New developments in treating children with insulin-dependent diabetes mellitus

A number of new developments in the management of insulin-dependent diabetes mellitus have occurred in the past several years. Primary care providers including pediatric nurse practitioners need to be aware of these developments so that they can work effectively with specialty providers in caring for children with insulin-dependent diabetes mellitus. This article discusses the implications of the Diabetes Control and Complications Trial for children and adolescents, the Diabetes Prevention Trial-Type I, and several other recent developments in caring for children with insulin-dependent diabetes mellitus.     

Relative nocturnal hypertension in children with insulin-dependent diabetes mellitus

Twenty-four-hour blood pressure and heart rate measurements were carried out in 14 newly diagnosed diabetics and in 28 diabetics with 5-13 years' duration of the disease; 8 healthy children were used as controls. Mean arterial blood pressure increased at night in 5, decreased slightly (less than 10%) in 5 and decreased markedly (more than 10%) in 18 diabetics with longer duration of the disease. The diurnal-nocturnal differences in heart rates were significantly lower in diabetics with relative "nocturnal hypertension" compared to the control group (p < 0.05). A significant negative correlation was found between maximal arterial blood pressure during physical exercise and the diurnal-nocturnal differences in mean arterial blood pressure in diabetics (r = -0.58; p < 0.02). In conclusion, we found elevated nocturnal blood pressure in a subgroup of children with longer duration of diabetes and without increased albumin excretion. However, longitudinal studies of blood pressure profiles are needed to identify the candidates for diabetic vasculopathy among diabetic children.     

Mood changes associated with blood glucose fluctuations in insulin-dependent diabetes mellitus.

Examined relationships between blood glucose (BG) levels and self-reported mood in 34 19–68 yr old insulin-independent diabetes mellitus patients. Four times each day, Ss completed a mood/symptom checklist before a self-measurement of BG until 40 checklists had been completed. Half the items of the checklist described physical symptoms, and half described mood states. Within-S correlations and regressions showed that moods were related to BG for the majority of Ss and that, like physical symptoms, mood–BG relationships were idiosyncratic. Low BG levels were associated with negative mood states; positive mood items were almost always associated with high BG. High BG levels also frequently correlated with negative mood states, although the negative mood items that related to high glucose (anger, sadness) differed from those that tended to relate to low BG. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Short-term memory and strategy use in children with insulin-dependent diabetes mellitus.

The present study was designed to examine recall and rehearsal in short-term memory among children with insulin-dependent diabetes mellitus (IDDM). Children with onset of IDDM before age 5 years, children with onset after 5 years, and children without IDDM were administered a measure of short-term memory that provides information about rehearsal as well as level of recall. Children with later onset of diabetes and children without IDDM were expected to recall more words and use more effective rehearsal strategies than children with early onset of diabetes. Results indicate that children diagnosed with IDDM early in life used similar rehearsal strategies but recalled fewer words than children with later onset of diabetes and children without IDDM. In addition, results provide evidence that children who are in poor control of their diabetes did not use strategies designed to increase recall as often, or as well as, children in better control of their diabetes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Growth and sexual maturation in children with insulin-dependent diabetes mellitus

Prediabetes, the interval preceding the clinical recognition of diabetes mellitus, is believed to consist of several months or years of beta-cell destruction associated with no clinically recognized signs other than possible increased growth velocity. This increased growth rate may be the result of increased insulin, increased growth hormone, or both. As insulin-dependent diabetes approaches clinical recognition, insulin deficiency becomes manifest as slowing of growth velocity and more obvious weight loss. If a prepubertal child has insulin-dependent diabetes mellitus, sexual maturation is frequently delayed and physical growth is adversely affected. Insulin is an anabolic hormone that regulates metabolic pathways involved in the production of protein, glycogen, and fat. The normal release of growth hormone and the hepatic production of insulin-like growth factor I is modulated by the action of insulin. The absence of physiologic insulin response leads to dysfunctional quantities of growth hormone, insulin-like growth factor I, and sex hormones, resulting in growth impairment and delayed sexual maturation. Delayed sexual maturation may cause concern because it has a major impact on growth and maturation of children. However, there is evidence that sex hormones have a stimulating effect on the tissue damage associated with chronic hyperglycemia. The loss of physiologic insulin release significantly affects physical growth, sexual maturation, and the chronic complications associated with insulin-dependent diabetes mellitus.     

