Ketoacidosis at onset of type 1 diabetes mellitus in pediatric age in Spain and review of the literature.

UNLABELLED: DKA at diagnosis of T1DM is a life-threatening situation that represents the main cause of morbidity and mortality in pediatric patients with T1DM. OBJECTIVE: To determine whether the occurrence and severity of DKA at diagnosis of T1DM has suffered any changes in recent years in the Spanish paediatric population. PATIENTS AND METHODS: Data from 1169 patients with T1DM under 15 years of age was retrospectively studied (2004 -2008) for the presence and severity of DKA at the onset of T1DM, and compared to previous available studies in Spain. This study is multicentric, nationwide with eleven major Paediatric Diabetes Units involved. RESULTS: Complete data were available from 1151 patients (98%). Frequency of DKA was 39.5%, which is not significantly different from previous Spanish studies. 33.8%, children of 0-4.9 years of age, 40.8% aged 5-10.9 and 25.2% aged 11-14.9 years. Mean age of patients with DKA was significantly lower than the one of patients without DKA (7.44 +/- 4.10 versus 8.47 +/- 3.63 years). Mild DKA was occurring more frequently than moderate and severe forms (47.8%, versus 34.4% versus 17.8%, p<0.0001). Incidence of severe DKA was significantly higher in children under 4.9 years of age, especially in those younger than 2 years (p<0.001). Severe DKA led to complications in three children (cerebral oedema [n=1]), cerebral infarction (n=1) and femoral vein thrombosis (n=1). CONCLUSION: Frequency of DKA at diagnosis of T1DM in Spain is still high although most cases were mild. Children under 2 years of age seem to be at increased risk for severe DKA.

[Low birth weight is a risk factor for type 1 diabetes]. / El bajo peso al nacer es un factor de riesgo de diabetes mellitus tipo 1.

INTRODUCTION AND AIM: Over recent years, the increasing incidence of type 1 diabetes mellitus (T1DM) has been associated with different factors, particularly increased obesity in childhood. The aim of this study was to find out if there was any relationship between birth weight, body mass index (BMI) increase during the first two 3 years of life, and BMI at diabetes onset with age at diagnosis, in a cohort of children diagnosed with T1DM. MATERIAL AND METHOD: Data from 100 Caucasian children with T1DM of both sexes (57 boys, 43 girls) between 10 months and 16 years of age, mean age 84.45 months (SD; 52.4), were studied. We analysed the following variables: age at diagnosis, gestational age, weight and height at birth, at two years of age and at diabetes diagnosis, expressed as SD scores (SDS). RESULTS: All children were between 38-40 weeks of gestational age. Diabetic patients have lower birth weight (-2.88 ((-0.51)-(-0.066)) and lower BMI at birth compared with healthy children -0.5 ((-0.77)-(-0.23)). Diabetic children have a significant increase in BMI during the first two years of life (4.58 versus 2.17; P<0.001). Children with the lowest BMI at birth (12.77 versus 13.06; P<0.006) are the youngest at onset of the disease. BMI at diagnosis was not related to any of the variables studied. There were no gender differences either. CONCLUSIONS: The low BMI at birth and the later increase in the following years of life seem to be related to intrauterine environment as a risk factor for T1DM.

[The HOMA and QUICKI indexes, and insulin and C-peptide levels in healthy children. Cut off points to identify metabolic syndrome in healthy children]. / Indice HOMA y QUICKI, insulina y péptido C en niños sanos. Puntos de corte de riesgo cardiovascular.

OBJECTIVE: The aim of this study was to establish the reference values of the Homeostasis Model Assessment (HOMA) and Quantitative Insulin Sensitivity Check (QUICKI) indexes, as well as those of insulin and C-peptide levels in healthy children and adolescents with a view to determining reference percentiles to detect those at cardiovascular risk. MATERIAL AND METHODS: A total of 372 children boys and girls of different ages and at distinct pubertal stages with normal body mass index participated in the study. Fasting glucose, insulin and C-peptide values were measured by chemiluminescence and the HOMA and QUICKI indexes were calculated. RESULTS: Fasting glucose levels were normal in all children. The mean values obtained for each variable were (mean (SD)): fasting glucose 87(7.75) mg/dL, insulin 7.74 (5.35) microU/mL, C-peptide: 1.76 (0.79) ng/mL, HOMA index 1.72 (1.27) and QUICKI index 0.72 (0.29). All the variables progressively increased with age, with statistically significant differences between prepubertal and pubertal children. The QUICKI index showed an inverse relationship. In addition, significant differences were found between sexes. The 90th percentile for all the variables was as follows: insulin 15.05 microU/mL, C-peptide: 2.85 ng/mL, HOMA index 3.43 and QUICKI index 1.10. CONCLUSIONS: Values of fasting glucose, insulin, C-peptide and the HOMA index significantly increased with age and pubertal stage, while the QUICKI index decreased. We defined the 90th percentile for all the parameters studied as the cut-off point to identify children at cardiovascular risk in our population.

