Type 1 diabetes: How to tackle the disease in children

Table of contents

• What causes type 1 diabetes?

• The role of insulin in type 1 diabetes

• Symptoms of type 1 diabetes

• Complications of type 1 diabetes

• Diagnostic tests for type 1 diabetes

• Management of type 1 diabetes in children

• Take-Home Points

• FAQs on Type 1 diabetes: How to tackle the disease in children

Introduction

Type 1 diabetes is a chronic condition where the pancreas's beta cells or insulin-making cells make little or no insulin. This chronic insulin-dependent diabetes was once known as juvenile diabetes, as it was seen more in children and young people, but type 1 diabetes can develop at any age. Type 1 diabetes has no cure; the treatment focuses on managing blood sugar levels using insulin, diet, and lifestyle to prevent other complications.

What causes type 1 diabetes?

The exact cause of type 1 diabetes is unknown. The possible causes include:

Autoimmunity

It is a condition where the body’s immune system mistakenly destroys the healthy cells and organs of the body. Type 1 diabetes is thought to be mainly due to autoimmunity, where the immune system attacks the beta cells of the pancreas, thus affecting insulin production.

Genetics

It is another factor that leads to type 1 diabetes. Certain genes passed from parents to the child could cause type 1 diabetes.

Viruses

Exposure to viruses and other environmental factors could lead to type-1 diabetes. 

The role of insulin in type 1 diabetes

The body uses glucose as the primary source of energy. The glucose enters the bloodstream by breaking down the carbohydrates from the diet. The beta cells produce insulin, which lets glucose enter the body's cells to provide energy. Any damage to the beta cells would affect insulin production, and the glucose does not move into the cells resulting in high blood glucose levels.

Symptoms of type 1 diabetes

Symptoms of type 1 diabetes include:

• Excessive thirst

• Unexplained weight loss

• Excessive hunger

• Blurred vision

• Slow healing of sores and cuts

• Fatigue

• Frequent urination

• Full diapers in infants

• Bedwetting in children

Complications of type 1 diabetes

Type 1 diabetes could affect the human body's major organs over time. High blood glucose levels lead to various complications involving the heart, kidneys, eyes, blood vessels, and nerves.

Blood vessel and heart diseases

The complications involving the blood vessels and heart include coronary artery disease with angina (chest pain), heart attack, stroke, atherosclerosis (narrowing of the arteries), and high blood pressure.

Nephropathy or kidney damage

High glucose levels in the blood could damage the kidneys over time and lead to end-stage kidney diseases. The treatment options for end-stage kidney diseases are dialysis and kidney transplant.

Eye damage

Diabetes can cause serious eye damage like diabetic retinopathy leading to blindness, cataract, and glaucoma. 

Neuropathy or nerve damage

Injury to the walls of the capillaries (tiny blood vessels) that feed the nerves causes numbness, tingling, and pain or burning sensation. These sensations commonly begin at the tip of fingers and toes and move upwards. Failure to manage high blood glucose levels over some time could cause the loss of all sensations in the affected limb. 

Mouth and skin diseases

Uncontrolled diabetes increases the risk of fungal and bacterial infections in the skin and mouth. Rashes, blisters, dry mouth, and gum diseases are common in patients. 

Diagnostic tests for type 1 diabetes

• Type 1 diabetes can be diagnosed easily through blood and urine tests.

• A blood test showing high blood glucose levels and the presence of autoantibodies indicates type 1 diabetes.

• Urine test for ketones: 

The human body generally uses glucose as a source of energy. In type 1 diabetic patients, the glucose does not move into the cells, making the body use the stored fats as an energy source. Burning fats for energy produces ketones; their presence in the urine indicates type 1 diabetes.

Management of type 1 diabetes in children 

Type 1 diabetes has no cure; thus,  the treatment focuses on managing blood sugar levels using insulin, diet, and physical activities.

1. Blood glucose management

a. Insulin

Insulin therapy is critical for survival in all people with type 1 diabetes. Intensive insulin regimens can prevent the risk of developing complications in teenagers through multiple daily injections of prandial and basal insulin. The insulin regimen helps to mimic the regular insulin secretion patterns and achieve near-normal glycemic control. 

Insulin doses for children on multiple daily injections (MDI) routine:

The initial daily insulin dose is calculated based on the patient’s weight. A child newly diagnosed with type 1 diabetes initially requires a dose of about 0.5 - 1.0 units/kg. One unit of insulin will process anywhere from 12 - 15 grams of carbohydrates and lower blood sugar by nearly 50 mg/dL.

The MDI (multiple daily injections) routine includes delivering long-acting insulin once a day in the morning or evening (sometimes twice a day in about 20% of patients) and rapid-acting insulin before snacks or meals. The long-acting insulin takes several hours to work and lasts about 24 hours, and rapid-acting insulin starts to work in about 15 minutes and continues to work for 2 - 4 hours. The doses are adjusted based on the carbohydrate intake and blood glucose level to achieve the blood sugar target. 

b. Insulin pump therapy or continuous subcutaneous insulin infusion

Insulin pumps are an alternate setup for insulin delivery in children with type 1 diabetes. Recent studies show that children treated with insulin pumps have lower A1C (HbA1c - glycated hemoglobin) levels, improved diabetes-related quality of life, less fear of hypoglycemia (a condition where the blood glucose level falls below the standard range), and higher treatment satisfaction. Incorporating CGM (continuous glucose monitor) device with the insulin pump demonstrates notable improvement in both hypoglycemia reduction and glycemic control in children.

