Understanding Diabetes in Children: A Lifelong Companion

Overview of diabetes mellitus (DM), including its various types, prevalence, risk factors, signs and symptoms, potential complications, and available treatment options.

Diabetes Mellitus (DM) is a common endocrine disorder in which the pancreas either fails to produce enough insulin or is unable to make any insulin at all. As insulin is essential for regulating blood sugar levels, deficiency of it may lead to various health complications.

Takeaways

• Type 1 DM is a lifelong condition usually diagnosed in children and young adults, where your blood sugar levels are abnormally high.

• Type 1 diabetes cannot be prevented, but people with type one diabetes need to take insulin every day to manage this condition effectively.

• Healthy lifestyles and diet always support better diabetes management.

Introduction

Diabetes mellitus is a common chronic metabolic condition worldwide, characterized by high blood sugar (glucose) levels. Glucose, the body's primary energy source, fuels the cells that form muscles and tissues, and acts as the primary energy source for the human brain.

There are different types of DM, categorized as type 1 & type 2, which are chronic. Maturity-onset diabetes of the young (MODY) and neonatal diabetes are also types of DM. Secondary diabetes, prediabetes, and gestational diabetes are reversible conditions.

• Type 1 diabetes: Also known as juvenile diabetes or insulin-dependent diabetes. This is the condition where your immune system attacks and destroys insulin-producing cells in your pancreas for unknown reasons. It can start at any age, but often begins in childhood or the teen years. There are two forms of type 1 diabetes: Immune-mediated diabetes and Idiopathic type. Immune-mediated diabetes is a condition in which the body’s immune system mistakenly attacks and destroys the insulin-producing islet cells in the pancreas, a process known as autoimmunity. This type of diabetes is more common. At the same time, Idiopathic is the rare form of the disease with no exact known cause to date.

• Type 2 Diabetes: This is the more common type, where your body doesn't make enough insulin or your body’s cells don’t respond normally to the insulin. Adults are primarily affected, but children can also develop this condition.

• Maturity-Onset Diabetes Of The Young (MODY): It is caused by pancreatic islet-cell dysfunction, which reduces insulin production. It usually runs in families, typically appears before age 25, and does not involve the production of autoantibodies or ketones.

• Gestational Diabetes: It occurs during pregnancy and usually goes away after delivery. 

• Neonatal Diabetes: This is a rare genetic condition characterized by the body's inability to produce insulin. It usually begins before 6 months of age and rarely appears between 6 months and 1 year.

• Secondary Diabetes occurs due to certain medications, endocrine diseases, or genetic conditions. Endocrine disorders like Cushing's syndrome and acromegaly lead to insulin deficiency. Other causes include Cystic fibrosis, beta-blocker use, Pheochromocytoma, pancreatic disorders, steroids, etc. 

• Latent Autoimmune Diabetes in Adults (LADA): LADA is a slow-developing form of Type 1 diabetes that appears in adults. It occurs in people who are often not overweight, so it is often misdiagnosed as type 2 diabetes.

• Prediabetes: a condition where blood sugar is higher than normal but not high enough to be diagnosed as diabetes, but it can lead to diabetes if not managed in time.  

Prevalence of DM

Approximately 1.25 million American children and adults (0.4%) have type 1 diabetes. In 2017, there were about 185,000 youth with type 1 Diabetes and 28,000 with type 2 diabetes. According to the Centers for Disease Control and Prevention (CDC), in 2021, an estimated 29.7 million people of all ages, or 8.9% of the U.S. population, had been diagnosed with diabetes.

352,000 U.S. children and adolescents under age 20 or 35 per 10,000 youths had diagnosed diabetes. This included about 304,000 with type 1 diabetes. Among adults aged 20 years and older, 1.7 million or 5.7% of those with diagnosed diabetes reported having type 1 diabetes and using insulin. 3.6 million adults, 12.3% of those with diagnosed diabetes, began insulin therapy within one year of their diagnosis. 

