Diabetes Mellitus

Childhood diabetes, also referred to as juvenile or growth-onset diabetes is characterized by wide-range of metabolic abnormalities of carbohydrates, proteins and fats in the body.

It is estimated that childhood diabetes accounts for around 5% of total population of diabetics. In India alone, there are likely to be about 4.00,000 infants and children with this disease. A WHO report places the figures at 40,000 in Bangladesh, 60,000 in Pakistan, 20,000 in Sri Lanka, 27,000 in Nepal and 5,000 in Afghanistan

Etiopamogenesis. Almost 95% of pediatric cases belong to the idiopathic category —absolute deficiency of insulin'—believed to be- a hereditary inborn error of metabolism. In a considerable proportion of cases, the disease runs in family. Siblings—identical twins in particular—show higher incidence than tie parents.

In a much smaller category, the disease is secondary to such causes as Cushing's syndrome, hyperpituitarism and surgical removal of the pancreas. Transient diabetes of the newborn is more or less a benign condition, it disappears in 4- to 8 weeks period.

How docs insulin lack produce multiple metabolic abnormalities? Since sugar cannot enter cells, the latter utilize amino acids or fatty acids as alternate energy sources. What follows is fat and energy (protein) wasting-Acetone, acetoacetic acid and beta-hydroxybutyric acid tend to accumulate in the circulation. Clinical Features. The onset is generally acute. Excessive thirst (polydypsya), polyuria (more marked at night; the so-called nocturia), enuresis in a child who was earlier dry, excessive hunger (polyphagia), weight loss, general weakness, tiredness and bodily pains, are the earliest presenting features. "Fainting attacks” due to. spontaneous hypoglycemia, vulvitis, pain abdomen, nausea and vomiting, irritability and deterioration in school performance may also occur. Often, diabetic coma may be the first manifestation forcing the parents to bring the child to the hospital.

Diagnosis. Once pointers in the clinical profile have aroused suspicion, the diagnosis, must be confirmed by certain investigations.

1. Urine examination for sugar and acetone. Urine sugar may be detected by Benedict's test or by employing the specially prepared strips which give the result within a minute are highly reliable.

For detecting acetone in urine,-ferric chloride and Rothera's tests orpaper strips may be employed.

2. Blood sugar above 160 mg% (fasting) is diagnostic of diabetes mellitus. A. level exceeding. 130 mg% is strongly suggestive whereas between 100 and 130 mg% is suspicious.

3. Glucose tolerance test should be performed in doubtful cases.

Treatment, in order to achieve initial stabilization, the diabetic child should be hospitalized for some days. Insulin in low dose regimen is the current recommendation. A daily dose of 0.5 unit/kg body weight of soluble insulin suffices in a great majority of the cases.This total dose should be divided into 3 parts, to be injected before breakfast, lunch and dinner. Urine should be examined before each injection. Some patients may require one or two additional injections before glycosuria and ketonuria are really controlled.

After a few days, a combination of rapidly-acting soluble insulin and delayed-acting insulin (Lente, intermediate or long acting) may be all right. It is worth noting that slight glycosuria is acceptable. In fact one should not be fussy about having too many "clear" samples of urine to minimize risk of hypoglycemia.

About 3-month insulin therapy may cause such a great deal of improvement that the patient requires no more insulin for many months. It is, however, advisable to-continue about 5 units of insulin during this phase of remission. This is of value in preventing insulin allergy as well as resistance when the full-dose insulin therapy is resumed on relapse. Diabetic coma is a serious emergency. Two regimens of insulin therapy are available:

1. Conservative (intermittent): 1 to 2 units/kg of soluble insulin is administered, half intravenously and half subcutaneously. If further administration is needed, the dose is 0.5 to 1 unit/kg after 3 to 4 hours or l/5th of the initial dose every 1 to 2 hours.

2. Continuous Low Dose infusion: This is me most modern treatment of diabetic ketoacidosis/coma. The dose of soluble insulin for this purpose is O. 1 unit/kg/hour. It is added to the delivery chamber of the infusion set. The method causes fall of blood sugar at the rate of 75 mg% every hour. Needless to say that insulin infusion is required to be continued until the blood sugar falls to 250 mg%. Rest of the treatment consists in giving:

(a) Intravenous drip to combat dehydration and electrolyte imbalance which are often present,

(b) Antibiotics to control any superadded infection,

(c) General nursing care.

With the aforesaid regimen, most children with diabetic coma can switch on to oral fluids after 8 hours and semisolids by 12 hours.

Management of childhood diabetes does, in no case, end with just stabilization on insulin. The physician should see to it that the patient leads, as far as possible, a normal life and achieves normal growth and development. Today, the trend is to avoid too many dietetic restrictions. Concentrated carbohydrates like candies, sugar sweets, chocolates and cakes should, however, be avoided. The physician must discuss this aspect with me child as also with parents. He should also reassure them and educate them about the various aspects of the problem. The exercise has got to be a continuing program. This needs a good rapport between the physician on one hand and the child and the family on the other.