Management
Most cases of T1D are diagnosed in patients younger than 18.9 Management of the child with T1D involves many challenges. The patient will experience an initial honeymoon period, that is, a brief remission during which the pancreas begins to secrete some insulin again and exogenous insulin demands are lower. However, this period is temporary, lasting only a few weeks, months, or years. Once pancreatic insulin secretion stops (as a result of complete beta-cell destruction), the exogenous insulin demands increase. In the case study, the child’s insulin demands were initially low, and she experienced hypoglycemia. Once she transitioned out of the honeymoon period, however, her blood glucose levels rose because her pancreas was producing little to no insulin.
As the patient ages, physical growth and hormone changes also alter the demand for insulin. A key factor to keep in mind is lifestyle changes: The child may need age-appropriate supervision and adjustments in exercise, diet, and diabetes education regimens when school routines and self-care capacities change. The child with T1D can only be educated as far as his or her cognitive ability will allow, but autonomy should increase with age.
Helping the patient reach glycemic goals requires special consideration, based on the child’s age. Whereas the target A1C for an adult with diabetes is below 7%, that for a young child is either < 7.5% or < 8.5%, depending on age (see Table 4).9 According to Danne et al, approximately 60% of children younger than 6 years have an imperfect awareness of hypoglycemia. 10 Because the risk for a hypoglycemic event is increased in this age-group, their target A1C is higher.10
This is also an important age for brain development: The metabolism of glucose in the brain of a young child occurs at double the rate of that in an adult brain.11 Between ages 1 and 6 years, the brain increases in size dramatically, reaching 90% of its adult volume by age 6.11 In retrospective studies reviewed by Arbelaez et al,data show that frequent, severe hypoglycemic and hyperglycemic events are associated with poor cognitive function, particularly memory and attention.11 Due to the timing of brain development and the risk for glycemic extremes in young children, practitioners are advised to follow the ADA recommendations shown in Table 4.9
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