Temporal Trends in the Treatment of Pediatric Type 1 Diabetes and Impact on Acute Outcomes

Abstract

Objective-To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes.Study design-Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N=299) was enrolled in 1997 and Cohort 2 (N=152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were A1c, z-BMI, and incidence rates (IR, per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits.Results-At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (≥4 times/ day: 72% vs. 39%, p<.001) and was prescribed more intensive therapy than Cohort 1 (≥3 injections/ day or pump: 85% vs. 65%, p<.001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs. 8.7%, p=.03) and study's end (8.7% vs. 9.0%, p=.04). The cohorts did not differ in z-BMI (0.83 vs. 0.79, p=.57) or IR of hospitalizations (11.2 vs. 12.9, p=.38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs. 55.4, p<.001) and ER visits (22.0 vs. 29.3, p=.02).Conclusions-T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable z-BMI. Along with improved control, IRs of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Treatment of T1DM in children and adolescents is difficult. The combination of severe insulin deficiency and the physical and psychosocial changes that accompany normal growth and development present unique challenges to pediatric health care professionals (6-9). In the DCCT, the 195 adolescents, ages 13-17 years at entry, had significantly higher A1c values compared to their adult counterparts, and the investigators anticipated that worldwide translation of treatment recommendations for youth would be especially challenging (10). Recent data, however, suggest that clinicians have gained success in implementing DCCT standards in pediatric practice. Advances in technology, such as improved methods of SMBG, modern insulin infusion pumps, and new short-and long-acting insulin analogs, as well as innovative behavioral and educational approaches, have contributed to this success (11-14). Keywords NIH Public AccessMaintenance of near-euglycemia, however, is not the only goal of intensive diabetes management. The prevention of excessive weight gain, previously associated with intensification of diabetes therapy (15...

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Intensively managed young children with type 1 diabetes consume high-fat, low-fiber diets similar to age-matched controls

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Type 1 Diabetes Mellitus and Cardiovascular Disease

“…68 These benefits were thought by the authors to outweigh the almost 3-fold increased risk of hypoglycemia seen in this early trial. Subsequent experience and publications report lower rates of hypoglycemia when adolescents are treated intensively to achieve lower HbA 1c , 69 which suggests concerns about high rates of hypoglycemia are likely unfounded.…”