Prediction of insulin-dependent diabetes mellitus in siblings of children with diabetes. A population-based study. The Childhood Diabetes in Finland Study Group

The relationship between parental divorce occurring during adolescence and young adult psychosocial adjustment was examined, as was the role of family process variables in clarifying this relationship. Participants were young Caucasian adults from divorced (n = 119) and married (n = 123) families. Assessments were conducted during adolescence and 6 years later during early adulthood. Young adults from married families reported more secure romantic attachments than those from divorced families; however, differences were not evident in other domains of psychosocial adjustment after demographic variables were controlled. Three family process variables (parent-adolescent relationship, interparental conflict, and maternal depressive symptoms) were examined as potential mediators and moderators of the association between parental divorce and young adult adjustment. No evidence supporting mediation or moderation was found; however, the parent-adolescent and parent-young adult relationships, particularly when the identified parent was the father, emerged as significant predictors of young adult psychosocial adjustment.     

Prevalence and magnitude of osteopenia associated with insulin-dependent diabetes mellitus

Effects of bilateral chemical inactivation of the nucleus tractus solitarius (NTS) by microinjection of kainic acid (KA) on fluid and NaCl absorption across the jejunum were examined in anesthetized Sprague-Dawley rats. Jejunal fluid and NaCl absorption was measured in a jejunal loop before and after the microinjection of artificial cerebrospinal fluid (aCSF) or KA into the NTS. Net fluid and NaCl absorption was not altered by a microinjection of aCSF. However, net fluid (from 1.12 +/- 0.07 to 1.66 +/- 0.06 ml/30 min) and NaCl (Na+ from 164.5 +/- 10.1 to 243.3 +/- 7.1 muEq/30 min; and Cl- from 175.9 +/- 7.5 to 260.8 +/- 6.5 muEq/30 min) absorption was significantly increased by the chemical inactivation of the NTS. To examine the efferent mechanism of the increased net absorption induced by the NTS inactivation, mesenteric nerve activity (MNA) was measured before and after the inactivation of the NTS. MNA was significantly increased by 165.9 +/- 74.2% after the bilateral inactivation of the NTS. Furthermore, absorption experiments were conducted in rats with pretreatment of atropine (acetylcholine-antagonist) or yohimbine (specific alpha 2-antagonist). In atropine treated rats, net jejunal absorption was significantly increased by the inactivation of the NTS. However, the increase in net absorption induced by the inactivation of the NTS was completely abolished by pretreatment with yohimbine. These results suggest that the NTS has a tonic suppression on jejunal absorption through alpha 2-adrenergic mechanism.     

Altered adrenal and thyroid function in children with insulin-dependent diabetes mellitus

In 129 children, aged 12.6 +/- 3.8 years, affected by type 1 diabetes mellitus, the levels of dehydroepiandrosterone sulfate (DHEAS), cortisol, T3, fT3, T4, fT4, rT3, TSH, cholesterol, and triglycerides were evaluated and compared with those of a control group of 458 healthy age-matched children. The results were also correlated with hemoglobin HbA1C. The DHEAS-standard deviation score (DHEAS-SDS; -0.36 +/- 0.77) was significantly different from zero in diabetic children, while the cortisol serum level was higher than in control subjects (485 +/- 94 vs 359 +/- 132 nmol/l). Moreover, the DHEAS-SDS and DHEAS-SDS/cortisol ratio correlated negatively with HbA1c. Diabetic patients also showed lower T3 values (2.22 +/- 0.4 vs 2.32 +/- 0.3 nmol/l) and a higher rT3/T3 ratio (0.17 +/- 0.09 vs 0.15 +/- 0.05) than controls. There was a negative correlation between T3 and HbA1C. Cholesterol (4.77 +/- 1.08 vs 4.51 +/- 0.76 mmol/l) and triglycerides (0.82 +/- 0.53 vs 0.63 +/- 0.37 g/L) levels were higher in diabetic children and positively correlated with HbA1c, but not with DHEAS-SDS. We can therefore conclude that diabetes, particularly if poorly controlled, tends to induce a dissociation of cortisol and DHEAS secretion and a low T3 syndrome, similar to that seen in other illnesses.     

Coping styles in youths with insulin-dependent diabetes mellitus.

The relationships between two coping styles (i.e., use of personal and interpersonal resources; ventilation and avoidance) and two health outcomes (i.e., adherence and metabolic control) were evaluated in 135 youths with insulin-dependent diabetes mellitus (IDDM). Individual characteristics (i.e., age, duration of illness) and contextual variables (i.e., stress, family relations) were used to predict coping styles. Poor adherence to treatment, older adolescent age, and long duration of IDDM were correlated with ventilation and avoidance coping. Youths with short duration of IDDM were more likely to cope through the use of personal and interpersonal resources, although this strategy was not associated with health outcomes. A multiple regression analysis indicated that high ventilation and avoidance coping was predicted by high stress, low family cohesion, and older adolescent age. In addition, the interaction between family adaptability and duration of IDDM significantly predicted ventilation and avoidance coping. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parasympathetic neuropathy associated with left ventricular diastolic dysfunction in patients with insulin-dependent diabetes mellitus

