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Diabetes Mellitus in Children

Also otherwise termed as growth-onset or juvenile diabetes, diabetes in children is a typical type of diabetes which occurs exclusively in children. Unfortunately it is usually missed by the parents, sometimes with tragic consequences.

Almost 95% of such cases belong to a special category called idiopathic where there is total absence of insulin in the body. It is believed to be hereditary and is an inborn error of metabolism. In a considerable proportion of cases the condition runs in the family with the siblings, particularly identical twins, showing higher degrees of occurrence than their parents.

In the rest 5% of the cases the conditions is a consequence of such causes like Cushing's syndrome, hyperpituitarism and removal of the pancreas.

There is a third category of diabetes in children which is known as 'transient diabetes of the new-born'. It is more or less a harmless condition and usually disappears within 4 to 8 weeks.

The manifestations of the condition are caused as a result of total absence of insulin in the body which prevents the sugar  present in the blood (as glucose) from entering the body cells. Sugar being the single source of energy that keep these cells alive and therefore must be available to them at all costs constantly, it is produced by the cells themselves from proteins (in the form of amino acids) or fats (in the form of fatty acids) by a process called neo-glucogenesis, in order to survive.

This results in wasting of the body fat and protein reserves. The process, neo-glucogenesis, also causes several toxic by-products to be created, namely acetone, aceto-acetic acid and -hydroxybutyric acid (called ketone bodies as a group), and these tend to accumulate in the blood. Being produced in quite large, and sometimes, in overwhelming quantities, these essentially toxic-to-the-body chemicals are the cause of the dangerous coma of diabetes.

This is unfortunately the first manifestation that forces the parents to consult a doctor on an emergency basis as the child becomes unconscious without any apparent rhyme or reason. The danger signals are always there (these are discussed later on) but they are inherently so innocuous by nature that they are easily overlooked. Diabetic coma is a serious emergency and needs to be countered on a war-footing. The treatment cannot be administered in the home but only in the hospital.

Usually the onset is sudden. There is usually a sudden onset of excessive thirst, excessive passage of urine (particularly at nights), bed wetting in children who were previously dry and excessive hunger. All of these are accompanied by loss of weight, general feeling of weakness, tiredness and body pains. These are the earliest occurring features.

Sudden "fainting attacks" due to spontaneous low blood sugar, inflammation of outer genitalia in girls, pain in the abdomen, nausea and vomiting, irritability and deterioration in performance at school may also occur.

Once the suspicion of diabetes has been aroused, certain investigations however need to be carried out without further delay:

  1. Examination of urine for sugar and ketone bodies (usually acetone). This may be done quickly by the doctor in his chambers using special strips available for the very purpose. However, for confirmation the urine must be re-checked by a competent laboratory for sugar and acetone.
  2. Examination of blood. Unless urine tests prove the presence of sugar, a random blood sugar [RBS] should be carried out as a matter of routine where the warning signals, like unexplained feeling of weakness, tiredness, deterioration of performance at school and particularly if the siblings/parents/other blood relatives are diabetics. If there is sufficient evidence to produce suspicion (this must be determined by the attending doctor), then a fasting blood sugar [FBS] followed by a post-prandial blood sugar [PPBS] tests must be carried out. Both the FBS and PPBS should be carried out in the laboratory. If urine tests are positive, then the RBS test can safely be given the go-by since it would show a strongly positive result in any case. The blood test must be performed without any delay, preferably in the same sitting. Alongwith a test for the presence of sugar and ketones in urine done with the help of strips in the doctor's chambers, an RBS test with the help of a specialised instrument called glucometer can be carried out in the doctor's chambers itself. Normally, an FBS level of 160 mg% + is diagnostic of diabetes.
  3. A specialised test called Glucose Tolerance Test [GTT] should be performed in all doubtful cases.

Once the diagnosis has been established, insulin injections are the only solutions and these have to be taken life-long. There is no escape from the daily prick, though specialised insulin delivery devices are increasingly coming into the market that are able to deliver 'painless' and measured shots. It is quite heart-rending to see these young children having to undergo the pain and the anguish of the parent who has to administer the shots, but there is nothing one can say other than to express their sympathy.

Unfortunately, the management of childhood diabetes does not send singly with stabilising the condition with insulin administration. To ensure the continuance of a reasonably good quality of life, it is most necessary to establish a very good rapport between the doctor, the child and the parents. While too many dietary restrictions are not advisable these days, food materials containing sugars in concentrated forms like sweets, plain sugar, chocolates, candies, cakes and similar stuffs should be avoided strictly. Unsweetened fruit juices and fruits are allowed though since the sugar that they contain do not cause any harm to a diabetic as a routine.

The other complications of diabetes, besides coma are as follows. As the condition affects nearly all body cells, it is of little surprise that nearly all body organs are affected, often with devastating and even fatal consequences. However, like coma, most of these complications develop late and that too in neglected cases.

  1. Nervous system - inflammation of the retina (nerve of the eye), and the peripheral nerves.
  2. Cardio-vascular system - high blood pressure, atherosclerosis.
  3. Kidneys - Kimmelstiel-Wilson Syndrome (KW Syndrome).
  4. Eyes - cataract.
  5. Liver - enlargement of the organ leading to a host of consequent problems.
  6. Chronic infections which simply refuse to heal easily - boils, infections of the eye (stye), abscesses, fungal infections, tuberculosis.

Since the improved understanding of diabetes as a whole and revolutionisation in its treatment, most children with controlled disease have fairly reasonable development and growth, all of which are accompanied by a healthy increase in the average longevity of life. However, the risks and the accompanying dangers of long-term complications are always there and the daily needle pricks can never ever stop till the last day of life.

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Compiled from various sources by Dr. S. B. Bhattacharyya.
Copyright [SUDISA]. All rights reserved.
Revised: September 09, 1999.