however, numbers were small and the time of discharge may have been selected when optimal control had been achieved. A shortcoming of this retrospective study that prevented full use of the index of diabetes control was the scant follow-up data for patients who had been discharged from hospital. Records of the day-care unit contained more details, indicating more comprehensive monitoring.
The study indicated that reasonably comparable control of diabetes, at one ninth the financial investment, was achieved by initiating insulin treatment in the day-care unit rather than in hospital. Another advantage of diabetic day-care management was the opportunity afforded patients to remain at school or at work while learning insulin administration at home. Thus, the disrupting effects of an admission to hospital were avoided.
We thank the staff of the day-care unit, particularly Bernice King, Lucy Noviks and Kay Vollick; Drs. A.B. MacMillan, C.H. Malcolmson, F.R. Orr and W.M. Wilson; and Dr. W.O. Spitzer, for his advice in preparing the manuscript. References 1. KING B, SPAULDING WB, WRIGHT AD: Prob-
lem-orientated diabetic day care. Can Nurse 70: 19, 1974 al: The clinical picture of diabetic control, studied in four settings. Am J Public Health 57: 441, 1967
2. WILLIAMS TF, MARTIN DA, HOGAN MD, Ct
Management of diabetes mellitus in children R.G. MCARTHUR,* MD, FRCP[C]; K.M. TOMM,t MD, FRCP[C]; M.D. LEAHEY4 B Sc N
In many respects the management of diabetes mellitus in children differs from the management in adults. Guidelines for the short- and long-term management of the child with diabetes mellitus, particularly as it relates to clinical presentation, treatment of ketoacidosis, long-term therapy and psychological counselling, are presented. The specific aspects of diabetes management that are unique to the child are best met by an increased understanding of the problems by the child and the family and an integrated approach by the physician and allied health personnel. Le traitement du diabete chez les enfants differe de bien des fa.ons du traitement chez l'adulte. On presente ici des directives pour le traitement a court et A long terme du diabete chez l'enfant, particulierement en ce qui a trait au tableau clinique, au traitement de l'acidocetose, a Ia therapie de longue duree et a l'orientation psychologique. On peut le mieux faire face aux aspects specifiques du traitement du diabete qui sont uniques a l'enfant en ameliorant Ia comprehension des problemes par I'enfant aussi bien que par sa famille, et par une approche integree du medecin et du personnel paramedical impliqu6. Most physicians are more familiar with the recognition and management of diabetes mellitus in adults than in children. In children initial symptoms may go unrecognized by the child, the parFrom the child and adolescent diabetic clinic, division of pediatrics and psychiatry, University of Calgary *Pediatric endocrinologist tChild and family psychiatrist .Nurse practitioner Reprint requests to: Dr. R.G. McArthur, Division of pediatrics, Faculty of medicine, University of Calgary, 2920 24th Ave. NW, Calgary, AB T2N 1N4
ents and the physician. Although diabetes in children is usually diagnosed before acidosis occurs, management of the latter in children differs from that in adults, particularly in relation to insulin administration (relatively smaller amounts of insulin are required) and fluid and electrolyte replacement (this depends on the state of hydration and the age and weight of the child). In the long term the devastating physical and emotional effects of diabetes mellitus on the adult patient and his family are well known. Recent evidence suggests that complications are related to the quality of diabetes control.1-3 Many physicians who deal with the pediatric age group, however, view diabetes mellitus in childhood as a relatively benign disease. Hence, often insufficient time is devoted to evaluation, education and counselling of the patient and his family. In these circumstances poor control can occur and the beginnings of future physical and psychological complications can take root. Clinical presentation and diagnosis A history of polyuria and polydipsia in association with glucosuria and hyperglycemia (with or without signs of dehydration and ketoacidosis) is evidence of diabetes mellitus. Polyuria and polydipsia are usually present initially in children with diabetes; the diagnosis should be questioned if these symptoms are not evident. The child who is not in ketoacidosis may appear relatively normal; the child with ketoacidosis looks ill, is dehydrated, has acetone on his breath, breathes rapidly and deeply, has a rapid pulse and may have an enlarged liver and a tender abdomen. Diabetes should always be suspected in the child who is in coma or whose state of consciousness is altered. Other causes of hyperglycemia and glucosuria, such as central nervous system diseases and certain poisonings
(e.g., acetylsalicylic acid) can be excluded by a careful history and a good physical examination. When diabetes is suspected from the history and physical findings, one should immediately check a urine sample for glucose and ketones and determine the blood glucose concentration. If the child appears ill and dehydration and acidosis are suspected, one should also measure concentrations of serum electrolytes, serum acetone and blood urea nitrogen, determine the hematocrit and analyse the blood gases (determining pH, base deficit, bicarbonate concentration and CO2 tension). Management of diabetic ketoacidosis The principles of therapy are the following: (a) volume expansion, (b) gradual reduction of hyperglycemia and early administration of isotonic or nearisotonic rather than hypotonic solutions, (c) gradual correction of acidosis, (d) infusion of glucose when its concentration in the blood has been reduced to approximately 250 mg/dl and (e) identification and treatment of precipitating infection. The major complications in the treatment of diabetic ketoacidosis are hypoglycemia, hypokalemia, renal failure and cerebral edema. Insulin In children with acidosis (pH, < 7.3; serum bicarbonate value,
The study indicated that reasonably comparable control of diabetes, at one ninth the financial investment, was achieved by initiating insulin treatment in the day-care unit rather than in hospital. Another advantage of diabetic day-care management was the opportunity afforded patients to remain at school or at work while learning insulin administration at home. Thus, the disrupting effects of an admission to hospital were avoided.
