- advertisement -

Are young children "protected" from comlplications of hyperglycemia?

Discussion in 'Parents of Children with Type 1' started by Darryl, May 10, 2009.

  1. Nightowl

    Nightowl Approved members

    Joined:
    May 6, 2008
    Messages:
    168
    In the Swedish Study, http://care.diabetesjournals.org/cgi/content/abstract/30/10/2523, although the researchers state:

    HTML:
    that onset of diabetes
    before the age of 10 years, and thus
    prepubertal, significantly influenced the
    time to development of ESRD due to diabetic
    nephropathy. 
    They also state:

    HTML:
    [B]This suggests, not that
    the early ages of onset are protective but
    rather that ?the clock does not run as fast?
    for the years before pubertal onset.[/B] Other
    studies have indicated that the prepubertal
    years with diabetes involve a reduced
    risk or a longer time to development of
    diabetic nephropathy and other microvascular
    complications, e.g., retinopathy
    (6,9,11,36 ?38).
    

    This same article clarifies that it isn?t that prepubertal damage isn?t occurring, but rather that damage occurs faster during puberty:

    HTML:
    The mechanism behind this effect of
    age at onset is not clear, but it has been
    speculated that puberty, characterized by
    both rapid growth, hormonal changes,
    and worsening in glycemic control, may
    accelerate the processes leading to
    chronic diabetes complications such as
    ESRD. Hyperglycemia is crucial and promotes
    early glomerular hyperfiltration
    and, in addition, stimulates pathways that
    may influence the development of diabetic
    nephropathy (39,40). A role of
    growth hormone has been indicated (41);
    however, the postpubertal susceptibility
    to diabetic nephropathy seems to be persistent
    during adulthood (9). 
    
    Another recent article in Diabetes Care, http://care.diabetesjournals.org/cgi/content/abstract/30/10/2523, states:

    HTML:
    Increased A1C as a marker of chronic
    hyperglycemia is the most established
    and unquestioned risk factor for diabetic
    kidney disease in adult- and pediatric onset
    type 1 diabetes (11,13,14,17). The
    DCCT and the follow-up Epidemiology of
    Diabetes Interventions and Complications
    study clearly demonstrate that previous
    intensive treatment of diabetes with
    near-normal glycemia has an extended
    benefit in delaying the development and
    progression of diabetic nephropathy (9,
    10). By Kaplan-Meier analysis, we found
    that a cumulative A1C of 7.5% significantly
    raised the probability of micro- and
    macroalbuminuria. This effect became
    evident after diabetes duration of 10
    years for microalbuminuria and 20
    years for macroalbuminuria. Therefore,
    efforts to normalize metabolic control
    should be started right from diabetes onset,
    although consequences on renal function
    might not be seen before adult age.
    
    The article goes on to describe the risk in young children:

    HTML:
    Several studies have indicated that
    prepubertal duration of diabetes delays
    the onset of diabetic nephropathy. In our
    study, microalbuminuria was delayed by
    very early onset of diabetes and confirmed
    these previous prospective studies
    (14,31,32). [B]We do not suggest that poor
    metabolic control in prepubertal children
    does not add to the risk of microvascular
    complications, but there is evidence that
    it does so at a lower rate[/B] (33).
    
     
  2. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    In 1998, a follow-up of the 855 DCCT participants who were within their first 5 yeard since dx found that intensive BG control (defined as "keeping BG in a normal range with A1C <7%") helps prolong beta cell function and c-peptide response if started as early as possible after dx.

    From Annals of Internal Medicine:
    http://www.annals.org/cgi/content/abstract/128/7/517
    Conclusions: Intensive therapy for type 1 diabetes helps sustain endogenous insulin secretion, which, in turn, is associated with better metabolic control and lower risk for hypoglycemia and chronic complications. These observations underscore the importance of initiating intensive diabetic management as early as safely possible after type 1 diabetes is diagnosed.
    In other words, prescribing a pump and CGM at diagnosis could extend the honeymoon period, and have significant life-long benefits for the newly diagnosed child.

