Wednesday, September 3, 2014

Diabetes in Children

Diabetes mellitus is a metabolic disease characterized by chronic hyperglycemia and results from either defects in insulin secretion/ insulin action or both. The incidence of type 1 diabetes varies between different countries and ranges from as low as 0.1 to 57.6/100,000. The Highest incidence has been documented in Finland and the lowest in China and is mostly in children 0-4 years of age.
Type 1 diabetes (T1D) is characterized by autoimmune destruction of the insulin producing beta cells in the pancreatic islets, leading to abnormal glucose tolerance and eventually ketoacidosis.
Currently the diagnosis of T1D leads to lifetime dependence on injections of exogenous insulin to control blood glucose levels . Unfortunately, control is difficult to achieve but is needed to avoid fluctuations in glucose concentration and prevent micro vascular damage and long-term complications.
The choice of insulin regimen will depend on many factors including age, duration  of diabetes, Lifestyle (dietary patterns , exercise schedules, school) targets of metabolic control and particularly individual patient / Family preferences. The treatment of diabetes in many parts is still regular insulin mixed with intermediate acting insulin in twice daily doses.

Now, insulin analogues have been developed and are in use all over the world, of which three rapid acting types are currently available for children (aspart, glulisine, and lispro) and the basal insulin analogues are glargine and detemir. Bolus/basal therapy that combine premeal aspart of lispro with glargine or detemir insulin has emerged as the 'Gold Standard' for intensive injection therapy provided through multiple daily injections (MDI) for adolescent and adults. An insulin pump (continuous subcutaneous insulin infusion) is currently the best way to imitate the physiological insulin profile and is an alternative to treatment with MDI. Its use has been increasing and proving to be successful in most of the western countries.

Glycaemic control is assessed by regular monitoring of blood glucose at home and 3 monthly HbA1c measurements. Insulin adjustments should be made until target blood glucose levels and target HbA1c are achieved. Recently much emphasis is being given on managing diabetes with consistent massages and specific target set for young people by the pediatric team. Studies have shown a strong association between the target glycaemic control set by pediatric doctor's team and that perceived by adolescents and their parents. It has also been shown that it is the centers effectiveness in implementing the treatment regimen that affects metabolic control and not the insulin regimens.
Currently large number of are being conducted which include role of vitamin D3, oral insulin, nutritional intervention (docoshaexaenoic acid) etc for prevention of type 1 diabetes . Long - term studies of the safety and efficacy of insulin analogues in children and development of islet cell transplantation as a therapy for T1DM are also being conducted.

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