Screening for Peripheral Neuropathies in Children With Diabetes: A Systematic Review

Abstract

BACKGROUND AND OBJECTIVE: Although guidelines for the management of children with type 1 diabetes include recommendations to screen for diabetic peripheral neuropathies (DPN), the research into the diagnostic utility of screening methods has not been systematically reviewed. The goal of this study was to summarize the findings with regard to the diagnostic accuracy of the Semmes-Weinstein monofilament and the Rydel-Seiffer tuning fork in detecting DPN in children and adolescents compared with the gold standard nerve conduction studies. METHODS:Based on a PubMed search (conducted on April 26, 2013) and secondary searching, we identified 72 articles for review. We included studies that: (1) assessed DPN with the gold standard nerve conduction studies; (2) used noninvasive screening for DPN (monofilament, tuning fork, or biothesiometer); and (3) were performed in the relevant population (children with diabetes). Five articles met these criteria. Study quality was assessed by using the revised Quality Assessment of Diagnostic Accuracy Studies criteria. Heterogeneous methods precluded a formal meta-analysis of effects.RESULTS: Diagnostic accuracies were heterogeneous for the different screening methods. Sensitivities ranged from 1% to 19% for the tuning fork (3 studies); from 61% to 80% for the biothesiometer (2 studies); and from 19% to 73% for the monofilament (2 studies).CONCLUSIONS: Data show extremely low diagnostic utility for standard screening methods (tuning fork and 10-g monofilament) but acceptable utilities for biothesiometry and finer (1 g) monofilaments. Data on the diagnostic utility should be used to inform national and international guidelines on diabetes management.

Difficulties in screening for peripheral neuropathies in children with diabetes

“…In conclusion, the present results highlight the need for improved non‐invasive screening methods for neuropathy in children with diabetes . In recent years, several new methods of screening for diabetic peripheral neuropathy have been developed, such as in vivo corneal confocal microscopy , but they are not yet applicable in primary care.…”

“…As a result, national and international guidelines recommend regular screenings for diabetic peripheral neuropathy using a monofilament and a tuning fork . Recent systematic reviews, however, indicate that the evidence base for these methods is relatively weak in both adults and children . In children, only five studies have presented data on the diagnostic accuracy of these non‐invasive screenings methods.…”

Type 1 Diabetes in Children and Adolescents

“…There are very few studies assessing the diagnostic utility of noninvasive screening methods in children with diabetes; among them, vibration and monofilament testing have suboptimal sensitivity and specificity in adolescents. Normative thresholds vary with age and gender (171). With the exception of intensifying diabetes management to achieve and maintain glycemic targets, no other treatment modality has been studied in children and adolescents.…”

The Reliability and Reproducibility of Corneal Confocal Microscopy in Children

“…However, traditional tools such as the use of Semmes-Weinstein monofilament to screen for peripheral neuropathy are often found to be unreliable, especially in children. 14,15 For example, in a recent study of 88 children with type 1 diabetes, the diagnostic use and interrater agreement were very low for both the monofilament and the tuning fork. 16 Assessment of diabetic neuropathy in children, therefore, remains a challenge due to the absence of clinical symptoms, lack of good pediatric normative data, difficulties with timeconsuming, technically more challenging, and sometimes uncomfortable electrophysiologic tests such as nerve conduction studies (NCS), and lack of reliability and diagnostic sensitivity of screening techniques deployed in adults.…”

“…10 National and international clinical practice guidelines for children with type 1 diabetes [11][12][13] recommend yearly screening for diabetic neuropathy at puberty and after 5 years of diabetes duration. According to prevalence statistics and recommendations, Hirschfeld et al 14 estimated that several hundred children with diabetes are screened for the presence of peripheral diabetic neuropathy every day in the United States. However, traditional tools such as the use of Semmes-Weinstein monofilament to screen for peripheral neuropathy are often found to be unreliable, especially in children.…”