Diabetes is a disease in which the body cannot adequately process glucose (blood sugar) for energy. It was once rare among children but is becoming more common. More than a third of Americans born in 2000 will eventually develop diabetes, according to the U.S. Centers for Disease Control and Prevention (CDC).

Children can develop type 1 diabetes or type 2 diabetes. Type 1 was once commonly called juvenile-onset diabetes, and type 2 diabetes was often referred to as adult-onset diabetes. However, type 2 diabetes is increasingly being seen in children because of rising rates of childhood obesity due to poor diet and lack of exercise. These same factors can cause a child with type 1 diabetes to develop double diabetes.

Other pediatric forms of diabetes include maturity-onset diabetes of the young (MODY), which may be diagnosed in adolescents, and Wolfram syndrome, a rare genetic condition. Some children develop secondary diabetes due to conditions including cystic fibrosis or Down syndrome. A rare disorder called Mauriac syndrome (diabetic dwarfism) afflicts some diabetic children.

People with type 1 diabetes or Wolfram syndrome require insulin therapy several times a day. People with type 2 or other forms of diabetes may be treated with diet and exercise alone, or they may require antidiabetic agents and insulin. Additional therapies are being developed.

The U.S. government has launched a massive study of diabetes and children. Other research projects are also under way to assess the scope of diabetes in children and to prevent, diagnose and treat it.

Diabetes is a disorder in the body’s ability to break down glucose (blood sugar). It is one of the most common chronic diseases affecting children in developed nations. According to U.S. government health agencies:

• 176,000 Americans under age 21, or 0.22 percent of that age group, have diabetes.
  
  
• One in every 400 to 600 American children and adolescents has type 1 diabetes.
  
  
• About 2 million American adolescents have prediabetes.
  
  
• More than a third of Americans born in 2000 will eventually develop diabetes.

The National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK) cautions that data on pediatric diabetes are inadequate. Although authorities generally agree that the prevalence of diabetes in childhood is growing, federal estimates were slightly reduced in 2005 because they were based on five years of data instead of the most recent three years, as was previously done. Improved reliability is expected upon completion of a major five-year project, SEARCH for Diabetes in Youth.

Children can develop both major kinds of diabetes:

• Type 1 diabetes. An autoimmune disease in which the body attacks the beta cells in the pancreas that make insulin. Insulin is a hormone the body needs to use glucose for energy. Type 1 was once called juvenile diabetes because it is often diagnosed at an early age. After diagnosis, several weeks or months may pass before the child requires regular insulin injections. This period of time is called the honeymoon period. After this period the person needs to take insulin regularly.
  
  
• Type 2 diabetes. A metabolic disorder in which the body develops insulin resistance and can no longer use insulin correctly. Over time, the pancreas may become unable to make enough insulin to regulate glucose. Type 2, which accounts for about 90 to 95 percent of diabetes cases, was formerly called adult–onset diabetes because it is often diagnosed in middle age.

Childhood obesity is strongly linked to pediatric type 2 diabetes. Children with type 2 diabetes, especially those who are overweight, can also have high blood pressure and unhealthy levels of cholesterol. Prediabetes generally develops before type 2 diabetes, but diagnosis and treatment of prediabetes can delay or prevent this escalation.

Other pediatric diabetes conditions include:

• Double diabetes. A condition in which people with type 1 diabetes develop insulin resistance, typically because of obesity due to physical inactivity and overeating.
  
  
• Maturity-onset diabetes of the young (MODY). An uncommon hereditary condition that is usually diagnosed in adolescents or young adults.
  
  
• Secondary diabetes. Diabetes caused by another condition or a medical treatment. Causes of secondary diabetes in children can include cystic fibrosis, celiac disease, growth hormone disorders, inherited neuromuscular diseases, insulin resistance syndromes such as ataxia-telangiectasia and leprechaunism, and chromosomal disorders such as Down syndrome, Klinefelter syndrome and Turner syndrome.
  
  
• Autoimmune polyglandular syndrome. A rare group of autoimmune endocrine conditions, often including type 1 diabetes.
  
  
• Wolfram syndrome. A rare hereditary condition that includes insulin-dependent diabetes, problems with vision and hearing, and diabetes insipidus.
  
  
• Persistent hyperinsulinemic hypoglycemia of infancy (PHHI, also called congenital hyperinsulinemia). A genetic disorder involving overproduction of insulin by the pancreas. Though rare, PHHI is nonetheless the leading cause of hypoglycemia in early infancy. Treatment typically includes drugs such as diazoxide and somatostatin and may require a partial pancreatectomy. 
  
