Juvenile
Diabetes
Juvenile
diabetes is an autoimmune disorder which can be due
to environmental trigger or virus, which hampers the
function of beta cell. Once the beta cells are destroyed
the body is unable to produce insulin. It is also
believed that Type 1 diabetes results from an infectious
or toxic insult to a child, whose immune system is
predisposed to develop an aggressive autoimmune response
either against molecules of the B cell or against
altered pancreatic B antigens, resembling a viral
protein.
A child with diabetic siblings is more prone to develop
juvenile diabetes than the child from a totally unaffected
family. It is considered to be a more hereditary problem
than excess eating or being obese. Pancreas produces
the exact amount of insulin, to breakdown the sugar
produced in the body. The juvenile diabetic lack the
production of insulin so, sugar builds up high in
the blood, overflows into the urine and passes from
the body unused. It is estimated that about 10-15%
in United States are suffering with juvenile diabetes.
Approximately 35 American children are diagnosed with
juvenile diabetes every day. Diagnosis and Epidemiology
Diabetes
is the most common metabolic disease in the young.
The Scottish Study Group for the Care of the Diabetes
in the Young showed that currently there are nearly
2000 people with diabetes aged under 16 years in Scotland,
with an annual incidence of 25 per 100,000 population
and a near tripling of new cases in the last 30 years.
Type 1 diabetes, resulting from beta-cell destruction
and absolute insulin deficiency, accounts for over
90% of diabetes in young people younger than 25, and
is autoimmune in origin. Non-type 1 diabetes is recognised
with increasing frequency, particularly emerging molecular
forms of diabetes, diabetes secondary to pancreatic
disease and a rise in type 2 diabetes and other insulin
resistance syndromes in the young.
TYPE 1 DIABETES
12-15% of young people under the age of 15 with diabetes
mellitus have an affected first degree relative (a
positive family history). Children are thrice as likely
to develop diabetes if their father has diabetes rather
than their mother. While there are known antibody
markers of prediction in high-risk subjects, there
is no evidence for effective methods of prevention
of diabetes. Screening is currently considered unethical
except in the context of a trial. There are several
randomised trials in progress (e.g. ENDIT, DPT-1,
DIPP) investigating different therapies for the prevention
of type 1 diabetes. It is anticipated that results
will be available in the next five years.
DIABETES AND CYSTIC FIBROSIS
20% of patients with cystic fibrosis develop secondary
diabetes by the age of 20, with an incidence which
increases thereafter to 80% by the of age 35. Limited
data suggest that clinical symptoms deteriorate when
diabetes develops in cystic fibrosis, although no
evidence exists that the presence of diabetes or its
treatment affects long-term survival.
Intiating
therapy at diagnosis
Home-based
instruction of the newly diagnosed child or young
person appears to be at least as effective as inpatient
instruction in terms of glycaemic control and family
acceptability over a two-year period. Management in
the community using a home-based education programme
for patients with newly diagnosed diabetes has been
shown also to be cost-effective.
The evidence on the role of the intensification of
therapy in the attempt to achieve as rapid as possible
normoglycaemia is inconsistent. In particular, there
is no evidence of a sustained effect of any specific
insulin therapy on glycaemic control during the first
few months after diagnosis. Therefore, no recommendation
can be given for the most appropriate insulin therapy
at diagnosis.
Continuing management
There is at present no evidence for the effectiveness
of any medication other than insulin in the management
of type 1 diabetes in the young.
INSULIN REGIMEN
Conventional
therapy for type 1 diabetes (twice daily insulin with
support from a multidisciplinary healthcare team and
regular diabetes and health monitoring) is associated
with variable results.Limited data support an improvement
in glycaemic control using three rather than two injections
per day. Evidence regarding the impact of an
intensive insulin regimen upon long term control is
derived principally from the Diabetes Control and Complication
Trial (DCCT) which also involved a comprehensive patient
support element (diet and exercise plans, monthly visits
to the health care team etc.). Intensive insulin therapy
(four injections or more per day or pump insulin) significantly
improves glycaemic control over a sustained period compared
with conventional insulin therapy (two injections per
day). DCCT did not include children aged less than 13,
due to the study design, it is impossible to separate
the benefits of intensive insulin therapy from intensive
support.
