Diabetes Care In Specific Populations

A. Children and adolescents

1. Type 1 diabetes

Although approximately three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age, historically, ADA recommendations for management of type 1 diabetes have pertained most directly to adults with type 1 diabetes. Because children are not simply “small adults,” it is appropriate to consider the unique aspects of care and management of children and adolescents with type 1 diabetes. Children with diabetes differ from adults in many respects, including insulin sensitivity related to sexual maturity, physical growth, ability to provide self-care, and unique neurologic vulnerability to hypoglycemia. Attention to such issues as family dynamics, developmental stages, and physiologic differences related to sexual maturity all are essential in developing and implementing an optimal diabetes regimen. Although current recommendations for children and adolescents are less likely to be based on evidence derived from rigorous research because of current and historical restraints placed on conducting research in children, expert opinion and a review of available and relevant experimental data are summarized in a recent ADA Statement. The following represents a summary of recommendations and guidelines pertaining specifically to the care and management of children and adolescents that are included in that document.

Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes, although this may not always be possible. At the very least, education of the child and family should be provided by health care providers trained and experienced in childhood diabetes and sensitive to the challenges posed by diabetes in this age-group. At the time of initial diagnosis, it is essential that diabetes education be provided in a timely fashion, with the expectation that the balance between adult supervision and self-care should be defined by, and will evolve according to, physical, psychologic, and emotional maturity. MNT should be provided at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets. 

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a. Glycemic control

While current standards for diabetes management reflect the need to maintain glucose control as near to normal as safely possible, special consideration must be given to the unique risks of hypoglycemia in young children. Glycemic goals need to be modified to take into account the fact that most children <6 or 7 years of age have a form of "hypoglycemic unawareness," in that counterregulatory mechanisms are immature, and young children lack the cognitive capacity to recognize and respond to hypoglycemic symptoms, placing them at greater risk for hypoglycemia and its sequelae. In addition, extensive evidence indicates that near normalization of blood glucose levels is seldom attainable in children and adolescents after the honeymoon (remission) period. The A1C level achieved in the "intensive" adolescent cohort of the DCCT group was >1% higher than that achieved for older patients and current ADA recommendations for patients in general.

In selecting glycemic goals, the benefits of achieving a lower A1C must be weighed against the unique risks of hypoglycemia and the disadvantages of targeting a higher, although more achievable, goal that may not promote optimal long-term health outcomes. Age-specific glycemic and A1C goals are presented in Table 10.

Table 10?? Plasma blood glucose and A1C goals for type 1 diabetes by age group

Values by age (years) Plasma blood glucose goal range (mg/dl) A1C Rationale
Before meals Bedtime/overnight
Toddlers and preschoolers (0??6) 100??180 110??200 <8.5% (but >7.5%) High risk and vulnerability to hypoglycemia
School age (6??12) 90??180 100??180 <8% Risks of hypoglycemia and relatively low risk of complications prior to puberty
Adolescents and young adults (13??19) 90??130 90??150 <8% ??? Risk of severe hypoglycemia
??? Developmental and psychological issues
??? A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia
Key concepts in setting glycemic goals:
??? Goals should be individualized and lower goals may be reasonable based on benefit-risk assessment.
??? Blood glucose goals should be higher than those listed above in children with frequent hypoglycemia or hypoglycemia unawareness.
??? Postprandial blood glucose values should be measured when there is a disparity between preprandial blood glucose values and A1C levels.

b. Screening and management of chronic complications in children and adolescents with type 1 diabetes.

