| Answers from Dr. Greene |
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QUESTION:
Dr. Greene, with a new diabetic child, I wonder why yeast infections are not included in the symptoms of onset -- especially in young infants and children? Parents I speak with (and my own daughter) first presented with yeast that was not resolving. She was 3 and potty trained and no one ruled out DM. Most parents I talk with had yeast, even boys. I was alarmed that my pediatric team did not consider this and it is not mentioned anywhere in public info pamphlets in what you should know about diabetes, because most kids are going into diabetic crisis before intervention. What do you think?
DSTimboCC_2, Nurse
DR. ALAN GREENE:
Timbo, I'm so glad you have raised this issue. There are indeed early ways to detect diabetes, but most children with type 1 diabetes are not diagnosed until the situation has become desperate. The diabetes symptoms that most people are familiar with (increased thirst and increased urination) are very late warning signs. By then, the child is dangerously close to the end, unless she receives prompt treatment.
Diabetes develops slowly
Diabetes is a slow process that begins much earlier than symptoms appear.
People who get type 1 diabetes were born with a genetic predisposition to it. Not everyone born with this predisposition gets diabetes, however. In fact, if an identical twin has diabetes, the other twin gets it only about half the time. Along the way, some of the predisposed individuals are exposed to something in the environment that triggers the diabetes. This may be a viral infection. The virus misleads the body's immune system into making antibodies against its own pancreas cells that make insulin. (This is why type 1 diabetes is now also called immune-mediated diabetes.)
Type 1 diabetes most often strikes young people, especially between the ages of 5 and 7 (when viruses run through the schools), or at the time of puberty (when so many hormones change). For this reason, it used to be called juvenile-onset diabetes. This term has now been eliminated, since we now know that it can appear at any age.
Normally, a hormone called insulin pushes sugar from the blood into the body's cells where it can be used for fuel. This insulin is produced in the pancreas. Diabetes is an attack on the pancreas.
When diabetes first begins, the insulin-producing cells of the pancreas are destroyed gradually over months or years. The remaining cells are able to compensate for this by increasing their insulin production. The body can still make enough insulin to keep the concentration of sugar in the blood within a fairly narrow range.
Diabetes is usually diagnosed soon after symptoms appear
When 90% of the insulin-producing cells have been destroyed, the person suddenly begins to develop symptoms. Thus, type 1 diabetes generally brews for years, but appears abruptly. Once symptoms appear, it rarely goes undiagnosed for more than a few weeks.
The classic symptoms of type 1 diabetes are increased urination (polyuria), increased thirst (polydipsia), increased eating (polyphagia) and weight loss. Anyone with the classic symptoms should have a blood sugar test as well as a urine test. Occasionally people also report fatigue, blurred vision, vomiting, abdominal pain, or frequent skin infections. If the disease remains undiagnosed, symptoms progress to include labored breathing, coma, and death.
Early detection
How much better it would be to diagnose diabetes long before everything is out of control! As you have pointed out, Timbo, chronic yeast infections (or other skin infections) can be an early warning sign. Healthy kids in diapers commonly get yeast diaper rashes. But if these infections are very frequent, or not easy to clear up with appropriate treatment, I get concerned. If a child is out of diapers, I prefer checking a fasting blood sugar after only one yeast infection, especially if there is a family history of diabetes.
Other tests are available for even earlier detection of the diabetes process. People with type 1 diabetes have measurable antibodies in their blood that reveal their autoimmune condition. One autoantibody found in people with type 1 diabetes is the islet cell antibody. This antibody is often detectable months or years before symptoms appear. Other antibodies include the ICA 512 antibody and the GAD (or 64-K) antibody. The presence of these antibodies is a sign that the body is attacking its own insulin-producing cells. I expect that testing for autoantibodies will get less expensive and more common in the near future.
An intriguing study released in October 1999 showed that by measuring the number of autoantibodies in siblings of children with diabetes, they were able to predict the risk each of these siblings had for going on to develop diabetes. They were even able to predict how long it would likely take for diabetes to develop.
Clearly this is useful information. It will become especially powerful when we find ways to prevent the autoantibodies from completing their destructive actions.
My hope is that in this next century, most diseases -- from cancer to diabetes to the common cold -- will no longer be thought of as beginning when we first notice the symptoms. As we are able to detect the true start of these processes, we will be far more able to prevent and treat diseases before they wreak mayhem and destruction in our bodies.
Alan Greene, M.D. earned a Bachelor's degree from Princeton University and graduated from medical school at University of California at San Francisco. Upon completion of his pediatric residency program at Children's Hospital Medical Center of Northern California in 1993, he served as Chief Resident. During his Chief year, Dr. Greene passed the pediatric boards in the top 5% of the nation.
Dr. Greene entered primary care pediatrics in January 1993. He is on the Clinical Faculty at Stanford University School of Medicine where he sees patients and teaches Residents. He serves as the Chief Medical Officer of A.D.A.M., Inc., a leading provider of consumer health information, and helps direct A.D.AM.'s editorial process. As A.D.A.M.'s CMO, he served as a founding member of Hi-Ethics (Health Internet Ethics) and helped URAC develop its standards for eHealth accreditation. He is also the Founder & CEO of DrGreene.com. Dr. Greene was also named Intel's Internet Health Hero for children's health. He is an author, medical expert, and a media personality.
He is the author of The Parent's Complete Guide to Ear Infections (People's Medical Society, 1997). Dr. Greene has appeared in numerous publications including the Wall Street Journal, Parenting, Parent, Child, American Baby, Baby Talk, Working Mother, Better Home's & Gardens, and Reader's Digest. He also appears frequently on television and radio shows as a medical expert.
References
American Diabetes Association. Standards of medical care in diabetes--2009. Diabetes Care. 2009 Jan;32 Suppl 1:S13-61.
Alemzadeh R, Wyatt DT. Diabetes mellitus in children. In: Kliegman RM, ed. Kliegman: Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders;2007:chap 590.
Eisenbarth GS, Polonsky KS, Buse JB. Type 1 diabetes mellitus. In: Kornenberg HM, Melmed S, Polonsky KS, Larsen PR. Kronenberg: Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 31.
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Reviewed By: Nancy J. Rennert, MD, FACE, FACP, Chief of Endocrinology & Diabetes, Norwalk Hospital, Associate Clinical Professor of Medicine, Yale School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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