    Compare this with the conventional wisdom of how newly dx children are processed... no pump, no CGM, no training... just go home, keep yourself alive... don't treat BG's unless they're over 200... and if you show up at your endo appt. with an A1C under 7%, expect to get a lecture from the endo.

    I wonder how many endo's have considered the possible benefits they could impart by helping newly dx children start on intensive therapy immediately (with training and support of course), thereby possibly prolonging the honeymoon and making it easier to control BG in the years to come? The 855 newly dx's DCCT participants found out the answer to this question 10 YEARS ago, and continued to have the lowest rate of complications throughout the next 8 years of followup which extended through 2006.
     
  3. Jacob'sDad

    Jacob'sDad Approved members

    Joined:
    Nov 20, 2007
    Messages:
    3,803

    I think they would first have to figure out a way to evaluate the parent's ABILITY to utilize that intensive therapy. There are still many parents of type 1 kids who don't show up for appointments, and then there are those that do, but don't bring any logs or meters. When the endo has to deal with those parents, keeping their kid alive IS the primary goal.

    First the parents have to WANT intensive training and support and then they have to be able to USE what they are being taught. Many can do it. Many others can't or don't want to.
     
  4. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    No one could argue with that!

    I am just asking shouldn't parents at least be given an option, a suggestion, or an opportunity to explore these alternatives at dx?

    "Intensive therapy" is also much easier now than it was in the days of the DCCT. They did not use CGM's or pumps.
    The same or better control can be achieved now with minimal risk of hypo's.
     
  5. MReinhardt

    MReinhardt Approved members

    Joined:
    Dec 29, 2007
    Messages:
    2,953

    I believe that some drs underestimate what the parents are capable of doing, thus shooting down the best possible tools thats available.

    Along with that, it does not help that the parents WANT the intensive training and the best of insulin, pumps, cgms, and are being told no by the drs. (and I speak by personal issues here)

    Look... how many parents asked their endos for the pump? How many parents have asked for the cgms? Drs says "no" Drs over rule? Insurnace over rule?

    I dont think that drs really know what the outcome of complications actually are. Lets look at Chell for the moment. Chell was diagnosed in diabetes in May of 2004. Less than 4 years later, gastroparesis, (diagnoses Feb 2008) neuropathy (Aug 2008). Her endo says this is no way diabetes related. Gi drs, neuromuscular drs both says "diabetes gastroparesis" "diabetes neuropthay" So who is right? Did diabetes play a role in the complications?
     
  6. StillMamamia

    StillMamamia Approved members

    Joined:
    Nov 21, 2007
    Messages:
    13,195
    Forgive me if these links have already been posted, but here they are:

    http://care.diabetesjournals.org/cgi/reprint/26/4/1224

    You may have to manual download this.

    Particular attention at the end of page 1227 and beginning of page 1228 (of the paper, not the link). It mentions that the impact of lower levels of "dehydroepiandrostenedione" (DHEA ??) in children who present early retinopathy, and also mentions that an increase in growth hormones during puberty MAY (not will) speed up microvascular complications.

    Here is another link, but not very in-depth as you have to register to get the full text:

    http://www.journals.elsevierhealth.com/periodicals/jdc/article/PIIS1056872703000734/abstract


    These links are actually mentioned at the bibliography index of Hanas' book. He references them on page 314. HOWEVER, he also references 2 other studies, which show that A1c levels before puberty are also a determinant factor for long-term complications.

    Soooo, I think that there is no 100% certainty that pre-pubertal onset of diabetes will protect ong-term from complications. We can only do what we've been doing, and that is doing our best to keep BGs in range, and correct any high BGs and avoid too many lows, and strive to lower the A1c to a healthy level. There are too many variables in life and in a person.
     