Is a parental history of coronary arterial disease in children as discriminating as their lipoprotein profile? Niño Jesus Group.

The relationship between hyperlipidemia and a parental history of heart attack and other related disorders was studied in 2224 two- to 18-yr-old children in Madrid (Spain). Children were divided into three groups: those with a parental history of heart attack (first group), a parental history of stroke, hypertension, diabetes mellitus or hypercholesterolemia (second group), and no parental history of disease (third group). The number of children with higher than normal levels of total cholesterol (greater than 200 mg/dl), LDL-cholesterol (greater than 135 mg/dl) and/or apolipoprotein B100 (greater than 75 mg/dl) was significantly higher in the first and second group (positive parental history) than in the third (no parental history). Children and adolescents with a parental history of heart attack (first group) had significantly higher mean levels of total cholesterol and LDL-cholesterol; in the 2- to 13-yr age group a significantly higher level of apolipoprotein B was also found. Children and adolescents belonging to the second group had a significantly higher level of LDL-cholesterol, and a significantly higher level of apolipoprotein B was also found in the 2- to 13-yr age group. However, only 15% of children with hypercholesterolemia had a parental history of heart attack or other related disorders. This percentage was 41% when second-degree relatives were included in the family history. We conclude that a parental history is not enough to detect children with an abnormal lipid profile who might be at risk for early development of coronary arterial disease.

[Values of thyrotropin, free triiodothyronine and free thyroxine using chemiluminescence in children and adolescents in the Autonomous Community of Madrid (Spain)]. / Valores de tirotropina, triyodotironina libre y tiroxina libre en niños y adolescentes en la Comunidad Autónoma de Madrid mediante quimioluminiscencia.

OBJECTIVE: To establish the reference ranges of thyrotropin (TSH), free triiodothyronine (FT3) and free thyroxine (FT4) with the chemiluminescence method in healthy children and adolescents in Madrid, Spain. METHOD: A total of 371 children and adolescents of both sexes, with different ages and at different pubertal stage participated in the study. Serum values of TSH, FT3, and FT4 were determined by chemiluminescence. RESULTS: TSH, FT4 and FT3 reference ranges decreased inversely with chronological age. Significant differences were found between prepubertal and pubertal groups. In some groups, there were also occasional differences between sexes. CONCLUSIONS: Thyroid hormone levels decrease with chronological age. Because of the differences in hormone levels between prepubertal and pubertal subjects, we believe that different pubertal stages should be included in the standard reference values of these hormones.

[Treatment of the child and adolescent with type 1 diabetes: special paediatric diabetes units]. / Asistencia al niño y adolescente con diabetes. Unidades de referencia en diabetes pediátrica.

Intensive treatment of type 1 diabetes mellitus (DM1) delays and slows down the progression of chronic diabetes complications (DCCT 1993). This type of treatment in children and adolescents with DM1 has a different complexity to other stages of life and therefore, needs specialized care units. Various documents and declarations of diabetic patient's rights are evaluated, and the need for an adequate health care is emphasized. In the last decade, several projects have been developed in Europe to create a benchmark treatment of pediatric diabetes, with the aim of establishing hospitals with highly qualified healthcare to control it. The Diabetes Working Group of the Spanish Society for Pediatric Endocrinology (SEEP) has prepared this document in order to obtain a national consensus for the care of children and adolescents with type 1 diabetes in specialist Pediatric Diabetes Units, and at the same time advise Health Care Administrators to establish a national healthcare network for children and adolescents with diabetes mellitus, and organize comprehensive pediatric diabetes care units in hospitals with a reference level in quality of care.

[Current status and recommendations on the use of continuous blood glucose monitoring systems in children and adolescents with type 1 diabetes mellitus]. / Estado actual y recomendaciones sobre la utilización de los sistemas de monitorización continua de glucosa en niños y adolescentes con diabetes mellitus tipo 1.

Glucose monitoring methods have made great advances in the last decade with the appearance of the continuous glucose monitoring systems (CGMS) that measure the glucose levels in the interstitial liquid, providing information about glucose patterns and trends, but do not replace the self-monitoring of capillary glucose. Improvement in diabetes control using the CGMS depends on the motivation and training received by the patient and family and on the continuity in its use. Due to the development and widespread use of these systems in clinical practice, the diabetes group of the Sociedad Española de Endocrinología Pediátrica has drafted a document of consensus for their indication and use in children and adolescents. Only a limited number of trials have been performed in children and adolescent populations. More data are needed on the use of this technology in order to define the impact on metabolic control.

[Assessment of the secular trend in puberty in boys and girls]. / Valoración de la tendencia secular de la pubertad en niños y niñas.

