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January 27, 2002

Complications

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Question from a podiatrist in Bury, Lancs, United Kingdom:

What is the incidence of neuropathy in children? What tests would you carry out as part of a foot screen on children? What is the best advice on foot care for children?

Answer:

From: DTeam Staff

Actual clinical neuropathy is very rare in kids (even in adolescents) unless long term glycemic control is extremely poor with hemoglobin A1cs way over 10% for many months and years. We routinely do deep tendon reflexes and filament testing annually, but I can’t remember the last time I actually saw an abnormality in anyone under 15 years of age.

However, if you look for subtle neuropathy using subclinical tests, there are lots of abnormalities — heart beat to beat variations, tilt test abnormalities of BP, gastric emptying and even nerve conduction times are all abnormal without much clinical correlation, and all seem to correlate with A1c levels and glycemic control, of course.

In terms of practical applications for podiatry, we don’t do anything other than suggest people use common sense. If it’s too dangerous to walk on a hot sandy beach for anyone, it’s also too dangerous even when a person/child with diabetes does not have neuropathy. Toe nails should not be cut so close that they cause ingrown toenails or irritations. If it would be okay to walk in bare feet at home or outside or in the yard for anyone then it’s also okay for kids with diabetes without known neuropathy problems. Almost all of the rules about foot care are for adults who either don’t know if they have diabetes or have neuropathy/vasculopathy, and they just don’t apply to otherwise healthy kids who happen to have diabetes.

There are several elegant pediatric neuropathy studies that have been published over the last ten years — Neil White has done some in the US. Laszlo Madacsy in Budapest as well as Francisco Chiarelli in Chieti, Italy also have done some. In their articles, there will be some other references or you could do a PubMed search. I wrote a review article about complications of diabetes last year that has some of these references as well.

SB