  
• Mauriac syndrome (diabetic dwarfism). A rare complication of childhood diabetes that enlarges the liver, delays puberty and limits height.

• Damage to blood vessels (diabetic angiopathy and atherosclerosis)
  
  
• Eye diseases including diabetic retinopathy, glaucoma and cataracts

• Nerve damage (diabetic neuropathy)
  
  
• Kidney disease (diabetic nephropathy)
  
  
• Slow healing of wounds
  
  
• Dehydration, which is especially dangerous in children

These problems can lead to the most traumatic consequences of diabetes, including foot or leg amputation, blindness, chronic kidney failure, heart disease and stroke. Physicians are already noting chronic diabetic complications in some teens with type 2 diabetes.

Research has suggested a high prevalence of microvascular and macrovascular complications (problems with the small and large blood vessels) in young adults who developed type 2 diabetes as children, according to the National Institutes of Health (NIH). The rise of childhood obesity, insulin resistance and diabetes also raises the risk of heart disease.

Recent studies have also linked childhood diabetes to periodontal disease, childhood type 2 diabetes to behavioral and psychiatric disorders, and childhood glucose irregularities to impaired learning and memory.

Pediatric type 2 diabetes was first noted in significant numbers in the 1980s. Studies have found the incidence of type 2 diabetes in children is increasing in the U.S. with the highest rates among members of racial or ethnic minorities. American children with type 2 diabetes typically are overweight or obese, have a family history of the disease and tend to be Hispanic, Native American, black or Asian. Type 1 diabetes, in contrast, is more common in white children, particularly those of Northern European ancestry.

When children are diagnosed with diabetes, it is common for parents to feel overwhelmed or helpless. Children with type 1 diabetes must take insulin by syringe injection or other means several times every day, and children who develop type 2 diabetes must improve their diet and exercise habits. They may also need to take insulin or other medication.

A child’s attitude toward the condition will, to a large extent, reflect the parents’. It is important for parents to approach diabetes management in a matter-of-fact way, so their children do not develop feelings of being inferior or handicapped. Properly managed, diabetes does not have to prevent children from growing, learning, playing and achieving.

For instance, there may be a temptation to be overprotective or overindulgent with a child who has diabetes. As with all children, this can lead to discipline problems, feelings of incompetence and other issues. Many experts suggest that parents love, teach and discipline their children as if diabetes were not a factor.

Learning about diabetes is a crucial factor in being able to control anxiety for parent and child. Both should learn as much as possible by working closely with a certified diabetes educator.

For children with type 1 diabetes, insulin administered by syringe injection, insulin pen, jet injector or insulin pump is necessary. When diabetes occurs in infants, parents must learn how to test glucose (blood sugar) and administer insulin. They should also be aware of symptoms of hypoglycemia, or low blood sugar. Such symptoms include:

• Paleness
• Sweating
• Trembling or clumsiness
• Crankiness
• An unusual cry
• Clammy skin or a bluish tinge to the lips or fingers
• Hunger

Symptoms of hyperglycemia include:

• Excessive thirst (polydipsia)
• Frequent urination (polyuria)
• Fatigue

Youngsters in elementary and middle school can begin to take some responsibility in management of diabetes. Many can use a glucose meter by age 7, describe symptoms of high blood glucose by age 9 and give themselves injections by age 10. Concerns at this age include:

• Diabetes management in school. Administrators, teachers and coaches need to know about injections, insulin pumps, lancets and other diabetic equipment. There have been cases of uninformed school officials confiscating such devices.

• Education rights. Groups such as the American Diabetes Association (ADA) can inform parents and children with diabetes about their legal rights to accommodation in schools and other facilities, such as camps.
  

• Overnight visits with friends. Schoolmates’ parents and leaders of youth groups may need information about a child’s diabetes and emergency treatment plan (for example, if glucagon must be injected in case of severe hypoglycemia).

Adolescents may rebel in diabetes management as well as other ways. Parents may need to be more flexible in setting goals and learn to ask questions rather than confront. Concerns at this age include:

• Hormonal changes. Onset of pediatric diabetes often occurs around puberty. The release of growth hormones can lead to insulin resistance. Increased levels of estrogen and testosterone can cause fluctuations in glucose levels. Insulin and other medications may need to be adjusted.
  
