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Childhood Diabetes Mellitus
Pediatricians in India often dismiss childhood onset diabetes as "rare", but recent data suggests significant disease burden. Diabetes is the second commonest chronic disorder of childhood, after asthma. Almost all children with onset under the age of 15-18 years have the insulin dependent form (IDDM). It is important to realize that "While it has been possible to treat IDDM since 1922, optimal management to ensure a high quality of life while preventing late tissue damage demands a high degree of skill by both patients and their professional advisors." (Consensus Guidelines: European IDDM Policy Group) We now have greater understanding of the problem, improved technology (test strips, meters, syringes, needles, insulins; tests for early detection of complications), patient education and self home blood glucose monitoring (SHBGM). Today it would be tragic to condemn a child to mere survival, with a once-daily dose of insulin and monitoring of only blood glucose 3-6 times/ year: we must orient ourselves to diagnosing diabetes when it occurs, and managing it optimally: ensuring a confident youngster, with normal physical, mental, and psychosocial development, who can look forward to a productive life and several decades free of chronic complications.
Of the nearly 450 young diabetics registered at the Diabetes Clinic at AIIMS over 1989-95, 76.9% had proven IDDM with history of ketosis, 17.1% had IDDM clinically (without documented ketosis), 3.6% the ketosis resistant form, and 2.4% calcific pancreatitis. All needed insulin for metabolic control. Age of onset was < 5 years in 8.3%, between 5-10 years in 26.2%, 10-15 years in 38.1%, and 15-20 years in 27.4%. Several of them remembered consulting 2-5 (even upto 11!) doctors before the diagnosis was made. Diagnosis is easy because blood sugars are usually unequivocally high. It is important to think of the possibility: test any child presenting with polyuria, nocturia (recent bed wetting), weight loss, or unconsciousness, drowsiness, dehydration, or tachypnea. Screening with urine glucose and confirming with blood glucose is needed, so test-strips for blood and urine glucose should always be available, particularly in emergency areas. This discussion is confined to the more demanding long term management. Insulin Most children, once out of coma and stabilized, need 0.5-1 units of insulin/ kg/ day. Good control is rare with once-daily injections. In the first few months after diagnosis (initial insulin resistance, stress, later honeymoon phase) and during adolescence (counter-regulatory effect of sex steroids, emotional stress), insulin needs may swing widely, even from day to day. The most practical regimen is twice-daily injections of a mixture of short acting (1/3) and intermediate acting (2/3) insulin: 20-40 minutes before breakfast (2/3) and dinner ("mix-split"). During periods of wide swings (infancy, honeymoon phase, adolescence, sick days), 3-4 injections per day may be needed. We advise that the injections should be given by the child (after age 6-10 years) or by parents (in younger children). Injections by health professionals must be strongly discouraged. Plastic syringes with fixed needles are best, and can be reused 8-12 times if precautions of hygiene are taken. Shots must be given subcutaneously: sites recommended are the abdomen for the morning dose, the thigh or upper arm for the evening dose. Rotation of sites within these areas is important to reduce lipohypertrophy. Human insulin should be started in a newly diagnosed diabetic child if the family can afford it for a lifetime. Once animal insulins have been given, the indications for switching to human insulin are insulin allergy and severe lipohypertrophy. Diet Diet should be a balanced one, based on the child's/ family's own eating habits, with minimum necessary changes. Total amount and calories should be sufficient to maintain ideal body weight, proteins 0.9-1 gm/ kg/ day (high protein is necessary and may be detrimental to renal function), fats ~ 30% of total calories and the rest as carbohydrates. Most children present with weight loss and may need a period of high calorie intake to regain normal weight. Excess salt and free sugars should be avoided. Food should be divided into 3 main meals (breakfast, lunch, dinner) and 2-3 mid-meal snacks (mid-morning, evening, bedtime). Rapidly digested foods like rice, potatoes, fruits, etc. are NOT forbidden: when eaten withplenty of fiber (e.g. with salads, or as a mixed meal), the rate of absorption is slowed down. Occasionally (at festivals, parties) sweets, cakes and sweetmeats should be permitted to improve compliance and allow the child to feel "normal". Exercise Regular physical activity should be strongly encouraged, and provision made for extra calories before exercise (e.g. sandwich or fruit before games). Rest is advised during periods of ketosis. Patient Education For optimal control the child and family must be trained to load, inject and handle (storage, transport, etc.) insulin correctly. They must learn the principles of dietary management and food exchanges. They must do some sort of home monitoring and learn to make necessary adjustments in diet, activity and insulin doses accordingly. They should know how to handle insulin doses during sickness, extra activity, or social occasions, and how to manage hypoglycemia. All these skills must be taught to them slowly and non-threateningly, over several months, and later checked frequently for correctness. It is important not to overload the child and family with information, especially immediately after diagnosis, when they are upset and trying to accept the reality of diabetes. Monitoring Some sort of home monitoring is a MUST: once-daily testing (tests at different times of the day) is the MINIMAL acceptable frequency. Blood glucose should be tested pre-meal (fasting, pre-lunch, pre-dinner, bed-time): once a day by rotation (or all 4 sugars 2-3 times a week), and at 2-3 am once a month. Money can be saved by cutting Hemoglucotest strips into half and reading them visually (thus also saving the cost of the meters). The target is to maintain pre-meal blood glucose in the range of 80-140 mg%. If daily blood testing strips cannot be afforded, pre- and post-meal urine testing, and blood testing at time of suspected hypoglycemia, must be done. Many doctors believe that in India regular monitoring cannot be achieved. We found that by constant persuasion, and cost-cutting techniques, of our patients (who come from all economic strata), 57% were monitoring at home with blood testing and 21% with urine tests, with varying degrees of regularity; only 22% were not doing any home monitoring. Insulin doses and timing should be adjusted according to the child's life schedule, using this on-going monitoring. In addition, glycated hemoglobin levels (which give average glycemic control over the preceding 10-12 weeks) should be tested every 3 months, and maintained around 0.5-1% above the non-diabetic range. This may be difficult in very young children and the pubertal years. GHb obviously cannot be used for insulin dose adjustments. Day-to-day consistency in amount and timing of diet, exercise and insulin is the crux of good control. However, some flexibility should be permitted to ensure compliance. Over months and years, adjustments would be needed in keeping with development (e.g. higher doses during puberty), changing life-style and schedules. |