i. Nephropathy

Recommendations

* Annual screening for microalbuminuria should be initiated once the child is 10 years of age and has had diabetes for 5 years. Screening may be done with a random spot urine sample analyzed for microalbumin-to-creatinine ratio. (E)
* Confirmed, persistently elevated microalbumin levels should be treated with an ACE inhibitor, titrated to normalization of microalbumin excretion (if possible). (E)

ii. Hypertension

Recommendations

* Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached within 3??6 months of lifestyle intervention, pharmacologic treatment should be initiated. (E)
* Pharmacologic treatment of hypertension (systolic or diastolic blood pressure consistently above the 95th percentile for age, sex, and height or consistently greater than 130/80 mmHg, if 95% exceeds that value) should be initiated as soon as the diagnosis is confirmed. (E)
* ACE inhibitors should be considered for the initial treatment of hypertension. (E)
* Hypertension in childhood is defined as an average systolic or diastolic blood pressure 95th percentile for age, sex, and height percentile measured on at least three separate days. “High-normal” blood pressure is defined as an average systolic or diastolic blood pressure 90th but <95th percentile for age, sex, and height percentile measured on at least 3 separate days. Normal blood pressure levels for age, sex, and height and appropriate methods for determinations are available online at http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf.

iii. Dyslipidemia

Recommendations

Screening

* Prepubertal children: a fasting lipid profile should be performed on all children >2 years of age at the time of diagnosis (after glucose control has been established) if there is a family history of hypercholesterolemia (total cholesterol >240 mg/dl), if there is a history of a cardiovascular event before age 55 years, or if family history is unknown. If family history is not of concern, then the first lipid screening should be performed at puberty (>12 years). If values are within the accepted risk levels (LDL <100 mg/dl [2.6 mmol/l]), a lipid profile should be repeated every 5 years. (E)
* Pubertal children (>12 years of age): a fasting lipid profile should be performed at the time of diagnosis (after glucose control has been established). If values fall within the accepted risk levels (LDL <100 mg/dl [2.6 mmol/l]), the measurement should be repeated every 5 years. (E)
* If lipids are abnormal, annual monitoring is recommended in both age-groups. (E)

Treatment

* Treatment should be based on fasting lipid levels (mainly LDL) obtained after glucose control is established. (E)
* Initial therapy should consist of optimization of glucose control and MNT aimed at a decrease in the amount of saturated fat in the diet. (E)
* The addition of a pharmacologic lipid-lowering agents is recommended for LDL >160 mg/dl (4.1 mmol/l), and is also recommended in patients who have LDL cholesterol values of 130??159 mg/dl (3.4??4.1 mmol/l) based on the patient??s CVD risk profile, after failure of MNT and lifestyle changes. (E)
* The goal of therapy is an LDL value <100 mg/dl (2.6 mmol/l). (E)

iv. Retinopathy

Recommendations

* The first ophthalmologic examination should be obtained once the child is 10 years of age and has had diabetes for 3??5 years. (E)
* After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations may be acceptable on the advice of an eye care professional. (E)

Although retinopathy most commonly occurs after the onset of puberty and after 5??10 years of diabetes duration, it has been reported in prepubertal children and with diabetes duration of only 1??2 years. Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, and experience in counseling the pediatric patient and family on the importance of early prevention/intervention.

c. Other issues.

A major issue deserving emphasis in this age-group is that of “adherence.” No matter how sound the medical regimen, it can only be as good as the ability of the family and/or individual to implement it. Family involvement in diabetes remains an important component of optimal diabetes management throughout childhood and into adolescence. Health care providers who care for children and adolescents, therefore, must be capable of evaluating the behavioral, emotional, and psychosocial factors that interfere with implementation and then must work with the individual and family to resolve problems that occur and/or to modify goals as appropriate.

Since a sizable portion of a child??s day is spent in school, close communication with school or day care personnel is essential for optimal diabetes management. Information should be supplied to school personnel, so that they may be made aware of the diagnosis of diabetes in the student and of the signs, symptoms, and treatment of hypoglycemia. In most cases it is imperative that blood glucose testing be performed at the school or day care setting before lunch and when signs or symptoms of abnormal blood glucose levels are present. Many children may require support for insulin administration by either injection or continuous subcutaneous insulin infusion before lunch (and often also before breakfast) at school or in day care. For further discussion, see the ADA position statement and the report from the National Diabetes Education Program.

