A. Children and adolescents
1. Type 1 diabetes
Although approximately three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age, historically, ADA recommendations for management of type 1 diabetes have pertained most directly to adults with type 1 diabetes. Because children are not simply "small adults," it is appropriate to consider the unique aspects of care and management of children and adolescents with type 1 diabetes. Children with diabetes differ from adults in many respects, including insulin sensitivity related to sexual maturity, physical growth, ability to provide self-care, and unique neurologic vulnerability to hypoglycemia. Attention to such issues as family dynamics, developmental stages, and physiologic differences related to sexual maturity all are essential in developing and implementing an optimal diabetes regimen. Although current recommendations for children and adolescents are less likely to be based on evidence derived from rigorous research because of current and historical restraints placed on conducting research in children, expert opinion and a review of available and relevant experimental data are summarized in a recent ADA Statement. The following represents a summary of recommendations and guidelines pertaining specifically to the care and management of children and adolescents that are included in that document.
Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes, although this may not always be possible. At the very least, education of the child and family should be provided by health care providers trained and experienced in childhood diabetes and sensitive to the challenges posed by diabetes in this age-group. At the time of initial diagnosis, it is essential that diabetes education be provided in a timely fashion, with the expectation that the balance between adult supervision and self-care should be defined by, and will evolve according to, physical, psychologic, and emotional maturity. MNT should be provided at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets.
a. Glycemic control
While current standards for diabetes management reflect the need to maintain glucose control as near to normal as safely possible, special consideration must be given to the unique risks of hypoglycemia in young children. Glycemic goals need to be modified to take into account the fact that most children <6 or 7 years of age have a form of "hypoglycemic unawareness," in that counterregulatory mechanisms are immature, and young children lack the cognitive capacity to recognize and respond to hypoglycemic symptoms, placing them at greater risk for hypoglycemia and its sequelae. In addition, extensive evidence indicates that near normalization of blood glucose levels is seldom attainable in children and adolescents after the honeymoon (remission) period. The A1C level achieved in the "intensive" adolescent cohort of the DCCT group was >1% higher than that achieved for older patients and current ADA recommendations for patients in general.
In selecting glycemic goals, the benefits of achieving a lower A1C must be weighed against the unique risks of hypoglycemia and the disadvantages of targeting a higher, although more achievable, goal that may not promote optimal long-term health outcomes. Age-specific glycemic and A1C goals are presented in Table 10.
Table 10??school, close communication with school or day care personnel is essential for optimal diabetes management. Information should be supplied to school personnel, so that they may be made aware of the diagnosis of diabetes in the student and of the signs, symptoms, and treatment of hypoglycemia. In most cases it is imperative that blood glucose testing be performed at the school or day care setting before lunch and when signs or symptoms of abnormal blood glucose levels are present. Many children may require support for insulin administration by either injection or continuous subcutaneous insulin infusion before lunch (and often also before breakfast) at school or in day care. For further discussion, see the ADA position statement and the report from the National Diabetes Education Program.
2. Type 2 diabetes
Finally, the incidence of type 2 diabetes in children and adolescents has been shown to be increasing, especially in ethnic minority populations. Distinction between type 1 and type 2 diabetes in children can be difficult, since autoantigens and ketosis may be present in a substantial number of patients with otherwise straightforward type 2 diabetes (including obesity and acanthosis nigricans). Such a distinction at the time of diagnosis is critical since treatment regimens, educational approaches, and dietary counsel will differ markedly between the two diagnoses. The ADA consensus statement provides guidance to the prevention, screening, and treatment of type 2 diabetes, as well as its comorbidities in young people.
B. Preconception care
* A1C levels should be normal or as close to normal as possible (<1% above the upper limits of normal) in an individual patient before conception is attempted. (B)
* All women with diabetes and child-bearing potential should be educated about the need for good glucose control before pregnancy. They should participate in family planning. (E)
* Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, neuropathy, and CVD. (E)
* Among the drugs commonly used in the treatment of patients with diabetes, statins are pregnancy category X and should be discontinued before conception if possible. ACE inhibitors and ARBs are category C in the first trimester (maternal benefit may outweigh fetal risk in certain situations), but category D in later pregnancy, and should generally be discontinued before pregnancy. Among the oral antidiabetic agents, metformin and acarbose are classified as category B and all others as category C; potential risks and benefits of oral antidiabetic agents in the preconception period must be carefully weighed, recognizing that sufficient data are not available to establish the safety of these agents in pregnancy. They should generally be discontinued in pregnancy. (E)
Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes. Observational studies indicate that the risk of malformations increases continuously with increasing maternal glycemia during the first 6??ch as amitriptyline and imipramine has been confirmed in several randomized controlled trials, although they do not have formal FDA approval for this condition. Although cheap and generally efficacious in the management of neuropathic pain, side effects limit their use in many patients. Tricylcic drugs may also exacerbate some autonomic symptoms such as gastroparesis.
