A consultant paediatrician and endocrinologist at the Federal Medical Centre, Asaba, Delta State, Dr Kayode Adeniran, discusses diabetes in children with ALEXANDER OKERE
What is diabetes mellitus?
It is a chronic health condition that affects how the body turns food into energy, due to impaired ability of the body to produce or respond to insulin. It is characterised by elevated blood glucose (or blood sugar), which can lead to serious consequences and complications.
What are the general risk factors for diabetes?
The risk factors differ depending on the type of diabetes. Risk factors for Type 1 diabetes include having a family history (parent or sibling), injury to the pancreas (such as infection, tumour, surgery or accident), autoantibodies that mistakenly attack the self-body tissues or organ and exposure to some chemicals.
The risk factors for Type 2 diabetes are family history, being overweight, physically inactive (sedentary), if the person is aged 45 or older, having high blood pressure, having low HDL cholesterol (the “good cholesterol”), being a smoker and excessive alcohol intake. The risk factors for gestational diabetes are family history, over 25 years maternal age and being overweight prior to getting pregnant.
What are the general symptoms?
Generally, the symptoms are increased thirst, excessive drinking of water, frequently passing urine, getting tired or weak and weight loss or weight gain (depending on the type of diabetes). Others are blurred vision, numbness or tingling sensation in the feet or hands, frequent unexplained infections and slow healing of wounds.
Are there symptoms peculiar to men and women?
The symptoms peculiar to men are decreased sex drive, erectile dysfunction, reduced amount of ejaculation, retrograde ejaculation and decreased male sex hormone (testosterone). In women, they are vaginal infection, characterised by itching, soreness, vaginal discharge, painful sex and oral yeast presenting as white coating on the tongue and inside the mouth. Urinary tract infection symptoms include painful urination, burning sensation when passing urine, cloudy or bloody urine. If this is not treated on time and well it this can lead to infection of the kidney.
In addition to the above symptoms, the person may have very high fever.
What are the other types of diabetes?
The other types are gestational diabetes, maturity-onset diabetes of the young, latent autoimmune diabetes in the adult, neonatal diabetes, drug-induced diabetes, etc. Type 1 diabetes is insulin-dependent, meaning that treatment with insulin injection is necessary from the time the disease is first diagnosed. The cause is autoimmunity – the body cells attacking each other. In this regard, some type of white blood cells that protect the body inadvertently start to destroy insulin producing cells (beta cells) of the pancreas, this ultimately leads to a significant loss of the insulin production.
Without insulin, glucose remains within the bloodstream and the blood glucose increases, especially after eating meals. Glucose is then passed out of the urine because the kidney can’t reabsorb the excessive amount of glucose in the blood. While the inheritance of gene contributes to the risk of having Type 1 diabetes, long-term risk of siblings developing this type of diabetes is about three to six per cent for parents with this type of diabetes. If it is the mother, the risk for the child is one to two per cent. If it is the father, the risk is four to six per cent and in identical twins, it is 35 per cent.
Type 2 diabetes is also called adult-onset diabetes or insulin independent diabetes – the former because the onset usually is after the age of 35 years (though children are now increasingly developing this type of diabetes) and the latter name because insulin is not usually needed for the treatment. At a later stage of Type 2 diabetes, many need insulin treatment just as in Type 1 diabetes). Furthermore, in Type 2 diabetes, the ability to produce insulin does not disappear completely as it is in Type 1 diabetes, instead, the body gets resistance to the insulin, so there is enough insulin but the body isn’t responding to it appropriately. The oral drugs used in treating Type 2 diabetes does not contain insulin but increases the sensitivity of the body to insulin or by increasing the release of insulin from the pancreas.
The major risk factor to developing this Type 2 diabetes is overweight –obesity – which can be related to lifestyle, inadequate exercise, eating too much, especially unhealthy diet, and taking too much refined sugar and fat. Central obesity is found mostly in people with Type 2 diabetes. There is a genetic contribution to Type 2 diabetes as it runs in some families. However, there is a non-obese Type 2 diabetes that though less common has a very strong genetic family risk. There is a rash called acanthosis nigrican mostly common around the nape of the neck, underarms, groin and elbows. It feels velvety, rough and looks dark brown or black. This is a sign of insulin resistance.
