Diabetes In Children, Myanmar Perspective

Increasing number of Diabetes cases has been noticed nowadays. According to the data from International Diabetes Federation Atlas (2019), more than 463 million people are living with Diabetes. Moreover, above 1.1 million children and adolescents below 20 years have Type 1 Diabetes. Ten percent of global health expenditures is spent for Diabetes at the present moment. Diabetes is one of the alarming conditions in most countries and becomes a fastest challenging health problem because of the risk of both short term and long-term health complications. The increasing prevalence of diabetes around the world is due to the complex interaction of socioeconomic, demographic, environmental and genetic factor.

The children can have all types of Diabetes, including two major distinct forms of Diabetes namely Type 1 and Type 2, but can also present with other types such monogenic diabetes. Although the most common type of Diabetes in children is Type 1 Diabetes, because of increasing urbanization and changing of life style habits (e.g. higher calorie intake, increasing consumption of processed foods, sedentary lifestyles) increasing prevalence of type 2 diabetes is seen in children together with rising trends of obesity. Diabetes in children is still one of under recognized condition in Myanmar.

Diagnosis of Diabetes in children

Diagnostic criteria for all types of Diabetes in children and adolescent are based on laboratory measures of plasma glucose criteria and presence of hyperglycemic symptoms
as follows.

1. Classic symptoms of Diabetes or hyperglycemic crisis, with random plasma glucose level ≥11.1mmo/L (≥ 200mg/dl )or
2. Fasting plasma glucose level ≥7mmol/L ( ≥126mg/dl ) . Fasting is defined as no caloric intake for at least 8 hour
3. Two hour post prandial glucose≥ 11.1 mmol/L ( ≥200 mg/dl) during Oral Glucose Tolerance Test, the test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water or 1.75g/kg body weight to a maximum of 75 g. or
4. HbA1C ≥ 6.5%

In the absence of unequivocal hyperglycemia, the diagnosis based on these criteria should be confirmed by repeat testing.

The classic symptoms of hyperglycemia in diabetes are polyuria, polydipsia, weight loss and fatigue. Moreover, the children can have the symptoms like nocturia, enuresis and weight loss which may be accompanied by polyphagia. Behavioral disturbances including impairment of school performance and blurred visions, impairment of growth and susceptibility to certain infections may accompany chronic hyperglycemia

Type 1 Diabetes

Type 1 diabetes is characterized by chronic immune –mediated destruction of pancreatic B cells leading to partial or absolute insulin deficiency. The etiology of Type 1 Diabetes is multifactorial interplay including genetic susceptibility, environmental factors and the immune systems. Diabetes associated autoantibodies which are serological makers of B cell autoimmunity include GAD, IA2, IAA and ZnT8 antibody and these are more commonly expressed in children. The majority of Type 1 Diabetes cases results from auto immune mediated destruction of pancreatic B cells, which occurs at a variable rates and clinically apparent when about 90% of B cells are disturbed. The children progress through three stages of depend on the residual pancreatic B cells: stage 1 is defined by the presence of B cell auto immunity with norm glycaemia and a lack of clinical symptoms, which can be variable time from months to years. Stage 2 is a condition that progress to dysglycaemia but the child remains asymptomatic and stage 3 is the onset of symptomatic disease.

The incidence of Type 1 Diabetes varies greatly between different countries, within countries and also within different ethnic group. In Asia, the incidence of Type 1 diabetes is low, Japan approximately very low 2 per 100.000 persons per years., China 3.1 per 100, 000, Taiwan approximately 5 per 100,000 .

Type 2 Diabetes in children

There is increasing incidence of Type 2 Diabetes in children has increased dramatically, that accounts for significant proportion of youth onset diabetes in certain risk population. The worldwide incidence of type 2 diabetes in children and adolescence vary among countries and ethnic groups. The epidemiological studies have shown the incidence range from 1 to 51 per 1000. The incidence of impaired fasting glucose and impaired glucose tolerance has also increased and associated with increasing trend of childhood obesity. It is due to inadequate secretion of insulin to meet the increasing demand posed by insulin resistance and leading to relative insulin deficiency.

Type 2 Diabetes in youth should be diagnosed using American Diabetes Association criteria. The diagnosis can be made based on fasting glucose, or 2-hour glucose concentration during oral glucose tolerance test (OGTT) or Hemoglobin A1C. If the child does not have the symptoms, testing should be confirmed with a repeat test on different day. Diabetes autoantibody testing should be considered in all pediatric patients with clinical diagnosis of diabetes. Type 2 Diabetes in children should be considered in the following settings.