  
• Alcohol. Binge drinking can increase the risk of hypoglycemia. Intoxication can mask symptoms of hypoglycemia, including confusion and trembling.
  
  
• Tobacco. Smoking increases risk of damage to the heart, blood vessels and circulation. Teens with diabetes need to know how smoking can worsen the condition and contribute to the development of complications.
  
  
• Eating disorders. Anorexia, bulimia and other conditions can affect glucose levels and have severe consequences with diabetes.
  
  
• Increased self-consciousness. The wish to avoid seeming different may reduce compliance with insulin, diet and other treatments. Peer groups can help teens as well as younger children.

Researchers are exploring why the rate of type 2 diabetes has risen among children in the United States and worldwide, especially among U.S. ethnic minorities. They believe that the complex causes of diabetes include genetics as well as behavioral, environmental, social, economic and cultural factors. Contributing factors include:

• Obesity. Up to 85 percent of children with type 2 diabetes are overweight or obese, according to the American Diabetes Association (ADA). Obesity is strongly associated with the insulin resistance that can lead to type 2 diabetes. Obesity also contributes to double diabetes and may contribute to the development of type 1 diabetes at an earlier age. Contributors to obesity include physical inactivity and a diet high in calories, saturated fats, starches and sugars.
  
  
• Exposure in the womb. Exposure to diabetes in utero may be a cause of the increase in type 2 diabetes among children, according to the Centers for Disease Control and Prevention (CDC).
  
  
• Genetics. A family history of diabetes increases a child’s risk of the disease. Genetics is also a factor in obesity.

Scientists are also investigating the causes of type 1 diabetes. It is an autoimmune disorder in which the body mistakenly attacks and destroys the insulin-making beta cells of the pancreas.

Risk factors for type 1 diabetes include family history, genetics and race and ethnicity (white race, especially of Northern European heritage). Other possible contributors to type 1 diabetes include:

• Viruses
• Chemical and environmental factors
• Diet

Potential causes of secondary diabetes in children can include other endocrine disorders, celiac disease (gluten intolerance), some pancreatic conditions, inherited neuromuscular diseases, insulin resistance syndromes, chromosomal disorders and blood disorders.

Genetics is the major factor in maturity-onset diabetes of the young (MODY) and Wolfram syndrome.

Diabetes often goes undetected in children because symptoms may be absent, mild or misinterpreted as the flu.

The following indicators may be seen with type 1 diabetes or type 2 diabetes:

• Drowsiness, fatigue or lack of energy.
  
  
• Extreme thirst (polydipsia).
  
  
• Bedwetting and polyuria (increased urination).
  
  
• Unexplained weight loss.
  
  
• Increased appetite (polyphagia).
  
  
• Obesity. Obesity often accompanies the insulin resistance that can lead to type 2.
  
  
• High glucose (hyperglycemia).
  
  
• Frequent infections.
  
  
• Slow healing of sores.
  
  
• Itching (pruritus).
  
  
• Vision changes.
  
  
• Mood changes and depression.
  
  
• Dizziness.
  
  
• Sweet, fruity-smelling breath. This may indicate ketosis. High levels of a waste product called ketones can form in the blood when the body uses stored fat for energy rather than glucose (blood sugar).
  
  
• Ketoacidosis. A dangerous condition involving ketosis and severe hyperglycemia. Some children are diagnosed with diabetes through being hospitalized with ketoacidosis.
  
  
• Hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Dangerously high glucose along with dehydration. Some children are diagnosed with diabetes through being hospitalized with HHNS.
  
  
• Insulin resistance. The body’s impaired response to insulin may be an early sign of diabetes.
  
  
• Acanthosis nigricans. A skin condition marked by velvety dark patches, usually on the armpits, back of the neck or thighs. It is generally a sign of high levels of insulin (hyperinsulinemia).
  
  
• Vaginitis. A fungal infection of the vagina that is common in girls with diabetes.
  
  
• Polycystic ovarian syndrome (PCOS). A condition seen in girls with insulin resistance or type 2 diabetes, irregular or absent menstrual periods, increased hair on the face or body and high levels of male hormoneshormone (androgens).

Methods used by a physician in diagnosing diabetes in children may include:

• Family history. Children with a family history of either type 1 or type 2 diabetes are more likely to get diabetes. Children with a family history of the disease should be screened every two years after age 10 or at time of puberty if it occurs earlier.
  
