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A 100 years ago, before the first insulin treatment implementation, diagnosis of childhood diabetes was almost always fatal. Since then, both treatment and diagnostic methods have improved significantly, changing the face of the disease. Prolonged survival became possible. However, type 1 diabetes incidence rates in children have increased dramatically over the decades, starting since the mid-century [1], and continue to rise [2–4].
Alongside the changes in global and local incidence, the clinical picture of the disease at the diagnosis has also changed. In the early 20th century, in the pre-insulin era, children were diagnosed mostly when a severe diabetic ketoacidosis (DKA) had already developed. Availability of insulin treatment and better access to medical care resulted in a significant reduction of DKA prevalence in newly recognized type 1 diabetes in children, reaching about 30% at the end of the 20th century [5]. Alongside the reduction in DKA occurrence, decrease in DKA-related co-morbidities (e.g., cerebral oedema, hypovolemic shock) [6] was observed. Unfortunately, a rapid increase of type 1 diabetes incidence, especially in young children (up to 5 years of age) and the COVID-19 pandemic caused a global upward trend in DKA prevalence in last two decades [7–9]. Moreover, some studies report, that still in certain populations even up to 70% of children diagnosed with type 1 diabetes present with DKA [10].
Not only DKA prevalence has changed in time. Overall medical care improvement and health-related awareness led to early diagnoses of type 1 diabetes in numerous cases. Individuals with positive family history of type 1 diabetes are usually diagnosed earlier and in a better clinical condition. Parents who have experienced the disease themselves or observed its signs in relatives usually seek medical care for their children as soon as the symptoms start. Another group of early diagnosed children are those diagnosed “by accident” in a course of a routine medical care: glucose measurements are often included in routine medical tests (e.g., scheduled by sport medicine specialists) or are performed when diagnosing other medical conditions, revealing hyperglycemia before the symptoms of diabetes occur. In these situations patients meeting the criteria for diabetes diagnosis may start treatment with relatively low doses of insulin or sometimes reach good glycemic control only with dietetic approach. In newly diagnosed type 1 diabetes, the initial daily dose of insulin is typically 0.3–0.7 U/kg/day for prepubertal children and 0.7–1.0 U/kg/day for adolescents [11], however for individuals diagnosed at an early clinical stage lower initial doses might be sufficient to reach glycemic goals without an increased risk of hypoglycemia.
A specific challenge emerges in relation to global increase of obesity rates among children [12]. It becomes more difficult to distinguish between type 1 and type 2 diabetes at the disease presentation in some cases. Traditional division of underweight type 1 patients and obese type 2 patients became not so obvious anymore. Children with obesity and insulin resistance symptoms may as well suffer from an autoimmune destruction of beta cells and the importance of islet autoantibody testing in these patients needs to be highlighted.
Better understanding of the natural history of disease and development of available autoantibody tests allowed to describe preclinical stages of type 1 diabetes. Screening programmes are now implemented in several countries, including Poland [13–15] to find children with positive islet autoantibodies (in preclinical stage 1 and 2) [16] long before the disease symptoms occur. These children (identified by population or family-based screening) benefit from regular medical assessment, glucose monitoring and their parents received detailed medical advice regarding the disease and its alarming symptoms, aiming to reduce DKA prevalence. The International Society for Pediatric and Adolescent Diabetes (ISPAD) and local guidelines for screening, staging and management of individuals with preclinical type 1 diabetes became necessary to standardize the care of these children [16]. With the spread of screening programmes across more countries and regions, an increasing number of pediatric patients diagnosed with “prediabetes” becomes a real challenge for clinicians. However, studies have already demonstrated that even those progressing to clinical diabetes present better condition and less DKA [13]. Emerging new therapeutic methods aiming to prevent or delay the disease development (such as teplizumab already approved by Food and Drug Administration (FDA) for stage 2 treatment [17] and numerous ongoing clinical trials for different stages of the disease [18, 19]) will surely lead to a significant shift in pediatric diabetes care and in disease presentation at onset in the following years.
The world is changing. Medicine is changing. Diseases, their incidence and clinical presentation are changing as well – type 1 diabetes in children and adolescents is no exception. We continuously need to provide the best possible patient care for both children with severe hyperglycemia and DKA at onset, and for children with preclinical stages gradually progressing to overt diabetes. New challenges continue to emerge, but the current situation gives cause for cautious optimism.
