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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine:
--The Treatment of Diabetes: The Rule of “1’s”

  

The Outpatient Management of Diabetes*

Introduction.  The diabetes control and complications trial, published in 1993, showed conclusively that tight metabolic control delays complications.  In fact, another NEJM showed in Jan 2001 that exercise and diet definitely decreases onset of diabetes in those with type 2 characteristics.  The first study compared intensive insulin treatment (3-4 shots/day) to traditional treatment. (1-2 shots/day, results in teens: better control, reduced microvascular complications, but more hypoglycemia and obesity) 

Dangers of strict control: Very difficult to do; hypoglycemia events probably causes neurocognitive abnormalities.  Study found that hypoglycemia occurs most often during the night, is frequently asymptomatic, and bedtime snacks don’t prevent it.  Most common in younger children.  As Hgb A1C drops, episodes of hypoglycemia increase.  American Diabetes Association: strict control only with caution under age 7 years.

Outpatient Management:
Major Goal: Achieve the best possible control that does not allow hypoglycemia to occur.

1. Consider using graduated intensification program: varies by age: younger: less intense

Age Specific Goals: Sugar and Hgb A1C

Age

Prior to Meals

2 hrs post prandrial

Prior to hs snack

2Am – 3AM

<2 yrs

100-150

<200

100-180

>90

2-5 yrs

90-140

<190

100-170

>80

5-13 yrs

80-130

<180

90-160

>75

>13 yrs

70-120

<180

80-150

>65

2. Once optimal control attained, empower patients (parents) to adjust insulin doses; call only if values are more than 20% from the goal.

3. Support efforts of patient and family to achieve these goals by any of the following:

  • Adjust total insulin dosages, number of injections of insulin; may also consider changing the type of insulin: e.g. ultra short acting insulin analogue if having postprandial hypoglycemia.
  • Consider dietary adjustments particularly as relates to intense exercise.
  • Consider insulin infusion using an external infusion pump.
  • Return to office quarterly or monthly or even more often.  On physical exam, check BP, height, weight, nutritional status, fundi.  On lab, spot check Accuchek, urinalysis.  Every 6 months: Hgb A1C; annual thyroid
  • Refer to ophthalmology if have had diabetes for 3-5 years or have poor control, hypertension
  • Other possible referrals: psychologist, nutritionist, nephrologist
  • Consider diabetologist, if nearby, check child so that if problems child and family familiar with tertiary center and physician.

*Reference: Newman: Ped Annals 1999, pg 594 (back to the top)

Reviewed 4/01

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004