The management of pediatric systemic lupus erythematosus

Most children and adolescents with systemic lupus erythematosus (SLE) now survive into adulthood, leading the pediatric rheumatology community to focus on preventing long-term complications of SLE, including atherosclerosis, obesity, and osteoporosis, and their treatment. Unfortunately, because of the paucity of data in pediatric SLE, little is known about epidemiology, long-term outcome, and optimal treatment. Most research focuses on adults with SLE, but pediatric SLE differs significantly from adult SLE in many aspects, including disease expression, approaches to pharmacologic intervention, management of treatment toxicity, and psychosocial issues. Children and adolescents with SLE require specialized, multidisciplinary care. Treatment can be optimized by early recognition of disease flares and complications, minimizing medication toxicity, educating families about prevention, promoting school performance, addressing concerns about reproductive health, and negotiating the transition to adult-centered medical care. Developmentally appropriate concerns about pain, appearance, and peers often affect treatment adherence and must be addressed by the health-care team. Research in pediatric SLE is desperately needed and provides a unique opportunity to understand how developmental immunology and the hormonal changes associated with puberty affect the pathophysiology of SLE.     

Adipositas und Typ-2-Diabetes im Kindes- und Jugendalter

Diagnosis and treatment of type-2 diabetes mellitus together make up a completely new area of expertise in paediatrics. Prevention of the disease must be pivotal for all physicians who see obese paediatric patients. Lifestyle modifications (weight reduction, increase in physical activity) are important factors that can reverse progression of the disease, though this is more easily said than done. All physicians who are active in the politics of healthcare need to be made aware that attention needs to be focused on prevention of this condition by implementing multidisciplinary treatment programmes and specifically tailored rehabilitation clinics for obese children and adolescents. However, there is no point in any programmes except those that have been subjected to evaluation and are coordinated.     

Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes

Hypoglycemia is a frequent occurrence in children and adolescents with type 1 diabetes. A variety of efforts have been made to standardize the definition of hypoglycemia and to define one of its most significant psychosocial consequences—fear of hypoglycemia (FOH). In addition to documenting the experience of FOH in children and adolescents type 1 diabetes and their parents, studies have investigated the relations between FOH and glycemic control and diabetes technology use. This review provides a summary of the recent FOH literature as it applies to pediatric type 1 diabetes.     

Atherosclerosis in childhood and adolescent type 1 diabetes: early disease, early treatment?

Autopsy studies have shown that atherosclerosis begins in adolescence in otherwise healthy individuals, and imaging techniques have shown that atherosclerosis develops earlier and is more prevalent in children with diabetes than in age-matched healthy controls. Cardiovascular disease has now overtaken diabetic nephropathy as the leading cause of premature mortality in young adults with diabetes, and the emphasis on disease prevention has accordingly shifted to a younger age group. The majority of children and adolescents with diabetes have suboptimal blood glucose control, and this contributes to accelerated arterial disease in this age group. Other conventional risk factors for coronary heart disease also need to be considered and treated aggressively. Effective early prevention of cardiovascular disease will involve lifestyle modification and full implementation of existing treatment guidelines, and large-scale prospective studies will be needed to establish the risks and benefits of early pharmacological intervention in children and adolescents.     

Diabetesschulung in der Pädiatrie

Structured education courses at diagnosis and at follow-up are considered an integral part of long-term pediatric diabetes care. Children and adolescents with type 1 diabetes and their parents are supposed to acquire theoretical knowledge as well as practical skills to manage the diabetes therapy in everyday life on their own responsibility. In addition families should be supported in coping with the disease emotionally and in developing an optimistic future perspective. Evaluated German education programs and curricula for young patients and their families are reviewed as well as the criteria for qualification of multidisciplinary teams. Team members should be trained to adapt the contents and structure of education courses to the needs and resources of an individual child and its family. Furthermore psychosocial risk factors should be identified as early as possible to provide specific psychosocial support.     

Management of diabetes mellitus in infants

Diabetes mellitus diagnosed during the first 2 years of life differs from the disease in older children regarding its causes, clinical characteristics, treatment options and needs in terms of education and psychosocial support. Over the past decade, new genetic causes of neonatal diabetes mellitus have been elucidated, including monogenic β-cell defects and chromosome 6q24 abnormalities. In patients with KCNJ11 or ABCC8 mutations and diabetes mellitus, oral sulfonylurea offers an easy and effective treatment option. Type 1 diabetes mellitus in infants is characterized by a more rapid disease onset, poorer residual β-cell function and lower rate of partial remission than in older children. Insulin therapy in infants with type 1 diabetes mellitus or other monogenic causes of diabetes mellitus is a challenge, and novel data highlight the value of continuous subcutaneous insulin infusion in this very young patient population. Infants are entirely dependent on caregivers for insulin therapy, nutrition and glucose monitoring, which emphasizes the need for appropriate education and psychosocial support of parents. To achieve optimal long-term metabolic control with low rates of acute and chronic complications, continuous and structured diabetes care should be provided by a multidisciplinary health-care team.     

