DIABETES IN CHILDREN AND ADOLESCENTS: ANYTHING NEW AND EXCITING?

FYI: Below, I have posted a short outline and reference list to accompany a lecture I was asked to give at the University of Missouri Annual Family Medicine Update, April 2013.  If you want a copy of the actual powerpoint from the lecture, let me know and I will send it to you.  By the way, the answer to the question posed in the lecture title is that not much is new, at least over the past 20 years or so.  But, we did make extraordinary advances in diabetes care back in the 1990s which have not yet been fully translated into better patient care.  I am not exaggerating when I state that all diabetes chronic complications are now more or less completely preventable; yet many patients are still developing serious complications of the disease.  We as physicians, nurses, dietitians, and others who care for patients with diabetes must do whatever it takes to lead to better patient outcomes.  Of course, it is not enough that health care givers do their part; patients and their families also must do their part.

 

DIABETES IN CHILDREN AND ADOLESCENTS: ANYTHING NEW AND EXCITING?

David E. Goldstein, M.D., Professor Emeritus, University of Missouri Health Sciences Center

35Th Annual Family Medicine Update- April 19-20, 2013

1. Diabetes mellitus is a syndrome with many different causes,  all of which have  three things in common: insulin deficiency, hyperglycemia, and risks for the development of chronic complications.  About 95% of patients have either type 1 (T1DM) or type 2 (T2DM) diabetes.

2. Most diabetes in children and adolescents is T1DM, an inherited, autoimmune disorder with destruction of the pancreatic islet beta-cells.  About  1 in 500 children and adolescents in the U.S. have T1DM; about 1 in 1000 have T2DM but it is rare before age 10 yrs.  The prevalence of T2DM is 3-5 times higher in African American and Hispanic American youth than in non-Hispanic white youth.

3. Most patients with T1DM present in the “classic” manner with polyuria, polydipsia, and poly/hyperphagia with weight loss over the previous 2-4 weeks.  About 40% of patients have ketoacidosis (DKA)at presentation.  DKA  should be always considered a medical emergency.  Very young children often present with a flu-like illness.  Some patients present with an “acute abdomen,” which can be mistaken for acute appendicitis.

4.  Diagnosis can be established by one of the following criteria: random plasma glucose > 200 mg/dl with typical symptoms; fasting plasma glucose 126 mg/dl or greater; plasma glucose 200 mg/dl or greater  2 hours after a 75 gm oral glucose load; or hemoglobin A1c (HbA1c) 6.5% or greater.

5.  Routine management is best accomplished by a “team approach,” that ideally includes a diabetes specialist, dietitian, nurse-educator, a social worker, and a behaviorist.  The patient’s primary care physician/nurse should be part of the team.  Treatment goals should be defined at the onset and  reviewed frequently.  Key care components include the following: appropriate insulin therapy (basal-bolus), monitoring of glycemic status (daily fingerstick blood glucose testing by patients and HbA1c testing) , nutrition counseling, and monitoring for chronic diabetes complications.  Patient and family education at the onset and at regular intervals are critical to success.

6. In the long run, an important goal is for patients to be independent in managing all aspects of their diabetes.  But, shared responsibilities between pediatric patients and their parents are critical to success.  The health care team must fully understand developmental stages and not promote too much or too little patient independence in the diabetes management.

7. The future is bright for children with diabetes.    Better insulin delivery systems and better methods for monitoring glycemic control and for preventing hypoglycemia are on the horizon.  Both prevention and cures for diabetes remain important but elusive goals to achieve.

 

References 

 

1. The SEARCH for Diabetes in Youth Study.  The many faces of diabetes in American Youth: type 1 and type 2 diabetes in five race and ethnic populations.  Diabetes Care 2009;32 (suppl 2):S99-S147.

2. Duncan GR: Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002.  Arch Ped and Adolesc  Med 2006;118:1510-18.

3. The Centers for Disease Control and Prevention; National Center for Health Statistics.  National Health and Nutrition Examination Survey.  http://www.cdc/nchs/nhanes/nhanes_questionnaires.htm.

4. The Diabetes Control and Complications Trial Research Group: the effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med 1993;329:977-86.

