Type-1 diabetes: the basics

Managing type-1 diabetes in children and young people requires a multidisciplinary team, writes Dr Keith Barnard.

Type-1 diabetes is a chronic condition in which the pancreas produces little or no insulin. Causes of type-1 diabetes include genetic factors and exposure to certain viruses.

Although type-1 diabetes typically appears during adolescence, it can develop at any age. There is no curative treatment, but with good management a long, healthy life is possible.

Providing this care usually involves a multidisciplinary team of professionals who can help the GP tackle holistic diabetes management in all ages.

Type-1 diabetes accounts for more than 90 per cent of diabetes in patients under the age of 25. There is a hereditary element, and 12-15 per cent of young people under the age of 15 will have a first-degree relative with the condition.

Cystic fibrosis (CF) is a common association, and 20 per cent of patients with CF will develop diabetes by the age of 20, rising to 80 per cent by the age of 35. All patients with CF should be screened annually for diabetes from the age of 10.

This article focuses on the management of type-1 diabetes in children and young people, and is based on NICE clinical guideline 15.

Diagnosis of diabetes

According to the WHO criteria, diabetes is diagnosed if there are diabetic symptoms (poly- uria, polydipsia and unexplained weight loss) together with a fasting glucose of [s40]7.0mmol/L or a two-hour plasma glucose of [s40]11.1mmol/L.

Urgent (usually same-day) referral to a paediatric diabetes care team is essential.

Once a diagnosis of type-1 diabetes is made, the process of advising and supporting the patient and relatives or carers is of vital importance.

This cooperative approach is especially significant in children and young people, where the psychological impact of the restrictions of the condition, the disruption to family life and the prospect of a lifetime of repeated injections is inevitably daunting.

The detrimental effects of alcohol, poor diet, smoking and substance misuse should be emphasised.

Psychological and educational interventions can help families to cope and minimise stress.

Insulin preparations

The box shows the types of insulin preparations and the durations of action.

Insulin is usually given before eating, but can be given just after food if eating habits are erratic, as is often the case in children under the age of five.

Various regimens can be used and adapted according to circumstances. Common regimens include one, two or three injections a day of a rapid- or short-acting insulin that is pre-mixed or self-mixed with a long-acting insulin.

A multiple daily injection (MDI) regimen consists of rapid- or short-acting insulin used before meals with an intermediate- or long-acting insulin. In a few cases an insulin pump may be indicated.

In young people, it is usual to offer MDI, but if it is not possible to maintain HbA1c at <7.5 per cent without troublesome hypoglycaemia, then the one, two or three injections per day regimen may be offered.

Glycaemic control

For short-term monitoring, self-measurement of blood glucose should be used where possible.

The objective is a pre-prandial glucose of 4-8mmol/L and a postprandial level of <10mmol/L. If the patient is using two injections per day, the insulin dose should be adjusted according to the trend in pre-prandial, bed-time and night-time measurements. If the patient is using an MDI regimen, the dose can be adjusted after each pre-prandial, bed-time or night-time reading.

Should the patient develop an intercurrent illness, blood glucose measurement should be carried out more than four times a day.

Additional support is needed if the HbA1c is >9.5 per cent. A high HbA1c increases the risk of microvascular complications, but over-enthusiastic attempts to keep levels low can increase the risks of disabling hypoglycaemia.

Exercise and sport should be encouraged and examples, such as that of Olympic rower Sir Steve Redgrave, show that anything is possible.

It is important to give advice on avoiding exercise-induced hypoglycaemia by careful monitoring and appropriate adjustment of insulin and diet.

Hypoglycaemia

In mild hypoglycaemia, where the patient is aware and responds to their symptoms, it may be enough for the patient to eat any foodstuff containing a rapidly absorbed simple carbohydrate, followed by more complex long-acting carbohydrates. Blood glucose should be re-checked after 15 minutes.

In severe hypoglycaemia, where the patient is unable to respond, IM glucagon is easy to administer but slow to act.

Oral complex carbohydrates should be given as soon as possible followed by repeated appropriate blood glucose measurements.

  • Dr Barnard is a former GP in Fareham, Hampshire.

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