Tight glycemic control may be harmful to babies
Hypoglycemic incidents more frequent
Contrary to the dictums of the Diabetes Control and Complications Trial (DCCT), tight glycemic control may be harmful to infants and toddlers with Type 1 diabetes, as confirmed by findings in a recent Mayo Clinic study.
When all signs are pointing toward the benefits of tight control, researchers at Mayo Clinic in Rochester, MN, found that tight blood glucose control in infants and toddlers younger than 2 increases the risk of severe hypoglycemic reactions.
Even at reasonably well-controlled HbA1c levels of 8 or below, they found 55% of the children under 2 experienced severe and unpredictable hypoglycemic reactions, compared to 45% of the children ages 2 to 5 and only 13% of the children ages 5 to 9.
Parents and patients of appropriate age were taught to determine plasma glucose concentrations and to adjust doses of insulin accordingly.
Insulin difficult to administer
"Many clinicians responsible for the care of infants and young children with Type 1 diabetes mellitus think that less aggressive plasma glucose control is needed in these patients," wrote Aida N. Lteif, MD, and W. Frederick Schwenk II, MD, authors of the study of 59 children published in Mayo Clinic Proceedings.
While tight control can be achieved, researchers concluded, it may not be advisable because of possibility of errors in administering the correct amount of insulin, especially when small doses must be administered.
Although Type 1 diabetes is relatively rare in infants and toddlers, incidents of hypoglycemia in apparently well-controlled young patients are not uncommon, says Robert Goldstein, MD, PhD, vice president of research of the Juvenile Diabetes Foundation in New York City.
While about 40% of children with newly diagnosed Type 1 diabetes are younger than 10, that number is increasing each year, says Goldstein.
Changing environmental factors
"The main recurring theme is that somehow the environment has changed, and environmental factors are triggering the autoimmune response," he says.
While the Lteif-Schwenk study recommends a relaxed pre-meal blood glucose range for young children, it does not designate a specific level.
But Goldstein recommends that the goal for children under 2 should be 100 to 150 mg/dL. "Clinicians need to loosen up their criteria in taking care of young kids."
The problem of infant hypoglycemia is well-known and well-defined, Goldstein says.
While the Mayo study is very small, he agrees that incorrect measurement of insulin may be the cause of the hypoglycemic reactions and should serve as an alert to physicians treating very young children. "They are more susceptible to hypoglycemia because they’re not like little adults. They need smaller amounts of insulin, and it has to be measured very carefully because it is easy to make a mistake," he says.
Goldstein advises clinicians to be certain parents are measuring correctly and re-check their skills if there are repeated hypoglycemic incidents. "Tight glycemic control is achievable in young patients, therefore you should change the guidelines you’re aiming for," he says.
[Robert Goldstein can be reached at (800) 533-2873.]
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