eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Diabetes Mellitus, Type 1: Follow-up

Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK
Contributor Information and Disclosures

Updated: Jul 2, 2009

Follow-up

Further Inpatient Care

• Where a diabetes care team is available, admission is usually required only for children with diabetic ketoacidosis (DKA).

Further Outpatient Care

• Regular outpatient review with a specialized diabetes team improves both short-term and long-term outcomes.²⁷ Most teams have a nurse specialist or educator, a dietitian, and a pediatrician with training in diabetes care. Other members could include a psychologist, a social worker, and an exercise specialist. Involvement with the team is intense over the first few weeks after diagnosis while family members learn about diabetes management.^28,29
• Conduct a structured examination and review at least once annually to examine the patient for possible complications. Examination and review should include the following:
  • Growth assessment
  • Injection site examination
  • Retinoscopy or other retinal screening such as photography
  • Examination of hands, feet, and peripheral pulses for signs of limited joint mobility, peripheral neuropathy, and vascular disease
  • Evaluation for signs of associated autoimmune disease
  • Blood pressure
  • Urine examination for microalbuminuria

Inpatient & Outpatient Medications

• Insulin
• Blood glucose testing strips
• Urine ketone testing tablets or strips
• Blood ketone testing strips (also available)

Deterrence/Prevention

• No practical way of preventing type 1 diabetes mellitus has been identified, even in children at high risk. Although maximal immune suppression prevents progression of autoimmune islet cell destruction, the side effects of life-long immunosuppressive medication are far worse than those expected from type 1 diabetes mellitus itself.
• Actively discourage patients from smoking because it markedly increases the risk of developing cardiovascular complications.
• Discuss issues of sexual health with older children. Provide young women with information on pregnancy planning to ensure the best possible outcomes for themselves and their offspring.
• For older adolescents, discuss the effects of alcohol and illegal substance use on diabetic control.

