A good start does it matter? Intensive diabetes management from diagnosis
Paediatric diabetes ranks amongst the commonest chronic diseases in childhood and affects about 23 000 children under 17 years. Acute medical management at manifestation is well established and successfully conducted in the vast majority of cases. The chronic long-term treatment is challenging and involves self-managed, regular subcutaneous insulin administration, together with diet, exercise and lifestyle support to avoid short and long-term complications. Glycaemic control in UK children is worse than in many other European countries. Insulin therapy is the central part of structured treatment and education programs for children with type 1 diabetes. During the initial structured education, patients, parents and other care takers should be enabled to conduct insulin therapy independently. This should include a good mix of theoretical and practical skills, which is required from diagnosis. Fear of parents and health care professionals of hypoglycaemic episodes should be overcome by improving self-management skills and competencies. It is important to communicate that conventional therapy does not allow for physiological insulin replacement. Multiple daily injection strategies are preferred, but they do not necessarily equal an intensified conventional therapy (ICT). ICT aims to mimic physiologic insulin secretion with variable insulin doses including different carbohydrate to insulin ratios at different times, considering different sensitivities and different circadian rhythms according to age in an individualised fashion. An even closer to physiologic replacement can be achieved using continuous subcutaneous insulin infusion via insulin pumps. The more sophisticate the insulin replacement method becomes the more theoretical and practical knowledge is required by patients, parents and healthcare professionals. In addition, the self-monitoring of blood glucoses and tightly linked improvement of glycaemic control should be communicated from the beginning. Detailed education should start at diagnosis to enable patients and their families to manage their diabetes as early as possible at a high level of independence to improve long-term outcomes.