By 2060, these numbers are expected to rise significantly. Type 1 diabetes cases may increase to 335,000 (a 65% rise), and Type 2 Diabetes cases may rise to 220,000 (a 67.3% increase). In the United States, approximately 1.24 million people live with Type 1 diabetes, and that number is expected to grow to five million by 2060. According to IDF Diabetes Atlas (8th Edition), the number of young people (<20 years) living with type 1 DM worldwide is more than 1 million. If current trends continue, the number of cases is expected to increase by more than 100,000 every year.

Risk Factors For Type 1 DM

The exact cause of type 1 diabetes is still unknown. However, it is widely believed that it's a result of a combination of genetic and environmental factors. The risk factors that may increase the likelihood of type 1 diabetes are considered to be:

• Family History: Having a parent or sibling or close relatives with type 1 diabetes slightly increases your risk.  General population (with no family history): ~0.4% risk, if your biological mother has type 1 diabetes:1%–4% risk, if your biological father has type 1 diabetes: 3%–8% risk, if both parents have type 1 diabetes: Up to 30% risk

• Genetics: Specific gene variants (especially Human Leukocyte Antigen (HLA)- DR and HLA- DQ genes) are associated with higher susceptibility.

• Geography: The incidence of type 1 diabetes tends to be higher in countries farther from the equator.

• Age: Although type 1 diabetes can occur at any age, there are two notable peak periods of occurrence. First peak: In children between 4 and 7 years old, and second peak: In children between 10 and 14 years old.

• Ethnicity: In the U.S., White individuals are more likely to develop type 1 diabetes than African American or Hispanic/Latino individuals. 

• Environmental Factors, like early exposure to certain foods or toxins, may trigger type 1 diabetes in genetically predisposed individuals. These include obesity, poor gut microbiome diversity, diet, and vitamin D deficiency. Breastfeeding may lower the risk, while early exposure to cow's milk and cereal (before 3 months) could increase it. Individuals in northern climates and those with lower sun exposure may be at a higher risk, with diagnosis rates peaking in winter and declining in summer.

Type 1 diabetes can be diagnosed at any age and in people of every race, shape, and size. 

Signs and Symptoms of Type 1 DM

The symptoms of diabetes occur because the lack of insulin means that glucose is high but is not used by your muscles as fuel for energy. When blood glucose levels are high, glucose is lost in the urine, and you may become dehydrated. The signs and symptoms of type 1 diabetes in children usually develop quickly, often within a few hours or days, while in adults, the symptoms often take longer to develop (a few days or weeks). Once they appear, the symptoms can be severe. Symptoms can vary from person to person.  However, the most common symptoms are listed below. 

• Increased thirst – Due to excessive glucose in the blood, leading to dehydration.

• Frequent urination – The kidneys work harder to remove excess sugar, causing frequent urination, including full diapers in infants and bedwetting in children.

• Extreme hunger & weight loss – The body struggles to use glucose properly, leading to increased appetite while losing weight.

• Weakness & fatigue – Energy levels drop due to poor glucose absorption.

• Irritability & mood changes – Blood sugar fluctuations can affect mood and emotions.

• Fruity breath & fast breathing – Potential signs of diabetic ketoacidosis, a serious diabetes complication.

• Abdominal pain – Can occur due to digestive system effects or ketoacidosis.

• Blurry vision – Excess glucose affects fluid levels in the eyes, leading to vision issues.

• Slow-healing cuts & sores – High blood sugar affects circulation and the immune response.

• Vaginal yeast infections in girls – Excess sugar promotes yeast growth.

Note: Symptoms of Type 1 diabetes can resemble those of other illnesses, such as the flu. Always consult a healthcare provider if you notice any of the above symptoms. Early diagnosis is critical to avoid life-threatening complications.

