From Mississippi, USA:
Our 4 year old granddaughter has had Type 1 diabetes for two years. Her doctors told us to be more careful about too low glucose levels than too high. They don't seem too concerned with sugar ranges above 200. At puberty, however, they said tight control would be very important. I would like to find an answer as to why moderately high sugar in young children does not seem to have the damaging effects on blood vessels and nerves it does on adults. Could you help?
You are quite right when you ask whether and why high blood sugar does not affect blood vessels in young children compared to older ones. This observation was due to the fact that pediatricians generally did not continue to look after their young patients after the adolescence or young adulthood and therefore quite rarely they could observe complications. The diabetes complications were described, on the other hand, mainly by adult diabetologists. The scientific explanation for that apparent inability of high sugar to exert its effect in children compared to adults was thought to be that the different hormonal milieu of puberty makes the individual prone to the damaging effect of high blood sugar.
All this is not considered true any longer by pediatric diabetologists worldwide and a "priming" effect of prepuberty hyperglycemia on future complications has been described in clinical followup studies. This is why current practice recommendations are increasingly aimed for meticulous control from the beginning of the disease, i.e., a glycohemoglobin that is not greater than the 15% above the upper limit of the normal for the method used or as near to that as is reasonably possible given the age of the small child.
This also means that you must not worry about short and modest fluctuations of blood sugar in your granddaughter because it's the average metabolic control that counts in all diabetic complications. And control, as you know, is achieved by obtaining a high level of education to enable patient's parents and relatives to learn how to manage the diabetes themselves (with the help of their diabetes team), and later on to teach the child the basic principles of self-monitoring and self-management.
It sounds like you probably need to further discuss the care of your granddaughter with a Pediatric Endocrinologist or Pediatric Diabetologist experienced in taking care of small children with Type 1 diabetes.
Additional Comment from Linda Mackowiak, Diabetes Nurse Specialist:You have asked a very important, and very difficult, question to answer. Experts in the field of diabetes continue to discuss this same question.
The DCCT and other important studies have given us valuable information on the importance of blood sugar control in diabetes. We also have information about the danger of hypoglycemia in very young children when their brain is still in the development stage.
Previously there had been a belief, from analyzing data from large numbers of adults with diabetes, that the development of complications seemed to relate to the years a person had diabetes from the start of puberty. It was extrapolated from this study that the years prior to puberty may not have mattered. There continued to be debate, and more recently it has been felt by most experts that the years before puberty do matter, but the subject is still controversial.
Where does that leave your wonderful little granddaughter? Well, most pediatric diabetes teams would encourage the "best" control possible with the least hypoglycemia. This is a real challenge. Young children have variable food intake, unpredictable activity levels, frequent illnesses, rapid growth, behavioral issues, tiny little insulin doses where an air bubble or error in dose or small amount of insulin leakage could make a big difference in their insulin doses. (I could go on.) Don't despair, but instead try to keep the big picture in mind: how she is growing and developing, look at the hemoglobin A1c's and overall blood sugars (try not to get lost in the day to day numbers!) and do the best you can given the limits of our current therapy. Then she'll be healthy and ready for newer treatments as they become available.
In general, I tell parents of toddlers and pre-schoolers to have a goal of blood glucose readings in the 100-200 mg/dl range. This is a goal, and there may be some days when you just can't reach your goal.
Original posting 26 Jul 97
Additional comment posted 29 Jul 97
Last Updated: Tuesday April 06, 2010 15:08:54
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