Original article
Temporal Trends in the Treatment of Pediatric Type 1 Diabetes and Impact on Acute Outcomes

https://doi.org/10.1016/j.jpeds.2006.12.009Get rights and content

Objective

To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes.

Study design

Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits.

Results

At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (≥4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (≥3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study’s end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02).

Conclusions

T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.

Section snippets

Participants

Two cohorts of youth with T1DM were followed longitudinally for 2 years and acute adverse event rates of the two groups were compared. Eligibility criteria for both cohorts included: age 8 to 16 years, duration of T1DM >6 months, stable living environment, no major psychiatric problems, and intention for routine follow-up care at the clinic. All youth had received insulin since diagnosis and had insulin requirements ≥0.5 U/kg/day at enrollment. The Committee on Human Studies of the Joslin

Patient Characteristics

The Table displays baseline characteristics for each cohort. The mean number of clinic visits per patient per year was 3.8 (1.7) in Cohort 1 and 4.1 (0.8) in Cohort 2 (P = .03). At study entry, only 39% of patients in Cohort 1 were performing SMBG ≥4 times/day, compared with 72% of Cohort 2 (χ2 = 48.0, df = 3, P < .0001) (Figure 1A). Cohort 2 had a significantly higher mean frequency of SMBG than Cohort 1 at both baseline (3.8 [0.9] vs 3.1 [1.0], P < .0001) and after 2 years of follow-up (3.6

Discussion

By comparing two pediatric cohorts with T1DM followed at the same center and separated in time by 5 years, we found that intensive insulin therapy and frequency of SMBG increased significantly in the post-DCCT era. A significant improvement in glycemic control coincided with these changes in treatment practices. Although the results are somewhat encouraging, the integrated mean A1c for the cohort enrolled in 2002 remained 0.5% higher than the intensively treated adolescent group in the DCCT.

Our

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    Supported by grants from the NIH: RO1DK046887 (to L.M.B.L.) and 5T32DK063702 (to B.M.S. and E.M.). Support was also received from the Charles H. Hood Foundation, the Katherine Adler Astrove Youth Education Fund, and the Maria Griffin Drury Fund.

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