MEDICAL COMPLICATIONS ASSOCIATED WITH DIABETES IN CHILDREN

Children with both types 1 and 2 diabetes are at risk for several complications. Data indicates that 1 in 3 adolescents with type 1 diabetes and around 3 in 4 adolescents with type 2 diabetes exhibit symptoms of at least one diabetes-associated complication. However, diabetes complications in children and youth have not been well studied.

While the same effects of diabetes are common to all age groups, one of the important factors in the development and severity of diabetic complications is the length of time diabetes is present. Young children diagnosed with diabetes have a potentially greater risk for microvascular complications as they proceed into their adult years, compared to their peers without a diagnosis of diabetes.

The types of complications are also similar between forms of diabetes, but there is a difference in prevalence rates. For example, retinopathy can occur more frequently in youth with type 1 diabetes, whereas microalbuminuria and hypertension occur more often in youth with type 2 diabetes. It has also been found that diabetic-related complications occur at a younger age in youth with type 2 diabetes compared to those with type 1 diabetes.

The presence of diabetes is a major risk factor for earlier mortality related to cardiac disease. Research shows that the risk of cardiac disease and acute myocardial infarction has a 30-times increase in those who diagnosed with type 1 diabetes before the age of 10 (ADA, 2018; NIDDK, 2018; Tamborlane, 2021).

Complications and Type 1 Diabetes

DIABETIC KETOACIDOSIS (DKA)

One of the most serious complications for children with T1D is diabetic ketoacidosis. When the body is unable to utilize glucose for energy due to a lack of insulin, it turns instead to its fat stores as an energy source, and the byproducts of this process are ketones (fatty acids), which alter the serum and urine pH and eventually result in DKA (ADA, 2017a).

The condition can develop slowly, but without treatment it is fatal. DKA is the most pervasive cause of mortality in children with T1D (ADA, 2017a). DKA has also been proven to result in serious consequences for brain development and function (ADA, 2020a).

Signs of DKA include:

Excessive thirst
Dry mouth
Weakness
Lethargy
Fruity breath-smell
Nausea
Vomiting
Abdominal pain
Difficulty breathing

Once vomiting occurs, the child’s condition can quickly deteriorate to full-blown DKA within a matter of a few hours. A child with DKA requires immediate medical treatment to correct dehydration and bring blood glucose levels back down to normal. Acute kidney injury can occur in children during episodes of DKA; research has found that this can lead to slight cognitive impairment, which includes short-term memory loss and decreased IQ scores (Weiner & Karlya, 2017; Zolot, 2021).

CARDIOVASCULAR DISEASE

Clinicians may not consider cardiovascular disease as a problem in children and youth, however current data indicates that 14%–45% of children with T1D develop two or more atherosclerotic cardiovascular diseases (ADA, 2020a). Cardiovascular disease risk factors are highest among minority youth, and girls are at higher risk than boys.

ADA recommendations for screening of cardiovascular disease in children and youth with T1D include:

Blood pressure measurement at each visit using an appropriate-size cuff for a child
Lipid evaluation shortly after diagnosis with T1D

Treatment interventions focus primarily on lifestyle modifications, with emphasis on dietary modifications and exercise (ADA, 2020a).

RETINOPATHY

Retinopathy is another major medical complication associated with T1D. Current data indicate a small risk of developing retinopathy in children before the age of 12. Problems with retinopathy most frequently occur after the start of puberty and after the presence of T1D for 5 to 10 years.

ADA recommendations for retinopathy screening include a comprehensive eye examination, along with dilation, for a child who is at least 11 years of age or older or who has reached puberty and is 3 to 5 years postdiagnosis with T1D, whichever happens first. Once a baseline exam has been conducted, a comprehensive eye exam with dilation is advised every two years. This may be extended to every four years on the advice of an eye care specialist.

Clinicians must educate parents and youth on the importance of eye exams. Parents should seek out an eye specialist with expertise in diabetic retinopathy and who is well versed in counseling families and youth in prevention measures and the signs and symptoms to observe for in order to ensure early detection (ADA, 2020a).

NEUROPATHY

Diabetic neuropathy is not commonly found in children with T1D before puberty, or within the first 1 to 2 years following onset of diabetes. The ADA recommends a yearly foot examination beginning at the onset of puberty or at 10 years of age or greater, whichever occurs first. The ADA also recommends a complete clinical foot inspection during each routine visit as a means to educate the young person on the importance of foot care (ADA, 2020a).

Medical Complications in Type 2 Diabetes

Compared to youth with T1D, medical complications are higher in youth with T2D. Likewise, studies show that T2D is a more severe disease in children than in adults. When adults are diagnosed, complications may not arise for a considerable length of time, often up to 10 years. However, in children with T2D, complications start developing within a few years of diagnosis.

The rates of T2D are higher in racial/ethnic minorities, many of whom live in environments in which diabetes self-care, health management, and lifestyle changes can be challenging. Youth with T2D may already have other health conditions present at the time of diagnosis, similar to those discussed above for T1D. Other problems unique to T2D must also be taken into account.

COMPLICATIONS OF TYPE 2 DIABETES

Kidney disease is a frequent complication of T2D in children (Curry, 2016). The evidence shows that in youth with T2D, there is a faster ongoing deterioration in beta-cell function than in adults with T2D.

The development of vascular defects, including ischemic heart disease and stroke, seems to be more prominent in youth with T2D compared to youth with T1D with a similar duration since diagnosis.

Micro- and macrovascular changes are among the most serious medical complications of T2D in this population, which heightens their risk of cardiovascular disease and death at a younger age when compared to those diagnosed with T2D at later stage in life. It is believed that this increased susceptibility to adverse cardiovascular events is due to the greater lifetime exposure to hyperglycemia and other variants associated with T2D, such as insulin resistance, dyslipidemia (abnormal blood lipid levels), high blood pressure, and chronic inflammation (ADA, 2020a).

Other complications include:

Polycystic ovary disease (a hormonal condition resulting in irregular or extended menstruation)
Hyperandrogenism (a higher-than-normal level of male sex hormones)
Sleep apnea
Hepatic steatosis (a build-up of fat in the liver)
(ADA, 2020a)

SCREENING RECOMMENDATIONS

ADA recommendations for screening youth who are newly diagnosed with T2D include:

Screening for retinopathy at the time of diagnosis or shortly thereafter
Evaluation for nonalcoholic fatty liver disease at the time of diagnosis, using AST and ALT measurements, and follow-up testing yearly
Screening for symptoms of sleep apnea, snoring restless sleep, and morning headache at each visit and, if necessary, referral to a pediatric specialist for further evaluation
For adolescent girls with T2D, assessing for menstrual problems and, if warranted, for polycystic ovary disease
Lipid screening once glycemic control has been established, and then repeated yearly
Baseline foot exam at the time of diagnosis and on a yearly basis to monitor for neuropathy
(ADA, 2020a)