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Pediatric Diabetes - Diabetes in Children

Diabetes Type 1 or Type 2?   Factors to Consider

Author/s: Timothy F. Kirn
Family Practice News May 15, 2000

Honolulu - Differentiating type 1 diabetes from type 2 is no easy task these days, with the prevalence of type 2 diabetes rising so rapidly in the pediatric population, Dr. Francine Ratner Kaufman said at a meeting sponsored by the American Diabetes Association.

One should not assume that an obese child or adolescent has type 2 diabetes, cautioned Dr. Kaufman, director of the Comprehensive Childhood Diabetes Center at Children's Hospital of Los Angeles.

Perhaps as many as one-quarter of children with type 1 diabetes may be overweight at the time of the diagnosis, she noted.

At Children's Hospital, she and her colleagues have developed a score sheet for adding up the different factors that are associated with each type of diabetes to aid in diagnosis.

The factors that lean toward a diagnosis of type 2 are:

* Body mass index greater than 25.
* Family history of type 2.
* Acanthosis nigricans.
* African American, Hispanic, or Native American race.

 The factors favor a diagnosis of type 1 are:

* Symptoms of less than 3 weeks duration.
* Diabetic ketoacidosis or ketosis.
* Family history of type 1.
* Positive test for islet-cell antibodies.

Dr. Kaufman and her coworkers are refining their score sheet to weight each factor in comparison to the others.

Many questions about type 2 diabetes in children remain, Dr. Kaufman said, including the crucial one of whether type 2 in children really is equivalent to type 2 in adults or whether it has important differences. One thing suggesting it may be different is that children with type 2 present fairly commonly with ketonuria (33%) or even ketoacidosis (5%-10%). They also have a high rate of acanthosis (70%-90%).

This lack of knowledge extends to treatment. There are no primary data on the use of oral agents in pediatric diabetic patients, she said. "We are currently gathering data on the use of metformin."

The most recent estimates, from last year, suggest that type 2 may now account for as many as 45% of new diabetes cases in the pediatric population, depending on the center where the survey was done, she said. Studies of African American children in Ohio and Arkansas found that 70%-75% of new cases are type 2. A study of a Hispanic population in Ventura, Calif., found that 31% of new cases were type 2.

The increase in type 2 cases means that it is essential for physicians to make a concerted effort to identify patients who may have diabetes, she said.

The children or adolescents recommended to be screened by the consensus report of the American Diabetes Association include those with a high body mass index, a relative with type 2 diabetes, any signs of insulin resistance such as acanthosis nigricans, or those who are members of any of the racial groups with a high rate of diabetes (African American, Hispanic Native American, or Asian-Pacific Islander).

The presence of hypertension, dyslipidemia, or polycysric ovary syndrome also should trigger screening, Dr. Kaufman added.

Go Slowly When Teaching Parents About Caring for Diabetic Child

Physicians and hospitals too often overwhelm parents of children with newly diagnosed diabetes with too much information, Dr. Joseph I. Wolfsdorf said at a meeting sponsored by the American Diabetes Association.

Providers need to lake it easy and focus on teaching parents the basic skills they need to take care of their child, said Dr. Wolfsdorf, director of the diabetes program at Children's Hospital in Boston.

"The big fat books with hundreds of pages of information are really not relevant at all.”

"The important message here is that you have to teach them what they need to learn, but encourage them to go at their own pace," he said.

Education and teaching should be done by one person to avoid giving parents mixed messages and confusing them.

Dr. Wolfsdorf likes to keep the child in the hospital for a few days at least to allow the parents time to begin to come to terms with the diagnosis, even when that means fighting the family's HMO plan.

"At the time of diagnosis, an atom bomb goes off in the family," he noted.

It's essential that both parents be involved in learning about the disease and its management, when possible, Dr. Wolfsdorf said. When both parents are not available, another relative or intimate, like a grandparent, should be enlisted to help. The care that's involved, particularly for a child under 5 years of age, is so demanding that no one person can do it alone with any measure of comfort.

The number of new cases of diabetes in children under 5 years of age is increasing at 11% a year, Dr. Wolfsdorf noted.




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