    Last edited: May 16, 2009
  7. Nancy in VA

    Nancy in VA Approved members

    Joined:
    Jul 16, 2007
    Messages:
    7,308
    I think that our population on the board is not representative of the population of T1 parents as a whole. We are obviously, as evidenced by our participation in online forums, etc, more technologically sophisticated and engaged than the overall T1 parental population as a whole.

    I would venture to guess that more than 60% of parents of a newly diagnosed T1 child would throw themselves off a bridge if they were sent home with a new disease, no sleep, a pump, and a CGMS to manage that disease. And I don't think that, at this point, should be the recommended "starting position" for diabetes management.

    I do believe that good control is important, but not to the detriment of overall good life. I absolutely believe that a patient (or a patient's parent) can become obsessive about diabetes care to an unhealthy level. Our Endo has been very supportive of our wishes with regards to pumping and CGMS (and trust me, they don't have many children on CGMS's in their practice) but they also work very hard to make sure there is a healthy "overall home life" to go along with diabetes management.

    There is also the argument that just because the technology is there, it isn't always better for overall "well being". I do not believe a child should be forced to wear a pump or CGMS when they don't want to (when they are really of age to have an opinion - 10 or 12 and older, maybe) unless there are serious issues with the level of management they are currently doing. Is a 0.3 or 0.4 difference in A1C worth the emotional issues that will come by having a child who doesn't want the technology forced to wear it.

    I think talking about long term complications is good. I think we need to be aware of them. But I think its also important to think about long term overall and mental health of the child who is living with this disease. I do not think pumping and CGMSing are always the answer.
     
  8. StillMamamia

    StillMamamia Approved members

    Joined:
    Nov 21, 2007
    Messages:
    13,195
    Excellent point Nancy! Long-term, it's the whole "human" package which matters (a good balance of science/psychology/etc).
     
  9. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    Michelle,

    Thank you for speaking out here. You and Chell are never far from my mind when I raise issues like the ones in this thread.
     
  10. Reese'sMom

    Reese'sMom Approved members

    Joined:
    Jan 18, 2009
    Messages:
    1,294
    I do think there should be more of a discussion with parents at dx about intensive management and the tools and techniques that are involved. When Reese was dx'd, I asked about pumps and how soon, and I googled, found CWD and checked out books to learn this stuff. I did not get any information about intensive management and the possibility of lowering the risks of complications this way from the endo practice.

    I do feel that most Endo's are painting the entire population of newly dx'd families with the same "brush" and assuming that this would be too much or assuming that intensive management from the beginning would interfere with the quality of a child's mental life. But WE are Reese's parents, and WE should be the ones making those judgment calls. My family has easily handled the information, transitioned to a pump asap, and we are intensely managing his BG without damaging the quality of his childhood. I am personally very tired of Drs. telling us how we ought to "live" and what is best emotionally for our kids. I went through a wide variety of opinions about how to let a "kid be a kid" while Reese went through chemo and had almost no immune system. I prefer to get only medical information and advice and less parenting advice from physicians. There are psychologists for that, and perhaps we should have all been given mandatory appointments with psych to talk through the mental well-being stuff.

    No one should be forced to manage diabetes more intensively, but the spectrum of management tools and techniques along with the benefits and draw-backs SHOULD be provided to every newly dx'd family, IMO.
     
  11. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    I know everyone is different, but having been sent home with a box of needles,
    NPH, a BG meter, and a hotline to the emergency room diabetes team. I certainly
    remember that "jump off a bridge" feeling very well!

    I honestly can't imagine anything more complicated than the bag of tools we were
    given. The pump and CGM made things SO much easier.
     
  12. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    I agree but think the main problem is that many endo's are simply uninformed (do not even
    know about current standards of care until their patients explain it to them), stuck in a narrow
    patient revenue model, and not interested in making the changes to their practice that would
    necessary to adopt current standards of care.

    The endo would need to obtain training for themself and their staff, implement training programs
    for their patients, learn how to access patient CGM data over the internet, obtain billing codes to
    analyze patient data via the internet, and ultimately figure out how to maintain their revenue
    when patients become indendent and no longer need to consult with the endo on a frequent basis.

