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Understanding Juvenile Diabetes
Type 1 diabetes in children, formerly known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in the body where the pancreas produces little or no insulin, which is a hormone needed for sugar (glucose) to enter cells to produce energy. For unknown reasons, the body's own immune system destroys the insulin-producing cells of the pancreas, called beta cells. This results in a complete deficiency of the insulin hormone leading to increased blood and urine glucose.
Type 2 diabetes, which is much more common, occurs when the body becomes resistant to the effects of insulin or doesn't make enough. Some people develop a type of diabetes, called secondary diabetes, which is similar to type 1 diabetes, but the beta cells are destroyed by some other factor, such as cystic fibrosis or pancreatic surgery.
With type 1 diabetes, sugar is not moved into the cells because there is no insulin. When sugar builds up in the blood instead of going into cells, the body's cells virtually starve for nutrients and other systems in the body must provide the energy needed for many important bodily functions. As a result, high blood sugar develops and can cause dehydration, weight loss, diabetic ketoacidosis (DKA), and damage to the body that can lead to heart attack and stroke.
Various factors may contribute to type 1 diabetes, including genetics and exposure to certain viruses. Although type 1 diabetes typically appears during adolescence, it can develop at any age. This disease is relatively uncommon, and accounts for only about 5% of people with diabetes. The condition is more commonly found in the white population than in other populations and occurs equally in both men and women.
Most people who develop type 1 diabetes are otherwise healthy. In spite of much active research, the disease is still not fully understood and no cure has been developed although it can be managed effectively. With proper treatment, people who have type 1 diabetes can expect to live longer, healthier lives than in the past.
Since it's an autoimmune disease, type 1 diabetes can occur along with other autoimmune diseases such as hyperthyroidism from Graves disease or the patchy decrease in skin pigmentation that occurs with vitiligo.
Symptoms of type 1 diabetes
The classic symptoms of type 1 diabetes include: polyuria (frequent urination), polydipsia (increased thirst), xerostomia (dry mouth), polyphagia (increased hunger), fatigue, and weight loss. Blood sugar levels can be very high for long periods of time, which could cause DKA before a person knows they have diabetes. These symptoms could be xeroderma (dry skin), rapid, deep breathing, drowsiness, gastralgia (abdominal pain), and copremesis (vomiting).
Signs and symptoms of type 1 diabetes in children usually develop quickly over a period of weeks. The symptoms are often subtle, but they can become severe. They include:
- Increased thirst and frequent urination - as excess sugar builds up in your child's bloodstream, fluid is pulled from the tissues.
- Extreme hunger - without enough insulin to move sugar into your child's cells, your child's muscles and organs become energy depleted and triggers intense hunger.
- Weight loss – in spite of eating more than usual to relieve the hunger, a child may lose weight — sometimes rapidly. Unexplained weight loss is often the first sign to be noticed.
- Fatigue - cells deprived of sugar may cause tiredness and lethargy.
- Irritability or unusual behavior - sudden moodiness or irritability.
- Blurred vision – high blood sugar means fluid may be pulled from the lenses of the eyes, affecting the ability to focus clearly.
- Yeast infection - Girls may have a genital yeast infection, and babies can develop diaper rash caused by yeast.
If you notice any of these signs or symptoms of type 1 diabetes, see your doctor immediately.
Signs of an emergency with type 1 diabetes also include:
- Shaking and confusion
- Rapid breathing
- Fruity smell to the breath
- Abdominal pain
- Loss of consciousness (rare)
Managing type 1 diabetes
Unless treated with insulin, type 1 diabetes is eventually fatal. Insulin treatment is usually administered through injection, which is the most common method, pumps and inhalation. Other available alternatives are pancreatic transplants and also pancreatic islet cell transplantation. Transplantation is still in experimental stages.
The diagnosis of type 1 diabetes in children can be overwhelming at first. Suddenly you and your child, if age appropriate, must learn how to administer injections, count carbohydrates and monitor blood sugar. Although the treatment requires consistent care, advances in blood sugar monitoring and insulin delivery have greatly improved the daily management.
Many people with type 1 diabetes live long, healthy lives. The key to good health when living with this disease is keeping your blood sugar levels within the target range, which can be done with meal planning, exercise, and intensive insulin therapy. Blood sugar levels must also be checked regularly and adjustments of insulin, food, and activities to maintain a normal sugar level.
Treatment for type 1 diabetes is a lifelong commitment of blood sugar monitoring, insulin, healthy eating and regular exercise — even for kids – and must be continued indefinitely. As children grow and mature, so will their diabetes treatment plan. Over the years, different doses or types of insulin, a new meal plan or other treatment changes may be needed.
