Greetings fellow MahaIAPians !

Diabetes prevalence is increasing in pediatric and adolescent ages across the globe. Although Type 1 still comprises of the majority; with alarming rise in obesity, the percentage of type 2 diabetes is also increasing. While we are at the brink of developing artificial pancreas, there are still many challenges that are faced by a paediatrician while managing pediatric diabetes.

Late diagnosis

Almost 70-80% of Indian type 1 diabetic children are detected late, with DKA. Frequent urination is often taken as a norm or a seasonal variation in infants; thus delaying the diagnosis. Acidotic breathing in DKA is often considered as pneumonia; and it may take hours to days to arrive at a diagnosis of DKA. Many healthcare providers may simply not think of the diagnosis, due to its rarity. A high index of suspicion needs to be kept in a child with frequent urination, unexplained weight loss, frequent infections, vague complaints, or tachypnea with clear chest. A blood sugar testing should be mandatory at hospitalization for any reason. Type 2 diabetes should be suspected and screened for in every obese child above the age of 10 years. While a type-1 child walks in with symptoms, a diagnosis of type-2 diabetes often comes as a surprise while investigating obesity.

Lack of expert care :

Despite wide availability of paediatricians, a vast majority of children are treated by general practitioners. While paediatricians manage DKA very well, the follow-up care is generally handed over to diabetologist/endocrinologist. If the specialist is not tuned to pediatric diabetes care, the child is at risk of being treated in adult-diabetes-fashion. OHAs and premix insulins have almost no role in type 1 diabetes management. Basal-bolus therapy with 3-4 pricks a day is universally accepted and the most correct mode of insulin treatment in these children. The Indian Society for Pediatric & Adolescent Endocrinology [ISPAE] has come up with the second edition of Type 1 diabetes management. Year 2016 witnessed first-of-its-kind national conference and workshop on pediatric diabetes management: "ISPAE 2106: Sugars & Beyond". More of such training programs are required.

Economic hindrance :

Medical insurance companies in India do not cover the expenses on insulins, syringes, glucometer strips or insulin pumps. Average expense per month for a diabetic child is 1.5-4k rupees depending on the testing frequency and insulin type. A single admission for DKA may cost an amount much more than the annual expense for diabetes supplies. Hence it is important to prevent hospitalizations by ensuring frequent self monitoring of glucose [SMBG] testing and dose adjustments. Choosing a right glucometer, a right testing frequency and a right combination of insulins can ease out the financial burden of the family. Diabetic child, parents and siblings should have their own mediclaim to tackle with additional healthcare expenses. For yellow/orange ration-card holders in Maharashtra, there is provision of free hospitalization for type 1 diabetes under Rajiv Gandhi Jeevandayi Yojana at approved centres.

Lack of motivation :

More than the economics, it is the lack of motivation that leads to poor standard-of-care in diabetes. Healthcare providers often don't motivate the parents to test their child's sugars frequently. Type 1 diabetes cannot be managed without SMBG. Frequent SMBG is associated with better sugar control and less complications. A minimum of 7 SMBGs a week is easily achievable. Maintaining a sugar diary is as important as giving insulin.

Unregulated healthcare delivery :

With the systems of parallel medicines and unregulated media advertorials on diabetes management, anyone can claim to treat type-1 diabetes. A blind-hope of curing their child's diabetes can cost lakhs of rupees, and can risk the child's survival and future. It is important to convince the parents about the fact that insulin is 'The-Only-Medicine' for type 1 diabetes. Stem cell therapy is the cure for type-1 diabetes, but it is still in research phase. Insulin pumps are wonderful semi-automatic devices to manage type-1 diabetes, but they require lot of inputs and participation from the patient/parents. One needs to actually count the carbohydrates in the food, and make few calculations before taking the boluses. One still has to test blood glucose frequently while on insulin-pump. The higher versions of the pumps are sensor-augmented, but very expensive.

Recurrent DKA :

First DKA is no-one's fault. But second DKA is the fault of our healthcare system. With proper guidance regarding dose adjustments, sick-day care and urine ketone testing, DKA admission can be averted in most of the cases. Recurrent DKA is an independent predictor of mortality in type 1 diabetes.

Hypoglycemia :

Children below 5 years are unable to report hypoglycaemia symptoms. Recurrent hypoglycaemias cause autonomic failure and blunt the protective responses. Hypoglycemia is number 1 cause of mortality in pediatric diabetes. Use of basal-bolus [instead of twice a day insulin], insulin analogues, cheking midnight sugars are the ways of preventing hypoglycaemia. A dispersible glucose tablet [Eg. Hypotab] can be kept in the school bag and the teacher can be informed of the warning signs of hypoglycaemia.

Role of a pediatrician :

With scarcity of pediatric endocrinologists, a paediatrician has to get equipped to manage diabetic children. With little training, they can do a wonderful job. A printed flowchart of DKA management can be put in the pediatric ICU. Going slow on fluids and insulins is the key to successful DKA management. While shifting from I/V to subcutaneous insulin, it has to be basal-bolus therapy. The parents need to be taught regarding the survival skills including sugar testing and hypoglycaemia management before they leave the hospital. While there is no special diet for diabetic children, they must follow 3 meals [with bolus insulin] and 2 snacks in order to avoid hypoglycaemia. Paediatrician should give clear instruction on how to check urine ketones when sick and having high sugars. Diabetic children require additional vaccination and liberal use of antibiotics due to susceptibility to infections. On follow-up visits, the injection sites need to be checked along with the sugar diary. While Al c reflects the average sugar control over last 3 months, it doesn't obviate the self testing with glucometer. Puberty can complicate diabetes management due to various physiologic and psychological changes. It is our duty as a paediatrician to ensure good diabetes control and no complications till the time transition of the care to adult physician.

Dr. Tushar Godbole

Editor, Maha-IAP Bulletin 2016
Pediatric Endocrinologist