Elizabeth A. Doyle

Persistence of Benefits of Continuous Subcutaneous Insulin Infusion in Very Young Children With Type 1 Diabetes: A Follow-up Report

Objective. Use of continuous subcutaneous insulin infusion (CSII) has increased dramatically in recent years, and pump therapy has been shown to be a safe and effective alternative to multiple daily injections in adults and older pediatric patients with type 1 diabetes. Its use in very young children, however, has been limited, although this group might be expected to benefit the most from CSII. The objective of this study was to analyze the CSII efficacy and safety data in very young children with type 1 diabetes from our Diabetes Clinic database. Methods. Glycosylated hemoglobin (HbA1c), severe hypoglycemia (SH), and ketoacidosis (DKA) in the year before CSII were compared with corresponding values during pump treatment in all children who started CSII before age 7. Results. Sixty-five children (mean age: 4.5 y at CSII initiation; range: 1.4–6.9 years; 28 girls; 3 black, 1 Hispanic) were analyzed for >162 patient-years of follow-up. Mean HbA1c (7.4 ± 1.0 prepump) decreased to 7.0 ± 0.9 after 12 months of CSII and continued to improve even after 4 years on CSII. The rate of SH was reduced by 53% (from 78 to 37/100 patient-years). Children who received daytime care from paid caregivers (n = 26) experienced significant reductions in HbA1c and hypoglycemia frequency. There were no episodes of DKA requiring emergency treatment in the year before CSII and 4 episodes (4 per 100 patient-years) after transition to pump. Conclusions. CSII is a durable and effective means of optimizing glycemic control in very young patients with type 1 diabetes and may be superior to multiple daily injections in minimizing the risk of severe hypoglycemia in this age group. Employment of paid caregivers does not preclude safe and effective use of CSII.

Comparison of fingerstick hemoglobin A1c levels assayed by DCA 2000 with the DCCT/EDIC central laboratory assay: results of a Diabetes Research in Children Network (DirecNet) Study.

Abstract:  Background:  The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) high‐performance liquid chromatography (HPLC) method for measuring hemoglobin A1c (HbA1c) serves as a reference standard against which other assays are compared. The DCA 2000® + Analyzer (Bayer Inc., Tarrytown, NY, USA), which uses an immunoassay, is a very popular device for measuring HbA1c levels in pediatric diabetes practices.

Impaired overnight counterregulatory hormone responses to spontaneous hypoglycemia in children with type 1 diabetes

Abstract:  To assess the changes in counterregulatory hormones overnight after an afternoon of structured exercise or sedentary activity in children with type 1 diabetes mellitus (T1DM), the Diabetes Research in Children Network (DirecNet) studied 50 children (10 to <18 yr) with T1DM in five clinical research centers on two separate days (with and without an afternoon exercise session) using a crossover design. Glucose, epinephrine, norepinephrine, cortisol, growth hormone (GH), and glucagon concentrations were measured hourly overnight. Nocturnal hypoglycemia [plasma glucose concentrations ≤70 mg/dL (3.9 mmol/L)] occurred more frequently on the nights following exercise (56 vs. 36%; p = 0.008). Mean hourly concentrations of most hormones did not differ between sedentary or exercise nights or between nights with or without hypoglycemia. Spontaneous nocturnal hypoglycemia only stimulated small increases in plasma epinephrine and GH concentrations and failed to cause a rise in norepinephrine, cortisol, or glucagon levels in comparison with values during the hour before or after hypoglycemia or other times during those same nights. Counterregulatory hormone responses to spontaneous nocturnal hypoglycemia were markedly decreased regardless of whether there was antecedent afternoon exercise in children with T1DM. Sleep‐induced impairments in counterregulatory hormone responses likely contribute to the increased risk of hypoglycemia during the entire overnight period in youth with T1DM.

Disease Management in the Young Diabetic Patient: Glucose Monitoring, Coping Skills, and Treatment Strategies

Type 1 diabetes mellitus was thought to be the prevalent type of diabetes in children and adolescents; however, increasing numbers of juvenile patients appear to have type 2 diabetes. Management of all diabetes in young patients should include regular assessment, careful monitoring for glycemic control and the presence of hypoglycemia, and educational training on disease management. Hypoglycemic episodes, especially nocturnal events, are frequent in the young diabetic patient. Improvements in glycemic control and nocturnal hypoglycemia have been observed with continuous subcutaneous insulin infusion and insulin glargine. A continuous glucose-monitoring system can provide important insight into 24-hour glycemic control. Overall, careful management, monitoring, and education can improve glycemic control and yield positive treatment outcomes in the child or adolescent with diabetes.

