BE ALERT TO THE OCCURRENCE OF TYPE 1 DIABETES IN CHILDREN

Diabetes Mellitus (DM) is a metabolic disorder characterized by chronic hyperglycemia and abnormalities in carbohydrate, fat, and protein metabolism, resulting from defects in insulin secretion, insulin action, or both. This disease not only affects adults but also children.

According to data from the Indonesian Pediatrician Association (IDAI), there were 1,220 children with Type 1 DM in Indonesia. The incidence of Type 1 DM in children and adolescents increased approximately sevenfold from 3.88 to 28.19 per 100 million population between 2000 and 2010. In 2017, 71% of children with Type 1 DM were initially diagnosed with Diabetic Ketoacidosis (DKA), an increase from 63% in 2015 and 2016. It is suspected that many Type 1 DM patients go undiagnosed or misdiagnosed during their initial hospital visits. The exact incidence of Type 1 DM in children in Indonesia is not known precisely due to the difficulty in national data collection.

PATHOGENESIS OF TYPE 1 DIABETES

Type 1 DM, previously known as Insulin Dependent Diabetes Mellitus (IDDM) or Juvenile Diabetes, occurs due to damage to the ß cells of the pancreas (autoimmune reaction). ß cells are the only cells in the body that produce insulin, which regulates blood glucose levels. When damage to ß cells reaches 80-90%, DM symptoms begin to appear. This damage occurs more rapidly in children than in adults. Most Type 1 DM patients are affected by autoimmune processes, with only a small percentage being non-autoimmune.

Many factors contribute to the pathogenesis of Type 1 DM, including genetic, epigenetic, environmental, and immunological factors. However, the specific role of each factor in the pathogenesis of Type 1 DM is not yet clear. Environmental factors related to Type 1 DM include viral infections and diet. Congenital rubella syndrome and human enterovirus infections are known to trigger Type 1 DM. Consumption of cow's milk, early cereal consumption, and maternal vitamin D intake are suspected to be associated with the incidence of Type 1 DM but require further investigation.

SYMPTOMS OF TYPE 1 DIABETES IN CHILDREN

The symptoms of Type 1 DM in children are similar to those in adults, including:

• Frequent urination
• Bedwetting
• Excessive thirst and hunger
• Weight loss
• Itching in the genital area
• Recurrent skin infections
• Decreased school performance and irritability

Other symptoms that may occur include numbness, weakness, slow-healing wounds, blurred vision, and behavioral disturbances. If these clinical symptoms are accompanied by hyperglycemia, the diagnosis of DM is no longer in doubt.

Misdiagnosis and delayed diagnosis of Type 1 DM are common. In some children, the onset of symptoms to the development of ketoacidosis can occur very rapidly, while in others, it may occur slowly over several months. Due to delayed diagnosis, Type 1 DM patients may enter a phase of ketoacidosis, which can be fatal.

Emergency signs of ketoacidosis (Diabetic Ketoacidosis or hyperosmolar hyperglycemic state) include:

• Moderate to severe dehydration
• Repeated vomiting and, in some cases, abdominal pain (leading to misdiagnosis as gastroenteritis)
• Persistent polyuria (excessive urination) despite dehydration
• Weight loss due to fluid and muscle loss
• Red cheeks due to ketoacidosis
• A fruity acetone odor on the breath
• Hyperventilation in diabetic ketoacidosis (Kussmaul breathing)
• Sensory disturbances (disorientation, apathy, and coma)
• Shock (rapid pulse, low blood pressure, worsening peripheral circulation with peripheral cyanosis)

Conditions that contribute to delayed diagnosis include:

• Severe ketoacidosis can occur rapidly in very young children because insulin deficiency occurs quickly, and the diagnosis is not immediately established.
• Hyperventilation in ketoacidosis can be misdiagnosed as pneumonia or asthma.
• Abdominal pain related to ketoacidosis can mimic acute abdominal conditions, leading to surgical referrals.
• Polyuria and enuresis can be misdiagnosed as urinary tract infections.
• Vomiting can be misdiagnosed as gastroenteritis or sepsis.

How to Manage Type 1 Diabetes in Children:

• Educate the child about Type 1 DM and motivate the child and family to adhere to treatment.
• Use insulin every day for life.
• Follow a healthy diet tailored to the child's needs.
• Engage in regular physical activity.

The core of Type 1 DM treatment is to maintain the balance of insulin levels to prevent blood glucose levels from becoming too high or too low.

Treatment options for Type 1 diabetes include:

1. Insulin injections When administering insulin injections, more than one type of insulin is usually required. This combination can be prescribed by a doctor to control blood sugar levels.

2. Insulin pump An alternative name for insulin pump therapy is continuous insulin infusion therapy, as the insulin pump continuously delivers a small amount of insulin into the body. The insulin pump has a small tube called a cannula that is inserted just under the skin and remains in place for several days before needing replacement. The cannula allows insulin to be delivered to the fatty tissue just beneath the skin, where it can be absorbed into the bloodstream. The insulin pump itself is typically worn outside the body, usually near the waist.

3. Managing blood sugar through diet and physical activity Regular blood sugar monitoring is essential to control blood sugar levels and reduce the risk of excessively high or low blood sugar levels. Diet plays a crucial role in controlling blood sugar. Insulin helps lower blood sugar by allowing cells to take in glucose from the blood, while the food you eat can raise blood sugar levels. During meals, carbohydrates in the food are broken down into glucose during digestion and absorbed into the bloodstream. Therefore, the food you consume plays a significant role in blood sugar control.