  
• Blood tests. These include the:
  
  
• Fasting plasma glucose test (FPG).  A sample of blood is taken from a vein after an individual has not had anything to eat or drink for eight to 10 hours. The blood is tested for the amount of glucose (blood sugar) in the sample. If the glucose level is at least 126 milligrams per deciliter (mg/dL), the physician suspects diabetes. Physicians usually make a diagnosis of diabetes when two FPG tests, done on different days, are greater than 125 mg/dL. A glucose reading of 100 to 125 mg/dL indicates prediabetes, a condition that also needs treatment.
  
  
• Oral glucose tolerance test (OGTT). The patient consumes a carbohydrate-rich diet for a few days, then fasts for 10 to 16 hours before the test. After a blood sample is drawn, the patient drinks a concentrated glucose liquid. Two hours later, blood glucose readings of 140 to 199 mg/dL indicate prediabetes and 200 or higher suggest diabetes.
  
  
• C peptide test. The cells in the pancreas that make insulin produce a protein called C peptide. Elevated levels indicate high levels of insulin in the body, an indication of type 2 diabetes rather than type 1.
  
  
• Autoantibody testing. This can reveal self-antibodies seen with type 1 diabetes but not type 2.

Goals in treating children with diabetes include avoiding the dangers of high glucose (blood sugar) and low glucose, maintaining normal growth and development, and avoiding complications such as kidney disease. Because children are more prone to more illnesses than adults are, it is especially important for young diabetic patients to have a sick-day management plan.

Some of the same therapies used in adults with diabetes are appropriate for children. Researchers are still testing use of some antidiabetic agents with children and working on alternatives. Hormonal changes and growth are two factors that can affect insulin, glucose and medication dosage in children.

Treatment options for diabetic children include:

• Glucose monitoring. Keeping track of glucose levels is important whether insulin is being administered or not. Ways to help children maintain correct levels of glucose include:
  
  
• • Explaining diabetes, glucose and insulin to everyone in the family
    
    
  • Trying the glucose meter under supervision of a physician or diabetes educator

The family should understand the plan developed by the physician to define, detect and treat irregular glucose levels (hyperglycemia and hypoglycemia). For example, the treatment plan for severe hypoglycemia may be an injection of glucagon administered by a parent, school nurse or other trained person.

The physician may also recommend regular ketone tests to help avoid diabetic ketoacidosis. Ketones are waste products produced when the body burns stored fat instead of glucose for energy and are of particular concern to people with type 1 diabetes.

• Exercise. Children with type 2 diabetes can help control the disease by losing weight through increased activity. Exercise can also help children with type 1 diabetes feel better and avoid double diabetes. Ways to get children more active include:
  
• • Setting an example, such as walking or bicycling more
    
    
  • Involving the whole family
    
    
  • Starting slowly, such as one family walk a week
    
    
  • Increasing activity levels as early goals become easy

• Diet. This is another lifestyle change that can help control type 2 diabetes and benefit children with type 1 diabetes. Ways to improve children’s eating habits include:
  
  
• • Getting nutrition counseling
    
    
  • Reducing portion sizes
    
    
  • Planning several small meals a day rather than fewer heavy ones
    
    
  • Introducing more vegetables, fruits and high-fiber whole grains
    
    
  • Limiting saturated fats, starches and sugars
    
    
    
  • Keeping healthful snacks on hand, such as yogurt and sliced vegetables
    
    
  • Showing children how to shop for food and read labels
    
    
  • Urging officials to make school meals more nutritious
    
    
• Insulin. Children with type 1 diabetes or Wolfram syndrome need to take insulinby syringe injection, insulin pen, jet injector or pump. Some children with type 2 diabetes or other forms of diabetes also require insulin therapy. The U.S. Food and Drug Administration (FDA) has approved inhaled insulin for diabetic adults but not children. Ways to help children take insulin include:
  
  
• • Alternating the test on different fingers
    
    
  • Pricking the side rather than the top of the fingertip
    
    
  • Having the child, if old enough, record the results in the logbook

• Oral medications (antidiabetic agents). The FDA has approved pediatric use of biguanides (metformin) and a sulfonylurea (glimepiride) for type 2 diabetes. Antidiabetic agents being assessed in clinical trials for use by children include thiazolidinediones, including rosiglitazone.

Exercise and nutrition, two essential management techniques for diabetes, can also be used to prevent the disease.