Case Study Contrasting Challenges of Insulin Pump Therapy in a Toddler and Adolescent With Type 1 Diabetes

Purpose To describe the challenges and outcomes of continuous subcutaneous insulin infusion (CSII) pump therapy in a toddler and adolescent with type 1 diabetes. Insight into patient-family aspects motivating pump use is provided. Methods Two cases treated at the Pediatric Diabetes Clinic at Yale University. Results Upon parental request, CSII was initiated to improve glycemic control in a 4-year-old boy (case 1) with unpredictable food intake. During 68 months of CSII therapy, hemoglobin A1C levels averaged 6.3% ± 0.6%. Severe hypoglycemic episodes ceased 36 months ago, and occasional postprandial hyperglycemia during early school years was corrected with school nurses’ reminders about premeal insulin bolus doses. Currently 9.5 years old, he independently manages all his insulin injections with parental assistance only to change the catheter site. Case 2 is a girl who was nearly 12 years of age when diagnosed with type 1 diabetes. Initially managed with daily injections, hypoglycemic episodes were interfering with her physically active lifestyle. At age 13 years, she elected CSII therapy, and glycemic control improved. Temporarily erratic in the immediate period pre- and postmenarche, metabolic control has since stabilized. At 15 years old, she successfully manages her diabetes independently. Conclusions To optimize glycemic control, CSII can be initiated and used effectively, both in children of all ages and in adolescents with type 1 diabetes. CSII may be ideal therapy for toddlers, with no apparent lower age boundary for initiating CSII; however, the parenting challenges and requirements for supportive education differ between toddlers and adolescents. When disease and pump management are appropriately individualized, CSII therapy can help children with diabetes achieve and sustain glycemic control. Lifestyle flexibility, quality-of-life improvement, and independence can thus begin early in childhood and be maintained throughout young adulthood.

UTILITY OF PSYCHOLOGICAL SCREENING OF YOUNG ADULTS WITH TYPE 1 DIABETES TRANSITIONING TO ADULT PROVIDERS.

OBJECTIVE Screening for depression, diabetes distress, and disordered eating in youth with type 1 diabetes (T1D) is recommended, as these comorbidities contribute to poor glycemic control. No consensus exists on which measures are optimal, and most previous studies have used nondisease-specific measures. We examined the utility of screening for these disorders using two disease-specific and one general measure at the time of transition from pediatric to adult care. METHODS Forty-three young adults from a T1D transition clinic completed the Patient Health Questionnaire, the Diabetes Distress Scale, and the Diabetes Eating Problem Survey-Revised. Chart review determined if clinicians noted similar symptoms during the year prior to transition. Metabolic data were also recorded. RESULTS Chart review identified 5 patients with depressive symptoms and 8 patients with diabetes distress. Screening identified 2 additional patients with depressive symptoms and 1 additional patient with diabetes distress. Of those noted to have symptomatic depression or diabetes distress on chart review, several subsequently screened negative on transition. Disordered eating was not detected by chart review, but 23.5% screened positive on transition. While depression, diabetes distress, and disordered eating positively correlated with glycated hemoglobin (HbA1c) (r = 0.31, P = .05; r = 0.40, P = .009; r = 0.63, P<.001, respectively), disordered eating accounted for the majority of observed variance (df = 1; F = 18.6; P<.001). Even though HbA1c was higher in patients with versus without disordered eating (P<.001), body mass index did not differ between the 2 groups (P = .51). CONCLUSION In young adults with T1D, formal screening provides an opportunity to detect psychological problems, which, when treated, may help optimize metabolic control during the transition process. ABBREVIATIONS T1D = type 1 diabetes HbA1C = hemoglobin A1c YCDP = Yale Childrens Diabetes Program PHQ-8 = Patient Health Questionnaire-8 DDS = Diabetes Distress Scale DEPS-R = Diabetes Eating Problem Survey-Revised.

Transitional Care for Young Adults With Congenital Heart Disease: A Case Study

INTRODUCTION Congenital heart defects, any of myriad innate problems with the structure and function of the heart, affect nearly 1% of births in the United States annually (Centers for Disease Control and Prevention, 2016). Historically, a congenital heart defect was regarded as an inevitable fatality. However, immense strides in diagnosis, operative techniques, and critical care over the past 60 years have increased an infant’s chance of survival into adulthood to 85% to 90% (Gurvitz et al., 2016). In fact, adults account for two-thirds of the overall congenital heart disease (CHD) population (Jacobs et al., 2015). This transition from mortality to vitality is an epic achievement, but it is not lacking in controversy. On the contrary, adult CHD poses very unique challenges to patients and health care providers alike. Most prominent is the ambiguity surrounding which providers should follow adult patients with pediatric heart conditions. The following case elucidates the nature of this novel dilemma, leading to a discussion of the critical role of the pediatric nurse practitioner (PNP) in the transition of care as children with CHD become adults.

Assessing Palliative and End-of-Life Educational Needs of Pediatric Health Care Professionals: Results of a Statewide Survey

Children with serious, complex medical or life-threatening conditions and their families often fail to receive effective, consistent, timely, and competent care that meets their physical, emotional, and spiritual needs. Enhancing both basic education and advanced skills in pediatric palliative and end-of-life care education is recommended so that health care providers will enter practice with some form of formal preparation. In this quantitative descriptive study, we used the End-of-Life Professional Caregiver Survey to assess unmet palliative and end-of-life educational needs of pediatric health care providers in the state of Connecticut. Participants who received palliative care education in the past 5 years had higher mean scores on all 3 factors of the End-of-Life Professional Caregiver Survey, which may reflect the evolvement and depth of current pediatric palliative care education. Future palliative educational programs for pediatric providers in Connecticut should include sharing pediatric palliative care principles and national guidelines, describing services provided by pediatric hospice and timing of referral, developing systems to ensure continuity of care crossing all settings, addressing request for assisted suicide, meeting needs of staff and providers caring for the dying child (self-care), and describing cultural and ethical values specific to diverse populations in Connecticut.