Psychological reactions at the onset of insulin-dependent diabetes mellitus in children and later adjustment and metabolic control

The initial psychological reactions at the onset of insulin-dependent diabetes mellitus (IDDM) in a population-based sample of 76 children were studied with staff observations and a self-report questionnaire for children 12 years of age and more. Younger children reacted with more anger and less distress than the older children. High initial self-reported distress was associated with poorer subjective psychological IDDM adjustment at a follow-up 10 months later for the older children. The children's initial reactions as well as later adjustment were intimately associated with maternal initial reactions in the total group. The metabolic control, estimated as the mean level of the major fraction of glycosylated haemoglobin (Hb A_Ic) during the first 2 years, was poorer in the adolescent group. Initial anxiety over injections and protest but low general distress in mothers and children were associated with better metabolic control.     

Circulating thyroid antibodies and thyroid function studies in children and adolescents with insulin-dependent diabetes mellitus

Significant high titres (1400–125,600) of circulating thoroid microsomal antibodies (MCHA) were found in the sera of 5 out of 59 non-ketoacidotic, insulin-dependent diabetic (IDDM) patients (mean age 14.5 years). Among these five patients (four females, one male), all of whom were over 11 years, two also had thyroglobulin antibodies. Increased thyrotropin (TSH) response to TRH was found in 3/5 MCHA positive patients and in 3/54 without circulating MCHA. Serum thyroxine (T₄) and free T₄ (FT₄) average values were significantly lower (P<0.01 and P<0.001) in diabetics (7.1±1.8g/dl and 10.2±3.1 pg/ml, x±SD) as compared to normal sex and age matched controls (8.9±1.9 g/dl and 12.2±2.2 pg/ml, respectively). T₄ and FT₄ values were inversely related to the duration of the disease. Subnormal T₄ values were found in six (five females and one male) patients, four of whom had subnormal FT₄ values. No patient had low triiodothyronine (T₃) and high reverse T₃ (rT₃) values, i.e. none displayed the biochemical pattern of the low T₃ syndrome described with ketoacidotic status. This indicates also a satisfactory compensation of IDDM in all the patients. At the time of study no patient (including also those with circulating MCHA and TGHA and with TSH hyper-response to TRH) showed either thyroid size enlargement or clinical features of thyroid dysfunction including impaired growth and bone age retardation.Abbreviations MCHA thyroid microsomal antibodies - IDDM insulin-dependent diabetes mellitus - TSH thyrotropin - T₄ serum thyroxine - FT₄ free T₄ - T₃ triiodo thyronine - FT₃ free T₃ - rT₃ reverse T₃ - TGHA thyroglobulin antibodies - TRH thyrotrophin releasing hormone     

Normal stimulated growth hormone secretion but low peripheral levels of insulin-like growth factor I in prepubertal children with insulin-dependent diabetes mellitus

The hypothalamo-pituitary-insulin-like growth factor I (IGF-I) axis was studied in 24 prepubertal children with insulin-dependent diabetes mellitus (IDDM) and 12 non-diabetic children. There were no significant differences between the diabetic and control subjects in basal concentrations of immunoreactive growth hormone releasing hormone (ir-GHRH), growth hormone (GH) or stimulated GH levels, but after exercise ir-GHRH concentrations were higher in the diabetic children. Peripheral IGF-I levels were significantly lower in the diabetic children, and even lower in those with poor metabolic control. A positive correlation was found between IGF-I levels and circulating free insulin concentrations in the diabetic subjects (r = 0.49, p < 0.05). These observations suggest that the GH response to physiological stimulation is normal in prepubertal diabetic children. Exercise-induced GH response may not be mediated by GHRH. IGF-I levels were reduced in prepubertal children with IDDM and even more so in subjects with poor metabolic control. This may be a consequence of transitory hypoinsulineamia, emphasizing the importance of adequate insulinization to facilitate optimal growth in children and adolescents with IDDM.     

