts much before it is diagnosed. Most of the patients come to me with extreme weight loss, polydipsia (excessive thirst), polyuria (passing large volumes of urine), or diabetic ketoacidosis (DKA). Almost 50 per cent of patients present with DKA or severe weight loss.
Puberty is challenging for all children. During this phase the teenagers start rebelling, there is less compliance in terms of diet, medication and exercise. As a result, teenagers need frequent counseling to manage their Diabetes better. The bright side is there is no difference in the pubertal development of a child with Type 1 Diabetes as compared to a child without Diabetes.
Since Type 1 Diabetes is an autoimmune disease we generally scan children for other autoimmune diseases as well, like thyroid disease (hypothyroidism) or celiac disease (an autoimmune disorder that can occur in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine), which is commonly seen in patient with Type 1 Diabetes. In patients with thyroid diseases and Diabetes we give them thyroxine replacements and in cases with celiac disease the children are given a gluten free diet. These conditions are life- long and parents and children require a lot of counseling and guidance in managing these autoimmune conditions. It is a permanent condition, although early diagnosis is better, the condition as such has to be dealt with as long as the child lives.
Diabetes is a challenge! But over the years, there has been so much advancement in technology. We now have better- insulins, programs and awareness, insulin pumps, ways of monitoring blood glucose levels (continuous monitoring glucose monitoring). So I personally feel that we are going to win the Type 1 Diabetes war and I do hope that eventually all this helps the children live a longer life (70-80 years) like normal people.
The corner stones of Diabetes management are insulin injections, home blood glucose monitoring, education, diet control and exercise. If patients are motivated well and take special care then managing Diabetes is quite easy. Children require special care and attention and parents need to be proactive in helping their children manage their condition better.
DrAshutoshPakaleisConsultantDiabetologist
