Background: The DCCT study showed intensified insulin regimes [4 injections a day] improve control [also increase the risk of hypos], but only in adults with Type 1 diabetes, not children, so it should not be assumed that this also applies to children.

The evidence Two recently published studies that provide evidence to help decide about regimes for children.

First study: Intensive therapy and pump therapy over 10 years has not improved HbA1cs but has increased insulin dose

Prevailing therapeutic regimes and predictive factors for prandial insulin substitution in 26 687 children and adolescents with Type 1 diabetes in Germany and Austria. Diabetic Medicine, October 2007

The researchers classified the information about 26,687 children, treated from 1995 to 2005 in 152 paediatric clinics. Their average age was 13.6 years and average duration of diabetes 5.4 years. 73% were treated with 4 or more daily injections [intensive therapy], 14% with continuous subcutaneous insulin infusion [CSII] and 13% with 1-3 injections per day [conventional therapy].

The researchers concluded that:

• 87% of the children were treated with intensive or pump therapy but while this percentage increased over the period of the study, the average HbA1c [approx 8.0%] was almost constant – in other words, it did not improve.
• Those using insulin analogues received up to 11% higher insulin doses per day compared with those treated with human insulin.

Second study: Twice-daily free mix insulin regimes gave the best HbA1cs

Continuing stability of centre differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? Diabetes Care, Vol 30, number 9, September 2007

This international study in 21 paediatric diabetes centres investigated the influence of changes in insulin regimes, and other factors, on HbA1cs, hypoglycaemia and ketoacidosis. The 2,269 participants were aged between 11-18 and had diabetes at least a year. Fourteen of the centres had participated in previous studies so allowing a direct comparison of glycaemic control between 1998 and 2005.

The average HbA1c result for the whole group was 8.2 with girls having higher results than boys [8.3 vs 8.1] and those who had a longer duration of diabetes had modestly higher HbA1cs. 85.3% of the children/adolescents were on one of 5 insulin regimes - the remaining 309 were on regimes that could not be classified.

The HbA1c results for the different regimes were as follows:

Regime	HbA1c   8.2	Insulin Dose [bye body weight]
Miscellaneous	8.2	0.66
Twice daily premix	8.6	1.01
Twice daily free mix	7.9	1.00
Thrice daily	8.2	1.24
Basal bolue	8.2	1.03
Pumps	8.1	0.92

BMI [weight] was not significantly associated with HbA1cs. Insulin dosage was unrelated to hypoglycaemia but was significantly correlated with diabetic ketoacidosis [DKA], with higher insulin dose associated with poorer metabolic control and more frequent DKA.

Comparison of the 1998 and 2005 studies

• Participants in the 2005 study had a higher BMI and were on more intensive regimes than in the 1998 study.
• There has been no significant improvement in HbA1cs and no difference in the frequency of hypoglycaemia.
• Only two centres significantly improved glycaemic control compared with 1998 but this was not explained by intensification of insulin regimes.

So what did the researchers conclude?

Despite many changes over the past 10 years including increased use of insulin analogues, basal bolus regimes [4 injections + a day] and pumps:

• those using twice daily free mix of soluble/regular plus NPH [intermediate-acting] and had lower HbA1cs than all other groups. “This suggests that the so-called conventional regimes may be superior to modern intensive regimes.”
• HbA1cs on pump therapy were not significantly different from the total group even in centres where considerable numbers of patients were using them.

So the researchers concluded that despite major and continuing changes in insulin and insulin regimes, glycaemic control has not improved over a decade in 21 international centres.

So back to injecting at school………..

So lunchtime injections can be avoided with free-mix as we did or with premix insulins. Look at the available evidence so that your choices are informed ones.

Glycaemic control and a happy childhood are paramount for our children with diabetes. The above evidence gives choices that you and your clinic may not have considered. If injecting at school is a problem or your child does not want to have so many injections, the alternative of twice daily injecting is an option especially as it appears to give the best HbA1cs, needs a lower daily insulin dose that reduces the risk of diabetic ketoacidosis and less weight gain!

More….

One of the most frequently raised issues by parents are the difficulties they are experiencing at school with injecting and blood glucose testing, especially for young primary school children. Lunchtime injecting and testing has become much more of a problem as a result of the introduction of insulin analogues, as the rapid-acting insulin has only has a short duration of action and doesn’t last long enough to cover lunch.

Let’s look at both sides and undoubtedly, the school system should provide for children with diabetes at school. It should not entail long verbal battles between parents and teachers. There are fairly stringent regulations about what teachers can and can’t do with children – the typical stories being that they are not even allowed to put a plaster on a cut and most certainly not allowed to hug a child in need of consolation. So asking them to do blood test and inject a young child, does seem to be outside their remit. At the same time, if young children are on a regime that requires a lunchtime test and at least one blood glucose test during the school day, what are parents supposed to do?

Recent had conversations with several parents:

Parent 1: has a son whose last two HbA1cs were 6.4 and 6.2 on twice daily injections – really good, yet the hospital want him to change insulins and go on to 4 injections a day. He doesn’t want to and his mum does not want to upset him when he is achieving good results without injections at school. So she’s putting her son’s wishes first and he is not changing to 4 injections a day.

Parent 2: her 5 year old daughter was on 4 injections a day before starting school and now she has started, the school is refusing to take responsibility for doing the lunchtime injections and blood tests. There is an ongoing letter-writing battle………

Parent 3: her 9 year old daughter is using insulin analogues and a pump. She has chosen this option for her daughter because she believes that it will provide better control and will be less likely to cause future complications.

Parent 4: has a son who is really unhappy about injecting at school on his 4 injections a day regime and after looking on the internet, she found that there are alternatives eg twice daily injections. She is quite angry that this choice has never been offered to her or her son.

Four different experiences and views but they all raise one question – have the parents and the children been given an informed choice of all treatment options? In considering the options we need to ask some pretty pertinent questions:

• Does injecting and testing at lunchtime, make your child feel different from the rest of the class? Is this causing your child extra stress [which can raise blood sugars]?
• Which is the best regime for your child and is there evidence that it produces the best HbA1c results?
• Is ‘going into battle’ with the school going to solve the problem and could it hinder your child’s overall needs? Will it single your child out with the teachers as being ‘different’ and is this what you want?
• What will give your child the best quality of life?

 

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IDDT Newsletter January 2008

http://www.iddtinternational.org/