Short-term and long-term initial stay in hospital of children with insulin-dependent diabetes: adjustment of families after two years

A randomized prospective trial on the effect of the length of initial hospital stay (23 ± 4 days and 9 ± 3 days) in 61 consecutive children with newly diagnosed diabetes was carried out. Since the metabolic outcome was similar in the treatment groups for the first two years, we analyzed the adjustment and subjective well-being of families to the diabetes after a two-year follow-up period. A semi-structured interview by a psychologist who was blinded to the initial treatment length and medical history of the child showed that 74% of the families in the short-term and 58% in the long-term treatment groups had good overall psychosocial ability to function (ns); there were no unusual fears in 37% and 15% of the families (ns), respectively. After short-term treatment, families needed slightly but not significantly less time to be confident about the management of diabetes in the family. These findings show that the short-term initial hospital stay does not unfavorably affect the adjustment of the family to diabetes and should probably be preferred over the long-term initial hospital stay.     

Signal-averaged electrocardiogram in children and adolescents with insulin-dependent diabetes mellitus

We report on the potential usefulness of the signal-averaged electrocardiogram (SA-ECG) in young patients with insulin-dependent diabetes mellitus (IDDM) to predict subclinical cardiovascular complications. Sixteen patients with IDDM and 18 age-matched healthy subjects were studied. The IDDM group included 4 males and 12 females, aged 7 to 20 y (mean 14.2 +/- 3.8 y, +/- SD). The duration from the onset of IDDM to the study ranged from 1.2 to 9.8 y (mean 5.4 +/- 3.8 y), and HbAlc value ranged from 6.6 to 12.4% (mean, 10.0 +/- 1.8%). SA-ECG was recorded and analyzed using the methods described by Simson. Values of filtered QRS duration (f-QRS), root mean square voltage (RMS), the duration of low amplitude signal (LAS) and late duration (LD) were calculated and compared between the groups. These parameters were not significantly different between the IDDM and control groups. However, in patients with poor glycemic control (HbAlc >10%), f-QRS was long and RMS was significantly low (p < 0.05, each) compared with the control group. Three patients with IDDM were positive for ventricular late potentials, although none had ventricular tachyarrhythmia. None of the control subjects showed ventricular late potentials. CONCLUSION: Certain parameters of SA-ECG showed abnormal values in IDDM patients with poor glycemic control. Thus, SA-ECG is a potentially useful and non-invasive method for the assessment of subclinical cardiac impairment in diabetic children and adolescents.     

Metabolic control in children with insulin-dependent diabetes mellitus 5y after diagnosis. Early detection of patients at risk for poor metabolic control

Children ( n = 38) aged 3-15 y were randomly chosen, at the time of diabetes diagnosis, for conventional management at a hospital ward, or for treatment partly in a training apartment where the family was offered problem-based education and special therapeutic support. HbA1c, blood glucose stability, urinary C-peptide excretions and incidence of hypoglycaemic attacks and diabetes ketoacidosis (DKA) were monitored and some standardized, self-estimated psychological tests were performed during the first 2 y after diagnosis. During the 3 y thereafter, HbA1c, presence of DKA, microalbuminuria, retinopathy and hypertension were monitored. None of the patients demonstrated signs of diabetes microangiopathy or DKA. The overall mean HbA1c level was 7.2% 5 y after diagnosis and 30% of the children had HbA1c values < 6.3%. There were no differences in the HbA1c values for the patients treated by the different management regimens. Blood glucose variability (SD) was also similar, with 75% of the values in the range of 3–10 mmol/l. Patients with poor glycaemic control (mean HbA1c >8.3%) year 5 after diagnosis had already the second year after diagnosis significantly higher HbA1c values and blood glucose variability. The fathers of these patients demonstrated a higher degree of maladjustment. On the basis of increasing HbA1c values, high blood glucose variability and psychosocial risk factors such as their fathers'emotional responses, patients at risk for poor metabolic control in the future can be identified within 2 y after diagnosis. Efforts and resources can thus be focused at an early stage on this group.     

Higher drive for thinness in adolescent males with insulin-dependent diabetes mellitus compared with healthy controls

Eating behaviour in adolescent males with insulin-dependent diabetes mellitus (IDDM) living in central Sweden was compared with that of healthy age-matched male controls using the Eating Disorder Inventory for Children and an interview. The patients were heavier than controls (p = 0.004) and had higher Drive for Thinness scores (p = 0.002). None was diagnosed as having a current eating disorder. Conclusion: The results of the study may indicate an increased risk of future eating disorders in males with IDDM.     

