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Covid and Diabetes in children
 
The most common cause of diabetes in children is type 1 diabetes due to insufficient release of Insulin from pancreas. With the increasing prevalence of overweight and obesity, type 2 diabetes is also on the rise, especially in families with a strong hereditary predisposition. Insulin therapy along with proper dietary management and regular physical activity is the mainstay of treatment in type 1 diabetes. With proper management these children can lead a healthy life free of immediate and long term complications. The treatment of type 2 diabetes in children is dietary modification, avoiding simple sugars and restricting carbohydrates, along with regular physical activity and medications to improve Insulin sensitivity.

The year 2020-2021 saw SARS-CoV-2 infection spread across the globe with WHO declaring it a pandemic in March 2020. Most countries saw their health sector, both private and public, gear up to deal with the pandemic. Covid 19 infection has had a major impact on care of children and adolescents with chronic conditions like diabetes.

The presence of Angiotensin converting enzyme ( ACE) 2, the functional receptor for SARS CoV, on Insulin producing pancreatic islet cells causes transient changes in blood sugar levels following covid infection. Later follow up showed that only a minority of patients had persistent diabetes suggesting that the injury to pancreatic beta cells is mostly transient.

Patients with underlying diabetes had more complications and death rates following Covid infection, when compared to individuals without diabetes. However most of the studies suggesting this were from adult patients with type 2 diabetes who typically have a range of comorbidities like obesity ,hypertension and cardiovascular diseases as compared to type 1 diabetes patients who are otherwise healthy. It was also found that people younger than 40 years with either type of diabetes were at very low absolute risk for in-hospital death with SARS-CoV-2, indicating that co morbidities might have increased the mortality in earlier studies. In a population based study from England among people with type 1 and type 2 diabetes, patients with HbA1c of 10 % or more had increased COVID-19 related mortality when compared to patients with HbA1c of 6.5 to 7 %. Thus in patients with diabetes, it is important to optimize their glycemic control by frequent monitoring of blood glucose and adjusting Insulin levels accordingly.

Children with type 1 diabetes who developed Covid 19 had mild disease or were asymptomatic, similar to children without diabetes. Patients with type 1 diabetes also had lower rate of hospitalization when infected with SARS CoV. There could be various reasons for this, like type 1 diabetes being a disease of younger people and the altered immune system in patients with type 1 diabetes reducing the disease severity from SaRS CoV2. Most type 1 diabetic patients receive ongoing education about management of their sugars when ill. This could also explain the lower rates of complications following CoV in these children. Some centers have shown that stay at home initiative and school closure often resulted in improved blood sugar control for children with diabetes secondary to close parental monitoring.

However, during the pandemic, children with newly diagnosed diabetes presented with a more severe form of diabetic complication, diabetic keto acidosis. This could be because of reduced access to primary care services and fear of seeking health care service during the pandemic period leading to late diagnosis.

Lastly the pandemic has forced many health care teams caring for patients with diabetes to implement telemedicine as a tool to provide ongoing care. Telehealth services and newer technologies like continuous glucose monitoring devices and continuous insulin infusion devices will likely continue to support the care of these children even after the pandemic recedes.
There has been a spike in the other form of diabetes seen in children, type 2 diabetes, in Covid era. In order to slow down the spread of virus and thus to reduce mortality, most Governments imposed social restrictions like lock down measures for a variable period of time. With classes becoming online and with restrictions on physical activity and games, children suffered the most. What followed was an inevitable increase in screen time for academics and for entertainment. Free access to food, especially processed and junk food led to a spurt in overweight and obesity among children from affluent families. This led to an increase in glycemic abnormalities like prediabetes and overt diabetes in those with an underlying insulin resistance.

Until we have further data to confirm or refute the possibility of SARS-CoV-2 causing diabetes in long run, it is important to have a long term follow up of children and adults presenting with hyperglycemia and new onset diabetes during this time. Meanwhile it is prudent that children with diabetes observe preventive measures like social distancing and personal protective measures like wearing masks, and optimize their glycemic control to minimize the impact of Covid 19 infection on these vulnerable population.

Dr Sheeja Madhavan
Pediatric Endocrinologist
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