Diagnosis of DM

Diagnosis of type 1 DM has historically been made based on detecting blood glucose level dysregulation. The diagnosis perspective of type 1 diabetes is relatively simple. In patients with classic symptoms (e.g., polyuria, polydipsia, polyphagia), a random (non-fasting) plasma glucose ≥200 mg/dL (11.1 mmol/L) or a fasting plasma glucose concentration of 126 mg/dL (6.99 mmol/L) or higher confirms diabetes. This test is crucial for diagnosis and immediate management.  And, to assess for chronicity, we can check HbA1c levels.

According to the American Diabetes Association (ADA), diagnosis can be made if any one of the following criteria is met:

1. A1C ≥ 6.5% (≥ 48 mmol/mol), Performed in a laboratory using an NGSP (National Glycohemoglobin Standardization Program) certified and DCCT (Diabetes Control and Complications Trial) -standardized method.

               OR

2. Fasting Plasma Glucose (FPG) ≥ 126 mg/dL (≥ 7.0 mmol/L), no caloric intake for ≥ 8 hours.

                OR

3. 2-hour Plasma Glucose (PG) ≥ 200 mg/dL (≥ 11.1 mmol/L), during an OGTT using 75-gram anhydrous glucose dissolved in water, per WHO (World Health Organization) guidelines.

                OR

4. Random Plasma Glucose ≥ 200 mg/dL (≥ 11.1 mmol/L). In an individual with classic symptoms of hyperglycemia or a hyperglycemic crisis, a sample can be taken at any time of day, regardless of the time since the last meal.

Treatment of DM

The primary goals of treating type 1 diabetes in children are to maintain stable blood sugar levels (Aiming for an A1c goal of less than 7.5% is currently recommended for all pediatric patients) and prevent associated health issues. This includes avoiding sudden complications, such as dangerously low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia), preventing long-term problems that can affect organs over time, and supporting normal growth and development, which is especially important for children. The treatment primarily focuses on medical nutrition therapy (MNT), exercise or physical activity, and medication management.

Medical Management

Insulin remains the cornerstone of treatment for type 1 Diabetes. Insulin is administered either by injection, using a pen, rapid-acting inhaled insulin, or an insulin pump.

Rapid-acting insulin starts working in 15 minutes, peaks in 1 hour, and lasts about 4 hours (e.g., Humalog, NovoLog). Short-acting insulin (regular insulin) begins to work in 30 minutes, peaks in 90–120 minutes, and lasts 4–6 hours (e.g., Humulin R, Novolin R). Intermediate-acting insulin starts working in 1–3 hours, peaks in 6–8 hours, and lasts 12–24 hours (e.g., Humulin N, Novolin N). Long-acting & ultra-long-acting insulin provides coverage for 14–40 hours (e.g., Lantus, Levemir, Tresiba).

Note: In pediatric Type 1 DM, glimepiride (4 mg) showed no significant benefits over insulin in key parameters, though it was safe.  Exenatide, a GLP-1 agonist, reduced hyperglycemia but didn't effectively suppress glucose levels, suggesting it could be an adjunct to insulin therapy. Pramlintide, an amylin analog, reduced glucose levels and had minimal complications, also lowering glycated hemoglobin, Body Mass Index (BMI), and insulin dose, making it a promising treatment for type 1 DM.   Further research is needed to optimize these therapies.

Exercise

Regular exercise is important for everyone, including children with type 1 and type 2 diabetes. Maintaining a healthy BMI (18.5–24.9) and reducing screen time to less than 2 hours per day is necessary. Be active for at least 60 minutes every day. Check your blood glucose before and after exercising. If your blood sugar is lower than the target range before you start, it's recommended to eat 15 grams of carbohydrates (younger children may need a smaller amount). During long or intense exercise, check your blood sugar every hour and again after you finish. This will guide you on how much carbohydrate may be needed and whether your insulin dose needs to be adjusted.