Continuous subcutaneous insulin injection for self-care of young patients with insulin-dependent diabetes mellitus

Continuous subcutaneous insulin injection was used for the self-care of five patients aged 10–18 years with insulin-dependent diabetes mellitus. After an introduction to the concept and procedures for continuous subcutaneous injection, the patients soon became familiar with self-care using an insulin pump at home and at school. Three months later, the control of blood glucose improved with smaller doses of insulin in four cases and milder hypoglycemia was observed compared to when using multiple injections. Significantly decreased variations and lowered means of early morning blood glucose values were observed and seemed to explain the reason for better glycemic control. Buffered regular insulin continuously injected by pumps brought a more stable nocturnal blood glucose level compared to isophane insulin injected at bedtime, the absorption of which seemed to vary considerably. On the contrary, unbuffered regular insulin injected by pumps brought frequent nocturnal hypoglycemia, sudden worsening of glycemic control and skin infections and thus, was deemed inadequate for continuous subcutaneous injection.     

Transient focal neurologic deficits associated with hypoglycaemia in children with insulin-dependent diabetes mellitus

We describe 54 transient focal neurologic deficits (TFND) episodes in 44 children under 18 y observed retrospectively during a 5-y period (1991–96). Mean age and duration of insulin-dependent diabetes mellitus (IDDM) were 8.4 and 3.4 y, respectively. None of the children had a history of seizure disorder and only one had a personal history of migraine. Twenty-nine episodes were characterized by right- and 25 by left-sided hemiparesis. Three of six patients who presented more than one event had alternate episodes of right- and left-sided hemiparesis. On 8 occasions the episode was preceded by a brief convulsion, in 39 it was not witnessed, and in 7 it was certainly absent. Hypoglycaemia (<2.77 mmol/l) was documented on 26 occasions. On 18 of these 26 occasions, the episodes did not resolve promptly after sugar administration. The clinical course was benign, all patients remained neurologically normal and none developed migraine at follow up. Episodes of TFND were associated with hypoglycaemia in the majority of our cases and we do not consider invasive investigations to be mandatory, since the long-term prognosis was invariably good.     

Clinical significance and time course of antibodies to glutamic acid decarboxylase in Japanese children with type I (insulin-dependent) diabetes mellitus

Although anti-glutamic acid decarboxylase antibodies (GADAb) have been reported to be a useful diagnostic and predictive marker of insulin-dependent diabetes mellitus (IDDM, type 1 DM) in Caucasians, a precise analysis of GADAb in Japanese children has not been reported. We examined the clinical significance and time course of GADAb in Japanese IDDM children, who have different genetic backgrounds from Caucasians. Twenty-three of 34 (67.6%) sera from recent-onset (<6 months) IDDM, and 16 of 49 (32.7%) sera from long-standing (≥2 years) IDDM patients were positive for GADAb. This prevalence of GADAb in IDDM patients was significantly higher than in normal controls and the other groups including non-insulin-dependent DM. autoimmune thyroid disease and congenital hypothyroidism, and was also significantly higher in recent-onset than in longstanding IDDM. Time course analysis suggested that autoimmune response against GAD could follow different courses in individual cases after the initiation of insulin therapy. The incidence of GADAb was significantly higher in females than in males in the older age group (11 15 years). Other clinical features including residual pancreatic β-cell function after diagnosis were demonstrated to be similar between GADAb-positive and -negative patients. In conclusion, this study using the newly established radioimmunoassay (RIA) for GADAb revealed a high prevalence of autoimmune reactivity to GAD in Japanese IDDM children. These results, using this RIA procedure, might assist in laying the groundwork for future trials of immunomodulation therapy for IDDM in Japan.     

Age at onset and long-term metabolic control affect height in type-1 diabetes mellitus

Reduced height as a consequence of type-I-diabetes mellitus in childhood has been reported in many studies. However, it is still debated whether good metabolic control can normalize the growth rate. A total of 436 children (204 boys, 232 girls, mean age at diagnosis of diabetes 8.2±0.2 years) were followed at our outpatient diabetes centre. Z-scores for height were evaluated in relation to duration of diabetes, age at onset and long-term metabolic control. At diagnosis, height in children with diabetes was significantly above the reference population (+0.43± 0.09). Standardized height decreased during the subsequent course of diabetes. This likely represents a delay of growth, as the final height (chronological age >18 years, n = 144) was +0.27 ± 0.09. Growth reduction was more pronounced in patients diagnosed before the onset of puberty and final height in patients with a prepubertal onset of diabetes was significantly lower (+0.10 ± 0.13) compared to patients with a pubertal/postpubertal onset (+0.52 ± 0.14). Among patients with a prepubertal onset, the subgroup with “poor” metabolic control (long-term median HbA_1c >7%) lost significantly more height compared to patients with “good” metabolic control. Conclusion Despite modern treatment regimens, reduced longitudinal growth can still be demonstrated in type-I diabetes. This parameter therefore provides a valuable endpoint for quality control in paediatric diabetology. Received: 8 December 1997/ Accepted in revised form: 11 March 1998     

