The role of the paediatric interdisciplinary diabetes team in the care of children and adolescents with diabetes

The “Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada” (1) recommend that all children and adolescents with type 1 diabetes should have access to an experienced paediatric diabetes health care team and specialized care starting at the time of diagnosis. The guidelines also suggest that children with type 2 diabetes should receive care in consultation with a multidisciplinary paediatric diabetes team. These recommendations are supported by the 2000 ISPAD (International Society for Pediatric and Adolescent Diabetes) consensus guidelines (2). The ISPAD defines the essential multidisciplinary team members as a paediatrician specializing in diabetes/endocrinology (or a physician with a special interest in paediatric diabetes), a diabetes nurse educator and a dietitian. All team members should have training and expertise in diabetes, paediatrics, and growth and development. The ISPAD guidelines also indicate that children and adolescents should have access to paediatric psychosocial services. Managing type 1 diabetes involves balancing insulin, food and activity, while the management of type 2 diabetes involves treating the relative insulin deficiency with weight loss, exercise and, if necessary, oral antihyperglycemic agents, insulin or combination therapies. These strategies sound simple enough, but in the context of a child's or adolescent's world they are complex and challenging. Most family practitioners and diabetes educators have an abundance of experience managing adults with type 2 diabetes, but see relatively few clients with type 1 diabetes, especially in the younger population. Most paediatricians are also unlikely to have a large case load of children and adolescents with diabetes. Clinical expertise evolves from knowledge and evidence-based practice, as well as experience and intuition which can only be gained over time through following many children at various ages and stages. Diabetes management has become high-tech, with an abundance of blood glucose monitoring devices offering various features, computer software for blood glucose analysis, insulin analogues, basal/bolus regimens, injection devices, continuous blood glucose monitors, insulin pumps, carbohydrate counting and glycemic index. Many parents are well-read, Internet savvy, and aware of the ‘latest and greatest’ ways of managing diabetes. They are assertive and request that their child receive the newest technologies. For complex management strategies to work, the child and his/her family need to be assessed for the appropriateness of the intervention, thoroughly educated on how to implement the treatment and evaluated on an ongoing basis to ensure safety and efficacy. It is not possible for one health care professional, be it a physician, nurse or dietitian, to have expertise in all areas – hence the need for a multidisciplinary team. The term ‘multi’ implies many while the term ‘inter’ implies between or among. Successful paediatric diabetes care involves all the team players (the referring family physician or paediatrician, paediatric endocrinologist, diabetes nurse educator, dietitian, psychologist or social worker and, of course, the child and his/her family) sharing information, and planning and working together. Therefore, the more appropriate terminology is ‘interdisciplinary paediatric diabetes team’, with the focus on all team members delivering equally valuable, conjoint care. Knowledge of growth and development as it relates to children with diabetes is essential for effective diabetes care. Insulin regimens can be prescribed and families can be educated on meal planning, insulin administration, monitoring and hypoglycemia management, but customizing treatment and education for various age groups is an art. Meal planning needs to be flexible in timing and content to reflect the chaotic world of children and their families. Insulin doses constantly change in the paediatric and adolescent population, and a thorough understanding of typical requirements at diagnosis, during the honeymoon period, during puberty and at times of illness is necessary for metabolic control. Insulin omission and blood glucose fabrication are common occurrences in the paediatric and adolescent population, which require assessment and intervention. Most children 10 years of age and older are capable of many aspects of self-care, but lack the maturity and interest to manage on their own, and therefore, the transfer of responsibility from parent to child needs to be timely and appropriate. Eating disorders complicated by insulin omission are common among adolescent girls with diabetes. These are just a few of the growth and development issues that require expertise which can only be derived from managing many clients at various stages from infancy to adolescence. In summary, paediatric and adolescent diabetes is challenging and complex, and all children and adolescents with diabetes should have access to a paediatric interdisciplinary diabetes team to ensure safe and effective care.

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