Pediatric Diabetic Peripheral Neuropathy: Clinical Update
The global burden of diabetes is currently estimated at 425 million and rising (1). Unfortunately, this well-documented increase in diabetes among adults is mirrored by a similar trend in the pediatric population (2,3,4). Further analysis reveals a disturbing increase in Type 2 diabetes among these patients which some have linked to a rise in childhood obesity (5).
This combination of diabetes and obesity in adulthood can lead to devastating foot complications including lower extremity amputations. Another one of the essential precursors on the path to limb loss is diabetic peripheral neuropathy (DPN). Although neurological screening for DPN is routine in adults, pediatric patients often are not assessed for this complication. Despite evidence indicating that up to 25% of pediatric diabetic patients have neuropathy, the majority are subclinical possibly explaining this oversight (6). Furthermore, widely accepted guidelines for neurological screening in pediatric patients have not been established. Although several studies have evaluated the efficacy of screening tools currently in use, consensus has not been reached on a standardized approach (7). A summary of relevant research on this topic is found in Table 1.
Table 1. Selected studies evaluating DPN testing methods in pediatric patients
|10 gram SWMFa||Hirschfeld(8) (Systematic Review)||Low diagnostic utility|
|128 Hz Tuning Fork||Hirschfeld (Systematic Review)||Low diagnostic utility|
Hirschfeld (Systematic Review)
|Acceptable diagnostic utility|
|NCVb||Hasani(5)||Highest diagnostic utility|
a. Semmes-Weinstein Monofilament, b. Nerve Conduction Velocity
In light of the known potential complications in adulthood, most experts recommend routine screening for early neuropathy in pediatric diabetic patients even when the condition is subclinical. Research has shown NCVs to be the gold standard for large fiber nerve assessment in adult and pediatric patients. Unfortunately, this test is invasive, painful, expensive and time-consuming. A more practical screening method is assessment of vibration perception thresholds (VPTs) with a biothesiometer. Although this method is painless and non-invasive, most clinicians have not purchased the device. Small fiber nerve assessment utilizing pinprick or thermal challenge is advised in these patients just as in adults per American Diabetes Association guidelines.