Treatment of diabetes focuses on lowering blood sugar or glucose (BG) to near normal range, approximately 80–140 mg/dl (4.4–7.8 mmol/L). The ultimate goal of normalizing BG is to avoid long-term complications that affect the nervous system (e.g. peripheral neuropathy leading to pain and/or loss of feeling in the extremities), and the cardiovascular system (e.g. heart attacks, vision loss). People with type 1 diabetes always need to use insulin, but treatment can lead to low BG also known as hypoglycemia. Hypoglycemia is a very common in people with diabetes, usually the result of a mismatch in the balance among insulin, food and physical activity, although the nonphysiological method of delivery also plays a role.
In addition, treatment should not significantly impair normal activities but can be done adequately if sufficient patient training, awareness, appropriate care, discipline in testing and dosing of insulin is taken. However, treatment remains burdensome for many people and complications may arise with both low and high blood sugar. Low blood sugar may lead to seizures or episodes of unconsciousness, requiring emergency treatment, and high blood sugar may lead to increased fatigue and can also result in long-term damage to organs.
When type 1 diabetes isn't controlled well, a number of serious or life-threatening problems can develop, including:
- Retinopathy – an eye problem causing vision loss that affects about 80% of adults who have had type 1 diabetes for more than 15 years. Diabetic retinopathy in type 1 diabetes is extremely rare before puberty regardless of how long a child may have had the disease. Fortunately, the vision loss can be prevented in most people with the condition.
- Kidney damage (nephropathy) – affects 20% to 30% of people with type 1 diabetes. The risk increases over time and becomes evident 15 to 25 years after the onset of the disease. This complication carries significant risk of serious illness -- such as kidney failure and heart disease.
- Poor blood circulation and nerve damage - damage to nerves and hardening of the arteries leads to decreased sensation and poor blood circulation in the feet. This can lead to increased risk of injury and decreased ability to heal open sores and wounds, which in turn significantly raises the risk of amputation. Damage to nerves may also lead to digestive problems such as nausea, vomiting, and diarrhea.
If managing your child's diabetes seems overwhelming, take it one day at a time and remember that you're not alone. Strive to work closely with your child's diabetes treatment team — doctor, diabetes educator and registered dietitian — to keep your child's blood sugar level as close to normal as possible. Below are some common tips to help with your child’s treatment.
Blood sugar monitoring
Depending on the type of insulin therapy your child requires, you may need to check and record your child’s blood sugar at least three times a day to ensure that the level remains within the target range — which may change as your child grows and changes – obtained from your child’s doctor.
Continuous glucose monitoring (CGM)
CGM is the newest way to monitor blood sugar levels, and may be most helpful for people who have developed hypoglycemia unawareness. CGM is attached to the body using a fine needle just under the skin that checks blood glucose levels at short intervals. CGM is not currently considered as accurate as standard blood sugar monitoring, and is therefore used as an additional tool, not as a replacement method.
Insulin and other medications
Everyone with type 1 diabetes needs insulin therapy to survive. There are many types of insulin which include:
- Rapid-acting insulin
- Long-acting insulin
- Short-acting insulin
- Intermediate options
Depending on your child’s age and treatment needs, your doctor may prescribe a mixture of insulin types for day and night time use.
Options for getting insulin into the body currently include:
- Injection – using a fine needle and syringe or insulin pen
- Insulin pump infusion – using a device worn on the outside of the body
- Wireless pump – newly available and uses small pods filled with insulin
Unfortunately, insulin cannot be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action.
Untreated type 1 diabetes commonly leads to coma, often from diabetic ketoacidosis, which is fatal if untreated. Ketoacidosis causes cerebral edema, an accumulation of liquid in the brain. This complication is very life-threatening, making ketoacidosis the most common cause of death in pediatric diabetes.
Oral medications are sometimes prescribed as well, such as:
- Pramlintide (Symlin) – taken before eating to help slow food movement through the stomach to curb the sharp increase in blood sugar that occurs after meals.
- High blood pressure medications - even if you don't have high blood pressure, your doctor may prescribe medications known as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) to help keep kidneys healthy in addition to lowering blood pressure.
- Cholesterol-lowering drugs - your doctor may not wait until your cholesterol is elevated before prescribing cholesterol-lowering agents known as statins. Cholesterol guidelines are more aggressive for people with diabetes because of the elevated heart disease risk.
- Investigational treatments
- Pancreas transplant - a successful pancreas transplant means that injected insulin treatment is no longer needed. However, pancreas transplants procedures pose serious risks and are not always successful. The lifetime of potent immune-suppressing drugs to prevent organ rejection can have serious side effects, including a high risk of infection and organ injury. Since the side effects of these drugs can be more dangerous than the diabetes itself, pancreas transplants in children generally aren't done.
