I. Juvenile - Onset Diabetes Mellitus (JOD)
    Juvenile - Insulin Dependent Diabetes Mellitus (JIDDM)
    Type 1 Diabetes Mellitus (IDDM)

Age of onset usually from 1 year up to 15 years, occasionally up to 18 - 20 years. Occurs in less than 1% of all cases of diabetes in India. In South India it is less than 0.5%

II. Early Onset Diabetes (EOD) and LADA.
    Maturity - Onset Diabetes in the Young (MODY)

Age of onset is usually above 15 years and up to 25 years (MODY) and 30 years (EOD). Some cases from these two groups could be having insulin requiring Diabetes Mellitus. These are grouped under the term LADA (Latent Autoimmune Diabetes in Adults) as they exhibit significant levels of antibodies to the insulin producing beta cells of the pancreas gland. Occurrence is about 3 to 5% of all cases of Diabetes seen in India.

III. Genetic Syndromes Associated with Diabetes

Age of onset: At Birth

Occurs very rarely but in our centre, up to 0.5% of all cases of Diabetes.

Type 1 Diabetes Mellitus or IDDM

When Diabetes Mellitus strikes young children it is usually explosive, with classical symptoms of

• Excess Thirst
• Excess Urination
• Excess Hunger
• Excess Tiredness / Listlessness
• Unexplained Loss of Weight
• Occasionally with gradual drowsiness -dehydration, chest pain, breathing difficulty and slipping into coma.

Diagnosis

When the urine is examined, it shows high sugar (4+) and frequently ketone bodies (1+ to 3+). Fasting, random and postprandial blood sugars are all very high - usually over 300 mgm/dl (over 16 mmol/L). A Glucose Tolerance Test (GTT) is usually NOT NECESSARY, for diagnosis of this condition.

Management

If the child is ambulant and active, the child should be referred to a Diabetic center equipped with integrated special care facilities for the management of juvenile Diabetes.

In any child or adolescent coming to a hospital or an emergency service with acute, rapid, shallow breathing, complaints of chest pain, with sweet odour of the breath, vomiting and abdominal pain and dehydration - Diabetic Ketoacidosis (DKA) should be suspected and spot check of capillary blood sugar and urine sugar / acetone done. If these are high, emergency investigations and treatment should be instituted.

Insulin therapy in children

Dr.H.B.Chandalia and Dr.P.S.Lamba have presented their point of view in a succint manner and with clarity in their paper in paediatric on call. For a detailed analysis of the various aspects of insulin therapy in children view .

Early Onset Diabetes and MODY

The genetic 'Phenomenon of Anticipation' is usually seen when the younger generation precedes their older generation (son and father) in getting a hereditary disorder.

This is sometimes classically seen in Diabetes when a 25 or 30 year old person is detected to have Type 2 Diabetes, but at that point of time his parents may not have the disorder - it may manifest in them at a later date - say a year or two later. So when a young person (below 30 years of age) comes with any problem, without classical symptoms of Diabetes, and routine blood / urine sugar examination shows high or border line - high values, a GTT test (75 g) should be ordered for making a definitive diagnosis.

EOD cases vary in severity, usually give a positive family history of Diabetes, are generally overweight and very often the condition is discovered when they consult their doctors for 'minor' symptoms or undergo routine medical check - up, prior to job placement or for Life Insurance purposes. Diagnosis is confirmed by a GTT test.

Management

As per type 2 Diabetes protocol, diet, exercise, drugs - oral hypoglycemic agents ± insulin.

LADA

There is a small sub group in this category of young Diabetics who may progress (march) on to type 1 Diabetes or IDDM. They are termed as Latent Autoimmune Diabetes of Adults or LADA and current research identifies this subgroup on the basis of antibody titres against the insulin producing beta cells of the Islets of langerhans. (PICA, IAA, GADA etc.)

These persons are better treated with insulin injections than oral medication for their Diabetes. There are no controlled studies on this subject in clinical Diabetology, and the final opinion on this subject is yet to emerge.

MODY

This type of Diabetes usually occurs in young people (15 to 25 years) who have a strong three generation, family history of Diabetes viz. grand father, father, son / daughter. It is thought to be genetically transmitted by an autosomal dominant trait. There are several genetic sub types described in MODY patients.

(Ref. Ewan R. Pearson, and Andrew T. Hattersley; J.R. Coll. Physicians, London. 2000, 34, 332 - 5).

Again, the type of presentation is similar to the one described above under EOD. These young persons are usually overweight, have very few symptoms and are managed initially with diet, exercise, weight reduction and if required oral drugs. As a matter of fact, the definition of MODY requires 2 years of management of this type of diabetes without insulin. Insulin is used only in situations like infection, surgery or pre- pregnant state (i.e. married and planning to conceive) and during pregnancy.

Again, a small percentage of these cases of MODY may turn to be cases of LADA on follow-up. Hence close surveillance and monitoring is essential for all cases of Diabetes in the young.