    What we have is ignorance, apathy, and revenue concerns. vs. the physical and psychological
    well-being of our children. As long as it is most profitable to send newly dx home with the
    traditional bag of tools to manage D, that is what most endo practices will continue to do. It has
    little to do IMO with any legitimate concern over whether parents who use PC's and PDA's all day
    (and who presumably have enough math background to manage the complicated regimens of NPH
    or Lantus, and who presumably have the ability to draw up and mix insulin accurately, and who
    are OK with injecting their child with a needle) would have any trouble managing a pump, a CGM,
    and a single insulin.
     
  13. hawkeyegirl

    hawkeyegirl Approved members

    Joined:
    Nov 15, 2007
    Messages:
    13,157
    Well, I do think that part of the problem is that endos tend to teach to the "lowest common denominator." The big city that our endo serves has a large disadvantaged population (for lack of a better word), and I do think that they do consider it a success for most of their patients when they are just able to keep them alive. That doesn't excuse the fact that when they get parents like my husband and I who show all the signs of being to handle a lot more than that, they don't go out of their way to "fast track" them into an intensive management program.

    I also think that insurance companies play a role here. I doubt they will reimburse doctors for the kind of education needed to survive on a pump and CGMS. (Most of us got that education here, as opposed to our endo's office.) That is really sad, and I hate the fact that there are kids out there not getting the treatment they deserve, just because their parents don't know that there's more out there.
     
    Last edited: May 16, 2009
  14. wilf

    wilf Approved members

    Joined:
    Aug 27, 2007
    Messages:
    9,652
    I also have a somewhat different take on pumps and CGMs - for me they are just tools for BG measurement and insulin delivery.

    Just because your tools work for you, doesn't mean that you should assume that they're the only tools that work.. :cwds:

    There are also other tools available, and it is quite possible to use a variety of combinations of the available tools and successfully manage Type 1 D.
     
  15. hawkeyegirl

    hawkeyegirl Approved members

    Joined:
    Nov 15, 2007
    Messages:
    13,157
    Sorry, I deleted that portion of my post while you were typing. I didn't want to get us off on a tangent.

    I agree that it is possible to use any number of tools and successfully manage type 1 D. There are people now in their 70s who have had T1 most of their lives who don't have any complications. That doesn't mean I'm considering going back to urine glucose testing or one shot a day.

    You're clearly an example of someone who (presumably) is achieving very good control without using any of the current technology. I've never said that the current technology is better for everyone. But there's no question that it's better for us. I can see what Jack's BG is anytime with a push of a button. I can give tiny corrections anytime with a push of a button. I can sleep entire nights, knowing that he will be safe. I could not do any of those things without the tools that we use. (I don't know how anyone can, but I'm trying to be careful here, because I know how sensitive some people are to the notion that pumping or CGMing is "better".) So for us, it's a no-brainer. The pump and CGMS are no more just a "different" way of administering insulin and checking BG than urine testing is a "different" way of checking BG.

    ETA: I've used the other tools. We've been on NPH/Humalog, Lantus/Humalog, using a meter alone, using a pump, and using a CGM in conjunction with a meter. I'm not talking about methods that I've never tried. We've used them, and made a choice based on actual experience, not what we think an experience would be.

    Sorry we've gotten off-topic here. I honestly don't care what tools anyone else uses to manage their kids' diabetes. But I strongly dispute the notion that pumps and CGMs are just "different" ways of administering insulin and checking BG. It completely ignores the many, many advantages of those tools.
     
    Last edited: May 16, 2009
  16. selketine

    selketine Approved members

    Joined:
    Jan 4, 2006
    Messages:
    6,057
    I am right there with you. William was on NPH and diluted humalog for a few months and it was a nightmare! NIGHTMARE! I was begging the pedi endo for a pump at our first appointment and she told me that he didn't use enough insulin 24 hours a day to go on a pump (which I know now is not true). We weren't taught basal/bolus or carb counting either - even when we went on lantus. I had to learn it from reading and asking people.