While there is no evidence on the most effective form
of support package, in general this refers to increased
contact between patients and their families with a local
multidisciplinary team of health professionals delivering
specific health care strategies.The risk of hypoglycaemia
increases with intensive therapy but rapid acting insulin
analogues, as part of a three or four injection regimen
can reduce hypoglycaemia.
Diet
Control
A
discipline that includes diet control improves glycaemic
control. Limited evidence was identified
concerning the optimal type of dietary therapy. There
is a lack of evidence to recommend either a qualitative
or quantitative approach as the most effective mode
of dietary therapy.
Psychological Factors
Specifics that contribute to an increased risk of young
people with diabetes developing psychological problems
include:
- a reluctance to cope with the situation
- too great an onus placed on the child
- family difficulties
- lack of communication, both within families and
with the diabetes team
- low socio-economic status
- non-traditional family structure
- poor maternal health, especially depression.
Eating
disorders are more prevalent in adolescents with diabetes
compared with non-diabetic peers, and adversely affect
glycaemic control.
Specific psychological problems (e.g. maladaptive coping
strategies) linked to future glycaemic control, can
be identified at diagnosis and 1-2 years later, using
validated tools performed by a trained practitioner.
Psychological or educational interventions have positive
effects on psychological outcomes, knowledge about diabetes
and glycaemic control. Maintaining parental involvement
improves glycaemic control. Interventions
which promote diabetes-specific coping skills are effective
and add to the effectiveness of intensive management.
Long
term complications and screening
RISK
OF MICROVASCULAR COMPLICATIONS
Early abnormalities in children and adolescents (e.g.
microalbuminuria, background retinopathy) predict
later development of long-term microvascular complications.Maintaining
glycaemic control to as near normal as possible significantly
reduces the long term risk of microvascular diseases.Poor
glycaemic control (HbA1c >10%) over time in young
people with diabetes increases the risk of the development
of retinopathy by approximately eightfold.
SCREENING
FOR EARLY SIGNS OF MICROVASCULAR DISEASE
The literature is confusing in relation to the timing
of commencing screening in young people with diabetes.
Age and puberty are reported without any strict definition.
For clarity and simplicity the guideline development
group suggests 12 years of age in both boys and girls.Early
microvascular abnormalities may occur before puberty,
which then appears to accelerate these abnormalities.Several
cohort studies demonstrate the ability to detect the
following in young people with diabetes:
- retinopathy (by ophthalmoscopy or fundal photography)
- microalbuminuria (by albumin excretion rate (AER)
or albumin/creatinine ratio (ACR))
- hypertension.
Evidence level 2+, 3
Young
people with diabetes should receive examination of the
retina annually from the age of 12 years.
Young people with diabetes should have their urine microalbuminuria
(overnight AER or first morning ACR) tested annually
from the age of 12 years.
Blood
pressure should be measured annually in young people
with diabetes from the age of 12 years.
Young
people with diabetes who have abnormal recorded levels
of microalbuminuria or hypertension should make intensive
efforts to optimise glycaemic control to minimise
progression to microvascular disease.
There is no evidence that routine screening for autonomic
neuropathy or hyperlipidaemia are of benefit.
ASSOCIATED CONDITIONS
Thyroid and coeliac disease are reported to be increased
in young people with type 1 diabetes compared with
non-diabetic subjects. Both thyroid and coeliac disease
may occur with minimal symptoms that may be missed
during routine care.
Young people with diabetes should be screened for
thyroid and coeliac disease at onset of diabetes and
at intervals throughout their lives
Standard blood tests exist to screen for thyroid and
coeliac disease but there are limited data to support
the specific frequency of screening.
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