Diabetic ketoacidosis in children.

Diabetic ketoacidosis is a serious condition that warrants immediate and aggressive intervention. Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group. With appreciation of its severity, proper understanding of the pathophysiology, and careful attention to the details of management and close monitoring, most cases will have a satisfactory outcome. Because treatment is costly and because the risk for morbidity remains even under the best of circumstances, prevention of DKA must be a major goal in the treatment of type 1 diabetes mellitus. Involvement and close follow-up by a multidisciplinary team of health care professionals with experience in dealing with diabetes in children and adolescents is the best way to avoid DKA.     

Nutrition therapy for overweight children and adolescents with Type 2 Diabetes

The increased number of children and adolescents diagnosed with type 2 diabetes presents new challenges to pediatricians, nurses, and dietitians. Treatment with medications and lifestyle changes is similar to that for adults with type 2 diabetes, but must be developmentally appropriate for children and adolescents. Registered dieticians must apply knowledge from treatment for overweight children and adolescents without diabetes with treatment for adults with type 2 diabetes to provide effective nutrition therapy for this population.     

Diabetesschulung im Kindes- und Jugendalter

Education of children and adolescents with type 1 diabetes must incorporate age-appropriate needs and abilities. Furthermore, educational concepts should be adaptable flexibly to the current situation and developmental changes. Being an integral part of long-term diabetes therapy, training must be guideline-based, evaluated, and certified. A multidisciplinary qualified paediatric team is a precondition for success. An important aim is training of families in self-management. Future research should evaluate specific therapeutic components in family care.     

Diabetespr?vention bei Kindern

Type 1 diabetes is the most frequent metabolic disease in children and adolescents with an increasing annual incidence of approximately 4.4%. Patients affected by type 1 diabetes are becoming younger and consequently have to inject insulin subcutaneously for their whole life span. Studies aiming at the prevention (primary prevention) or delay (secondary and tertiary prevention) of the autoimmune process causing type 1 diabetes must therefore be initiated during childhood and adolescence. The present review concentrates on recent or current diabetes prevention studies involving children and adolescents and discusses the pros and cons for study participants and their families.     

Practical Management of Type 1 Diabetes Mellitus in Adolescent Patients

Type 1 diabetes mellitus in adolescents presents diagnostic and management challenges. Diagnostically, the challenge is to distinguish type 1 from type 2 diabetes. A thin adolescent in diabetic ketoacidosis is easily recognized as having type 1 diabetes. However, since obesity does not negate the presence of type 1 diabetes, it is appropriate to measure diabetes-related antibody, C-peptide, and insulin levels in individuals who are thought to have type 2 diabetes to ensure that they do not have type 1 or a mixed type of diabetes. The goals for the management of type 1 diabetes in adolescents are to (i) prevent diabetic ketoacidosis; (ii) prevent severe hypoglycemia; (iii) maintain normal growth and development; and (iv) prevent long-term diabetic complications. To prevent diabetic ketoacidosis, patients must take their insulin appropriately. To ensure that this happens, increased parental supervision, psychological counseling, or placement in a different home environment may be necessary. All patients must be taught to appropriately manage sick days and test their urine for ketones when hyperglycemia is present. Prevention of severe hypoglycemia involves ensuring that the patient understands the symptoms of hypoglycemia and knows to test and treat it when the signs are present. Patients and families also need to know how to adjust insulin doses to prevent hypoglycemia and how to manage exercise appropriately. Patients with hypoglycemic unawareness need to meticulously avoid hypoglycemia. To maintain normal growth and development, adolescents with type 1 diabetes must have the appropriate tools to effectively match their meals to their lifestyle and to avoid the increased weight gain associated with improved glycemic control without intentionally manipulating their insulin dose to lose weight. The Diabetes Control and Complications Trial demonstrated that improved glycemic control decreased the risk of long-term diabetic complications. The goals of treatment in this study should be the goals for all adolescents with type 1 diabetes. To reach these goals, home glucose monitoring is critical. Patients need to know how to adjust insulin to maintain glucose levels in the range of 70-120 mg/dL (3.9-6.7 mmol/L) before meals. Insulin regimens need to be individually tailored to meet each patient's needs. Patients should be followed in a clinic using a multidisciplinary team approach at least every 3 months. Glycosylated hemoglobin should be measured at each visit. Regular eye exams, blood pressure monitoring, and urinary microalbumin measurements are critical. In this manner, the goals of management of type 1 diabetes in adolescents can be met.     