    I would have probably done much better with a pump at diagnosis. I understand it would be too much for some but I strongly believe that the pedi endo should gage the parent's (and child's if they are old enough) interests and capabilities and go from there.

    I was wondering if Darryl saw the post about the 50 year medal study that said that a1c didn't correlate with complications. I'd like to see more about that...it seems to figure in that some people have more protections (naturally - the way their body is) from complications than other people.
     
  17. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    Wilf,

    There is a fundamental difference between a CGM and a BG meter. The most direct illustration I can think of is like this:

    Let's say you do a BG test, and is 120. What do you do?
    Is it 120 going up? In which case, give insulin.
    Is it 120 going down? In which case, give carbs.
    Is it 120 stable? In which case, do nothing.

    You almost have to guess as to what to do, and have a 1/3 chance of getting it right.

    This is the essence of the problem with BG testing, and why relying on BG testing can lead to a rollercoaster of BG's caused by improper corrections.

    If a BG test says 40 or 500, I would agree that the treatment is pretty clear, but with regards to trying to keep BG close to a non-D range, BG tests just don't provide the necessary information unless done very often (at least hourly).

    The pump is partially about convenience (and in some ways a pump may be inconvenient), but when trying to keep BG close to a non-D range (a 40-point range), with ISF's typically 100 to 300 for children, being able to dose accurately in 0.1u increments is also essential to targeting a non-D range.

    CGM's and pumps are by no means perfect or always reliable or accurate, but I have to compare this to our experience with BG testing (at best, reliable for dosing decisions 1/3 of the time), and injections (large increments, and subject to human error), our ability to control BG to close to a non-D range for all of the past 2 years, with not a single severe hypo, would have simply been impossible using BG tests and MDI.

    I don't propose that CGM's and pumps should be prescribed for every T1 child, but I do propose that every endo should present the options to every newly dx family, and if feasible for the family, support the prescription and training. I think it's wrong for a family to leave their first endo appointment not knowing that these options are available.
     
  18. Darryl

    Darryl Approved members

    Joined:
    May 8, 2008
    Messages:
    4,313
    Lisa,

    If you look through my posts, you'll see that I never singled out or criticized your endo. I don't even know what your endo recommends or supports.

    I referred only to "many endo's" in my posts, and I think that is accurate, based on the reports of many parents here.

    I can single out one endo, the one who was responsible for our daughter at dx. When I asked him about the pump, he said "not until a year from now, it would be too early and not adviseable during the honeymoon". Since we haven't visited him since, he would not know that we got her a pump anyway, and got her a CGM too, and here she is 2 and a half years later still in the middle of what appears to be a unusually long honeymoon with non-D blood sugars 80% of the time. I still can't understand why our endo did not suggest a pump and CGM at dx, or why other endo's are still not doing so now that the technology has matured to 2nd and 3rd-generation products and pediatric FDA approvals were granted years ago.
     
  19. wilf

    wilf Approved members

    Joined:
    Aug 27, 2007
    Messages:
    9,652
    Is your daughter still honeymooning? I did not know that. And if so, wouldn't it be fair to attribute at least some of your good fortune in managing her D to the fact that she is honeymooning?
     
  20. Reese'sMom

    Reese'sMom Approved members

    Joined:
    Jan 18, 2009
    Messages:
    1,294
    Not trying to answer for Darryl, but I would say that my son is definitely honeymooning and I attribute his 5.7 A1c in large part to that...
    ...BUT, if I am understanding some of the literature Darryl is quoting, the honeymoon itself is likely to be extended through intensive blood glucose control. So, this is part of why making a newly dx'd family aware of the tools and techniques of managing bg intensively right from the start is being advocated by some (myself included).
     

Share This Page

- advertisement -

  1. This site uses cookies to help personalise content, tailor your experience and to keep you logged in if you register.
    By continuing to use this site, you are consenting to our use of cookies.
    Dismiss Notice