OBJECTIVE: Changes in the onset of puberty have been reported in the last few years. The aim of this study is to determine pubertal trends in boys and girls. METHOD: Longitudinal study was conducted on 310 caucasian children. We analysed birth weight (BW), weight (kg), height (cm) and body mass index (BMI) (%), bone age, duration of puberty growth and pubertal height spurt. RESULTS: For boys the mean age at stage 2 was 12.4 (1.5) years with a bone age of 11.9 (1.3) years, and stage 5: 15.6 (1.5) with a bone age of 14.5. Mean age (years) (SD) for girls stage 2 was 10.1 (1.4), with a bone age of 10.3 (1.1). Age at menarche was 12.0 (1.3), with a bone age of 13.2 (0.9). Duration of puberty growth for boys was 3 years (1.2), and for girls 2.5 years (1.1). Pubertal height spurt in boys was 19.5cm (7.6) and for girls was 15.7cm (5.0). Girls with puberty onset<9 years of age show a greater pubertal height gain (19.7cm (4.3)) than girls >9 years of age [14.4 (4.5) (P<0.0001)] and a longer period of pubertal growth 3.1 years (0.8) versus 2.3 (0.9) (P<0.0001). Boys with puberty onset <11 years of age had a greater pubertal height gain [27.3cm (7.9)] than boys > 11 years of age [17.4 (5.9) (P<0.0001)] and a longer period of puberty growth of 3.9 years (1.2) versus 2.7 (1.1) (P<0.001). CONCLUSIONS: Boys presented secondary sex characteristics at the same age as other studies, but the girls reached puberty and menarche at a younger age than previous studies in the Mediterranean area. Bone age correlates with chronological age for both sexes at the beginning of puberty but not at the end. Early onset of puberty was associated with a greater pubertal height gain and a longer period of pubertal growth. There was no correlation between BW or BMI with onset of puberty.

[Consensus document on continuous subcutaneous insulin infusion (CSII) treatment in paediatrics with type I diabetes]. / Documento de consenso sobre tratamiento con infusión subcutánea continua de insulina de la diabetes tipo 1 en la edad pediátrica.

This article reports on the Spanish Position Statement for the Diabetes Pediátric Group for the Spanish Pediatric Endocrinology Society (SEEP) on continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes. The practical issues about their indications, appropriate candidates, feasibility, and limits are outlined. The conclusions are based on the comprehensive review and balanced assessment of the evidence base on the international consensus and consensual answers to these questions for the participants.

Status asthmaticus: is respiratory physiotherapy necessary?

We present the case of a four year-old girl diagnosed of moderate extrinsic asthma that in the course of an episode of asthmatic status, she presented after treatment with respiratory physiotherapy an abrupt worsening of its clinical state, with appearance of a pneumotorax that precised intensive care treatment. The use of respiratory physiotherapy is dissuaded as part of the treatment in the initial phase of acute asthma, being reserved this treatment later in the recovery phase, anytime when a component of hypersecretion exists and the intensity of the bonchoconstriction has diminished.

[Lipid profiles of children and adolescents in Madrid]. / Patrón lipídico de niños y adolescentes de Madrid.

We have studied 2,224 children and adolescents of both sexes, ranging between 2 and 18 years of age, at five schools in the city of Madrid. We determined the lipid profile: total cholesterol (T-C), cholesterol bound to high density lipoproteins (HDL-C), cholesterol bound to low density lipoproteins (LDL-C), cholesterol bound to very low density lipoproteins (VLDL-C), triglycerides (TG), apolipoprotein AI and apolipoprotein B100 (Apo A1 and Apo B100, respectively). In relationship to age and sex, in males, as age increases, there is an elevation in LDL-C and TG and a diminution in T-C, HDL-C, Apo AI and Apo B100. There are no changes in VLDL-C. In females, there is a diminution in LDL-C, TG, Apo-B100 and an increase in HDL-C, Apo AI and T-C, with the increase in T-C being found only in those older than 15 years.

[The effect of the socioeconomic level on the lipid pattern in children and adolescents]. / Influencia del nivel socioeconómico en el patrón lipídico de niños y adolescentes.

BACKGROUND: The aim of this study was to evaluate the association between socioeconomic status and the presence of cardiovascular risk factors in children from Madrid. METHODS: We studied 2224 boys and girls, ages 2-18 years, attending five different school centers. They were divided into three socioeconomic groups: low class, middle-low class and middle high class, in regard to their parent's occupation and educational attainment. The evaluation included a blood analysis of serum triglycerides (TG), total cholesterol (CT), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), apolipoprotein A1 (ApoA), apolipoprotein B100 (Apo B), and the Apo A/Apo B and LDL/HDL ratios. RESULTS: There was a positive correlation between socioeconomic status and total cholesterol, Apo A, Apo B and Apo A/Apo B, whereas socioeconomic status and triglycerides were inversely related. The LDL/HDL ratio varied according to age. CONCLUSIONS: Unlike some previously published studies, we found that children belonging to high socioeconomic status have a more atherogenic lipid profile than those of middle low or low socioeconomic levels.