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Autonomic neuropathy in children and adolescents with diabetes mellitus.

Diabetic autonomic neuropathy (DAN) is a complication that is clinically evident in adult patients with diabetes mellitus (DM). Characteristic neuronal alterations occur early in the course of the disease. The diagnosis of subclinical DAN has been achieved using tests on heart rate variation (HRV) and pupillary function. In children, the prevalence of abnormality in three or more conventional HR tests ranges from 0.5-10%, the prevalence of reduced HRV using power spectral analysis is reported to be 15%, while the prevalence of pupillary abnormality ranges from 7.9-19%, in different studies. Pupillary tests have been considered more sensitive and reproducible than HR tests. Pupillary abnormalities have shown a relationship with duration of DM and glycemic control, while this has not been observed in HR variables. From the pupillometry studies it is evident that parasympathetic abnormalities precede the sympathetic ones in children, as in adults, with DM. It seems that the best tests for the routine evaluation of autonomic function in children and adolescents with DM are HR response to deep breathing and standing, power spectral analysis of HRV and pupillary adaptation in darkness. It is important to identify the children and adolescents with impaired indices of autonomic neuropathy in order to take appropriate measures to prevent the progression of DAN.