Type 1 Diabetes

In type 1 diabetes there is gradual destruction of the beta cells in the pancreas, happening over a few years (or sometimes over a few months, as happens in infants and toddlers). The cause for the destruction is the body’s own immune system attacking itself (autoimmune disease), and in this case, the insulin-producing beta cells in the pancreas.

There are immune cells that destroy the beta cells and others that produce antibodies that can be detected in a blood test. Type 1 diabetes may also be associated with other autoimmune diseases, most commonly affecting the thyroid gland, that present before, at, or after the diagnosis of type 1 diabetes.

Because of the destruction and lack of insulin, treatment of children with type 1 diabetes relies on giving them back insulin. At present, insulin is given as multiple daily injections with a very thin and short needle or a pump that delivers insulin under the skin through a plastic tube. Other types of insulin, such as inhaled or oral insulin, may in the future replace injections to some degree.

Symptoms

Eventually, after 80 percent or more of the insulin-producing beta cells are destroyed, there is true insulin deficiency, leading to the typical symptoms of diabetes, which usually appear over a short time (weeks), and become progressively worse:

  • Excessive urination (sweet urine, thus diabetes mellitus)
  • Bed-wetting in a child who was previously toilet trained
  • Excessive thirst and/or dry mouth
  • Increased appetite
  • Weight loss, despite overeating
  • Fatigue and weakness
  • Blurred vision that fluctuates (due to changes in blood sugar)
  • Other non-specific complaints are irritability, apathy, decline in school performance and restlessness. Adolescent girls may develop yeast infections.

Children often present during an acute illness, such as diarrhea or a “cold,” in which case the symptoms of diabetes can develop over days. In addition children may become significantly dehydrated. During an infection and stress there is a higher demand from the body to produce insulin, and the load becomes excessive for the small number of remaining beta cells. Children who are diagnosed during an acute illness are often sicker and develop a condition called diabetic ketoacidosis (DKA). Symptoms associated with DKA, such as nausea or vomiting can be confused with “stomach flu,” and the abdominal pains seen in DKA can sometimes lead to a false diagnosis of appendicitis.

What is DKA?

As the body cannot use glucose, fat is broken down and ketone bodies are produced, resulting in acidosis. These can also be detected in the urine. As more ketone bodies are produced and acidosis progresses, it reaches a dangerous condition called ketoacidosis. The child tries to compensate by breathing heavily, and parents may notice their child’s breath smells fruity. Other complaints can be nausea, vomiting or abdominal pains.

If left uncared for, DKA is a life-threatening condition!

Children need to be admitted promptly to a hospital, often to an intensive care unit, that allows close monitoring and support of fluids and electrolyte imbalance, as well as being on the alert for mental status changes. Rady Children’s Hospital offers experienced pediatric endocrinologists well versed in administering continuous insulin drips, and an excellent intensive care setting, to treat this serious condition, which can lead to brain swelling. As in many conditions in pediatrics, prevention is the best strategy. Recognizing the signs and symptoms of diabetes early, can prevent a child from progressing to DKA.

Who Gets Type 1 Diabetes in Childhood?

Most of the time there is no prior family member with type 1 diabetes, although other family members may have another autoimmune condition affecting the thyroid, skin (vitiligo) or other organs.

Diabetes is NOT contagious!

  • There is a 1 in 20 chance of another family member getting type 1 diabetes.
  • If a first-degree relative of a child has type 1 diabetes, there is a 1 in 10 risk for that child to develop type 1 diabetes.
  • If one twin has type 1 diabetes, there is a 50% or greater chance that his identical twins will develop it later in life, sometimes only as an adult.

What to Expect

Your child was just diagnosed with type 1 diabetes and was discharged from the hospital.

Rady Children’s Clinic Visit Schedule

First visit: 7-10 days after discharge. Making sure all is well with the diabetes management and adjustment, prescriptions are fine, examine the child, and to answer any questions or concerns.

Second visit: 1 months following initial visit. Often the child is in or entering the honeymoon period, and adjustments and further education is needed,

Subsequent visits: every 3 months. Sooner if there are problems.

In each visit a resident/fellow physician in training may see the child first, prior to the attending physician. A nurse, social worker and dietitian are available. Separate outpatient meetings with the dietitian or nurse alone are possible to book.