Calcitonin secretion in children with insulin-dependent diabetes mellitus

To test the hypothesis that calcitonin (CT) deficiency may contribute to bone mineral loss in insulin-dependent diabetes mellitus (IDDM), we studied basal and calcium stimulated (2 mg/kg body wt. in 5 min) CT levels in 15 children with IDDM and osteopenia. Ten age-sex matched healthy children were studied as controls. Since extractable CT (exCT) allows more sensitive and specific measurement of CT monomer, we measured both total serum CT (tCT) and exCT. Diabetic children had slightly but significantly (P<0.05) higher basal levels of both tCT (24.5±7.1 ng/l) and exCT (5.6±1.6 ng/l) than controls (tCT: 18.7±5.4 ng/l; exCT: 4.3±1.2 ng/l). Calcium stimulation test pointed out significant increase (P<0.001) of tCT and exCT in both groups with peak values not significantly different in IDDM in respect to controls. However, diabetic children showed a reduced CT reserve evidenced by a lower peak/basal ratio (diabetics: tCT 1.68, exCT 1.84; controls: tCT 2.49, exCT 2.88) and by a more rapid decrease in CT levels. We conclude that CT deficiency is not a causative factor of diabetic osteopenia. The slightly higher basal CT values suggest that an increased bone reabsorption may be operative in IDDM and it stimulates CT secretion. This chronic C cell stimulation may induce the reduction in CT reserve observed employing the calcium infusion test.     

Annotation Microvascular complications of insulin-dependent diabetes: Risk factors, screening and intervention

The ability to detect subclinical signs of the microvascular complications of diabetes during adolescence and our increased understanding of risk factors for their development provide an opportunity to prevent irreversible organ damage. Glycaemic control makes a major contribution to the risk and progression of microvascular complications. However, the unique psychological and physiological changes of childhood and adolescence present a considerable challenge for those attempting to reduce the burden of adult microvascular disease.     

Incidence, prevalence, and mortality of insulin-dependent (type 1) diabetes mellitus in Lithuanian children during 1983-98

Abstract: Aims/hypothesis: Our purpose is to analyze interrelations of the incidence, prevalence and mortality of childhood‐onset insulin‐dependent diabetes mellitus (type 1) in Lithuania. Methods: Incidence and prevalence rates were based on the national type 1 diabetes register during 1983–98. The cohort study was performed to evaluate the standardized mortality ratios. Results: The average incidence of type 1 diabetes during the 16‐yr study period was 7.36 per 100 000/yr. For both males and females the highest incidence of type 1 diabetes was recorded in the 10–14 yr age group. The regression‐based linear trends of the increase in incidence in various age groups and the annual percentage change for both genders was 2.05 (p = 0.0039) and the greatest regression slope is observed for both genders in the 10–14 yr age group. Regression‐based linear trends in type 1 diabetes prevalence indicate an even growth in all age groups (3.47; p = 0.001), although the annual percentage change is most prominent in the 5–9 yr age group for girls (4.95%/yr) and in the 10–14 yr age group for boys (4.06%/yr). The standardized mortality ratio of all‐cause mortality in people with diabetes is higher than in the common population 7.71 (p < 0.0001). The standard mortality ratio for all causes increases with longer diabetes duration. Conclusion/interpretation: The significant increasing trend of incidence and prevalence during 1983–98 is observed. The annual percentage change is similar. The young patients with type 1 diabetes have a higher mortality risk.     

Documented latent coeliac disease in a child with insulin-dependent diabetes mellitus

The histological development of coeliac disease has been documented in a child with insulin-dependent diabetes mellitus (IDDM). Serum antigliadin IgG was temporarily present at the onset of IDDM. It is assumed that IDDM may exert a trigger effect on the development of coeliac disease.     