5. The Diabetes Control and Complications Trial Research Group: Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus. J Pediatr 1994;125:177-188.

6. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group: Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 2000;342:381-89.

7. American Diabetes Association: Clinical Practice Recommendations. Diabetes Care 2013;36 (suppl 1): S11-S66 (Standards of Medical Care in Diabetes-2013).

8. American Diabetes Association: Clinical Practice Recommendations. Diabetes Care 2013;36 (suppl 1): S67-S74 (current approach to diagnosis and classification).

9. Hanas R et al: 2010 consensus statement on the worldwide standardization of the hemoglobin A1c measurement. Diabetes Care 2010;33:1903-5 (discussion of NGSP- DCCT-aligned HbA1c values vs. IFCC values).

10.  www.NGSP.org (detailed and up-to-date information about HbA1c standardization world-wide). 

11.  Silvestein J et al: Care of children and adolescents with type 1 diabetes.  A statement of the American Diabetes Association.  Diabetes Care 2005;28:186-212 (an excellent discussion of developmental stages in children and the rationale for different HbA1c goals than in adults). 

12. Pihoker C et al: Insulin regimens and clinical outcomes in a type 1 diabetes cohort: The SEARCH for Diabetes in Youth Study.  Diabetes Care 2013;36:27-33 (intensive insulin regimens lead to better glycemic control and are used more often in non-Hispanic whites in families with health insurance, high incomes, and high levels of parental education). 

13. Garvey KC et al: Health care transition in patients with type 1 diabetes. Diabetes Care 2012;35:1716-22 (we pediatric diabetes specialists do not seem  to do a very good job at facilitating a smooth transition from pediatric diabetes care to adult care). 

14. Barton FB et al: Improvement in outcomes of clinical islet-cell transplantation 1999-2010.  Diabetes Care 2012;35:1436-45 (a comprehensive review of the current status of islet-cell transplantation: there has been some progress but there is still a long way to go before the procedure can be considered standard of care for patients with T1DM). 

15. Buse JB et al: Diabetes screening with hemoglobin A1c vs. fasting plasma glucose in a multi-ethnic middle school cohort.  Diabetes Care 2013;36:429-35 (HbA1c <5.7% and less than 6.5% is a far better predictor of  diabetes than fasting plasma glucose between 110-125 mg/dl,  but “optimal screening strategies remain unresolved”). 

16. Bowers JK et al: No ethnic differences in the association of glycated hemoglobin with retinopathy: the National Health and Nutrition Examination Survey 2005-2008.  Diabetes Care 2013;36:569-73 (an important paper showing that apparent small differences in HbA1c normal ranges among different ethnic groups are not relevant to complication risks; ethnic-specific cut points for HbA1c for diagnosis or screening are not needed). 

17. Goldstein DE et al: Glycemic control and development of retinopathy in youth-onset insulin-dependent diabetes mellitus: results of a 12-year longitudinal study. Ophthalmology 1993;100:1125-32 (a study from the University of Missouri Health Sciences Center showing that total duration of diabetes, not just post-pubertal duration, is a risk factor for diabetes complications). 

18. www/.hlbi.nih.gov/hypertension/child_tbl.pdf (very useful table of blood pressure norms in children and adolescents with percentiles including blood pressure norms in relation to height percentiles). 

19. American Diabetes Association. Diabetes care in the school and day care setting. Diabetes Care 2013;36(suppl 1):S75-S79 (a very useful reference that provides guidelines for diabetes care for children in school and day care, including a discussion of  the various federal laws that define responsibilities that schools and day care facilities have for children and adolescents with diabetes). 

20.   American Diabetes Association. Diabetes and Driving. Diabetes Care 2013;36 (suppl1):S80-S85 ( a very important issue in treating adolescents with diabetes). 

21. Inzucchi SE: Diagnosis of diabetes.   N Engl J Med 2012;367:542-50 (an excellent discussion of the strengths and weakness of various approaches to diagnosis of diabetes.) 

22. Polonsky KS: The past 200 years in diabetes. N Eng J Med 2012;367:1332-40 (a nice summary of 2 centuries of progress in diabetes).

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