Gestational diabetes is diagnosed for the first-time during pregnancy (gestation). The high blood glucose that results can affect the mother, the foetus and the newborn baby. During pregnancy, the body makes more hormones and goes through a lot of changes, especially weight gain. These changes cause insulin resistance, leading to increased insulin production to meet the need of glucose metabolism. It usually develops in the 24th week of pregnancy. About 50 per cent of women with gestational diabetes go on to develop Type 2 diabetes, while others recover after the pregnancy and would not have diabetes.
Maturity onset diabetes of the young is a rare form of genetic diabetes that some children and adolescent have and there is usually a strong family history.
Neonatal diabetes is a special form of diabetes which occurs in the first six months of life and is usually due to a single gene defect. The infant usually does not produce enough insulin, leading to increased glucose unavailable for energy production in the cell.
How prevalent is Type 2 diabetes among children in Nigeria?
There are about 1,500 children with Type 1 diabetes in Nigeria, according to the diabetic register of the Society for Paediatrics and Adolescent Endocrinology in Nigeria which is a hospital-based survey. There is no community-based population survey currently in Nigeria, which is more ideal and would be more representative. So, this figure is likely an underestimation of the prevalence.
Which categories of children are most affected and why?
All children can be affected from birth to late adolescent, depending on the type of diabetes. However, aside the genes and environment, puberty is a time that makes children very vulnerable because of the hormonal changes that take place.
Can Type 2 diabetes affect a newborn?
The type of diabetes that affects the newborn is not Type 2 but a monogenic form, where a single gene mutation in one of the several genes that are involved in the normal development and function of the pancreatic beta cells, thereby affecting insulin production and function. It may be transient or permanent and usually present within the first six months of life, and occasionally up to 12 months of life.
What are the signs to look out for?
The presentation may be non-specific. However, the signs highly suggestive are frequently wet diapers, a large appetite, weight loss or inadequate weight gain, persistent thirst (always drinking water), yet dehydrated.
Can those signs be mistaken for other conditions?
Yes.
What are they?
They include diabetes insipidus, urinary tract infection, chronic pancreatitis, cystic fibrosis and secondary hyperglycemia (high blood glucose).
Does that also mean overweight kids whose parents think are well-fed may have Type 2 diabetes?
Society generally, parents inclusive, think that children who are overweight are well-nourished and it is assumed they are from a wealthy background in contradistinction to children who are of normal weight for their age and sex. Out of ignorance, a lot of parents indulge their children to make them get fat.
What is your general assessment of the attitude of parents towards child diabetes in Nigeria?
Anecdotally, from interaction, most people don’t know that children do have diabetes; those who know have a wrong understanding of its cause, course and care.
What is the first thing a parent or ward should do if they notice the signs symptoms you mentioned earlier?
They should get an appointment to see a certified medical doctor.
How is the diagnosis for Type 2 diabetes in kids done?
A doctor interviews the patient ascertaining, characterising and elucidating the symptoms. The past medical history, the family, social and lifestyle of the child are dissected, then a thorough examination (general and systemic) follows. All these would lead the doctor to have a working diagnosis, which needs confirmation by taking a blood sample after the child has fasted for at least eight hours. If the amount of glucose is above a certain cut-off value then it is confirmed that the child has diabetes. This is the same for Type 1. What saliently distinguishes Type 2 is that there is usually elevated fasting insulin levels, and C-peptide, and the absence of autoimmune makers.
What is the treatment method for children with Type 2 diabetes?
The treatment for children with Type 2 diabetes includes diabetic education and lifestyle, drug (oral) treatment to restore and maintain blood glucose to normal and concomitant treatment of high lipid or hypertension if they are found in the patient.
What lifestyle change should children with Type 2 diabetes be encouraged to adopt?
Children with Type 2 diabetes should be encouraged to ensure healthy eating (balanced diet), and healthy living (e.g. regular exercise and weight control).
Where do medications come in?
Medications are important to maintain normal blood glucose (euglycemia) and the drugs also have some effect on improving sensitivity to insulin, especially if there is insulin resistance. If and when there is co-morbidity, such as hypertension or hyperlipidemia, medication will normalise them.
Is surgery required in the treatment of the disease?
Weight loss surgery (bariatrics surgery) is an effective treatment for Type 2 diabetes and may result in an improvement in most cases.
Can Type 2 diabetes lead to complications?
Yes, it may be classified as acute (immediate) or long-term complications. The immediate complication is hyperglycemic crisis (hyperglycemic-hyperosmolar state, diabetic ketoacidosis and hypoglycemia). Complications from insulin resistance include hypertension, dyslipidemia and polycystic ovarian syndrome. Long-term complications include nephropathy, neuropathy, retinopathy, coronary artery disease.
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