2. Type 2 diabetes

Finally, the incidence of type 2 diabetes in children and adolescents has been shown to be increasing, especially in ethnic minority populations. Distinction between type 1 and type 2 diabetes in children can be difficult, since autoantigens and ketosis may be present in a substantial number of patients with otherwise straightforward type 2 diabetes (including obesity and acanthosis nigricans). Such a distinction at the time of diagnosis is critical since treatment regimens, educational approaches, and dietary counsel will differ markedly between the two diagnoses. The ADA consensus statement provides guidance to the prevention, screening, and treatment of type 2 diabetes, as well as its comorbidities in young people.

B. Preconception care

Recommendations

* A1C levels should be normal or as close to normal as possible (<1% above the upper limits of normal) in an individual patient before conception is attempted. (B)
* All women with diabetes and child-bearing potential should be educated about the need for good glucose control before pregnancy. They should participate in family planning. (E)
* Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, neuropathy, and CVD. (E)
* Among the drugs commonly used in the treatment of patients with diabetes, Statins are pregnancy category X and should be discontinued before conception if possible. ACE inhibitors and ARBs are category C in the first trimester (maternal benefit may outweigh fetal risk in certain situations), but category D in later pregnancy, and should generally be discontinued before pregnancy. Among the oral antidiabetic agents, metformin and acarbose are classified as category B and all others as category C; potential risks and benefits of oral antidiabetic agents in the preconception period must be carefully weighed, recognizing that sufficient data are not available to establish the safety of these agents in pregnancy. They should generally be discontinued in pregnancy. (E)

Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes. Observational studies indicate that the risk of malformations increases continuously with increasing maternal glycemia during the first 6??8 weeks of gestation, as defined by first-trimester A1C concentrations. There is no threshold for A1C values above which the risk begins or below which it disappears. However, malformation rates above the 1??2% background rate seen in nondiabetic pregnancies appear to be limited to pregnancies in which first-trimester A1C concentrations are >1% above the normal range.

Preconception care of diabetes appears to reduce the risk of congenital malformations. Five nonrandomized studies have compared rates of major malformations in infants between women who participated in preconception diabetes care programs and women who initiated intensive diabetes management after they were already pregnant. The preconception care programs were multidisciplinary and designed to train patients in diabetes self-management with diet, intensified insulin therapy, and SMBG. Goals were set to achieve normal blood glucose concentrations, and >80% of subjects achieved normal A1C concentrations before they became pregnant. In all five studies, the incidence of major congenital malformations in women who participated in preconception care (range 1.0??1.7% of infants) was much lower than the incidence in women who did not participate (range 1.4??10.9% of infants). One limitation of these studies is that participation in preconception care was self-selected by patients rather than randomized. Thus, it is impossible to be certain that the lower malformation rates resulted fully from improved diabetes care. Nonetheless, the overwhelming evidence supports the concept that malformations can be reduced or prevented by careful management of diabetes before pregnancy.

Planned pregnancies greatly facilitate preconception diabetes care. Unfortunately, nearly two-thirds of pregnancies in women with diabetes are unplanned, leading to a persistent excess of malformations in infants of diabetic mothers. To minimize the occurrence of these devastating malformations, standard care for all women with diabetes who have child-bearing potential should include 1) education about the risk of malformations associated with unplanned pregnancies and poor metabolic control and 2) use of effective contraception at all times, unless the patient is in good metabolic control and actively trying to conceive.

Women contemplating pregnancy need to be seen frequently by a multidisciplinary team experienced in the management of diabetes before and during pregnancy. Teams may vary but should include a diabetologist, an internist or a family physician, an obstetrician, a diabetes educator, a dietitian, a social worker, and other specialists as necessary. The goals of preconception care are to
1) integrate the patient into the management of her diabetes,
2) achieve the lowest A1C test results possible without excessive hypoglycemia,
3) assure effective contraception until stable and acceptable glycemia is achieved, and
4) identify, evaluate, and treat long-term diabetic complications such as retinopathy, nephropathy, neuropathy, hypertension, and CAD.

For further discussion, see the ADA??s technical review and position statement on this subject.

AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004

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May 27, 10 • Diabetes mellitus