BACKGROUND: As extracorporeal shock wave lithotripsy (ESWL) is frequently carried out on an outpatient basis, it is crucial to choose an adequate analgesic with less adverse effect. This study evaluated the use of three different intravenous agents: fentanyl, tramadol HCl and tenoxicam in ESWL. METHODS: One hundred and twenty patients undergoing lithotripsy were randomly assigned to receive either intravenous fentanyl 1 microgram/kg, tramadol HCl 1.5 mg/kg or tenoxicam 0.3 mg/kg before lithotripsy. Pain intensity was recorded using verbal rating pain scales (VRPS). Cases without adequate analgesia (VRPS > 4) or could not tolerate the pain, additional bolus of fentanyl 25 micrograms were given until adequate analgesia was achieved. Side effects were recorded as well. RESULTS: No significant differences were found among groups in demographic data, VRPS, number of total shock waves, cases with supplementary fentanyl, mean dose of supplementary fentanyl or the incidence of dizziness. However, the incidence of nausea or vomiting was significantly higher in fentanyl and tramadol groups comparing with tenoxicam group (15.0% and 25.0% vs. 0.0%). Oxygen saturation in fentanyl group was also significantly lower than the other two groups (p < 0.01). In addition, VRPS had a significant correlation with voltage intensities (p < 0.05). CONCLUSIONS: Lithotripsy can be satisfactorily performed by employing fentanyl, tramadol or tenoxicam for analgesia; tenoxicam apparently offers a better analgesic quality with less side effect. Furthermore, the need for stronger analgesia during larger voltage intensity should be tailored to the needs of the individuals.     

Blood glutathione in various phases of insulin-dependent diabetes mellitus in children

Reduced glutathione (GSH) in whole blood was studied in 15 insulin-dependent juvenile diabetic patients at onset of diabetes (group A). In 5 of these patients the blood GSH concentration was followed during the first month after onset. The blood GSH content was also analyzed in 16 children with insulin-dependent diabetes mellitus (IDDM) with a duration of diabetes of more than 2 years (group B), and in a control group of 76 healthy children (group C). The GSH levels in groups A, B and C were 48.3 +/- 5.7, 47.1 +/- 4.6 and 47.6 +/- 4.3 mg/100 ml erythrocytes, respectively. Thus, there were no significant differences between the patients and the control group. In group A, there were no significant differences in blood GSH values at onset and 1 month later.     

Increase in incidence of insulin-dependent diabetes mellitus among children in Finland

It has been proposed that NO may function as an endogenous cardioprotectant. We have investigated whether modulation of NO levels (detected in coronary effluent by chemiluminescence) by a blocker of its synthesis, by supplementation of its precursor, and by administration of an NO donor can influence reperfusion arrhythmias in the isolated rat heart. Rat hearts were perfused with modified Krebs' solution and subjected to 5, 35, or 60 minutes of left regional ischemia followed by 10 minutes of reperfusion. NG-Nitro-L-arginine methyl ester (L-NAME), which blocks NO synthase, increased the incidence of reperfusion-induced ventricular fibrillation (VF) from 5% in the control condition to 35% after 60 minutes of ischemia (n = 20, P < .05). The profibrillatory effect of L-NAME was prevented in hearts coperfused with 1 or 10 mmol/L L-arginine (an NO precursor) but persisted in hearts coperfused with D-arginine (1 mmol/L). L-NAME did not increase VF susceptibility in hearts reperfused after 5 or 35 minutes of ischemia. L-NAME caused sinus bradycardia (264 +/- 10 versus 309 +/- 5 bpm in control groups, P < .05) and reduced coronary flow before ischemia (6.2 +/- 0.6 versus 9.2 +/- 0.6 mL.min-1.g-1 tissue in controls, P < .05). L-NAME reduced coronary effluent NO levels after 60 minutes of ischemia; during the first minute of reperfusion, values were reduced from 1457 +/- 422 to 812 +/- 228 pmol.min-1.g-1 (P < .05). This effect was prevented by coperfusion with L-arginine (10,344 +/- 1730 pmol.min-1.g-1, P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Psychological functioning among mothers of children with insulin-dependent diabetes mellitus: A longitudinal study.