Increased height in diabetes mellitus corresponds to the predicted and the adult height

This study was conducted to analyse the effect of childhood-onset diabetes mellitus on adult height. The height at time of diagnosis of 35 children with insulin-dependent diabetes mellitus (IDDM) was compared with growth reference data. Predictions of the adult height were made at the time of diagnosis using the target height and the Tanner-Whitehouse II method. The adult height was compared with both the predicted values and the height of healthy adults. The height at time of diagnosis of the prepubertal children was increased compared with growth reference data, in contrast to pubertal children who had normal heights. Only the prepubertal boys were taller at time of diagnosis. The adult height of the prepubertal patients was taller than growth reference data. The mean adult height in all patients did not differ significantly from the predicted heights. In conclusion, the increased height at the start of IDDM in prepubertal children persists until adulthood.     

HLA system in Chinese children with insulin-dependent diabetes mellitus

ABSTRACT. HLA in 12 unrelated Chinese paediatric patients with insulin dependent diabetes mellitus (IDDM) were found to have an increased frequency of BW22, B17 and AW33.
BW22 was observed in 5/12 (41.7%) of IDDM patients compared to 40/330 normal unrelated Chinese controls (p < 0.005, RR = 5.2). AW33 and B17 were observed in 6/12 (50.0%) and 7/12 (58.3%) of IDDM patients respectively, compared to 36/330 and 46/330 in the normal controls respectively (AW33: corrected p < 0.0026, RR = 8.2, B17: corrected p < 0.0026, RR = 8.6). HLA B8, B15 and B18 did not demonstrate any significant association with IDDM in this series of patients. The results of this study further emphasize the well recognized race specificity in HLA antigen distribution in normal population as well as disease states.     

Ocular complications in young adults with insulin-dependent diabetes mellitus since childhood

A cross-sectional study in 80 insulin-dependent diabetic patients born 1963–1968 who experienced the onset of diabetes before 15 years of age showed that at a mean age of 21.6 (range 17–25) years and after a mean duration of diabetes of 13.3 (range 6–24) years, 80% of the patients had retinopathy: 70% had background and 10% proliferative changes. Retinopathy correlated with the duration of the diabetes and poor glucose control at 15 years of age but not with the actual level of glycated haemoglobin. The severity of retinopathy was worse in women than in men. One patient (1.2%) was blind. Two patients had had cataract operations and 66% had myopic refraction in one or both eyes. In 61 patients a further period of ophthalmological follow-up of 3–4 years was included. After 20 years of diabetes, all had retinopathy and 29% had proliferative changes: 33% had received laser treatment after 8–27 (mean 16.1) years of diabetes. Altogether, 2 patients (2.5% of the original series) were blind. For prevention of diabetic retinopathy and blindness, good glucose control from puberty and careful ophthalmological follow-up after transfer of the patient from paediatric to adult diabetes care play major roles.     

Non-genetic risk determinants for type 1 (insulin-dependent) diabetes mellitus in childhood

Using the prospective Hungarian childhood diabetes register, a nationwide case-control study was carried out to investigate the possible role of various non-genetic factors as risk determinants for type 1 diabetes in childhood. A questionnaire (covering family characteristics, social status, fetal and perinatal events, breast-feeding habits, infectious diseases and stressful life events) was sent by mail to all incident diabetic children in 1990 ( n = 163) and to two referent children (for each diabetic chdd), matched for age, sex and county. Diabetic children had a tendency to have mothers > 35 years of age (odds ratio (OR) = 3.52; 95% confidence intervals (CI) 0.74–16.79), a lower proportion of their mothers had higher education (OR = 1.69; 95% CI 0.95–3.0) and these children tended to move home more frequently (OR = 1.99; 95% CI 0.97–4.1). Although the duration of exclusive breast feeding was similar in both groups, the proportion of diabetic children who received no breast milk tended to be higher (OR= 1.76; 95% CI 0.91–3.4). A higher proportion of diabetic children reported non-specific infections (OR = 2.94; 95% CI 1.19–7.21) and the number of stressful life events was higher in diabetic children aged 10–14 years (OR = 3.9; 95% CI 1.14–13.27). As the risk determinants for childhood insulin-dependent diabetes mellitus identified in our low-risk population appear to be similar to those detected in the genetically different, high-risk Swedish population, our study strongly supports an etiological role for these non-genetic risk factors in IDDM.