- Islet cell transplantation - Researchers also are experimenting with islet cell transplantation, which provides new insulin-producing cells from a donor pancreas. While this experimental procedure has had problems in the past, new techniques and better drugs to prevent islet cell rejection may hold promise for the future. Still, islet cell transplantation requires the use of potent immune-suppressing medications, and present the same risks.
There’s no such thing as a diabetes diet. Your child will not be restricted to a lifetime of boring, bland foods. Instead, he will need plenty of fruits, vegetables and whole grains — foods that are high in nutrition and low in fat and calories. Also, consuming fewer animal products and sweets is the best meal plan for your child, and the whole family.
Understanding your child’s dietary needs can prove to be challenging. Have a registered dietitian help you to develop a meal plan that fits your child's health goals, food preferences and lifestyle.
Everyone needs regular aerobic exercise, and children who have type 1 diabetes are no exception. Encourage your child to get regular physical activity. They can sign up for sports teams or dance lessons, or even participate in activities with you like playing catch or basketball, and walking or running through your neighborhood. Make physical activity part of your child's daily routine.
But remember that physical activity usually lowers blood sugar, and it can affect blood sugar levels for up to 12 hours after exercise. If your child begins a new activity, check your child's blood sugar more often until you learn how his body reacts to the activity. You also may need to adjust your child's meal plan or insulin doses to compensate for the increased activity.
Even if your child takes insulin and eats on a rigid schedule, the amount of sugar in his or her blood can change unpredictably. With help from your child's diabetes treatment team, you'll learn how your child's blood sugar level changes in response to a variety of factors such as food, physical activity, medication, illness, growth spurts and puberty and sleep habits:
Low blood sugar (hypoglycemia)
Blood sugar levels can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin. Hypoglycemia occurs more frequently with intermediate-acting insulin.
It is critical for people with type 1 diabetes to learn how to recognize the symptoms of low blood sugar, and test their blood sugar if levels seem to be dropping. Ask your doctor what's considered a low blood sugar level for your child. Teach your child the symptoms of low blood sugar, and that when in doubt, always do a blood sugar test.
The early signs and symptoms of low blood sugar include:
- Dizziness or lightheadedness
- Pale skin
- Rapid or irregular heart rate
- Blurred vision
Later signs and symptoms of low blood sugar, which can sometimes be mistaken for alcohol intoxication in teens and adults include:
- Behavior changes, sometimes dramatic
- Poor coordination
If hypoglycemia develops during the night, it may cause night sweats or headaches and unusually high blood sugar reading first thing in the morning.
For low blood sugar readings, have some fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar. Then retest your blood sugar in about 15 minutes to make sure it has gone up into the normal range, and repeat until a normal reading appears. It's a good idea to eat a meal or snack once a normal reading is reached. A mixed food source, such as peanut butter and crackers, can help stabilize the blood sugar.
If a blood glucose meter isn't readily available, treat for low blood sugar anyway if you have symptoms of hypoglycemia, and then test as soon as possible.
Make sure your child always carries a source of fast-acting sugar with you. Left untreated, low blood sugar will cause you to lose consciousness. If this occurs, an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood – will be needed. Be sure you always have a glucagon emergency kit available — at home, at work, when you're out — and make sure it hasn't expired.
Sometimes people may lose the ability to sense that their blood sugar levels are coming down, because they've developed a condition known as hypoglycemia unawareness. With hypoglycemia unawareness, the body no longer reacts to a low blood sugar with symptoms such as lightheadedness or headaches. The more you experience low blood sugars, the more likely you are to develop hypoglycemia unawareness. The good news is that if you can avoid having a hypoglycemic episode for several weeks, you may start to become more aware of impending lows.
High blood sugar (hyperglycemia)
As with low blood sugar, your child’s blood sugar could rise for many reasons, including eating too much, eating the wrong types of foods, not taking enough insulin, or illness. Signs of hyperglycemia include:
- Frequent urination
- Increased thirst
- Blurred vision
- Difficulty concentrating
If you suspect your hyperglycemia, check your child’s blood sugar. You might need to adjust your child’s meal plan or medications. If the blood sugar is higher than the target range, you'll likely need to administer a "correction" using an insulin shot or through an insulin pump. A correction is an additional dose of insulin that should bring your blood sugar back into the normal range. High blood sugar levels don't come down as quickly as they go up. Ask your doctor how long to wait until you recheck. If your child uses an insulin pump, random high blood sugar readings may mean you need to change the pump site.
