Pediatric Annals

EDITORIAL 

Childhood Diabetes-New Knowledge and Remaining Problems

Milton I Levine, MD

Abstract

Diabetes is not very common in the pediatric age group. It has been estimated that of the approximate 3,000,000 cases of diabetes in the United States at the present time, only 4% are below 15 years of age. 1 might note that in a very active pediatric practice in New York City for over 50 years, there were only three cases of diabetes among my patients. This is such a serious disease requiring a great deal of close and individualized attention that it is important to renew our knowledge and bring the latest information to the practicing pediatrician.

Four years ago we published an excellent review of childhood diabetes under the Guest Editorship of Dr. H. Peter Chase, Professor of Pediatrics at the University of Colorado, and Director of the Barbara Davis Center for Childhood Diabetes in Denver. To bring modem pediatricians in line with the present knowledge, we have asked Dr. Jay S. Skyler, Professor of Medicine and Pediatrics at the University of Miami School of Medicine, Miami, Florida, to act as Guest Editor. Dr. Skyler is well known and highly experienced in dealing with diabetic children.

During my college years I received a scholarship to the Biological Laboratory at Cold Spring Harbor in Long Island. While I was there, I observed the experiments of Dr. Wilbur Swingle to cure diabetes in depancreatized cats by transplanting pancreases under their skin. As I recall, the result was favorable initially but the transplanted tissue soon disintegrated. At that time many scientists all over the world were attempting to find a treatment or possible cure for diabetes. And then, in 1921, Banting and Best announced the successful treatment of the disease by insulin injections.

I entered Cornell University Medical College in 1923, and in 1924 as a student observing on the pediatric ward of Bellevue Hospital, I watched the early use of the drug. It was both a thrilling and chilling experience. A comatose child would receive an injection of insulin. She would awaken in a short time - alert, interested, talkative, and even joking with us. After possibly one half to three quarters of an hour, she would gradually go back into coma. The attendings and house staff would give her more insulin but the coma continued. (Remember, in those days it took approximately 6 hours to get a report on blood sugar. ) Then it was found that the child was in a severe hypoglycemic shock, and quick measures were taken to overcome it.

In the years that followed, many advances have been made in the treatment of diabetes, but the insulin dependent child still requires routine daily subcutaneous injections of insulin. Today, progress has been made in the use of purified insulin and in preparations of long duration. Children do not respond to oral treatment, although many adults have had good results.

Many of us had hoped that the increasing knowledge in successful organ transplants would make pancreatic transplants possible. Kidneys, hearts, livers, and lungs have already been transplanted with success. However, to date transplantation of the pancreas has not been permanently successful.

In spite of our present ability to prevent diabetic coma and ketoacidosis, and to avoid hypoglycemia, we have not as yet successfully prevented the chronic complications. These include capillary changes, retinopathy, nephropathology, and neurological pathology, and are among the subjects covered in this present symposium.

The first article deals with the "Etiology and Pathogenesis of Insulin Dependent Diabetes Mellitus" and has been written by Dr. Jay S. Skyler, Guest Editor of this issue of Pediatric Annals, and Dr. Alexander Rabinovitch, both of the Department of Medicine,…

Diabetes is not very common in the pediatric age group. It has been estimated that of the approximate 3,000,000 cases of diabetes in the United States at the present time, only 4% are below 15 years of age. 1 might note that in a very active pediatric practice in New York City for over 50 years, there were only three cases of diabetes among my patients. This is such a serious disease requiring a great deal of close and individualized attention that it is important to renew our knowledge and bring the latest information to the practicing pediatrician.

Four years ago we published an excellent review of childhood diabetes under the Guest Editorship of Dr. H. Peter Chase, Professor of Pediatrics at the University of Colorado, and Director of the Barbara Davis Center for Childhood Diabetes in Denver. To bring modem pediatricians in line with the present knowledge, we have asked Dr. Jay S. Skyler, Professor of Medicine and Pediatrics at the University of Miami School of Medicine, Miami, Florida, to act as Guest Editor. Dr. Skyler is well known and highly experienced in dealing with diabetic children.

During my college years I received a scholarship to the Biological Laboratory at Cold Spring Harbor in Long Island. While I was there, I observed the experiments of Dr. Wilbur Swingle to cure diabetes in depancreatized cats by transplanting pancreases under their skin. As I recall, the result was favorable initially but the transplanted tissue soon disintegrated. At that time many scientists all over the world were attempting to find a treatment or possible cure for diabetes. And then, in 1921, Banting and Best announced the successful treatment of the disease by insulin injections.

I entered Cornell University Medical College in 1923, and in 1924 as a student observing on the pediatric ward of Bellevue Hospital, I watched the early use of the drug. It was both a thrilling and chilling experience. A comatose child would receive an injection of insulin. She would awaken in a short time - alert, interested, talkative, and even joking with us. After possibly one half to three quarters of an hour, she would gradually go back into coma. The attendings and house staff would give her more insulin but the coma continued. (Remember, in those days it took approximately 6 hours to get a report on blood sugar. ) Then it was found that the child was in a severe hypoglycemic shock, and quick measures were taken to overcome it.

