The incidence of type 1 diabetes (T1D) continues to rise, with 18% of new diagnoses occurring in children aged 9 years and younger. In 2014, Current Diabetes Reports published a review of diabetes care in young children with T1D, highlighting the challenges of T1D care, current research in this population, and opportunities for future research and clinical care. Since 2014, numerous changes in the clinical presentation of diabetes have impacted young children. Research has reinforced the importance of maintaining glucose levels within a narrow target range for young people with T1D of all ages 

 The incidence of type 1 diabetes (T1D) continues to rise, with 18% of new diagnoses occurring in children aged 9 years and younger [1]. In 2014, Current Diabetes Reports published a review of diabetes care in young children with T1D, highlighting the challenges of T1D care, current research in this population, and opportunities for future research and clinical care [2]. Since 2014, numerous changes in the clinical presentation of diabetes have impacted young children. Research has reinforced the importance of maintaining glucose levels within a narrow target range for young people with T1D of all ages [3]. Current glycemic goals recognized by the American Diabetes Association (ADA) and the International Society of Pediatric and Adolescent Diabetes (ISPAD) recommend that young children maintain HbA1c levels < 7>

Physiological problems

Early onset of T1D places young children at increased risk for neurocognitive sequelae. Using both comprehensive neurocognitive testing and high-resolution structural magnetic resonance imaging (MRI), Mauras and colleagues found that young children with T1D did not differ from their peers without T1D on measures of cognitive and executive function, but children with T1D exhibited differences in brain growth [8]. Slower brain growth was associated with higher cumulative hyperglycemia and glucose variability among young children with T1D [8]. Another study found similar structural findings but also found subtle cognitive differences in children with T1D compared with children without T1D, including participants who were newly diagnosed with T1D (T1D duration in the study ranged from 1 month to 8 years). This study also found a trend toward an association between DKA and a history of severe hypoglycemia and IQ scores. This research suggests that glycemic controls may have detrimental effects on the developing brain [9]. In a longitudinal study, Kirchhoff and colleagues observed differences in cognitive function between young adults with T1D and their age-matched relatives without diabetes, with cognitive decline associated with both increased hyperglycemia and earlier age at T1D onset, which may pose challenges to the cognitive developmental trajectory [10,11]. Young children are at increased risk of diabetic ketoacidosis (DKA) at T1D onset [12, 13]. DKA at T1D diagnosis has been associated with higher A1c levels over time and a negative impact on cognitive function [14, 15]. Hey and colleagues found that DKA when diagnosed in young children was associated with lower cognitive scores as assessed by IQ tests, the Detectability and Commission subtests of the Conners’ Continuous Performance Test II, and the Dot Locations subtest of the Memory Scale for Children (Mtime since diagnosis = 2.8 years) [15]. Developing or improving public health education programs to help families and primary care physicians recognize early signs of T1D and DKA may be helpful in reducing the negative impact on cognitive development in young children [16]. Given the developmental expectations of young children, including limited language abilities and unpredictable eating and activity patterns, there is often more concern about hypoglycemia than in older children with T1D [17]. In addition, young children often take smaller, more accurate doses of insulin and have higher insulin sensitivity than older youth [2]. Recent studies have shown that parents may intentionally keep their young children’s blood glucose levels higher to avoid low blood glucose and the adverse effects of hypoglycemia [17,18]. Parental fear of hypoglycemia may interfere with achieving updated glycemic targets that recommend narrower glycemic ranges [19], which is problematic given the aforementioned research linking chronic hyperglycemia to negative cognitive impacts. As noted previously, since the 2014 review, the recommended A1c target for young children (children ≤ 6 years) has changed from < 8>

Nutrition

Diet quality and parental monitoring of mealtime behavior are important aspects of diabetes management in young children. Research has shown that although parents of young children generally know what healthy eating entails, they do not always follow healthy eating patterns due to barriers to feeding and mealtimes. One nutrition study assessing breakfast diet quality in a sample of young children with T1D found that less than half of the children met dietary recommendations for protein and fat (46

Diabetic ketoacidosis 

Diabetic ketoacidosis is a potentially life-threatening condition. It should be treated promptly in a specialized facility by a diabetology team experienced in treating children. There should be a written treatment plan for diabetic ketoacidosis in children and adolescents.

Biochemical criteria for ketoacidosis include:

•             pH<7>

•             Bicarbonate<15>

•             Hyperglycemia>11 mmol/L,>200 mg/dL, and Ketonuria and serum ketones.

•             Ketoacidosis is classified into 3 severity grades:

•             Mild (pH<7>

•             Moderate (pH<7>

•             The following treatment goals should be achieved in ketoacidosis:

•             Stabilization of the cardiovascular system with an initial volume bolus using isotonic saline,

•             Followed by slow balanced infusion therapy and electrolyte replacement,

•             Slow normalization of blood glucose levels,

•             Balancing acidosis and ketosis,

•             Avoiding complications of therapy (cerebral edema, hypokalemia), and Diagnosis and therapy of provoking factors.

During treatment of severe diabetic ketoacidosis, clinical observation and monitoring should be performed at least hourly. Patients with severe ketoacidosis and increased risk of cerebral edema should be treated immediately in an intensive care unit or a specialized diabetes unit with comparable equipment by a diabetology team experienced in paediatrics. Patients with suspected cerebral edema should be treated in an intensive care unit in collaboration with an experienced diabetology team. Patients with obvious signs of cerebral edema should be treated with mannitol or hypertonic saline until further diagnostic measures (MRI) are initiated. There are case reports or case series showing therapeutic efficacy in symptomatic cerebral edema with early intravenous mannitol (0.5–1 g/kg) over 10–15 min and repeated if necessary (after 30 min).

Hypoglycemia

Hypoglycemia is the most common acute complication in diabetes [Diabetes Control and Complications Study Group 1994]. According to the latest recommendations of the Hypoglycemia Study Group 

[International Hypoglycemia Study Group (2017)], a distinction is made between blood glucose values in the following groups: Stage 1: <70>

Nutritional recommendations

Nutrition counseling for children and adolescents with diabetes is an important part of a comprehensive treatment plan and should include the following components: Information about the effectiveness of carbohydrates, fats and proteins in relation to blood glucose levels, Promotion of healthy eating habits at family meals and in community settings: regular, balanced meals and snacks (fruits, vegetables, raw vegetables), prevention of eating disorders (especially uncontrolled, binge eating) and prevention of overweight, Consideration of cultural eating habits Sufficient energy for age-appropriate growth and development, Working towards a normal BMI, which includes regular physical activity, A good balance between energy intake and energy use according to insulin profiles, Nutrition during illness and exercise, and Reduction of the risk of cardiovascular disease. Nutritionists (dietitians/ecotrophologists) with in-depth knowledge of child and adolescent nutrition and insulin therapy should provide such advice Nutritional recommendations should include all dietary components and their proportion in daily energy intake [German Society for Nutrition/Deutsche Gesellschaft für Ernährung (DGE) 2015].

In summary, childhood diabetes mellitus is a multifaceted disease that requires a multidisciplinary approach to diagnosis and treatment. With due attention to early diagnosis, individualized treatment, lifestyle, and psychosocial support, the quality of life of children with diabetes can be significantly improved and the risk of developing serious complications can be reduced. This also highlights the need for further research in this area to improve prevention and treatment methods