Mothers of children with newly diagnosed insulin-dependent diabetes mellitus (IDDM) were assessed repeatedly over a period of 6 years in order to determine the psychological correlates of managing this chronic illness. Both maternal depression and overall emotional distress after the 1st year of the IDDM increased slightly with illness duration and were also influenced by other factors. Mothers' adjustment shortly after their children were diagnosed with IDDM was a strong predictor of their long-term emotional symptomatology. However, mothers' symptoms over time were not related to medical aspects of IDDM (i.e., the extent of the children's metabolic control, number of rehospitalizations, or their compliance with the medical regimen) and were also unrelated to the levels of depression or anxiety reported by their children. Mothers generally found it easier to cope with the IDDM the longer their children had the illness. However, the degree to which mothers perceived the IDDM to be bothersome or difficult to manage at any given point in time was associated with their overall levels of emotional distress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive functioning and academic achievement in children with insulin-dependent diabetes mellitus (IDDM).

Discusses the effects of insulin-dependent diabetes mellitus (IDDM) on cognitive and academic functioning in children. IDDM children may have lower intellectual functioning, but their performance is usually average. Early age of disease onset, severe hypoglycemia, and diabetic ketoacidosis are the disease risk factors for lower IQ scores. Boys with IDDM are at greater risk for learning problems than girls, and both acute and chronic metabolic abnormalities may relate to poorer cognitive functioning. The high-risk children need periodic monitoring of their academic achievement, and may require special intervention. Intensive preschool or early intervention programs may be especially beneficial for those under the age of 5. An abbreviated Wechsler Intelligence Scale for Children—Revised (WISC—R) or WISC-III may be used for evaluating children with IDDM, as prorated performance or full scale IQ scores may not act as traditional measures of nonverbal intelligence in such children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Peripheral osteopenia in adult patients with insulin-dependent diabetes mellitus

Alterations in bone metabolism in diabetes mellitus is a topic of special interest. Bone blood flow is increased in the distal limb of diabetic patients, which is believed to increase osteoclastic activity. We measure bone mineral density using dual-photon absorptiometry in the distal lower limb, the femoral neck, and the lumbar spine in 41 IDDM patients and in 30 control persons. In the diabetic group there was a 10% reduction of bone mineral density in the femoral neck (p < 0.01) and a 12% reduction in the distal limb (p < 0.001) compared with the control group. No significant difference was found in the lumbar spine (p = 0.22). Our data yield incidence for peripheral osteopenia in IDDM-patients, independent of any systemic bone disease such as osteoporosis. A link between decreased bone mineral density and diabetic neuropathy has been observed for the femoral neck (p < 0.001), but not for the distal limb or axial skeleton. Whether there is a common aetiological link or a casual connection between diabetic neuropathy and bone mineral density has still to be determined.     

Insulin edema in three adolescents with insulin-dependent diabetes mellitus

Three female patients with a previously poorly controlled Insulin Dependent Diabetes Mellitus (IDDM), without evidence of cardiovascular, hepatic or renal dysfunction, developed generalized edema after a substantial increase in their insulin dosage. Edema resolved in 2-3 weeks, without specific therapy. Our patient's findings met the criteria of diagnosis of insulin edema. Insulin edema during IDDM is an uncommon complication of insulin therapy (1/400) and its pathogenesis is not clarified so far; it is a transient and self-limiting condition. The diagnosis is based on exclusion of all other major causes of edema.     

Intellectual development and academic performance of children with insulin-dependent diabetes mellitus: A longitudinal study.

87 school-age children with insulin-dependent diabetes mellitus (IDDM) were assessed repeatedly over the 1st 6 yrs of their IDDM to determine the effects of the medical disorder on intellectual development and academic performance. At the initial diagnosis, verbal and nonverbal intellectual performance and school grades were in the average ranges. Over time, verbal performance and school grades declined, whereas nonverbal intellectual performance improved slightly. Duration of IDDM was found to be related to the outcome variables, but the degree of metabolic control was not. Analyses of longitudinal data for a 6-yr interval on a demographically closely matched post hoc comparison group revealed parallel but less pronounced trends in verbal and nonverbal intellectual performance but not in school grades. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The health belief model and adolescents with insulin-dependent diabetes mellitus.

Tested the predictive utility of the health belief model for adherence with a complex, ongoing medical regimen in 56 adolescent outpatients (aged 10–19 yrs) with insulin-dependent diabetes mellitus. A 3-construct model of health beliefs was tested: Threat (perceived susceptibility combined with severity), Benefits–Costs, and Cues to seek treatment. The Benefits–Costs and Cues constructs were related to compliance in the positive direction. Threat interacted with Benefits–Costs in the prediction of compliance and with Cues in the prediction of metabolic control. The greatest compliance was achieved with low perceived Threat and high perceived Benefits–Costs. Poor metabolic control was associated with high Threat and Cues. As age increased, adherence to the exercise, injection, and frequency components of the regimen decreased. (PsycINFO Database Record (c) 2010 APA, all rights reserved)