Complications

• Hypoglycemia³⁰
  • Hypoglycemia is probably the most disliked and feared complication of diabetes, from the point of view of the child and the family. Children hate the symptoms of a hypoglycemic episode and the loss of personal control it may cause.
  • Insulin inhibits glucogenesis and glycogenolysis, while stimulating glucose uptake. In nondiabetic individuals, insulin production by the pancreatic islet cells is suppressed when blood glucose levels fall below 83 mg/dL (4.6 mmol/L). If insulin is injected in a treated diabetic child who has not eaten adequate amounts of carbohydrates, blood glucose levels progressively fall.
  • The brain depends on glucose as a fuel. As glucose levels drop below 65 mg/dL (3.2 mmol/L) counterregulatory hormones (eg, glucagon, cortisol, epinephrine) are released, and symptoms of hypoglycemia develop. These symptoms include sweatiness, shaking, confusion, behavioral changes, and, eventually, coma when blood glucose levels fall below 30-40 mg/dL. The glucose level at which symptoms develop varies greatly from individual to individual (and from time to time in the same individual), depending in part on the duration of diabetes, frequency of hypoglycemic episodes, rate of fall of glycemia, and overall control.
  • Manage mild hypoglycemia by giving rapidly absorbed oral carbohydrate or glucose; for a comatose patient, administer an intramuscular injection of the hormone glucagon, which stimulates the release of liver glycogen and releases glucose into the circulation. Where appropriate, an alternative therapy is intravenous glucose (preferably no more than a 10% glucose solution). All treatments for hypoglycemia provide recovery in approximately 10 minutes.
  • Occasionally, a child with hypoglycemic coma may not recover within 10 minutes, despite appropriate therapy. Under no circumstances should further treatment be given, especially intravenous glucose, until the blood glucose level is checked and still found subnormal. Overtreatment of hypoglycemia can lead to cerebral edema and death. If coma persists, seek other causes.
  • Hypoglycemia was a particular concern in children younger than 4 years because the condition was thought to lead to possible intellectual impairment later in life. Persistent hyperglycemia is now believed to be more damaging.
• Hyperglycemia
  • In an otherwise healthy individual, blood glucose levels usually do not rise above 180 mg/dL (9 mmol/L). In a child with diabetes, blood sugar levels rise if insulin is insufficient for a given glucose load. The renal threshold for glucose reabsorption is exceeded when blood glucose levels exceed 180 mg/dL (10 mmol/L), causing glycosuria with the typical symptoms of polyuria and polydipsia.
  • All children with diabetes experience episodes of hyperglycemia.
  • Persistent hyperglycemia in very young children (<4 y) may lead to later intellectual impairment.³¹
• Diabetic ketoacidosis
  • DKA is much less common than hypoglycemia but is potentially far more serious, creating a life-threatening medical emergency.
  • Ketosis usually does not occur when insulin is present. In its absence, however, severe hyperglycemia, dehydration, and ketone production contribute to the development of DKA.
  • DKA usually follows increasing hyperglycemia and symptoms of osmotic diuresis. Users of insulin pumps, by virtue of absent reservoirs of subcutaneous insulin, may present with ketosis and more normal blood glucose levels. They are more likely to present with nausea, vomiting, and abdominal pain, symptoms similar to food poisoning.
• Injection-site hypertrophy
  • If children persistently inject their insulin into the same area, subcutaneous tissue swelling may develop, causing unsightly lumps and adversely affecting insulin absorption. Rotating the injection sites resolves the condition.
  • Fat atrophy can also occur, possibly in association with insulin antibodies. This condition is much less common but more disfiguring.
• Diabetic retinopathy³²
  • The most common cause of acquired blindness in many developed nations, diabetic retinopathy is rare in the prepubertal child or within 5 years of onset of diabetes.
  • Prevalence and severity of retinopathy increases with age and is greatest in patients whose diabetic control is poor. Prevalence rates seem to be declining, yet an estimated 80% of people with insulin-dependent diabetes mellitus (IDDM) develop retinopathy.
  • The first symptoms of diabetic retinopathy are dilated retinal venules and the appearance of capillary microaneurysms, a condition known as background retinopathy. These changes may be reversible or their progression may be halted with improved diabetic control, although some patient's conditions may worsen initially.
  • Subsequent changes in background retinopathy are characterized by increased vessel permeability and leaking plasma that form hard exudates, followed by capillary occlusion and flame-shaped hemorrhages. The patient may not notice these changes unless the macula is involved. Laser therapy may be required at this stage to prevent further visual loss. Proliferative retinopathy follows with further vascular occlusion, retinal ischemia, proliferation of new retinal blood vessels and fibrous tissue, then progressing to hemorrhage, scarring, retinal detachment, and blindness. Prompt retinal laser therapy may prevent blindness in the later stages, so regular screening is vital.
• Diabetic nephropathy and hypertension³³
  • The exact mechanism of diabetic nephropathy is unknown. Peak incidence is in postadolescents, 10-15 years after diagnosis, and may occur in as many as 30% of people with IDDM.
  • Microalbuminuria is the first evidence of nephropathy. The exact definition varies slightly between nations but an increased albumin excretion rate (AER) is commonly defined as a ratio of first morning–void urinary albumin levels to creatinine levels that exceeds 10 mg/mmol, or as a timed overnight AER of more than 20 mcg/min but less than 200 mcg/min. Early microalbuminuria may resolve. Glomerular hyperfiltration occurs, as do abnormalities of the glomerular basement membrane and glomeruli.
  • In a patient with nephropathy, AER increases until frank proteinuria develops, and this may progress to renal failure. Blood pressure rises with increased AER, and hypertension accelerates the progression to renal failure.
  • Progression may be delayed or halted by improved diabetes control, by administration of angiotensin-converting enzyme inhibitors (ACE inhibitors), and by aggressive blood pressure control.
  • Regular urine screening for microalbuminuria provides opportunities for early identification and treatment to prevent renal failure.
  • A child younger than 15 years with persistent proteinuria may have a nondiabetic cause and should be referred to a pediatric nephrologist for further assessment.
  • Diabetic neuropathy affects both the peripheral and autonomic nerves. Hyperglycemic effects on axons and microvascular changes in endoneural capillaries are amongst the proposed mechanisms.
  • Autonomic changes involving cardiovascular control (eg, heart rate, postural responses) have been described in as many as 40% of children with diabetes. Cardiovascular control changes become more likely with increasing duration and worsening control.³⁴
  • In adults, peripheral neuropathy usually occurs as a distal sensory loss.
• Macrovascular disease
  • Although this complication is not seen in pediatric patients, it is a significant cause of morbidity and premature mortality in adults with diabetes.
  • People with type 1 diabetes mellitus (T1DM) have twice the risk of fatal myocardial infarction (MI) and stroke than people unaffected with diabetes; in women, the MI risk is 4 times greater. People with type 1 diabetes mellitus also have 4 times greater risk for atherosclerosis.
  • The combination of peripheral vascular disease and peripheral neuropathy can cause serious foot pathology.
  • Smoking, hypertension, hyperlipidemia, and poor diabetic control greatly increase the risk of vascular disease.
• Autoimmune diseases
  • Hypothyroidism affects 2-5% of children with diabetes.³⁵
  • Hyperthyroidism affects 1% of children with diabetes; the condition is usually discovered at the time of diabetes diagnosis.
  • Although Addison disease is uncommon, affecting less than 1% of children with diabetes, it is a life-threatening condition that may reduce the insulin requirement and increase the frequency of hypoglycemia. (These effects may also be the result of unrecognized hypothyroidism.)
  • Celiac disease, associated with an abnormal sensitivity to gluten in wheat products, is probably a form of autoimmune disease and may occur in as many as 5% of children with IDDM.³⁶
  • Necrobiosis lipoidica is probably another form of autoimmune disease. This condition is usually, but not exclusively, found in patients with IDDM. Necrobiosis lipoidica affects 1-2% of children and may be more common in children with poor diabetic control.
• Limited joint mobility
  • Limited joint mobility primarily affecting hands and feet is believed to be associated with poor diabetic control.³⁷
  • Originally described in approximately 30% of patients with IDDM, limited joint mobility occurs in 50% of patients older than 10 years who have had diabetes longer than 5 years. The condition restricts joint extension, making it difficult to press the hands flat against each other. The skin of patients with severe joint involvement has a thickened and waxy appearance.
  • Limited joint mobility is associated with increased risks for diabetic retinopathy and nephropathy. Improved diabetes control over the past several years appears to have reduced the frequency of these additional complications by an approximate 4-fold factor. Patients have also markedly fewer severe joint mobility limitations.