Other ways of averting pediatric diabetes include:

• Prenatal care. Scientists report an increase risk of type 2 diabetes with poor prenatal nutrition, low birth weight (under 5 pounds) and excess birth weight (over 10 pounds). Programs are being developed to teach pregnant women the importance of exercise, diet and infant care, and to control prediabetes and diabetes in pregnant women.
  
  
• Not smoking. The many health dangers of tobacco include increased risk of diabetes and metabolic syndrome.
  
  
• Community involvement. Programs have had success in reducing and controlling diabetes in children by increasing awareness among patients, parents, teachers, healthcare providers, youth groups and community centers. The focus is on education, exercise, development of good eating habits and monitoring of glucose (blood sugar).
  
  
• Increased training of physicians. The U.S. Centers for Disease Control and Prevention (CDC) has called for improving physicians’ awareness and monitoring of diabetes in children, including the growing incidence of type 2 diabetes.
  
  
• Regular physician visits. Access to insurance and health care is an issue for some families. These factors can delay early diagnosis of diabetes and thus increase risk of complications.

The U.S. government has launched the largest study ever of diabetes in children. The five-year program, SEARCH for Diabetes in Youth, involves more than 5 million, or 6 percent, of Americans from infancy to age 19.

The main goals of SEARCH:

• Classify all types and variations of childhood diabetes
• Estimate the number of cases by type, race, sex and age
• Note the causes and characteristics of each type
• Detail the complications of the disease
• Describe the quality of life of children with diabetes

Scientists with SEARCH reported in 2006 that obesity, long known to be a major risk factor for type 2 diabetes, can also speed the development of type 1 diabetes in children who already have severe damage to the pancreas. Childhood obesity may help explain why type 1 diabetes is being seen at earlier ages, the researchers reported.

The U.S. government has also begun the TODAY Study (Treatment Options for type 2 Diabetes in Adolescents in Youth). TODAY is comparing the effectiveness of three treatments for type 2 diabetes:

• The glucose-controlling drugs biguanides alone
• Biguanides with rosiglitazone (a thiazolidinedione)
• Biguanides with exercise and weight loss

Federal health officials in 2006 announced the largest-ever long-term of children’s health. The goal of the National Children’s Study is to follow at least 100,000 American children from birth through adulthood, in an effort to find the causes of diseases ranging from diabetes to autism. The project is to begin in 2007, with the first results released about 2010.

A new international effort called TEDDY (The Environmental Determinants of Diabetes in the Young) is testing more than 200,000 babies for several genes known to increase the risk of type 1 diabetes. This four-year genetic screening is expected to identify 13,000 high-risk babies. Half of them will be followed for 15 years in an effort to determine which environmental factors contribute to type 1 diabetes.

A similar study, PANDA (Prospective Assessment in Newborns for Diabetes Autoimmunity), is using a blood sample to identify infants at high genetic risk of type 1 diabetes and following them for five years.

Other topics being studied include the relationship of obesity to childhood diabetes, prenatal causes of diabetes, whether type 1 diabetes is on the rise in the United States as it is in Europe, and the genetic, racial, ethnic and gender differences in childhood diabetes. Scientists and public health authorities hope that such research will help stem the rising tide of diabetes in children.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Parents or patients may wish to ask their doctor the following  questions about diabetes and children:

1. Is my child at risk of developing diabetes?
   
   
2. Can type 2 diabetes be prevented or delayed in my child?
   
   
3. Can type 1 diabetes be prevented or delayed in my child?
   
   
4. How can my child with type 1 diabetes avoid double diabetes?
   
   
5. What tests might my child need to undergo? What are the test results?
   
   
6. What diet and exercise plan do you recommend for my child?
   
   
7. What glucose (blood sugar) levels are recommended for my child?
   
   
8. How often should my child’s glucose be checked?
   
   
9. Do you recommend a technology that allows me to remotely monitor my child’s glucose levels?
   
   
10. Does my child need insulin or another diabetes medication?
    
    
11. Has the U.S. Food and Drug Administration approved use of this medication for children?
    
    
12. If my child needs insulin, what method of administration do you recommended?
    
    
13. What should my child and I know about hyperglycemia, hypoglycemia, diabetic coma and other emergencies?
    
    
14. Should teachers, coaches, youth leaders, friends and others be informed of my child’s diabetes and be trained in addressing a diabetic emergency? Should they be instructed in using glucagon in case of severe hypoglycemia?
    
    
15. What is my child’s outlook for diabetic complications such as kidney disease and retinopathy?