الفهرس 
Types and management Of Diabetes Mellitus in pediatricsOnly 14 pages are availabe for public view
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Abstract
Diabetes care should be organized around a multi- and interdisciplinary diabetes healthcare team. The goal of a diabetes care should be to achieve a near-normoglycemia without increasing the risk of hypoglycemia, to prevent the onset and/or the progression of diabetic vascular complications and to help the children and adolescents with diabetes to have a normal life by the continuing psychological and social support.
Therefore this cross-sectional study was designed to evaluate the quality of care of our diabetes clinic through evaluation of types of diabetes in the clinic, types and regimens of diabetes therapy, diabetes education, adequacy of diabetes control, frequency and severity of diabetic complications among all children and adolescents following up at the pediatric Diabetes Clinic, Ain Shams University Children’s hospital.
All children and adolescents following up in the Pediatric Diabetes Clinic of the Children’s Hospital of Ain Shams University in the period from December 2006 till June 2007 were included in the study. They all went through a complete history taking and a thorough physical examination and a complete evaluation of the adequacy of their care and follow up.
At the time our study was held, 96.2% of our patients had T1DM, 4.1% had been diagnosed based on fasting C-peptide assay as T2DM and 0.5% had neonatal DM.
In our study we found that 10.6% of our patients have a positive family history of DM.
We found that the commonest disease duration of patients following up in our clinic (55.6%) is the disease duration of 6 month-5 years, 6.6% have a disease duration between 10-15 years and only 1.3% have disease duration of more than 15years.
It was also noted that in the past 6 months there has been a marked increase in the number of the new cases presenting to our clinic (more than doubled).
We found that the commonest age group in the clinic is the 12-18 years old (i.e. adolescents) who represent 38.5% of all patients following up in our clinic (followed by children aged 7-12 years representing 36.2%).
Our data show that nearly a quarter of patients following up in our clinic have stunted growth and short stature with height percentile falling below 5th percentile. The percentage of these patients increases with age (peaks in adolescence).
In our study we found that 80.6% of our female patients aged 10-14 years have not menstruated in comparison to 20% in the age group 14-18years. As for male patients between 12-18 years 24.8% have delayed puberty. Both males and females with
delayed puberty had significantly higher HbA1c as compared to those who had within average development of their puberty.
Still the commonest type of insulin treatment in the clinic (used by 74.1% of our patients) is the combination of regular insulin +NPH and patients using this combination had a mean HbA1c 9.15 ±2.36 and a mean frequency of hypoglycemia/Patient/month 3.34±8.2 for daytime hypoglycemia 3.43 ±8.2 and 0.13 ±0.5 for nocturnal hypoglycemia of. Also 19.6% are using one of the insulin analogues in the form of rapid and/or long acting analogues. We also found that unfortunately 5.5% of our patients are still on Mixtard 30/70 (premixed insulin).
We could document a significant difference between groups using different insulin combinations. Patients using a rapid acting analogue+glargine had a mean HbA1c of 7.5±1.82. Patients on Mixtard 30/70 had a mean HbA1c of 11.6±1.8.
While for the relation between type of treatment and hypoglycemia frequency/patient/month, we
found a high frequency of daytime hypoglycemia was with the use of Rapid acting analogues +NPH (5.54 ±8.9) and actually this indicates the need of some of these patients for further education and stress on the correct timing of giving the insulin in relation to meals. As for Nocturnal episodes we found a high frequency/patient/month with the use of Mixtard (0.4 ±0.2) and the Rapid acting analogues+Long acting analogues (0.3 ±0.4). This latter is the group with the lowest HbA1c% and our study raises questions concerning the best timing of giving glargine in our patients and dietary modifications with it.
Our study demonstrated that 56.6% of our patients are taking insulin via insulin pens while only 20.7% of our patient are below the age of 7 years which is the age group who are the target to be given pens according to the clinic policy.
