Although pediatrie diabetes is by fer the most common endocrine deficiency disorder in childhood and accounts for upwards of 50% of pediatrie endocrinology practice, the general pediatrician is unlikely to be caring for more than a few patients with this disorder. Nonetheless, pediatrie patients with diabetes are appropriately managed by pediatricians with the support of specialized pediatrie diabetes centers, as needed, rather than by internal medicine diabetologists.1
It was because of this perspective, based on 3 decades of experience, that I welcomed the opportunity to be the Guest Editor of this issue of Pediatrie Annals. In this effort, I wished to avoid duplicating what would be readily available in any textbook of pediatrics and provide a perspective on new developments to assist practicing pediatricians in defining their role in the continuum of care for children and adolescents with diabetes.
As this issue of Pediatrie Annals goes to press, there is great uncertainty about the future organization of health services for children with special health-care needs, but it is unlikely that conditions will be established to train more pediatrie endocrinologiste to take care of young diabetics. This change comes at a time when the costs of diabetes care are increasing because of improved technology and because of recommendations for more intensive management, based on the lessons from the Diabetes Control and Complications Trial (DCCT), reported in this issue of Pediatric Annuls by John Malone, MC^ a participant in the trial.2 This study has led already to the recommendation of the American Diabetes Association that insulin-dependent patients be seen at 2-month intervals rather than at the 3-month intervals previously recommended, a phenomenal increase in the work load for already burdened diabetes treatment reams.
How will psychological interventions so necessary to the very survival of some youngsters with diabetes fere in the new health system? Janet Silverstein, MD, and Suzanne Johnson, PhD, who have been developing a spectrum of services for children with diabetes spanning clinic, hospital, camp, and long-term residential rehabilitation, address the complex needs and the all-pervasive importance of the psychosocial adaptation to diabetes.3,4
Hypoglycemia, with its potential deleterious effects ranging from social inhibition to brain damage and death has always been the fear inhibiting the natural desire for excellent control of diabetes, at all ages. Diabetic ketoacidosis remains the most important cause of death in children with diabetes and a frequent route to the medicolegal arena. Desmond Schatz, MD, and I discuss these acute threats in this issue.5'6
More than 30 years ago, when I first began taking responsibility for pediatrie diabetes patients, we marveled at the tools that we were available then, such as intermediate-acting insulin (so we no longer had to deal with the unpredictability of protamine zinc insulin and regular insulin mixes), tablets for urine testing (so that patients no longer had to mix reagents with their urine and boil it over a Bunsen burner), nitroprusside tablets for testing for ketonuria, and sharp disposable needles. TKe DCCT would not have been possible with the tools then available, but the last 20 years has seen the development of highly purified and then recombinant-derived human insulins, highly accurate disposable needle/syringe units with minuscule dead space and virtually pain-free needles, simple and clinically accurate self blood glucose monitoring systems, miniaturized pumps for continuous and bolus insulin administration, and means to prevent the majority of blindness caused by diabetes.
Nonetheless, contemporary treatment remains frustrating because insulin continues to be given in the wrong place (subcutaneously) from which it is absorbed at the wrong times, unrelated to the fed or testing state. The person without diabetes delivers insulin through the portal vein first to the liver where it has its major effects and then to the periphery in a very carefully controlled manner related to the balance of catabolic and anabolic needs (feeding versus fasting, exercise versus rest, awake versus sleeping, stressed versus nonstressed, etc).
How close are we to having a physiologic means of insulin delivery? Even more important, how close are we to being able to prevent the development of diabetes, using the explosion of information that has come from the marriage of immunology and endocrinology? Joseph Wolfsdorii MB, BCh, and Lori Laffel, MD, MPH, of the Joslin Diabetes Center, discuss the promises of the future in the closing article in this issue.7
The discovery and industrial extraction of insulin was one of the medical miracles of the 20th century. The technological advances in the management and understanding of the etiology and pathogenesis of diabetes since then has been enormous, so much so that few in our ranks would doubt that the 21st century will bring the fulfillment of our dreams. For established patients, this will be a fully automated system of insulin delivery dictated by a noninvasive blood glucose monitor. Ultimately, this system will become obsolete with genetic screening and immunespecific intervention to prevent diabetes.8
1. Rosenbloom AL Primacy and subspecialry care of diabetes meli itus in children and youth, ftdiotr Clin North Am. 1984:31:107-117.
1. Malone JI. Lessons tor pediatricians from che Diabetes Control and Complications Trial, ffedter Am. 1994;23:295-299.
3. Silversiein JH, Johnson S. Psychosocial challenge of diabetes and the development of a continuum of care. Pediaa Ann. 1994;Z3:300-305.
4- Rosenbloom AL Psychosocial aspects of diabetes meHitus. In: Lrishitz F, ed. Pediatrie Endocrinology. 2nd ed. New York, NY: Marcel Dekfcer; 1990:773-792.
5. Schau DA. Hypoglvcemia in childhood diabetes. Ptdiacr Ann. 1994;23:289-291.
6. Rosenbloom AL, Schatz CW. Diabetic ketoacidosis in childhood, ifetolr Ann. 1994:23:284-288.
7. Wolfcdorf Jl, Laffel LMB. Diabetes in childhood: predicting the tutine. Pediair Arm. 1994:23:306-312.
8. Rosenbloom AL. Diabetes in the year 2000. In: Travia LB, Brouhard BH, Schreiner BJ, eds. Diabetes Mellitus in Chadren and Adolescenti. Philadelphia, Pa: WB Sounders Co; 1987:266-269.