patient’s diagnosis. The categorization of diabetes requires further testing and workup. There are multiple subtypes of diabetes, including T1DM and type 2 diabetes mellitus. In both disease states, insulin deficiency results in worsened glycemic control. Type 1 diabetes mellitus typically presents as complete insulin deficiency, whereas type 2 diabetes mellitus is generally a slower and more progressive loss of function, often termed insulin resistance. Other forms of diabetes include gestational diabetes mellitus, drug-induced diabetes, and cystic fibrosis–
related diabetes. The most common type of diabetes in pediatric patients is T1DM. Diabetes care will vary throughout the course of the child’s life as they grow, both physically and emotionally. Multidisciplinary care is essential for education and management of medications, nutrition, and complications (ADA et al., 2022e). While it is important to ensure caregivers are adequately educated in accordance with their level of health literacy, it is also imperative to engage the pediatric patient in owning and managing their care as early as developmentally appropriate.
TYPE 1 DIABETES MELLITUS: BACKGROUND
Epidemiology According to the International Diabetes Federation Atlas, more than 1 million children and adolescents younger than 20 years of age are currently diagnosed with T1DM globally (Ogle et al., 2022). Within the U.S., the Centers for Disease Control and Prevention (CDC) estimates that 37.3 million people have diabetes, which is roughly 11% of the population (CDC et al., 2022a). New-onset diagnoses of T1DM in children and adolescents younger than 20 years of age are estimated to occur at a rate 18,000 cases per year in the U.S. alone (CDC et al., 2022a). These values make diabetes one of the most common chronic diseases among children in the country. Modeled data demonstrate that the rate of diagnosis has been increasing Pathophysiology and risk factors In patients diagnosed with T1DM, pancreatic islet β cells are partially or totally destroyed, typically secondary to an autoimmune response (Toni et al., 2017). Autoimmunity is primarily T-cell mediated, and destruction of β cells occurs at a variable rate. This process leads to insulinopenia, which results in hyperglycemia, hypertriglyceridemia, and ketoacidosis (ADA et al., 2022d). Most patients do not become clinically symptomatic until a majority of pancreatic β cells are destroyed. Markers of autoimmunity include islet cell autoantibodies, glutamic acid decarboxylase autoantibodies, insulin, tyrosine phosphatases islet antigens 2 and 2 β , and zinc transporter 8 (ADA et al., 2022a). These markers elucidate pathophysiology and can aid in early detection of T1DM prior to symptom onset. The risk of developing autoimmune destruction of β cells is genetic and environmental yet not completely understood. One of the areas of pathophysiology study is the altered microbiome. Antibiotic exposure, especially during the first two years of life, can significantly alter the gut microbiome (McDonnell et al., 2021). This dysbiosis is linked to infection risk, chronic illnesses, propensity for obesity, and development of allergies later in life (Kumbhare et al., 2019). Conflicting reports Presentation Pediatric patients with new-onset T1DM most commonly present with polyuria and polydipsia (ADA et al., 2022a). Other symptoms include weight loss and change in appetite over the course of a few weeks. Unfortunately, 40%–60% of all children present with diabetic ketoacidosis (DKA), a life-threatening complication of diabetes. In DKA, the body utilizes fat for energy, which produces ketones and creates an acidotic state. Diabetic ketoacidosis is considered a medical emergency and typically requires hospitalization for monitoring and treatment.
over time. Between 2002 and 2015, there has been a 1.9% increase in new pediatric cases, and between 2011 and 2015, non-Hispanic Asian and Pacific Islander children and adolescents had the largest significant increase compared to the rest of the U.S. population (CDC et al., 2022a). While the increased rates of diagnosis in the U.S. and worldwide are not fully understood, several causes are implicated (Abela & Fava, 2021). Postulated mechanisms include increased rates of childhood obesity, altered microbial exposure, and other environmental factors. These areas are under study and will hopefully elucidate methods of prevention. demonstrate antibiotic exposure in infancy and early childhood may be linked to the development of diabetes. A Danish cohort study concluded that risk of T1DM onset before the age of 15 years is associated with broad-spectrum antibiotic receipt during infancy in children delivered by cesarean section (Clausen et al., 2016). The authors did propose several limitations of this study and suggested the association may not be causal, as development of diabetes is multifactorial. A follow-up study evaluated antibiotic exposure from 0 to 24 months, and found that it was not associated with incidence of childhood T1DM, once adjusted for confounders (Antvorskov et al., 2020). Of note, this study did not account for maternal antibiotic use. Most recently, a study in South Korea determined that antibiotic exposure within the first two years of life was also not associated with future diagnosis of diabetes in children younger than 8 years of age (Lee et al., 2022). The authors concluded that although this information is meaningful, longer follow- up would be beneficial in future reports. As a relatively newer area of research, dysbiosis data is evolving, and future studies may elucidate novel biomarkers and modifiable childhood risk factors. Self-Assessment Quiz Question #1 Rob undergoes an evaluation for diabetes, and a plasma glucose level is obtained as part of his workup. Which of the following plasma glucose levels would qualify him for diagnosis (last meal = 6 hours prior)? a. Plasma glucose of 130 mg/dL. b. Plasma glucose of 190 mg/dL. c. Plasma glucose of 240 mg/dL. d. A plasma glucose level cannot be interpreted for diagnosis at this time because his last meal was 6 hours prior to measurement. recommended, as early therapeutic interventions are lacking. In the first stage, patients are normoglycemic, but multiple islet autoantibodies are detected. In stage 2, patients progress to dysglycemia with elevated plasma glucose and HbA1c levels just below the threshold for diagnosis. In stage 3, patients
Diagnosis Presentation of T1DM is categorized in three evolving stages, the first two of which are presymptomatic (ADA et al., 2022a). Screening during these stages may result in early detection of impaired pancreatic function and prevention of DKA; however, asymptomatic screening for diabetes is not yet routinely
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