Nutrition

The goal is to maintain stable blood sugar levels, support growth, and prevent the development of overweight or obesity. A consistent meal routine, consisting of three main meals and two snacks, helps regulate blood sugar levels and promote overall health. According to the “International Society for Pediatric and Adolescent Diabetes” (ISPAD) guidelines, the daily energy intake should consist of 45–50% of carbohydrates, 30–35% of fat (saturated fat <10%) and 15–20% of protein. Increase consumption of fruits and vegetables regularly. 

A diet should include foods that are high in nutrients and low in fat and calories, and limit the consumption of animal products. Avoid simple sugars. Dinner should be taken at least 2 hours before bedtime. Unsaturated fats, and particularly polyunsaturated fats (PUFAs), such as omega-3 and omega-6, are preferred.

• Carbohydrates: When we consume carbohydrates, they can be converted almost entirely into blood sugar, which fuels our daily activities. To support better health, it’s recommended to choose whole grains over refined grains, since they provide more nutrients and fiber.

• Protein: It plays a vital role in building, repairing, and maintaining body tissues, and is essential for healthy growth and development. Protein also forms the core of important substances, such as hormones, enzymes, and antibodies.  Although about half of dietary protein can be converted into blood sugar, it also helps slow the absorption of carbohydrates when eaten as part of a mixed meal. Luckily, most people can meet their protein needs with everyday foods, requiring no supplements, even for active athletes.

• Fat: Fat should make up less than 30 percent of the calories we eat each day. Although only about 10 percent of dietary fat is converted into blood sugar, fat plays several important roles. It enhances the flavor of food and helps the body absorb fat-soluble vitamins, such as A, D, E, and K. Fat is also a concentrated source of energy and slows the movement of food from the stomach, which can help regulate how carbohydrates are absorbed when eaten together in a meal.

Education

Teach the child, parents, and caregivers about what Type 1 Diabetes is, the lifelong need for insulin, how to check blood sugar and keep records, signs of low blood sugar, and its possible long-term complications. Also, cover healthy eating and balanced diet plans, as well as what to do when the child is sick.

Transforming Diabetes Care; The Power of Artificial Intelligence (AI):

The rise of new healthcare technologies has created exciting opportunities for better diabetes management. Given the complexity of diabetes and the need for ongoing monitoring and treatment adjustments, tools such as advanced glucose monitors and health tracking apps enable more personalized and effective care. AI and Machine Learning (ML) can predict diabetes early, enabling prevention before symptoms appear. ML models outperform traditional methods, achieving accuracy (AUC) of up to 0.80 and overall prediction accuracy of up to 94.9%.

These tools help identify individuals at high risk and enable early intervention. AI helps identify modifiable risk factors for diabetes, such as high blood pressure, high cholesterol, smoking, poor diet, inactivity, and obesity. By analyzing complex data, AI enables the development of targeted prevention strategies tailored to individual needs, thereby enhancing diabetes prevention efforts.

AI enables non-invasive, accurate, and accessible diabetes screening using large datasets and images. It outperforms traditional methods and helps detect early, hidden cases of diabetes, especially in high-risk groups. AI enhances diabetes care by improving health education through mobile apps, which boost patient knowledge and glycemic control. It supports nutrition therapy by automating food tracking and creating personalized diet plans. In physical therapy, innovative systems offer tailored exercise programs to increase adherence and effectiveness. AI also enables real-time glucose monitoring, predicting blood sugar changes to help prevent hypo and hyperglycemia.

Personalized Treatment	AI helps tailor insulin doses and treatment plans.
Better Diagnosis	AI improves accuracy in medical tests and scans.
Real-Time Monitoring	AI tracks blood sugar levels and gives alerts.
Predicting the Future	AI forecasts how diabetes may progress and how treatments will work.
Healthy Living Support	AI gives diet and lifestyle tips for better diabetes control.

Complications

Over time, type 1 diabetes can damage major organs like the heart, blood vessels, nerves, eyes, and kidneys. This can lead to complications such as heart disease, neuropathy, vision loss, and kidney failure. To reduce complications, keep your blood sugar levels within a normal range. Type 1 diabetes can lead to both short-term and long-term complications if not managed properly.