Prognosis

• Apart from severe DKA or hypoglycemia, type 1 diabetes mellitus has little immediate morbidity.
• The risk of complications relates to diabetic control. With good management, patients can expect to lead full, normal, and healthy lives. Nevertheless, the average life expectancy of a child diagnosed with type 1 diabetes mellitus has been variously suggested to be reduced by 13-19 years, compared with their nondiabetic peers.³⁸

Patient Education

• Education is a continuing process involving the child, family, and all members of the diabetes team. The following strategies may be used:
  • Formal education sessions in a clinic setting
  • Opportunistic teaching at clinics or at home in response to crises or difficulties such as acute illness
  • Therapeutic camping or other organized events
  • Patient-organized meetings
  • Information from national organizations and patient groups, including the following:³⁹
    • Children with Diabetes (This "online community for kids, families, and adults with diabetes" is an excellent resource with good links.)
    • International Society for Pediatric and Adolescent Diabetes
    • International Diabetes Federation
    • Diabetes UK
    • American Diabetes Association
    • Juvenile Diabetes Foundation International
    • Runsweet (This is a Web site devoted to giving advice on exercise management and diabetes.)
• Children should wear some form of medical identification such as a medic alert bracelet or necklace.
• For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Diabetes.

Miscellaneous

Medicolegal Pitfalls

• Diabetes is easily missed in an infant or preschool-aged child. If in doubt, check the urine for glucose.
• Diabetic ketoacidosis (DKA) may manifest as respiratory distress.
• Overzealous or inadequate treatment of hypoglycemia can lead to serious consequences.
• Addison disease rarely develops but is easily missed and potentially fatal.
• Failure to regularly examine for complications, especially renal and ophthalmic, can be detrimental.

Special Concerns

• Pregnancies should be planned and carefully managed to achieve healthy outcomes for mother and infant. Preconceptual normalization of blood sugars and folic acid supplements reduce the otherwise increased risk of congenital heart disease and neural tube defects. Blood sugar control during pregnancy must be strict to avoid hypoglycemia, which may damage the fetus, and persistent hyperglycemia, which leads to fetal gigantism, premature delivery, and increased infant morbidity and mortality. DKA during pregnancy may result in fetal death.
• Awareness of hypoglycemia becomes impaired over time, and severe hypoglycemia can occur without warning. Hypoglycemia is more likely to affect people who maintain low blood sugar levels and who already suffer frequent hypoglycemia attacks.
• Children with MODY may present as having type 1 diabetes. As they may respond better to oral hypoglycemic agents, recognizing MODY as a possibility is important. Always consider the diagnosis of MODY in the following circumstances:
• A strong family history of diabetes across 2 or more generations (The age of diagnosis usually falls with each successive generation.)
• Persistently low insulin requirements, particularly with good blood glucose control
• Development of diabetes from birth or within the first 6 months of life.

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