Type 1 diabetes

Kids seeing paediatricians for T1D get guideline-based care


Endocrinologists can be confident that kids with type 1 diabetes (T1D) managed by general paediatricians are getting guideline-based care, an Australian study shows.

The research, which builds on a 2017 survey of T1D management by ANZ endocrinologists and NZ paediatricians, explored the insulin initiation practices of 24 Australian paediatricians and their multidisciplinary diabetes units.

It found the units collectively treated 2,059 children with T1D, and responding paediatricians managed around 49 patients each.

Most paediatricians initiated multiple daily injections or continuous subcutaneous insulin infusions at diagnosis in all age groups, with total daily dose targets ranging from 0.5–0.75 Units/kg/day in patients under eight years old, and 0.76–1.0 Units/kg/day in older patients.

Almost all (93%) said they start intensive insulin therapy in 2–10 year olds at diagnosis and 83% implemented carbohydrate counting as part of flexible bolus dosing in line with International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines, lead author and paediatrician at Flinders Medical Centre, Dr Brian Coppin and his colleagues wrote in the Journal of Paediatrics and Child Health.

During the 2017 survey, 73%, 17% and 36% of Australian endocrinologists, NZ endocrinologists and NZ general paediatricians initiated intensive insulin therapy early on and 73%, 64% and 33% used carbohydrate counting, respectively.

While endocrinologists and NZ paediatricians’ practices may have changed since the original study, particularly with the release of ISPAD’s 2018 guidelines, Dr Coppin told the limbic that his work highlighted the “good quality and non-inferiority” of care given by Australian paediatricians.

This was especially important since the study “gives validity to anecdotal estimates that over 4000 young people living with T1D are in the care of general paediatricians and their clinical teams”, the authors wrote.

Why paediatricians?

When asked why so many patients with T1D see paediatricians, Dr Coppin suggested that preference, rather than access, may play a role.

“We didn’t study the reasons, so I’m only speculating, and I guess some if it’s historical access, some of it is location, but we’re not just seeing patients in rural and regional areas, we’re also seeing them in cities,” he said.

“There’s a big cohort in Geelong, there’s a big cohort here in Adelaide, there are general paediatricians in Brisbane who are looking after children in a place where access to tertiary care centres with paediatric endocrinologists.”

“And, it just may be that the model of care is favoured. I know in some places, where units use general paediatricians to look after these children with diabetes, that, the families favour being followed by a particular consultant, whereas, in some of the endocrine units, they could be seen by whichever endocrinologist is in on the day, a registrar or trainee, and they may not get that consistency of care.”

The study noted that most paediatricians follow up with patients via outpatient or home outreach visits within one to two weeks of discharge.

Despite their broad responsibilities, “there is no evidence that suburban and regional diabetes teams are funded any better than tertiary diabetes teams” — often relying on Medicare, while dieticians and diabetes educators’ salaries are state funded through public hospitals.

They’re also “often overlooked with resource allocation (e.g. access to point-of-care HbA1c) and not yet included in audit resources (Australian Diabetes Data Network)”, the authors wrote.

“Rather, regional teams have had to become flexible and creative, with diabetes educators giving dietician advice when dieticians are not available and paediatricians dealing with psychological issues when a child psychologist is not accessible. Initiation regimens rely heavily on inpatient nursing staff being skilled and clear protocols being in place.”

Though more resources and support could help paediatric units provide optimal and individualised T1D care, Dr Coppin said the study was “encouraging” and a “good news story” for clinicians and their patients.

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