We thank the staff of the day-care unit, particularly Bernice King, Lucy Noviks and Kay Vollick; Drs. A.B. MacMillan, C.H. Malcolmson, F.R. Orr and W.M. Wilson; and Dr. W.O. Spitzer, for his advice in preparing the manuscript. References 1. KING B, SPAULDING WB, WRIGHT AD: Prob-
lem-orientated diabetic day care. Can Nurse 70: 19, 1974 al: The clinical picture of diabetic control, studied in four settings. Am J Public Health 57: 441, 1967
2. WILLIAMS TF, MARTIN DA, HOGAN MD, Ct
Management of diabetes mellitus in children R.G. MCARTHUR,* MD, FRCP[C]; K.M. TOMM,t MD, FRCP[C]; M.D. LEAHEY4 B Sc N
In many respects the management of diabetes mellitus in children differs from the management in adults. Guidelines for the short- and long-term management of the child with diabetes mellitus, particularly as it relates to clinical presentation, treatment of ketoacidosis, long-term therapy and psychological counselling, are presented. The specific aspects of diabetes management that are unique to the child are best met by an increased understanding of the problems by the child and the family and an integrated approach by the physician and allied health personnel. Le traitement du diabete chez les enfants differe de bien des fa.ons du traitement chez l'adulte. On presente ici des directives pour le traitement a court et A long terme du diabete chez l'enfant, particulierement en ce qui a trait au tableau clinique, au traitement de l'acidocetose, a Ia therapie de longue duree et a l'orientation psychologique. On peut le mieux faire face aux aspects specifiques du traitement du diabete qui sont uniques a l'enfant en ameliorant Ia comprehension des problemes par I'enfant aussi bien que par sa famille, et par une approche integree du medecin et du personnel paramedical impliqu6. Most physicians are more familiar with the recognition and management of diabetes mellitus in adults than in children. In children initial symptoms may go unrecognized by the child, the parFrom the child and adolescent diabetic clinic, division of pediatrics and psychiatry, University of Calgary *Pediatric endocrinologist tChild and family psychiatrist .Nurse practitioner Reprint requests to: Dr. R.G. McArthur, Division of pediatrics, Faculty of medicine, University of Calgary, 2920 24th Ave. NW, Calgary, AB T2N 1N4
ents and the physician. Although diabetes in children is usually diagnosed before acidosis occurs, management of the latter in children differs from that in adults, particularly in relation to insulin administration (relatively smaller amounts of insulin are required) and fluid and electrolyte replacement (this depends on the state of hydration and the age and weight of the child). In the long term the devastating physical and emotional effects of diabetes mellitus on the adult patient and his family are well known. Recent evidence suggests that complications are related to the quality of diabetes control.1-3 Many physicians who deal with the pediatric age group, however, view diabetes mellitus in childhood as a relatively benign disease. Hence, often insufficient time is devoted to evaluation, education and counselling of the patient and his family. In these circumstances poor control can occur and the beginnings of future physical and psychological complications can take root. Clinical presentation and diagnosis A history of polyuria and polydipsia in association with glucosuria and hyperglycemia (with or without signs of dehydration and ketoacidosis) is evidence of diabetes mellitus. Polyuria and polydipsia are usually present initially in children with diabetes; the diagnosis should be questioned if these symptoms are not evident. The child who is not in ketoacidosis may appear relatively normal; the child with ketoacidosis looks ill, is dehydrated, has acetone on his breath, breathes rapidly and deeply, has a rapid pulse and may have an enlarged liver and a tender abdomen. Diabetes should always be suspected in the child who is in coma or whose state of consciousness is altered. Other causes of hyperglycemia and glucosuria, such as central nervous system diseases and certain poisonings
(e.g., acetylsalicylic acid) can be excluded by a careful history and a good physical examination. When diabetes is suspected from the history and physical findings, one should immediately check a urine sample for glucose and ketones and determine the blood glucose concentration. If the child appears ill and dehydration and acidosis are suspected, one should also measure concentrations of serum electrolytes, serum acetone and blood urea nitrogen, determine the hematocrit and analyse the blood gases (determining pH, base deficit, bicarbonate concentration and CO2 tension). Management of diabetic ketoacidosis The principles of therapy are the following: (a) volume expansion, (b) gradual reduction of hyperglycemia and early administration of isotonic or nearisotonic rather than hypotonic solutions, (c) gradual correction of acidosis, (d) infusion of glucose when its concentration in the blood has been reduced to approximately 250 mg/dl and (e) identification and treatment of precipitating infection. The major complications in the treatment of diabetic ketoacidosis are hypoglycemia, hypokalemia, renal failure and cerebral edema. Insulin In children with acidosis (pH, < 7.3; serum bicarbonate value,