The Honeymoon Period

A few weeks following the diagnosis of type 1 diabetes, insulin doses are lowered, while maintaining excellent blood sugar levels. Is the diabetes going away? No! This is the honeymoon period, a period of excellent control, with very low insulin requirements. A few children may even be able to skip at least one insulin injection. The honeymoon period may last from a few months and up to a year or longer, depending on the amount of insulin-producing beta cells left in the pancreas. Therefore, children who are diagnosed early are less sick and without DKA usually have a longer honeymoon period.

High blood sugar levels that are present prior to diagnosis are toxic to the remaining beta cells, and prevent those cells from producing insulin effectively. Once insulin injections bring down the blood sugar levels and give the remaining beta cells some rest, those beta cells return to function. The beta cells are able to help-out by secreting insulin whenever there is a need, allowing for lower insulin doses. It takes a few weeks to enter the honeymoon period because initially most children eat a lot in order to regain their lost weight and strength, and the remaining beta cells have not yet recovered.

Unfortunately, the autoimmune process continues to gradually destroy the remainder of beta cells. When there are hardly any beta cells left, the honeymoon period ends. It ends gradually, marked by gradual increase in insulin requirements. Keeping active and avoiding excessive weight gain may help reduce the demand for insulin, and prolong this period for a bit longer. Prior attempts to manipulate the immune system and prolong the honeymoon period have not been useful. There are research trials addressing this that are currently ongoing, and those can be discussed with our physicians.

Treatment Goals

Goals of treatment at the Rady Children’s Diabetes Clinic:

1. Maintain blood glucose levels (and A1c) as close to normal, while avoiding low blood glucose levels (hypoglycemia). This requires frequent blood sugar checks, at least 4 times daily in patients on insulin, before meals and at bedtime. Better control of blood sugar levels results in less long-term complication and slower progression of complications, should they develop. Hemoglobin A1c is a blood test done from a finger stick every 3 months, which measures the average blood glucose levels over that time, and helps guide therapy and home blood glucose monitoring. Continuous glucose monitoring is now also available,

2. Diabetes to revolve around a child’s life, and not visa versa. Towards that goal, a qualified and experienced diabetes team is available to constantly tailor the treatment plan (insulin regimen and diet) to the individual’s needs. These revolve around the daily schedule, meals, and family needs. To address these issues, our team includes certified diabetes educators, nurses, dietitian, social worker and physicians giving 24-7 coverage. Good communication and education are key to good outcomes.

An insulin pump is a useful tool to achieve some goals, but requires responsibility and a dedicated effort in managing diabetes. In addition, certain basic skills need to be learned before a pump can be prescribed. Good preparation is the key to success in the dozens of patients who are doing great with the insulin pump. We use 3 major brands of insulin pumps, and the ultimate choice of which pump to use is individual.

3. Promote healthy weight and diet. This is important in controlling blood pressures and lipid levels such as cholesterol and triglycerides. Preventing further weight gain or advocating moderate weight loss in obese patients with type 2 diabetes often helps control blood sugars, and prevents other complications associated with obesity.

4. Monitor for complications and other conditions associated with diabetes, during each visit to the clinic, and through periodic labs.

These include:

  • Height and weight to monitor growth. Growth can be affected by diabetes or conditions associated with diabetes: abnormal thyroid or adrenal glands, or celiac disease,
  • Blood pressure checks at each visit. Hypertension is particularly harmful in diabetes, and advances other complications more rapidly.
  • Monitor the thyroid gland on exam and yearly thyroid blood tests.
  • Monitor urine for protein leak (urine microalbumin), as a sign of kidney complication due to diabetes. If left untreated this can lead to kidney failure and dialysis in adulthood.
  • Ensure dilated eye examination done yearly after 5 years duration or as needed. This is to monitor for diabetes damage to the small blood vessels at the back of the eye, which can lead to blindness if left untreated,
  • Ensure good foot care and sensation, building good habits for adulthood. Preventing ingrown toenails and infections,
  • Monitor lipid levels (cholesterol, LDL, HDL and triglycerides), especially in type 2 diabetes, and treat as needed. This is crucial since abnormal lipids results in earlier heart disease and infarcts.

Written by Rady Children’s Division of Endocrinology/Diabetes