As for the regimen of insulin therapy we found that still 5.5% of our patients are on the conventional diabetes therapy regimen.
Only 9% are on the non-intensive therapy regimen which means that still 11.9% of those below the age of 7 are on the intensive diabetes therapy. However, we found that the mean HbA1c for patients on intensive regimen was 9.044% ± 1.12% which is surprisingly higher than those on the non-intensive regimen (8.84±2.31%). Therefore,
more effort should be put on Diabetes education and adjustment of insulin doses in relation to different dietary and exercise regimens to better approach achieving the required target of the intensive therapy regimen.
We also found that while 97.5% of our patients are doing frequent SMBG yet 59.5% of them have unsatisfactory results. Still, despite that 38% are reporting satisfactory SMBG readings, their mean HbA1c % was found to be 8.39±2.37%. One important issue this discrepancy may indicate is the inability of patients and their inadequate training on the proper use of visual glucose measuring strips.
Overall, we found that the mean HbA1c of the clinic is 9.04% ±2.3 and that 50.2% of our patients are not doing it regularly and that only 10.46% have a mean HbA1c below 7.5%. This could be due to the fact that we still have 5% of our patients on the conventional therapy regimen, 5.5% are using Mixtard, the short time available for each patient in the clinic and that only 1.8% attended diabetes education.
We could not document in our study any significant difference in mean HbA1c of the different age groups in our clinic.
In our study there is a significant difference in the reported hypoglycemia frequency in different
age groups being low in the age group below 3 years who are on the non-intensive therapy regimen and high in the age group 3-7 years followed by those in the age group 7-12 years. In these latter two age groups more attacks used to occur during daytime following doing extra exercise which again raises the importance of diabetes education in reducing DM-related morbidity and mortality.
We also documented a significant difference in the reported frequency of DKA being highest in adolescents (12-18 years old age group). On the average 5 patients are admitted monthly to our hospital with DKA. This is a relatively high rate and being as such again brings to light the value of issues of education and psychosocial support to our patients.
An inverse correlation was found between DKA frequency and hypoglycemia frequency in all age groups except for patients 7-12 years old where this relation was found to be a positive correlation. Indicating that these patients have marked fluctuations in their blood glucose lrvels. Adolescents were found to more likely present with DKA and younger patients 3-7 years old are more likely to present with hypoglycemia.
We found that only 19% of our patients came for education and only 1.8% of them attended the complete diabetes education program and only
0.5% came for assessment. It is worthnoting that the diabetes education program has just started at January 2007 and that with time we expect its’ results to be better.
In our study we found that 1.2% of our patients have thyroid disease, 1.2% have celiac disease,
0.7% have psychiatric disorder, in the form of bulemia Nervosa and personality disorders that were detected by the clinic physicians, referred to our clinic psychiatrist and managed by the whole team together.
Also, 2.65% have fatty hepatomegaly. They had mean BMI 19kg/m2, mean HbA1c 8.1% and negative family history of diabetes.
We also found that unfortunately 91.9% of our patients are not doing the annual fundus follow up. Seven percent (7%) have normal regular fundus examination and 0.7% have retinal hemorrhage detected by examination after presenting with acute loss of vision. No one is doing the CVS follow up, 90.2% are not doing the annual urine microalbumin check follow up,7%have normal follow up, 2.51% have microalbuminuria, one case has nephrotic syndrome and one case with ESRD. No one is doing the neurological examination and evaluation.
Our study also revealed that 10.8% of our patients have unsatisfactory school performance and
5% skipped school due to misthoughts about limitations due to having diabetes and problems in psychosocial adjustment at school imposed by the child, the teachers and other children.
According to N I C E guidelines, we can summarize our current audit indices as follows:
• Percent HbA1c < 7.5%: 89.2%.
• Microalbuminuria screened: 9.83%.
• Abnormal albumin excretion: 27.8%
• Eye screened: 8.1%.
• Eye damage: 0.7%
• Education performed: 1.8%.