1. In overweight or obese ( BMI ≥85th -94th and > 95th percentile for age and gender respectively )
2. Has a strong family history of T2DM
3. Has substantial residual insulin secretory capacity at diagnosis (reflected by normal or elevated insulin and C –peptide concentration )
4. Has insidious onset of disease
5. Demonstrates insulin resistance (including clinical evidence of polycystic ovarian syndrome or acnthosis nigrican)
6. Lack of evidence of diabetes autoimmunity (negative for autoantibodies typically associated with T1DM)
7. Maternal gestational diabetes

Situation in Myanmar

The Endocrine and Diabetes clinic was started at Yangon Children Hospital in January 2014. It’s the first Pediatric Endocrine and Diabetic Clinic in Myanmar. At first, we had very few cases per months and last year we had total 913 total cases at OPD. We see variety of cases including Diabetes in two children, thyroid cases, adrenal and disorder of sex development cases, obesity, endocrine conditions related to cancer and thalassasemia and metabolic bone disease, etc.

When we started the clinic, with the guidance of Professor Aye Maung Han, a survey about the conditions’ of diabetes in children was done by sending questionnaires to Pediatricians around Myanmar . It was included the questions whether they saw the Type1 Diabetes children within two years, what the presentations were, and what are the challenges in the management of Type 1 Diabetes children. The finding was the total Type 1 Diabetes under 12 years of age was 74 cases around Myanmar, mostly came with DKA and about 80% lost to follow up . Some cases came again with DKA and expired. The main challenges were cost of medical supply like insulin, daily blood glucose testing and access to the pediatricians or doctors who could take care of them.

At first, we had few Type 1 diabetes cases and increasing number of type 1 Diabetes cases within six years, up until now total 280 Type 1 Diabetes children around Myanmar. With the supports of donors including Changing Diabetes in Children project, we can supplyfree insulin (mostly human insulin), insulin syringes, glucometer, daily blood glucose testing, investigations for diabetes complication monitoring, diabetes education sessions and Diabetes camp yearly.

As we found out the result of the survey in 2014, the barriers in management type 1 diabetes were need to increase awareness and access to the doctors or pediatricians who can manage them properly. So we arranged the Health Care Professional Training and awareness session about Type 1 Diabetes in children around Myanmar. Moreover, we established eight Type 1 Diabetes clinics around Myanmar.

1. Yangon Children Hospital , Endocrine and Diabetes clinic
2. Yangon General Hospital , Endocrine Department
3. North Okkalapa General Hospital , Endocrine Department
4. Mandalay 550 Bedded Children Hospital , Diabetes Clinic
5. Mandalay General Hospital , Endocrine Department
6. Magway General Hospital , Diabetes clinic (at Pediatric ward)
7. Naypyidaw Children Hospital , Diabetes clinic
8. Taungyi Woman and Children Hospital , Diabetes clinic ( at Pediatric Ward)

The new clinic is started renovated at Mawlamyaing Woman and Children Hospital, at Pediatric ward. It will start functioning soon. We support free medical supply as described above in all Type 1 Diabetes clinics in Myanmar. The support is for the type 1 diabetes children up to 18 years of age. So the children and families can join the nearest clinic.

At first Type 1 diabetes was very unaware condition in Myanmar and almost all of the cases came with DKA. It was undiagnosed and late referral. It was very challenging to counsel the parents to take daily insulin injection and diabetes care of their children and regular follow up. We produce the pamphlets, education books about Type1 Diabetes in children in Myanmar. We plan to produce the exchange book for Myanmar food that is essential in Type 1 diabetes management. It is easier to explain the parents now as we have many education materials in Myanmar, and also many success stories about the type 1 Diabetes cases to share with families and children.

Even though we have achieved some success in diabetes care of children in Myanmar since 2014, still need to improve in many area and aspects. The diabetes education is too much time consumption to explain and educate the parents and children to have good achievement in metabolic control. We do not have a multi-disciplinary team for Type 1 Diabetes care and has very limited manpower. We do not have diabetes nurses, diabetes educators, dietitian in government setting. We are trying our best with limited resources.

References

1. Mayer-Davis EJ, Kahkoska AR, Jefferies C, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes. 2018;19 Suppl 27:7-19. doi:10.1111/pedi.12773
2. Thomas RL, Halim S, Gurudas S, Sivaprasad S, Owens DR. IDF Diabetes Atlas: A review of studies utilising retinal photography on the global prevalence of diabetes related retinopathy between 2015 and 2018. Diabetes Res ClinPract. 2019;157:107840. doi:10.1016/j.diabres.2019.107840
3. Zeitler P, Arslanian S, Fu J, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Type 2 diabetes mellitus in youth. Pediatr Diabetes. 2018;19 Suppl 27:28-46. doi:10.1111/pedi.12719