Treating children and adolescents with diabetes used to focus on keeping blood glucose in reasonably good control while steering them through their various hormonal and psychosocial changes and illnesses. Glucose control was important but secondary.
With the conclusive results of the Diabetes Control and Complications Trial, that has changed. It is now known that glucose control is the most important factor in preventing long-term complications of diabetes, and this applies to adolescents as well as adults. Of the trial participants, 14 percent (195) were age thirteen to seventeen, all of whom were insulin dependent. When the study began, it was assumed that these kids would respond differently because they were experiencing a sharp rise in growth hormone and other growth factors that are chemically similar to insulin. It was therefore gratifying to find that the adolescents’ response to intensive versus conventional diabetes therapy was similar in adolescents and adults, especially in terms of risk of microvascular changes that affect eyes and kidneys.
Adolescents in the trial also had the same adverse effects of intensive therapy as did adults: risk of weight gain and severe hypoglycemia. In fact, the rate of hypoglycemia in adolescent participants was higher than that of adults, but there were no long-term negative consequences of hypoglycemic episodes. The investigators believe that this higher risk of hypoglycemia is probably due, at least in part, to adolescents’ greater irregularities in exercise and food intake, but the larger insulin doses required by younger people also may have played a role.
The results of the DCCT underscore the importance of spreading insulin doses throughout the day for strict glucose control. Reasonably good control can be achieved by some teenagers with two injections a day, but control is better and safer with three or more injections. Of course, the practical problem is to get kids to try a multiple-dose program. An insulin pump would be an ideal way to deliver insulin, but most teenagers find it too inconvenient and embarrassing.
The DCCT did not include children younger than thirteen years old, but extrapolating from the data and from what is known about younger children’s physiology and biochemistry, most physicians believe that intensive therapy is less beneficial than conventional therapy for children younger than thirteen, especially infants and toddlers. They appear to be relatively well protected against eye and kidney changes with conventional therapy, and severe hypoglycemia is especially dangerous for brain development in younger children. Little kids, because their food intake and activity levels are so unpredictable, are particularly prone to severe hypoglycemia.
The more often blood glucose is monitored, and the more closely insulin dosage is tailored to the results, the less the risk of hypoglycemia and the better the glucose control.
