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Increasing incidence of hypoglycemic coma in children with IDDM
M Egger1, S Gschwend, G D Smith
1Department of Pediatrics, University of Berne, Switzerland.
Insights
Improved glycemic control in children with insulin-dependent diabetes mellitus (IDDM) increased severe hypoglycemia risk. Less tight control may be safer for those with undetectable C-peptide levels.
Area of Science:
- Pediatric Endocrinology
- Metabolic Disorders
- Diabetes Mellitus Research
Background:
- Insulin-dependent diabetes mellitus (IDDM) management in children requires balancing glycemic control with hypoglycemia risk.
- Understanding risk factors for severe hypoglycemia, such as hypoglycemic coma, is crucial for optimizing treatment strategies.
- Residual beta-cell function and glycemic markers like HbA1 levels are potential indicators of hypoglycemia risk.
Purpose of the Study:
- To determine the incidence of hypoglycemic coma in children with IDDM over an 8-year period.
- To identify residual beta-cell function, HbA1 levels, and other variables as risk factors for hypoglycemic coma.
- To investigate the impact of intensified diabetes management on hypoglycemia incidence.
Main Methods:
- Prospective study of 155 children with IDDM (age < 16) over 816.6 person-years.
- Standardized questionnaires and monthly clinical/laboratory assessments, including C-peptide and HbA1 levels.
- Case-control analysis matched for diabetes duration, using logistic regression to calculate odds ratios.
Main Results:
- Yearly incidence of hypoglycemic coma increased significantly from 4.4/100 person-yr (years 1-4) to 7.4/100 person-yr (years 5-8).
- This increase coincided with intensified insulin therapy, more daily injections, and lower mean HbA1 levels.
- Absent residual beta-cell function (OR 7.8) and near-normal HbA1 levels (OR 4.5) were significant risk factors for hypoglycemic coma.
Conclusions:
- Improved glycemic control in pediatric IDDM may paradoxically increase severe hypoglycemia incidence.
- For children with recurrent hypoglycemic coma and undetectable C-peptide, less stringent glycemic targets might be safer.
- Individualized treatment approaches are necessary to mitigate hypoglycemia risk while managing diabetes.
Objective:
To examine the incidence of hypoglycemic coma in children with insulin-dependent diabetes mellitus (IDDM) over 8 yr from 1981 to 1988 and to investigate the importance of residual beta-cell function of HbA1 levels and other variables as risk factors for hypoglycemic coma.
Research Design And Methods:
The study consisted of 155 children with IDDM aged less than 16 yr at study entry. Mean age at onset of diabetes was 7.9 yr (range 1.1-15.6 yr). We made a prospective assessment of hypoglycemic coma episodes, with a standardized questionnaire, over a total observation time of 816.6 person-yr. Three monthly clinical and laboratory examinations, which included determinations of C-peptide and HbA1 levels, were conducted. We compared children with hypoglycemic coma (cases) with children without hypoglycemic coma (controls) in a case-control analysis matched for diabetes duration. Yearly incidence of hypoglycemic coma, calculated as the number of subjects having an attack in 1 yr divided by the cumulative number of person-years for that year, was measured. Univariate and multivariate odds ratios were calculated from logistic regression.
Results:
Over the first 4 yr, the average yearly incidence was 4.4/100 person-yr compared with 7.4/100 person-yr during the later 4 yr (P less than 0.0001). This tendency was accompanied by intensification of insulin treatment with an increase in the mean number of daily injections and a decrease in mean HbA1 levels. In the case-control analysis, absent residual beta-cell function was the most important risk factor for hypoglycemic coma (adjusted odds ratio 7.8, 95% confidence intervals 2.0-31.2), followed by near-normal HbA1 levels (adjusted odds ratio 4.5, 95% confidence intervals 1.9-10.5).
Conclusions:
In this group of children, improvement of glycemic control apparently led to an increase in the incidence of severe hypoglycemia. In children with recurrent hypoglycemic coma and undetectable C-peptide levels, it may be safer to aim for somewhat less tight glycemic control.