In the years that followed, many advances have been made in the treatment of diabetes, but the insulin dependent child still requires routine daily subcutaneous injections of insulin. Today, progress has been made in the use of purified insulin and in preparations of long duration. Children do not respond to oral treatment, although many adults have had good results.

Many of us had hoped that the increasing knowledge in successful organ transplants would make pancreatic transplants possible. Kidneys, hearts, livers, and lungs have already been transplanted with success. However, to date transplantation of the pancreas has not been permanently successful.

In spite of our present ability to prevent diabetic coma and ketoacidosis, and to avoid hypoglycemia, we have not as yet successfully prevented the chronic complications. These include capillary changes, retinopathy, nephropathology, and neurological pathology, and are among the subjects covered in this present symposium.

The first article deals with the "Etiology and Pathogenesis of Insulin Dependent Diabetes Mellitus" and has been written by Dr. Jay S. Skyler, Guest Editor of this issue of Pediatric Annals, and Dr. Alexander Rabinovitch, both of the Department of Medicine, Pediatrics, and Psychology of the University of Miami School of Medicine.

The authors start their discussion by presenting the evidence of genetic transmission of the disease. They relate the apparent association between insulin dependent diabetes mellitus (IDDM) and certain HLA alleles, although the actual manner of inheritance of IDDM is poorly defined. However it appears that the diabetagenic genes give the individual a susceptibility to the disease, but as yet the gene has not been identified. But what triggers the susceptible child to overt diabetes? Doctors Skyler and Rabinovitch discuss environmental factors, viral infections, and immunological mechanisms in such a role.

They discuss favorable immune intervention trials, and the efforts being made to identify the nature of islet beta cell antigens. Once these antigens are identified, the authors state, specific immune intervention strategies may be undertaken. Once the diabetagenic gene is discovered, newborns with the potential for acquiring diabetes could be identified, and they would become candidates for intervention therapy. This is a fascinating article.

The second paper is on the "Management of Childhood Diabetes" and is contributed by Dr. Alicia Schiffrin, of the McGiIl University-Montreal Children's Hospital Research Institute in Montreal, Canada. In this article, Dr. Schiffrin clearly presents the early diagnostic features and then a full description of insulin and hydration therapy for children with only elevated blood glucose levels as well as those with ketonuria with or without acidosis.

The section devoted to treatment during the chronic phase emphasizes insulin regimens based on the needs of the individual child. The difficulty in controlling children, especially adolescents, is recognized and the use of a single or double dose regimen is suggested and described. Dr. SchifTrin states that urine ketones should be tested at least once daily and more often if there is an illness or unusual stress. She then describes the techniques of self- blood glucose monitoring for documentation of glycémie levels at home.

The author describes mechanical devices used for continuous insulin administration. Today, these are small lightweight portable insulin pumps which can be implanted subcutaneously. Usually with this method there is an extracorporeal battery-driven pump. One of my former patients, now attending college, is using one of these devices very successfully.

This excellent article stresses care during acute illness and surgery, stress and exercise. New insulins are also described including synthetic human insulin which is chemically and biologically similar to pancreatic insulin.

The chronic complications of diabetes should be of great importance to all pediatricians. Almost all parents react with shock and anxiety when they first learn that their child has the disease. The serious nature of diabetes is compounded by the constant discipline required in handling the child successfully. Many pediatricians hesitate at the onset to discuss chronic diabetic complications except as a warning to follow treatment accurately to avoid _omplications as much as possible. Parents will benefit by contacting the American Diabetes Association or the Juvenile Diabetes Association, both organizations which cooperate with physicians and provide parents with the latest educational material and information about complications and scientific attempts to avoid or minimize the pathology.

The third article, titled "Why Control Blood Glucose? Influence on Chronic Complications of Diabetes" is written by Dr. Jay S. Skyler, Guest Editor of the present symposium. This paper discusses current knowledge of the etiology of chronic complications of diabetes and efforts to prevent them.

Dr. Skyler describes the clinical manifestations of the various chronic complications, especially nephropathy and retinopathy, and notes that the available evidence points to metabolic derangement as the cause.

He follows this with a comprehensive review of the literature on this subject, comparing the reported results following the use of various treatment methods in the development of chronic complications and the means of controlling these pathological changes. This most interesting article makes the conclusion that "the evidence for a relationship between glucose control and diabetic complications is overwhelming. "

The final contribution deals with the "Psychosocial Aspects of Diabetes in Childhood and Adolescence," and is authored by Dr. Robert Tattersall, Consulting Physician, Department of Medicine of the University Hospital at Nottingham, England.

Dr. Tattersall presents the problems facing parents of diabetic children in their attempts to balance the strict discipline of treatment with their strong desire to encourage their children to lead normal lives. On diagnosis, the parents are faced with the loss of their normal child. They may react with fear, guilt, sadness, anger, and even denial.

The emotional and social problems frequently experienced by both the parents and the diabetic child are described. These include family difficulties and the problems of preschool age, school age, and especially adolescent children. Awareness and prompt attention to the various problems as they arise are urgently needed.

The psychological and social problems of diabetic patients should be in the forefront in directing parents. This is a superb article on the subject, and should be read and filed by all practicing pediatricians for ready reference whenever necessary.

10.3928/0090-4481-19870901-04

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