108
VOLUME 11 NUMBER 3 • SEPTEMBER 2014
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Paediatric diabetes with a focus on the adolescent
Barnesh Dhada, David Blackbeard, Gayle Adams
Correspondence to: Barnesh Dhada
Department of Paediatrics, Grey’s Hospital, Pietermaritzburg and Department
of Paediatrics and Child Health, University of KwaZulu-Natal, Durban
e-mail:
David Blackbeard
Department of Clinical Psychology, Grey’s Hospital, Pietermaritzburg
Gayle Adams
Department of Dietetics, Grey’s Hospital, Pietermaritzburg
S Afr J Diabetes Vasc Dis
2014;
11
: 108–110
B
oth type 1 and type 2 diabetes mellitus in children and
adolescents is increasing worldwide. While new cases are
diagnosed in South Africa annually, the true incidence is not
known.
The International Society for Paediatric and Adolescent Diabetes
(ISPAD) in conjunction with the International Diabetes Federation
(IDF) set out a comprehensive, evidence-based standard of
care guideline in 2011.
1
The goal of diabetes care is to achieve
optimal glycaemic control in order to achieve good quality of life
by preventing and treating complications. However, successful
implementation of all aspects of care is complex.
In local operational research in a paediatric diabetes clinic at a
tertiary level in KwaZulu-Natal, we have identified the following
‘mediating variables’ that often play a positive and/or negative
role in patient care: self-efficacy of child and caregiver; family
functioning for support and supervision; psychosocial interventions
for the individual, family and group; a cohesive multidisciplinary
team (MDT) for consistency of care; material and socio-cultural
resources and support; and mental health and stress exposures for
the child–caregiver dyad.
We have found that working as anMDT to tease out the complexity
and use the expertise of each team member is an advantage, with
the patient at the heart of the team’s efforts.
2
In this situation,
diabetes education for patients and all MDT members remains vital
to empower all, especially the patients and their families.
The diagnosis of type 1 diabetes mellitus is based on clinical
features of weight loss, polyuria, polydipsia and glycosuria. The
majority of patients in our setting present for the first time with the
life-threatening early complication of diabetic ketoacidosis; many
having seen a doctor in the preceding weeks to months with the
classic clinical features. Without a high index of suspicion and simple
bedside diagnostic tests, a random blood glucose level indicating
hyperglycaemia and urine dipstix for ketonuria, this relatively easy
diagnosis is often missed.
3
The underlying pathophysiology is a variable rate of auto-
immune-based pancreatic islet beta-cell destruction, with deficient
insulin production leading to hyperglycaemia. The subsequent
dehydration and acidosis with ketone body formation from the
oxidation of fats to meet cellular energy needs complete the clinical
picture. Exogenous insulin administration and correction of the
dehydration and electrolyte disturbances are essential to break this
fatal cycle.
Type 2 diabetes mellitus, hyperglycaemia with peripheral insulin
resistance is increasing, especially among adolescents. Major risk
factors include a family history of type 2 diabetes, and the increasing
obesity/metabolic syndrome pandemic. Clinical features of insulin
resistance are obesity, acanthosis nigricans, dyslipidaemia, features
of ovarian hyperandrogenism, and non-alcoholic fatty liver.
However, the distinction between type 1 and 2 diabetes is
becoming more difficult, with pancreatic autoimmunity present
among those with typical type 2 features, and the absence of
autoimmunity and the presence of obesity in type 1 diabetes.
The concept of ‘double diabetes’
4
has been coined to capture
this dilemma and it has implications for patient management,
complications and outcomes.
In the management of type 2 diabetes mellitus, the severity
of symptoms and signs at initial presentation determines the
need for insulin during stabilisation. Thereafter, therapy includes
dietary and lifestyle changes, exercise, weight management, and
oral hypoglycaemic agents (metformin and sulphonylurea), with
the need for insulin administration when these modalities fail to
maintain glycaemic targets.
There is controversy as to when insulin is initiated in these
patients and highlights again the multifactorial pathophysiology and
‘double diabetes’ phenomenon that makes individualised therapy
necessary. Co-morbidities such as hypertension, dyslipidaemia,
nephropathy – albuminuria, and retinopathy need screening at
diagnosis and annually thereafter, for early detection and treatment
of micro- and macrovascular complications. As diabetes in children
and adolescents increases, the burden of ongoing care and
complications will be borne by the adult services in the future and
must be considered in resource allocation in South Africa.
Other types of diabetes include monogenic diabetes, with
several genetic abnormalities identified with a strong family history,
gestational diabetes during pregnancy, and diabetes secondary
to other factors such as drugs, chemicals, infections and other
diseases (cystic fibrosis, endocrinopathies, genetic syndromes and
disorders of the exocrine pancreas). While insulin is the mainstay of
therapy and is responsible for control and survival, other important
facets of therapy cannot be ignored. These are similar to HIV/AIDS
care with highly active antiretroviral therapy (HAART). A recent
review by Westwood
et al.
, of transitional care in long-term health
conditions, while looking at a specific condition, makes reference
to the latest understanding of care in these conditions.
5
Innovation in insulin therapy has allowed flexibility and improved
quality of life for many diabetic patients. These include the currently
available human insulin, the variable onset and duration of insulin
action, highlighted recently by the availability of insulin analogues
both ultra-short-acting and long-acting preparations, the delivery
systems for insulin, while still injectable, moving from syringes
and vials to pen sets and insulin pumps, and now even the ‘bionic
pancreas’ as described by Russell
et al
.
6
Furthermore, patients on
‘intensive insulin therapy’ with multiple daily injections of four or
more had better glycaemic control and long-term complications
than ‘conventional’ twice-daily regimens with pre-mixed, bi-phasic
insulin combinations.
7
