Treatment of children and adolescents with diabetes

The importance of effective strategies for the treatment of diabetes in children and adolescents is accentuated by the knowledge that time-trend data, for countries where it is available, have demonstrated a clear increase in incidence of type 1 diabetes mellitus (DM) in these age groups. Such an increase suggests changes in environmental factors with the larger increase in children < 5 years of age suggestive of factors operative in early life. As alluded to elsewhere, cases of type 2 DM related to obesity are now being encountered, especially in high-risk ethnic groups.

Treatment strategies must incorporate knowledge of developmental milestones and behavioral, physiologic, psychologic and social factors that operate in this age group and impact so strongly on any chronic disease management program in children. Emotional problems are common, but controversy exists as to whether these have any long-term sequelae. Some studies have suggested that the onset of diabetes is associated with adjustment disorders which seemed to confer an increased risk of psychiatric problems later in life. A recent prospective study of adolescents with type 1 DM from Australia has documented the exhibition of a broad range of psychiatric diagnoses 10 years after disease onset, with females and adolescents with pre-existing psychologic problems being at particular risk.

Great skill by experienced teams comprising pedi-atric diabetic specialist nurses, dieticians, pediatric endocrinologists and child psychologists is needed to coordinate the effort to help diabetic children and their parents manage the diabetic condition. Difficult behavioral problems do occur in some children including denial of the disease, manipulative behavior and deliberate insulin overdosage and insulin omission. Frequent admissions with hypoglycemia or ketoacidosis usually reflect underlying emotional conflict. Such problems require a very sensitive approach to their management.

Most children (and their parents) rapidly become confident with insulin injections and self blood glucose monitoring. Older children (aged 8-12 years) are encouraged to self-inject. Childhood lasts a long time and, in order to minimize the risk of onset of microvascular complications, an attempt to achieve reasonable glycemic control should be made. This is often not easy to attain especially during puberty when glycemic control deteriorates. In a comparison of metabolic control in nearly 3000 children and adolescents with type 1 DM in 18 countries, the mean HbA1c was 8.6% with wide variation between centers. The degree of control achieved depends, to a certain extent, on many of the factors discussed above and often a compromise involving the child, the parents and the diabetologist has to be arrived at. Authoritarian approaches, especially during puberty, are likely to fail.

Total daily insulin requirements in children with type 1 DM are around 0.8 units/kg/24 h, increasing to 1.0-1.5 units/kg/24 h in mid-puberty. The principles of insulin therapy in children are broadly similar to those in adults. For reasons of simplicity or practicability, in many countries the standard insulin regimen consists of a twice-daily injection of a mixture of short-acting and isophane insulins either free-mixed into a syringe or, increasingly commonly, as a fixed mixture using a pen device. Two-thirds of the total daily dose is usually given at breakfast and one-third with the evening meal. A three-injection regimen, where the evening injection is split into a rapidly acting injection before the evening meal followed by an isophane injection before bed, is favored in some countries. More recently, newer preparations of more rapidly acting insulin analogs (lispro or aspart) with their protamine retarded counterparts (e.g. lispro/neu-tral protamine lispro, (Humalog Mix25®) aspart/neutral protamine aspart, NovoMix 30®) have become very popular and have certain advantages in children as they can be injected immediately before or even shortly after eating, the latter mode of administration allowing adjustment of the dose given according to the amount of food ingested (or refused).

Towards puberty and early adulthood, a greater need for flexibility emerges and, as the child becomes more independent, encouragement should be given to move towards multiple injection therapy with three injections of soluble or analog insulin with meals and twice-daily injections of isophane or a night-time dose of isophane insulin. Long-acting insulin analogs -insulin glargine and insulin detemir - are widely used in adults and are likely to prove useful in the treatment of adolescents particularly with regard to the prevention of nocturnal hypoglycemia. As in adults a typical regimen would be an insulin analog injected three times daily at meal times with long-acting analog injected once daily to provide a basal insulin supply usually before bed or at breakfast. At present few data are available examining the use of detemir in the pedi-atric population.

In children, who have less subcutaneous fat, the needle should not penetrate more than 3-5 mm to avoid intramuscular administration. It may be better to inject rapidly acting insulins into the abdomen where absorption is faster and delayed-action insulins into the thigh where absorption is slower. Continuous subcutaneous insulin infusion (CSII) is a perfectly acceptable method of insulin administration and is increasingly used within the pediatric diabetic population and has been associated in adolescents with less reported hypoglycemia, sustained improvements in HbA]c after 12 months and a lower total daily insulin dose.

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