A1C should be measured at 3-month intervals in all adolescents and children with type 1 diabetes to assess their overall glycemic control.

c. Artificial pancreas

Artificial pancreas or closed-loop systems focus on enhancing glycemic control in type 1 diabetes. It includes a CGM in constant communication with an insulin infusion pump and a blood glucose device used for CGM calibration. An external processor like a smartphone receives the data from CGM and runs the control algorithm software. The amount of carbohydrates consumed is entered manually into the external device. The insulin infusion pump receives dosing instructions from the external device based on the carbohydrate input and CGM data. 

d. Blood glucose monitoring to determine insulin needs

All adolescents and children with type 1 diabetes might need to have blood glucose levels monitored multiple times daily, including premeal and pre-bedtime, and as required for safety in specific situations such as driving, exercise, and the presence of symptoms of hypoglycemia or illness. 

SMBG (Self-monitoring of blood glucose) levels is essential in treating type 1 diabetes in children. Routine SMBG determines immediate insulin needs (e.g., mealtime), safety assessment (e.g., corrective action for or prevention of hyper- or hypoglycemia), and longer-term adjustment in insulin dosing regimens based on blood glucose patterns and trends.

Blood glucose targets vary with the patient’s age, insulin regimen, supervision levels, and other lifestyle issues to achieve as many glucose values as close to the target as possible without excessive hypoglycemia.

e. Urinary/blood Ketone Monitoring

The ketone levels need to be monitored in children with type 1 diabetes in prolonged or severe hyperglycemia and acute illness to determine if adjustment to treatment or referral to urgent care is required. 

2. Lifestyle changes for children with type 1 diabetes

The lifestyle changes to help children manage diabetes focuses on dietary changes, regular physical activity, and weight management. 

a. Dietary management

Dietary management or nutritional therapy is an essential element of the overall treatment plan, and it considers family habits, food preferences, cultural or religious needs, schedules, and physical activity. The key to achieving optimal glycemic control is monitoring carbohydrate intake. 

Carbohydrate intake from fruits, vegetables, legumes, whole grains, and dairy products, with a focus on foods higher in fiber and lower in glycemic load, is preferred over other sources containing added sugars. Saturated fats should be limited. Caloric intake should fuel normal growth and development and avoid being underweight and overweight. 

3. Exercise and weight management

Exercise is advised for all youth with type 1 diabetes with the goal of 60 min of moderate- to vigorous-intensity aerobic activity daily and vigorous muscle-strengthening and bone-strengthening activities at least three days per week. However, education about preventing and managing potential hypoglycemia during and after exercise is crucial.

Periodic glucose monitoring before, during, and after exercise, with or without CGM use, is essential as it helps to prevent, detect, and treat hypoglycemia and hyperglycemia. 

Approaches to prevent hypoglycemia during, after, and following exercise include reducing prandial insulin dosing for the meal preceding exercise, increasing carbohydrate intake, eating bedtime snacks, using CGM, and reducing basal insulin doses.

Given the present trends, at least one-third of adolescent patients with type 1 diabetes are obese or overweight. Proper and suitable diet and physical activity routines help to manage body weight.

1. Blood glucose management

a. Insulin

• Intensive insulin regimen using prandial and basal insulin

• Insulin pump

• Artificial pancreas

b. Blood glucose monitoring to determine insulin needs

2. Lifestyle changes for children with type 1 diabetes 

a. Dietary management

• Monitor carbohydrate intake

• Consume food rich in dietary fiber and low glycemic load

• Limit saturated fat 

• Avoid sugary foods and processed foods

b. Physical activity and body weight management

• Manage body weight with proper diet and exercises

• 60 minutes of aerobic activity daily

• Muscle and bone strengthening exercise at least three days per week 

Take-Home points

Type 1 diabetes is a chronic condition where the pancreas's beta cells or insulin-making cells make little or no insulin. Insulin lets glucose enter the body's cells to provide energy. Any damage to the beta cells would affect insulin production, and the glucose does not move into the cells resulting in high blood glucose levels.

This chronic insulin-dependent diabetes appeared mainly in children and young people and thus was known as juvenile diabetes, but type 1 diabetes can develop at any age. 

The exact cause of type 1 diabetes is unknown. However, it is thought to be mainly due to autoimmunity, where the immune system attacks the beta cells of the pancreas, thus affecting insulin production. Other possible causes include genetics, viruses, and other environmental factors. 

Type 1 diabetes has no cure; thus,  the treatment aims to manage blood sugar levels using insulin, diet, and physical activities.

References 

• Care of Children and Adolescents With Type 1 Diabetes

• Symptoms & Causes of Diabetes

• Type 1 Diabetes in Children

• Type 1 Diabetes

• Type 1 diabetes management