Gabapentin is a commonly prescribed anticonvulsant that has been shown to be efficacious in the treatment of neuropathic pain, although not approved for this condition. It is advisable to start at a small dose and then increase over days to weeks to the dosage that is well tolerated and produces symptomatic relief. The structurally related compound pregabalin is longer acting, has recently been confirmed to be useful in painful diabetic neuropathy in a randomized controlled trial, and is approved for use in this condition. Other anticonvulsant drugs may also be efficacious in the management of neuropathic pain.
The 5-hydroxytryptamine and norepinephrine reuptake inhibitor duloxetine has been approved by the FDA for the treatment of neuropathic pain.
Treatment of autonomic neuropathy
A wide variety of agents are used to treat the symptoms of autonomic neuropathy including metoclopramide for gastroparesis and several medications for bladder and erectile dysfunction. These treatments are frequently used to provide symptomatic relief to patients. Although they do not change the underlying pathology and natural history of the disease process, their use is recommended due to the impact they may have on the quality of life of the patient.
E. Foot care
* Perform a comprehensive foot examination and provide foot self care education annually on patients with diabetes to identify risk factors predictive of ulcers and amputations. (B)
* The foot examination can be accomplished in a primary care setting and should include the use of a monofilament, tuning fork, palpation, and a visual examination. (B)
* A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation. (B)
* Refer patients who smoke or with prior lower-extremity complications to foot care specialists for ongoing preventive care and life-long surveillance. (C)
* Initial screening for peripheral arterial disease (PAD) should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic. (C)
* Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options. (C)
Amputation and foot ulceration are the most common consequences of diabetic neuropathy and major causes of morbidity and disability in people with diabetes. Early recognition and management of independent risk factors can prevent or delay adverse outcomes.
The risk of ulcers or amputations is increased in people who have had diabetes >10 years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications. The following foot-related risk conditions are associated with an increased risk of amputation:
* Peripheral neuropathy with loss of protective sensation.
* Altered biomechanics (in the presence of neuropathy).
* Evidence of increased pressure (erythema, hemorrhage under a callus).
* Bony deformity.
* Peripheral vascular disease (decreased or absent pedal pulses).
* A history of ulcers or amputation.
* Severe nail pathology.
All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. People with one or more high-risk foot condition should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every visit with a health care professional. Evaluation of neurological status in the low-risk foot should include a quantitative somatosensory threshold test, using the Semmes-Weinstein 5.07 (10-g) monofilament. The skin should be assessed for integrity, especially between the toes and under the metatarsal heads. The presence of erythema, warmth, or callus formation may indicate areas of tissue damage with impending breakdown. Bony deformities, limitation in joint mobility, and problems with gait and balance should be assessed.
People with neuropathy or evidence of increased plantar pressure may be adequately managed with well-fitted walking shoes or athletic shoes. Patients should be educated on the implications of sensory loss and the ways to substitute other sensory modalities (hand palpation, visual inspection) for surveillance of early problems. People with evidence of increased plantar pressure (e.g., erythema, warmth, callus, or measured pressure) should use footwear that cushions and redistributes the pressure. Callus can be debrided with a scalpel by a foot care specialist or other health professional with experience and training in foot care. People with bony deformities (e.g., hammertoes, prominent metatarsal heads, or bunions) may need extra-wide shoes or depth shoes. People with extreme bony deformities (e.g., Charcot foot) that cannot be accommodated with commercial therapeutic footwear may need custom-molded shoes.
Initial screening for PAD should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ABI, as many patients with PAD are asymptomatic. Refer patients with significant or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options.
Patients with diabetes and high-risk foot conditions should be educated regarding their risk factors and appropriate management. Patients at risk should understand the implications of the loss of protective sensation, the importance of foot monitoring on a daily basis, the proper care of the foot, including nail and skin care, and the selection of appropriate footwear. The patient??t experienced in the management of individuals with diabetes. For a complete discussion on wound care, see the ADA??stas M, Salminen V, Uusitupa M: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343-1350, 2001
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