Diabetes care in children is complex

Abstract

The care of children with type 1 diabetes mellitus (T1DM) has changed dramatically in the past 20 years. This change has been fuelled, in part, by the publication of the results of the Diabetes Complications and Control Trial (DCCT) in 1993 (1). The DCCT included the evaluation of intensive diabetes management in adolescents. The DCCT taught us that glycemic control is directly related to microvascular complications. It also demonstrated the need for a dedicated, skilled, full-time diabetes education team to be co-located with physicians. This has been successfully translated into paediatric practice in the post-DCCT era. Sophisticated, full-time, paediatric diabetes teams with 24 h emergency telephone access have been established in every tertiary children’s hospital in Canada, as well as in many secondary centres with consultant paediatricians. The majority of children with T1DM at diagnosis are now managed on an ambulatory basis by such teams. Key ingredients of these modern diabetes teams are coordinated and flexible integration of care, education, support with case management, empowerment of parents and information systems for quality outcome assessment. Other remarkable developments that have catalyzed the revolution in T1DM diabetes care in children include faster and smaller blood glucose monitors, new ‘designer’ insulins and new technologies for insulin delivery. The rigid exchange system of starch, fruit and milk choices was abandoned as we recognized that all carbohydrates in the diet are similar in T1DM diabetes care and can be given in a usual eating pattern with appropriate flexible insulin doses. We have gained new insight into the psychology of diabetes in children, recognized that the most common cause of diabetic ketoacidosis is insulin omission and learned to use the hemoglobin A1c for identification of youth at risk for diabetic ketoacidosis. Insulin omission to promote weight loss is now a recognized form of an eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th revision (2) psychiatry diagnosis code. The globalization of information has provided parents and adolescents with endless sources of information to keep themselves well-informed. Paediatric diabetes care became even more complicated with the recognition of type 2 diabetes mellitus (T2DM) in youth in the 1980s. In most tertiary paediatric diabetes clinics in Canada, children with T2DM now account for 5% to 30% of the population followed in the clinic. Once diagnosed, T2DM is difficult to treat. It differs fundamentally from T1DM because it is a multisystem disorder, now known as the metabolic syndrome. The approach and treatment of an adolescent with T2DM must include the evaluation of the other components of the syndrome. Our understanding of the etiology, treatment and natural history of this new disease in children is evolving. It is imperative that we continue to expand our knowledge with well-designed treatment trials in this population. The extrapolation of adult data to the paediatric population is fraught with potential pitfalls. To add another wrinkle, it is now believed that 5% of children with diabetes have a monogenic form of inherited diabetes which is neither T1DM nor T2DM and which may respond to selective oral agents or insulin. We must be vigilant in asking a detailed family history of diabetes. The provision of care, education and support for children and adolescents with all forms of diabetes in children is complex. This complexity is reflected in the papers included in this special issue of Paediatrics & Child Health. All children and youth with diabetes in Canada need to have access to a coordinated and integrated diabetes care team to optimize their survival and minimize their morbidity. Diabetes is not a disease that can be managed well in isolation. We must work together to ensure that all our children and youth have access to care that truly makes a difference. The optimum system for delivery of care in our large country requires unique, flexible and creative solutions. Dedicated paediatric regional diabetes education teams are the cornerstone of this system and the creation of dedicated teams to meet the needs of vulnerable young adults with diabetes is the next logical step.