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Childhood Diabetes

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Children are developing type 2 diabetes at alarming rates.

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At one time, type 2 diabetes was called adult onset diabetes. The people at highest risk for developing this condition were once thought to be "over 40" and "overweight." We know much more about type 2 diabetes today—particularly that adolescents and children are being diagnosed in near epidemic proportions.

Diabetes is characterized by hyperglycemia. This excess glucose in the blood results from little to no insulin production or an ineffectiveness of the insulin that is produced. Type 1 diabetes is primarily an autoimmune destruction of insulin-producing beta cells that results in absolute insulin deficiency. Type 1 diabetes requires that insulin be replaced daily using multiple injections or an insulin pump. Type 2 diabetes is characterized by a combination of inadequate insulin production, insulin resistance and excess glucose production by the liver.

At one time, nearly 100 percent of children and adolescents diagnosed with diabetes had the type 1 form. Today, approximately 80 percent of new pediatric cases are type 1 and 20 percent are type 2.

Risk Factors
America is an overweight country, and obesity contributes to the development of type 2 diabetes. As a society, we fuel this problem by not making physical education a mandatory requirement in all schools. Computers, television and video games have also contributed to widespread inactivity. In many areas, outside recreation and play is curtailed for safety reasons. Children may have no area around their home where it is safe to run and play.

Besides being overweight, children with type 2 diabetes tend to share other risk factors. Diabetes has a strong hereditary link. Most diabetic children have a parent who also has type 2 diabetes, although it may not be known at the time the child is diagnosed. Certain groups are more prone to type 2 diabetes, including African Americans, Hispanics, Native Americans and Japanese.1,2

Age can be considered a risk factor as well. Because puberty causes an insulin-resistant state, many children are diagnosed during puberty. The presence of polycystic ovary syndrome also places women at risk. Type 2 diabetes has a female predominance, with many large pediatric diabetes centers reporting a female-to-male ratio of 2:1. Maternal history of type 2 diabetes also places a child at higher risk for this condition.

Presentation and Diagnosis
The presentation of type 2 diabetes in children and adolescents can vary from subtle to severe. In many cases, glucosuria, the presence of glucose in the urine, is picked up on a school or sports physical and should lead to a blood glucose value test.3 Tests may reveal diabetic ketoacidosis (DKA), the presence of ketones in the urine, but this does not always rule out the possibility of type 2 diabetes.

Other physical and laboratory characteristics that suggest diabetes are hypertension and dyslipidemias. A physical trait that children with type 2 diabetes sometimes share is acanthosis nigricans. This is a skin marking that typically occurs around the base of the neck or in areas such as the armpit. It is a dark marking that is slightly raised and has a velvety texture. It may be characterized as a "dirty neck."

The American Diabetes Association and the American Academy of Pediatrics published guidelines for the diagnosis and treatment of type 2 diabetes in 2000.1 The ADA recommends that the following criteria be used for the diagnosis of diabetes (type 1 and type 2) in children and adolescents:4

• A casual plasma glucose of > 200 mg/dL along with symptoms of hyperglycemia such as polyuria and polydipsia.

• Two fasting glucose values of > 126 mg/dL. Fasting is defined as no intake for 8 hours. These values should be obtained on different days.

• After an oral glucose tolerance test using 75 grams of glucose, report of a 2-hour blood glucose value of > 200 mg/dL.

After a diagnosis of diabetes is established, further testing is needed to distinguish the type. Laboratory values commonly obtained to help differentiate between type 1 and type 2 are:

• Islet cell antibodies: The presence of islet cell antibodies indicates that the autoimmune process against the insulin-producing cells on the pancreas has begun. Most of the time, this is a process that occurs in type 1 diabetes.

• C-Peptide levels: used to determine whether endogenous insulin production is occurring; high levels signal that insulin resistance is present.

• Insulin levels: also indicate the presence of endogenous insulin production.

• Glutamic acid decarboxylase (GAD): present when the autoimmune process of type 1 diabetes has begun.

• Hemoglobin A1c: a lab value that provides a 3-month average for blood glucose control. This value may be elevated at the time of diagnosis, depending on the duration of hyperglycemia.

Treatment
The course of treatment is determined by the patient's condition at diagnosis, and is altered according to progress of blood glucose values, along with other conditions such as weight loss. The level of hyperglycemia can cause "glucose toxicity." When blood glucose levels are high, oral medications designed to lower glucose levels are often ineffective and insulin therapy must be instituted. If patients show symptoms of hyperglycemia (frequent urination and very thirsty), insulin therapy is often the most effective intervention.

A wide variety of medications are available to treat type 2 diabetes today. These range from the insulin secretagogues (sulfonylureas) and shorter-acting medications taken with each meal (Prandin, Starlix) to the thiazolidinediones, which many people refer to as "TZDs" or "insulin sensitizers" (Actos, Avandia). These medications help make insulin more effective at the cellular level.

A class of medications called alpha glycosidase inhibitors also are used. These medications block the absorption of glucose to prevent post-meal spikes in blood sugar. Most of these medications do not have FDA clearance for use in children and adolescents. At the time that most of them were tested, there was no need for pediatric dosing because type 2 diabetes was not an issue in this age group.

The medication most often prescribed as monotherapy or in conjunction with insulin for type 2 diabetes in children and adolescents is metformin (Glucophage). This drug is used for many reasons, the first of which is that it does not produce hypoglycemia when used alone. Metformin diminishes hepatic glucose output, has an insulin-sensitizing effect and promotes weight loss in many patients. Side effects are mostly gastrointestinal in nature and can be diminished by taking the drug with meals and titrating the dose upward slowly. Lactic acidosis is a rare side effect of this medication. This drug should not be used in patients with renal insufficiency, so a baseline creatinine level should be obtained when prescribing it.

Beyond Medication
Medication is only one part of diabetes treatment for this population. The other components are things OTs specialize in: education, counseling and support. These young people and their families require education about diabetes self-management, including blood glucose monitoring, dietary management, exercise and weight loss.

Any treatment plan should take into consideration the developmental level of the child or adolescent and must involve the family. If the treatment plan does not involve the family, attempted lifestyle changes are not usually successful. Attainable goals must be set and must involve the family's input. The management of diabetes in children and adolescents is a continuous educational, motivational and dynamic process. It is not a one-time intervention or instruction.

Follow-up for this population should include monitoring for diabetes complications. A yearly examination by an ophthalmologist is recommended. The child should be screened for microalbuminuria, thyroid disease and dyslipidemia at least annually.

Children and adolescents with type 2 diabetes present challenges to the health care system. This disease has forced pediatric practitioners to learn more about a disease process once thought to be outside our domain because it was primarily an adult problem. Diabetes treatment for children and adolescents must be a family affair, and an OT can play an important role in this effort.

Joe Ward, NP, CDE, is a pediatric nurse practitioner and certified diabetes educator at the University of Alabama Children's Specialty Center in Mobile, AL.

References
1. Brosnan CA, Upchurch S, Schreiner B. Type 2 diabetes in children and adolescents: an emerging disease. Journal of Pediatric Health Care. 2001;15(4):187-193.

2. Nesmith JD. Type 2 diabetes mellitus in children and adolescents. Pediatrics in Review. 2001;22(5):147-152.

3. Pinhas-Hamiel O, Zeitler P. Type 2 diabetes: not just for grownups anymore. Contemporary Pediatrics. 2001;18(1):102-125.

4. American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics. 2000;105(3):671-680.




     

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