Managing Diabetes in Children and Adolescents—Is There an Optimal Regimen?
Treatment of Type 1 Diabetes in Children and Adolescents
Diabetes is one of the most common chronic conditions affecting children worldwide. Statistics gathered by the National Institutes of Health (NIH) in 2005 revealed that one out of every 400–600 children in the US had been diagnosed with type 1 diabetes.1 This figure increases annually, with reports of the global incidence of diabetes in children and adolescents increasing at a rate of 3% per year.2–4 The greatest increase in incidence has been reported in children ≤5 years of age.5 This equates to approximately 190,000 children, with their families attending to the usual demands of ensuring the physical, intellectual, and emotional health of a toddler, school-age child, or adolescent while trying to maintain their blood-glucose levels in a range as close to normal as possible.
An optimal therapeutic regimen needs to minimize episodes of hyperglycemia and hypoglycemia while maintaining the hemoglobin A1C (A1C) within the target range. The Diabetes Control and Complications Trial (DCCT) established A1C as the gold standard by which diabetes control should be assessed. This is because of the clear correlation between the decrease in A1C attained through intensive diabetes management and the decrease in subsequent incidence of both micro- and macrovascular complications.6,7 There is growing evidence that glycemic excursions may play an important independent role in the development of complications.8 This implies that insulin delivery that approximates physiological patterns of insulin secretion may decrease the incidence of micro- and macrovascular complications further than lowering A1C alone.
There are only two regimens that come close to approximating physiological insulin delivery, both of which operate on the theory of ‘basal–bolus’ insulin dosing. Multiple daily injection (MDI) regimens that utilize non-peaking, long-acting insulin (glargine) with boluses of rapidacting insulin analogs begin to mimic the pattern of endogenous insulin secretion. However, replication of an even more physiological pattern can be achieved by using continuous subcutaneous insulin infusion (CSII) via an insulin pump. CSII provides the user with the ability to deliver insulin doses in the most precise, flexible, and physiological pattern available. An optimal diabetes regimen should also allow for participation in all academic, social, and athletic pursuits that would be available to the child in the absence of the diagnosis. CSII provides children and adolescents with a flexible regimen that minimizes restrictions on activities that are important to their overall development.
A recent consensus statement presented a thorough discussion of the available evidence regarding the benefits and risks of the use of CSII in pediatric patients.9 A randomized controlled trial in adults reported a reduction of 0.5–1.2% in A1C in subjects using CSII versus those using MDI.10 A small, randomized trial that compared CSII with MDI in pediatric subjects found a significant reduction in A1C at short-term follow-up.11 Longer followup has been reported in numerous observational studies that support that this benefit persists over time.12–15 Recommended target values for A1C will differ between age groups and clinical centers. Generally, there is agreement that we should strive to keep the A1C as close to normal as possible while minimizing hypoglycemic events.
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- White NH, Cleary PA, Dahms W, et al., Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group. Beneficial effects of intensive therapy of diabetes during adolescence: outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT), J Pediatr, 2001;139(6):804–12.
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