If you have two consecutive blood sugar readings above 250 mg/dL (13.9 mmol/L), test for ketones using a urine test stick. Don't allow your child to exercise if his or her blood sugar level is high or anytime ketones are present. If only a trace or small amounts of ketones are present, have your child drink extra fluids to flush out the ketones.
If the blood sugar is persistently above 300 mg/dL (16.7 mmol/L), call your child’s doctor or seek emergency care.
Increased ketones in your child's urine (diabetic ketoacidosis - DKA).
If your child's cells are starved for energy, your child's body may begin to break down fat — producing toxic acids known as ketones. This is a serious condition and the signs and symptoms include:
- Loss of appetite, weight loss
- Abdominal pain
- A sweet, fruity smell on your child's breath
- Weight loss
If you suspect DKA, check your child's urine for excess ketones with an over-the-counter ketones test kit. If there is a large amount of ketones in the urine, call your child's doctor immediately or seek emergency care. Also call your doctor if your child has vomited more than once in a four-hour period, and has ketones in his or her urine.
Parenting a child with Juvenile Diabetes
Living with type 1 diabetes is not at all easy — for you or for your child. Good diabetes management requires a lot of time and effort, especially in the beginning.
When a child has type 1 diabetes they need parental support to manage and cope with the disease. Children usually need 2-4 injections daily, and monitoring by both parents and healthcare professionals. In most communities there are healthcare teams that provide education and support for families and children.
In parenting a child with diabetes, the goal is to help the child learn to manage their own symptoms and fully participate in childhood activities. Younger children will need parental help to ensure they have a strict diet and regular eating routines. The whole family can be involved in supporting healthy routines and helping a child manage blood sugar levels. Below are further considerations when parenting a child with diabetes.
Your child's emotions
Diabetes can affect your emotions both directly and indirectly. Poorly controlled blood sugar can directly affect your emotions by causing behavior changes, such as irritability. Diabetes may also make a child feel different from other children, and they may feel resentful at times for having to perpetually incorporate diabetes planning in all of their activities. Arranging activities for your child and other children who have diabetes may help with feelings of isolation.
People with diabetes have an increased risk of depression and anxiety, which may be why many diabetes specialists regularly include a social worker or psychologist as part of their diabetes care team.
Mental health and substance abuse
Teenagers, in particular, may have a particularly hard time dealing with diabetes. A child may rebel in the teen years by ignoring his or her diabetes care. Teens may also have a harder time telling friends, boyfriends or girlfriends that they have diabetes because they want to fit in. They may also experiment with drugs or alcohol, behaviors that can be even more dangerous for someone with diabetes. Eating disorders and forgoing insulin to lose weight are other problems that can occur more often in the teen years.
Ask your child’s doctor about the effects of drugs and alcohol on someone with diabetes and talk to your teenager. Also talk to your child’s doctor or therapist to have your teenager assessed for depression if you notice signs such as persistent sadness or pessimism, dramatic changes sleeping habits, friends or school performance. Additionally, let your child's doctor know if you notice that your son or daughter is losing weight or doesn't seem to be eating well.
Talking to a counselor or therapist can help you or your child to cope with the dramatic lifestyle changes that come with a type 1 diabetes diagnosis. Your child may also find encouragement and understanding in a type 1 diabetes support group for children.
As a parent, it may be helpful to connect with other people parenting children with type 1 diabetes. There are also numerous support groups available both online and in person, that can be good sources of current and helpful information if you are open to it. Speak to your child’s doctor for a recommendation or to find out about supports and resources in your area or community.
Putting information in context
Since complications from poorly controlled diabetes can be frightening, it's important to remember that many studies and a variety of literature you may be reading may not be up to date with the most recent advances in diabetes care. Many of the previously scary statistics do not necessarily apply to your child. If you work with your child's doctor and diabetes treatment team and do your best to control blood sugar levels, your child with likely live a long and normal life.
Helpful links or resources for type 1 diabetes
Canadian Diabetes Association - http://www.diabetes.ca/
JDRF Canada - http://www.jdrf.ca/
Government of Saskatchewan Adoption Guide - http://www.socialservices.gov.sk.ca/search?c=all&q=adoption+guide&x=0&y=0
Los Angeles Chinese Learning Center - http://chinese-school.netfirms.com/diabetes-juvenile.html
Canadian Diabetes Association - http://www.diabetes.ca/
American diabetes Association - http://www.diabetes.org/
Mayo Clinic - http://www.mayoclinic.com/health/type-1-diabetes-in-children/DS00931
WebMd - http://diabetes.webmd.com/guide/type-1-diabetes
Wiki - http://en.wikipedia.org/wiki/Juvenile_diabetes