Here are some guidelines for adjusting diet, insulin, and blood sugar monitoring to safely engage in physical activity for children and adolescents with Type 1 DM in their daily lives:

1. Before exercising: a) Determine the timing, duration, type, and intensity of exercise. Discuss with a sports coach or teacher and consult with a doctor. b) Consume carbohydrates 1-3 hours before exercise. c) Check metabolic control at least twice before exercising. d) If blood glucose is < 5 mmol/L and trending downward, add extra carbohydrates. e) If blood glucose is between 90-250 mg/dL (5-14 mmol/L), extra carbohydrates may not be needed (depending on the duration of activity and individual response). f) If blood glucose is > 250 mg/dL and ketones are present in urine/blood (+), postpone exercise until blood glucose is normal with insulin. g) For aerobic exercise, estimate energy expenditure and determine whether insulin adjustments or additional carbohydrates are necessary. h) For anaerobic exercise or exercise in hot conditions, or competitive sports, insulin should be increased. i) Consider providing fluids to maintain hydration (250 mL 20 minutes before exercise).

2. During exercise: a) Monitor blood glucose every 30 minutes. b) Continue fluid intake (250 mL every 20-30 minutes). c) Consume carbohydrates every 20-30 minutes if needed.

3. After exercise: a) Monitor blood glucose, including throughout the night (especially if not accustomed to the exercise program). b) Consider adjusting insulin therapy by reducing basal insulin doses. c) Consider additional slow-acting carbohydrates 1-2 hours after exercise to prevent delayed-onset hypoglycemia. Delayed-onset hypoglycemia can occur within 2 x 24 hours after exercise.

Physical activity is crucial for increasing insulin sensitivity and reducing insulin requirements. Additionally, physical activity can boost a child's self-confidence, maintain an ideal body weight, improve cardiovascular fitness, minimize long-term complications, and enhance overall metabolism. Recommendations for physical activity in children with Type 1 DM are the same as for the general population, including at least 60 minutes of daily activity involving aerobic, muscle-strengthening, and bone-strengthening activities. Aerobic activities should be prioritized, while muscle and bone-strengthening activities should be performed at least three times a week.

COMPLICATIONS Complications of Type 1 DM can be classified as acute and chronic, either reversible or irreversible. Most short-term or acute complications are reversible, while long-term or chronic complications are irreversible, but their progression can be slowed with optimal management. Common short-term complications include hypoglycemia and diabetic ketoacidosis (DKA). Diabetic ketoacidosis (DKA) results from insulin deficiency and is a medical emergency that requires immediate attention. DKA can occur at the time of diagnosis or in established patients. In adolescents, DKA is almost always caused by non-compliance with insulin use. Hypoglycemia often occurs when efforts are made to achieve normal blood glucose values. The tighter the control aimed for, the greater the risk of hypoglycemia.

Long-term complications of diabetes affecting the vascular system can lead to significant morbidity and mortality. These long-term complications result from microvascular and macrovascular changes. Microvascular complications include retinopathy, nephropathy, which begins with microalbuminuria, and neuropathy. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease, with the possibility of limb amputation.

MICROVASCULAR COMPLICATIONS:

• Retinopathy leading to blindness.
• Diabetic nephropathy leading to hypertension and kidney failure.
• Neuropathy causing pain, paresthesia, muscle weakness, and autonomic dysfunction.

MACROVASCULAR COMPLICATIONS:

• Coronary artery disease.
• Stroke.
• Peripheral vascular disease with the potential for limb amputation.

LIST OF REFERENCES: a) Rachmawati, A.M., Bahrun, U., Ruslin, B., Hardjoeno. Diagnostic tests for Diabetes Mellitus. In Hardjono et al., Interpretation of Diagnostic Test Results in Laboratory Diagnostics. 3rd edition. Hasanuddin University Educational Institution. Makassar. 2007. p. 167-82. b) World Health Organization. Diabetes Mellitus: Report of a WHO Study Group. World Health Organization. Geneva, Switzerland. 2015. p. 5-36. c) John. MF Adam. Classification and New Criteria for the Diagnosis of Diabetes Mellitus. Cermin Dunia Kedokteran. 2006; 127: 37-40. d) Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, et al. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatric Diabetes 2014: 15 (Suppl. 20): 4–17. e) Couper JJ, Haller MJ, Ziegler A-G, Knip M, Ludvigsson J, et al. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Phases of type 1 diabetes in children and adolescents. Pediatric Diabetes 2014: 15 (Suppl. 20): 18–25. f) Lange K, Swift P, Pankowska E, Danne T. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Diabetes education in children and adolescents. Pediatric Diabetes 2014: 15 (Suppl. 20): 77–85. g) Rewers MJ, Pillay K, de Beaufort C, Craig ME, Hanas R, et al. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Assessment and monitoring of glycemic control in children and adolescents with diabetes. Pediatric Diabetes 2014: 15 (Suppl. 20): 102–114.

Author: Dr. Nirma Amalia (Medical Consultant at PRAMITA Clinical Laboratory, Jl. Karunrung No. 9, Makassar)