944 have been reported to attempt suicide: "successful" suicide is about 6 times less common.2 Thus, 1 in 3000 might be a population rate for suicide at this age,

burgh

Occasional

Survey

CAUSES OF THE

7

DEATHS AMONG THE

45

DIABETIC PATIENTS

JUVENILE DIABETICS GROWING UP MALCOLM MACGREGOR Consultant Pœdiatrician, South Warwickshire Hospital Group

Investigation of the present state of 45 diabetic children diagnosed in South Warwickshire between 1950 and 1965 disclosed an unexpectedly high mortality and morbidity in this group.

Summary

of 45 is high. There were also 3 known attempted suicides in this group, making 11% for known suicide attempts in this series. 2

so

THE SURVEY

A SURVEY was undertaken to find out how children in whom diabetes had been diagnosed when they were less than 12 years old had fared after childhood. It is easy to understand why there are not more follow-ups of this kind: changed names and addresses, deaths and other vicissitudes made the tracing of 45 of 50 patients seem creditable. The preponderance of females (27 girls) is a chance finding (not compensated for by inclusion of the 5 untraced patients). The local incidence of juvenile diabetes in this period was 1 per 1000 child population, the figure calculated by Chance’ in Birmingham in 1969. The 3 oldest patients are now aged 32. The youngest was diagnosed at 11/2 and the oldest at 13. The shortest follow-up was 10 yr and the longest 26 yr (see accompanying figure). There was a family history of diabetes in close relatives in 10 (22%).

out

Non-fatal Handicaps 9 children had additional non-fatal handicaps not directly related to diabetes: (1) Mongol; chronic osteomyelitis of leg; died in status epilepticus. (2) Mental retardation; epilepsy; myxcedema; cataract. (3) Temporal-lobe epilepsy; attempted suicide. (4) Codiac disease; epilepsy; attempted suicide; juvenile delinquency.

(5) Overweight; attempted suicide. (6) Nephrectomy for hydronephrosis. (7) Hare-lip. (8) Diabetes insipidus; optic atrophy; neurogenic bladder; ileal conduit.

(9) Juvenile delinquency; attended approved school. The patient with Down syndrome eventually died in hypogiycxmia. Unless there is strong evidence to the contrary, epilepsy is the result of hypoglycaemia or its after-effects. Nevertheless, diabetics are believed to have a higher incidence of idiopathic epilepsy than the normal population.3 One of our patients with fits had a temporal-lobe focus probably resulting from severe hypoglycxmia in early childhood. 3 patients with fits out of 45 exceeds the 0.7% total-population figure for epilepsy in adults.3 The syndrome of optic atrophy, diabetes insipidus, and other features was reviewed by Page et al.4 "

Marital Histories 14 of the 38 survivors are married. Fetal loss in diabetic mothers has been recordeds as 15-20%. In this series, among 6 women who became pregnant two babies were

Period of follow-up

by

ages.

lost.

Occripation Patients’ remarks about their lives and included:

Deaths

3 of the 7 deaths among the 45 patients (15%) (see table) were certainly attributable to diabetes: renal failure; hypoglycaemia, and influenzal pneumonia, uncontrolled diabetes, and cardiac arrest. a

In the 2 suicidal deaths diabetes may well have been contributory factor. 1 in 500 teenage girls in Edin-

occupations

diabetes is not a handicap." "Travel abroad, take part in sports." "I do things first and see what happens afterwards." "Perhaps, being a diabetic, I have tried harder than

"Try everything:

most

people." "I have taken part in judo, motor-cycle racing, scrambling, and tracking up to international standard in Great Britain and Europe. Diabetes has not held me back at all."

945 The present

occupations of the 38survivors are: 5 4 1 1 27

Still at school Marned women without other job

Unemployed pemanent resident in In full employment:

subnormality hospital

including 3 1

parainedical telephone answenng service (blind) strenuous

physical: 1

riding school

agricultural

worker

1

PRESENT MANAGEMENT

In the past twenty years paediatricians have moved away from unrestricted dietary regimens for children to-

wards strict control, perhaps in the belief that if a rigorous discipline awaits their patients when they transfer to an adult department then the shock will be less atter controls have been imposed early. I have for some years started carbohydrate restriction at the age of 5 years, and many of the older children are already on two injections of insulin a day. It is therefore surprising to find that the prophesied austere future after departure from the paediatric enclosure has in many cases not come about. Thus, only half the patients now say that their diet is strict, and a quarter are on no diet at all. 40% of these older patients are still on only one injection a day. All the patients are on insulin and none on oral

hypoglycaemic drugs. Some of the details of management Insuhn injections One per day Two per day

are:

16 22

(mean age 21) (mean age 24)

18 10 9

(48%) (1 on corn oil) (27%) (25%)

Diet

reported Stnct Reasonable No diet

Visits

to

doctor

6-monthly

or more

often

1-2 years

30 5

,

2 "Rarely" Impossible to gauge stability of diabetic control. Many have had periods of instability, some as children, some as adolescents, a few always. Here are some patients’ comments on their diets:

"As I have got older I have come to understand my requirements better than my doctor. I know what I need to keep myself in balance, and I require more food and insulin in

winter." "When I go hunting I drop my insulin by 2 units, eat a large breakfast and carry loads of food with me. For two days afterwards I have to keep my insulin down, otherwise I have constant

hypos."

"I don’t like the British Diabetic Association journal, Balance, and don’t find it helpful. It tells how 11-year-old Jane cut the lawn to raise money, and how 27-year-old John cycled across the tundra living on penguin meat. There is a condescending attitude-people are to be congratulated on living and workmg as diabetics." "Join the B.D.A. I was surprised how much I learnt at 27." "Being allowed to eat an occasional sweet legally as a child was a great help, and seemed not to make one different from the crowd." "

References

to

ischaemic heart-disease-but they are not yet at an age for this. The complications in this series have been: 2 blind (retinal haemorrhages) (1 died of nephropathy) Visual 2microaneurysms reported 1 nephropathy and renal transplantation, died Renal ena 3 albuminuria (90 mg or more, in 2 specimens; 1 also with hyaline casts) Blood-pressure, none with diastolic>90 mm Hg Neuropathy, none

Juvenile diabetics growing up.

944 have been reported to attempt suicide: "successful" suicide is about 6 times less common.2 Thus, 1 in 3000 might be a population rate for suicide...
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