Short-term Complications

• Hypoglycemia (low blood sugar) can occur if too much insulin is administered or after exercise, which increases insulin sensitivity.

• Hyperglycemia (high blood sugar) can result from insufficient insulin or inconsistent medication use.

• Diabetic Ketoacidosis (DKA): A dangerous condition when high blood sugar leads to ketone buildup, requiring hospital care.

Long-term Complications:

• Microvascular damage (small blood vessels): Can lead to vision loss (diabetic retinopathy), kidney failure (diabetic nephropathy), or nerve damage (diabetic neuropathy)

• Macrovascular damage (large blood vessels): Can cause heart disease, heart attacks, strokes, and peripheral vascular disease.

Other Complications:

• Foot Damage: Nerve damage (neuropathy) and poor blood circulation in the feet can increase the risk of foot complications. Minor injuries, such as cuts or blisters, can develop into serious infections if left untreated. In severe cases, this may lead to amputation of a toe, foot, or even part of the leg.

• Skin and Mouth Conditions: Diabetes can increase your susceptibility to bacterial and fungal skin and mouth infections, thereby raising the risk of gum disease and dry mouth. These conditions can further contribute to dental problems and other oral infections.

• Pregnancy Complications: Poorly controlled blood sugar during pregnancy poses risks for both the mother and the baby. It raises the chance of miscarriage, stillbirth, and birth defects.

Conclusion

Type 1 Diabetes has become a growing concern in children over the past few decades in our society. It is an autoimmune condition that primarily affects individuals who are genetically susceptible. To manage pediatric type 1 diabetes effectively, a team effort is required, involving specialists such as endocrinologists, dietitians, and diabetes educators. We should provide continuous education and support for both patients and their families to ensure proper treatment adherence, promote self-care, and improve long-term health outcomes.

Frequently Asked Questions

What is the prognosis for this condition? 

Managing Type 1 diabetes is difficult, and nearly half of those with the condition develop serious complications, including vision loss and kidney disease. However, individuals who reach 20 years post-diagnosis without complications generally have a positive long-term outlook.

How can I take care of my child if they have Diabetes?

Learning your child has type 1 diabetes can be overwhelming. Parents should monitor carbohydrate intake, administer insulin as needed, and regularly check blood sugar levels. Emotional support is vital, and parents can help children recognize symptoms and manage their condition. Educating family and school staff builds a support network. Support groups can help individuals adjust to changes.

Do I still need to check my blood sugar and take insulin if my blood sugar level is okay and doing fine?

Even if you feel fine, managing type 1 diabetes requires regular blood sugar monitoring and proper insulin use. Your levels may be off without noticeable symptoms, and prolonged imbalances can cause serious complications like eye, kidney, and brain damage. Staying consistent with your treatment and collaborating with your healthcare team is crucial to maintaining long-term health.

What is the targeted blood sugar level for a type 1 diabetes patient?

You must check your blood glucose level at home using a blood glucose meter (glucometer), before meals (to assess baseline levels before food intake), before bedtime (to ensure safety overnight), at 2 a.m. (to detect nocturnal hypoglycemia) and when experiencing symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar.

How to check blood glucose level at home?

To check your blood glucose, wash and dry your hands thoroughly. Turn on your meter and confirm the date and time. Insert a test strip and perform a finger stick to obtain a drop of blood. Touch your finger to the test strip to let it fill, and the meter will display your reading shortly. Wipe your finger clean and record the result in your diary to help manage your health effectively.

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About Dr. Grishma Wosti, MBBS

Born and raised in Nepal, a scenic Himalayan country, I earned a medical degree and gained invaluable clinical experience in rural areas, which fostered strong communication and leadership skills. An approachable and positive personality with a passion for cooking, singing, and bicycle riding that adds vibrancy to life outside of medicine—preparing for the USMLE exams to pursue a medical residency in the United States.