CORRESPONDENCE

Ambulatory care of paediatric and adolescent diabetic patients in the Western Cape

To the Editor: It has been proposed that routine care of paediatric and adolescent patients with type 1 diabetes (T1DM) in the Western Cape should be devolved from centres of excellence to centres at secondary or even primary level. Experience with adults with type 2 diabetes (T2DM) in another African country is cited to support this notion.¹ However, these two conditions have completely different aetiologies. While T2DM is entirely preventable and treatable by simple measures, this is not the case with T1DM. T1DM usually starts in childhood, and children can by no means be considered 'little adults'. They vary in size, growth phase and pubertal stage. Their manipulative skills can catch many a health worker off-guard. Maintaining optimal blood glucose control in order to prevent both acute (diabetic ketoacidosis and hypoglycaemia) as well as chronic (microvascular and macrovascular) complications is therefore far more difficult in this age group than in any other. The International Society for Paediatric and Adolescent Diabetes (ISPAD) in the latest Clinical Practice Consensus Guideline (supported by delegates from Africa) therefore recommends that children and adolescents with diabetes 'should be cared for ... by members of a team of specialists, all of whom should have training, expertise, and understanding of both diabetes and paediatrics, including child and adolescent development'.² Such a team would consist of a paediatric endocrinologist or an experienced paediatrician, a diabetic nurse educator, a dietician, a social worker, a psychologist and an ophthalmologist.

Randomised controlled trials in children with T1DM to support ISPAD's recommendation are not available, and for ethical reasons may never be done. In certain African countries where there are no or few paediatric endocrinologists or diabetologists, children with T1DM have a shortened life expectancy (0.96 years in Mali, 3.5 years in Mozambique, 11.2 years in Zambia).³ This suggests that lack of expertise is indeed associated with significant mortality among diabetic patients. In adult ambulatory diabetic care, adherence, monitoring of blood sugar and detection of complications is significantly better when patients are looked after by endocrinologists as opposed to generalists.⁴ These patients usually also have a better HbA1c level, and significantly fewer develop end-stage renal disease. Furthermore, a multidisciplinary diabetes management team has been shown to impact on the cost of diabetic keto-acidosis, duration of hospital stay, number of emergency room visits and hospitalisations, hypoglycaemia and foot infections.⁴

Given the above, a secondary hospital geographically distant from a centre of excellence should only consider duplicating a diabetic ambulatory service if a multidisciplinary diabetes management team is available. An appropriately stocked dispensary, run by a motivated pharmacist, is also essential to prevent some of the problems frequently encountered at primary care centres.⁵ If these requirements cannot be met, it would not be in the interests of children and adolescents with T1DM to devolve their care to secondary or primary level.

Ekkehard Zöllner
Paediatric Endocrine Unit
Tygerberg Children's Hospital
W Cape
zollner@sun.ac.za

Steve Delport
Paediatric Endocrine Unit
University of Cape Town

1. Bahendeka S. The provision of hospital-based glucose monitoring and structured clinical files improves metabolic control of diabetics in rural areas of Uganda. Diabet Med 2006;23(P1709):603 (abstract).         [ Links ]

2. Pihoker C, Forsander G, Wolfsdorf J, Klingensmith GJ. The delivery of ambulatory diabetes care: structures, processes, and outcomes of ambulatory diabetes care. Pediatr Diabetes 2008;9:609-620.         [ Links ]

3. Beran D, Yudkin J, DeCourten M. Access to insulin and diabetes care in Mali, Mozambique and Zambia and differences in life-expectancy. Diabet Med 2006;23(P1722):603 (abstract).         [ Links ]

4. Cobin RH. Subspecialist care improves diabetes outcomes. Diabetes Care 2002;25:1654-1656.         [ Links ]

5. Haque M, Emerson SH, Dennison CR, Navsa M, Levitt NS. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. S Afr Med J 2005;95:798-802.         [ Links ]