Differenzialindikationen und Relevanz der Pumpentherapie im Kindes- und Jugendalter

Insulin pump therapy (continuous subcutaneous insulin infusion, CSII) has been established for the treatment of type 1 diabetes in childhood and adolescence. At present, more than 4000 children and adolescents use insulin pumps in Germany. The indications for CSII can be clinical (recurrent hypoglycaemia, wide fluctuations in blood glucose levels regardless of HbA1c, suboptimal glycaemic control, pronounced dawn phenomenon, needle phobia) as well as psychological (improved quality of life and greater flexibility in lifestyle). The decision to implement CSII in children with diabetes should be taken together with the child, his/her parents or legal guardians and the diabetes team. Every effort must be made to ensure that patients and their parents have realistic expectations of what CSII can and can not do, as well as what will be required to safely manage diabetes with this modality. Standardized and individually tailored patient education should be provided in order to guarantee high standards of knowledge about CSII in patients and their families.     

Psychosocial aspects in pediatric rheumatology

PURPOSE OF THIS ARTICLE: To review recent publications examining psychosocial adjustment to and coping with a pediatric rheumatic disease. RECENT FINDINGS: The articles discussed illustrate important areas of psychological vulnerability and potential risk for disturbance in affected children and adolescents within their environment. SUMMARY: Children and adolescents with rheumatic diseases and their families face a multitude of psychosocial challenges. Some of these are related to the illness directly, some to treatment. There is need for more systematic research, including multicenter studies, to identify psychosocial needs of patients and their families.     

Rapid psychosocial function screening test identified treatment failure in HIV+ African youth

Psychosocial dysfunction in older children and adolescents is common and may lead to nonadherence to HIV treatments. Poor adherence leads to HIV treatment failure and the development of resistant virus. In resource-limited settings where treatment options are typically limited to only one or two available lines of therapy, identification of individuals at highest risk of failure before failure occurs is of critical importance. Rapid screening tools for psychosocial dysfunction may allow for identification of those children and adolescents who are most likely to benefit from limited psychosocial support services targeted at preventing HIV treatment failure. The Pediatric Symptom Checklist (PSC) is used in high resource settings for rapid identification of at-risk youth. In 692 HIV-infected treated children (ages of 8-< 17 years) in Botswana, having a high score on the PSC was associated with having virologic failure (OR 1.7, 95% CI: 1.1-2.6). The PSC may be a useful screening tool in pediatric HIV.     

Cystic fibrosis in adults: diagnosis and management

Once regarded as a disease of infants and young children, cystic fibrosis now also must be considered a disease of adolescents and young adults. Disease complications and management, including hemoptysis, pneumothorax, sinusitis, pancreatic deficiency, and intestinal obstruction, are discussed in this review. In addition, a practical approach to the clinical evaluation, follow-up, and treatment of the older cystic fibrosis patient is presented for the physician who has not had extensive experience in managing these patients. Current research in identifying the CF gene, basic defect, and the use of heart-lung transplants is discussed.     

Psychosocial issues in youth with type 2 diabetes mellitus

Little published research exists on psychosocial issues in adolescents with type 2 diabetes mellitus (T2DM), because until two decades ago, diabetes diagnosed in children and adolescents was almost exclusively type 1 diabetes mellitus or insulin-dependent diabetes. In the past two decades, rates of T2DM have increased, especially in adolescents from families of minority racial and ethnic groups. Youth with T2DM are most often obese, have a parent or other first-degree relative with T2DM, and are of low socioeconomic status. To understand the complex set of interrelated psychological and social influences that affect the well-being of youth with T2DM, levels of influence from determinants of genetics, family, and community/societal and minority ethnic groups must be included.     

Demographic and personal factors associated with metabolic control and self‐care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self‐care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self‐care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self‐care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them. Copyright © 2013 John Wiley & Sons, Ltd.     

Ethnicity, obesity and the metabolic syndrome: implications on assessing risk and targeting intervention

Pediatric obesity threatens the future health of a growing number of children worldwide. An added challenge in identifying the patients at greatest need for intervention due to their elevated risk for future disease is that pediatric obesity and the associated metabolic syndrome manifest differently among different ethnic groups. African-Americans and Hispanics are more likely to exhibit obesity and insulin resistance and are at a higher risk for developing Type 2 diabetes. Nevertheless, using current criteria, African-American adolescents are much less likely to be diagnosed with metabolic syndrome, largely owing to lower rates of dyslipidemia. Further development is needed in ethnicity-inclusive means of risk identification among adolescents to accurately target treatment toward children at highest risk for future disease and to motivate adolescent patients and their families towards lifestyle improvement. Effective targeting and intensive treatment efforts may help in avoiding future sequelae of obesity among all ethnicities.