Elsevier

The Lancet

Volume 385, Issue 9982, 23–29 May 2015, Pages 2096-2106
The Lancet

Review
Care of diabetes in children and adolescents: controversies, changes, and consensus

https://doi.org/10.1016/S0140-6736(15)60971-0Get rights and content

Summary

Diabetes is one of the most common chronic medical disorders in children. The management of diabetes remains a substantial burden on children with diabetes and their families, despite improvements in treatment and rates of morbidity and mortality. Although most children with diabetes have type 1 diabetes, the increasing recognition of type 2 diabetes and genetic forms of diabetes in the paediatric population has important treatment implications. Diabetes therapy focuses strongly on targets for good metabolic control to reduce the risk of long-term complications. A parallel goal is to minimise short-term complications of hypoglycaemia and diabetic ketoacidosis. Technology offers opportunity for improvement in care, but has not yet fully lived up to its potential. New insights into the pathogenesis of diabetes and the development of new therapies have led to clinical trials aimed at the prevention of diabetes.

Section snippets

Epidemiology of paediatric diabetes: a growing problem?

Rates of type 1 diabetes in children show significant variation across the world. The Scandinavian countries have the highest incidence; in Finland, for example, 57 new cases are reported per 100 000 children under 15 years of age per year. The UK, Canada, the USA, and Australia also have high incidences, with more than 20 cases per 100 000 children per year, whereas Asia and sub-Saharan Africa have much lower rates.1 Incidence is rising in many countries. Analysis of a European

New insights into pathophysiology

Type 1 diabetes has long been recognised as an autoimmune disorder13 characterised by progressive loss of β cells in people with genetic susceptibility, probably stimulated by immune dysregulation and environmental factors. The best characterised indication of autoimmunity is the presence of autoantibodies against pancreatic β-cell components. The presence of more than one autoantibody is predictive of the future development of type 1 diabetes, whereas the risk in people with one autoantibody

Making the diagnosis: effect of correct diagnosis and action

Whereas most young patients presenting with new-onset diabetes have type 1 diabetes, the identification of those who have other forms of diabetes has important treatment implications (table 1). Obesity rates in people with type 1 diabetes are similar to the background rate in the general population, blurring a previous distinction between type 1 and type 2 diabetes. Patients with newly diagnosed type 2 diabetes benefit from lifestyle interventions and therapy with metformin, whereas insulin

Management of type 1 diabetes

In the 20 years after the landmark Diabetes Control and Complications Trial (DCCT)34 that defined the importance of metabolic control in terms of microvascular complications, there have been major changes in clinical approaches to and therapeutic options for the management of type 1 diabetes. In the first decade after the DCCT, most paediatric clinics reported reductions in mean HbA1c concentrations from more than 9% (11·7 mmol/mol) to 8–8·5% (10·1–10·9 mmol/mol). Much, if not most of this

Two injections, more injections, or pumping insulin?

Prior to the DCCT, most paediatric patients received insulin twice daily. In the subsequent transformation of the diabetes lexicon and dogma, so-called intensive therapy, associated with more than two injections per day, was strongly advocated by most paediatric diabetes clinicians and societies.46 Intensive therapy as originally done in the DCCT34 was much more than just an insulin regimen—it included a target-driven philosophy of care, increased monitoring and analysis of blood glucose

What are the fundamental determinants of metabolic control?

Whereas intensive therapy is now the norm in management of children and adolescents with type 1 diabetes, very few studies have assessed which children are most amenable to intensive therapy or which factors determine metabolic control. In one study, the young patients who benefited most from intensive therapy over an 18 month follow-up period were those who had the lowest baseline self-management competence.71 The Hvidoere Study Group did two studies that focused on adolescents and children in

Management of type 2 diabetes: limited evidence leads to limited options

The current approach to treatment of type 2 diabetes starts with lifestyle modification and metformin therapy, with the addition of insulin at diagnosis if the HbA1c concentration is greater than 9% (11·7 mmol/mol) and later, if metabolic control targets are not met.10 Outcomes in paediatric type 2 diabetes are suboptimal and can be worse than in type 1 diabetes. The SEARCH study group74 reported similar mean HbA1c concentrations in both groups, but poor control was more common in patients with

Can paediatric diabetes be prevented?

In view of the long subclinical phase identified by longitudinal studies of people at risk of type 1 diabetes,13 there is a clear opportunity for prevention. Many studies have focused on primary prevention of autoimmunity in high-risk patients, prevention of progression to diabetes in patients with diabetes-related auto-antibodies, and prevention of further loss of pancreatic β cells in patients with newly diagnosed diabetes. Results have been somewhat disappointing, with no highly effective

Future directions: closing the loop?

CSII therapy is rapidly moving towards a semi-independent, so-called closed-loop device whereby pumps and continuous glucose monitoring devices deliver insulin in response to current and predicted glucose levels. Despite the technological difficulties imposed by peripheral glucose sensing and subcutaneous insulin delivery, progress has been considerable.94 A plethora of clinical trials including paediatric patients in both hospital and ambulatory contexts, published in just the past year, are

Conclusions and consensus

A summary of the controversies, changes, and consensus in paediatric diabetes is provided in the panel. Perhaps what has most characterised the diabetes landscape in the post-DCCT period has been the desire to harmonise and optimise approaches to care. Within a year of publication of the DCCT findings, the Declaration of Kos106 was published by the International Study Group of Diabetes in Children and Adolescents (now ISPAD). The last commitment of the declaration was “to prepare and

Search strategy and selection criteria

For this Review, we searched Medline and the Cochrane Library for articles written in English with the search terms “type 1 diabetes”, “type 2 diabetes”, “maturity onset diabetes of the young”, and “neonatal diabetes” in combination with the terms “epidemiology”, “immunology”, “prevention”, “complications”, “nephropathy”, “retinopathy”, “insulin regimen”, “CSII/insulin pump”, “continuous glucose monitoring”, and “carbohydrate counting”. We restricted the search to study cohorts aged 18 years or

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