Intensive treatment of insulin-dependent diabetes mellitus during pregnancy often normalizes plasma glucose levels. However, it is unclear whether this adversely affects other metabolic fuels that are essential to normal fetal growth and development. Metabolic studies were conducted after the subjects ingested a standardized mixed meal during each trimester in 7 normal and 15 insulin-dependent diabetic pregnant women. The latter were treated with continuous subcutaneous insulin infusion or multiple injections, which were adjusted to achieve strict glucose control throughout pregnancy. Insulin, alanine, branched-chain amino acids, triglycerides, free fatty acids, and ketones were measured every 15 to 30 minutes before a standardized breakfast and for 150 minutes after the breakfast. Patients with insulin-dependent diabetes mellitus were studied while they received their unusual insulin dosages. Fasting glucose levels (87 +/- 7 mg/dl) and glucose levels 150 minutes after the meal (112 +/- 11 mg/dl) were near normal. However, normoglycemia was achieved at the expense of increased plasma insulin levels (area under insulin response curves, p less than 0.01, vs nondiabetic curves). Nevertheless, fasting and post-prandial plasma branched-chain amino acids, alanine, and free fatty acids were similar in both groups. Fasting cholesterol, triglyceride, and ketone levels were also normalized. We conclude that normalization of circulating amino acids and lipids in conjunction with correction of hyperglycemia may contribute to favorable outcomes in infants of intensively treated diabetic mothers.

Self blood glucose monitoring (SBGM) results in nine insulin- dependent diabetic patients who had elevated levels of glycosylated hemoglobin (HbA1 9.8% ±0.4%) despite intensive treatment were compared with those of 11 patients who were able to achieve strict diabetes control (HbA1 8.1% ± 0.2% ; normal 5.6%-8.0%). Surprisingly, both groups reported similar SBGM values and testing frequency, and both groups measured glucose levels accurately when values were checked in the laboratory. On the other hand, laboratory glucose values were lower and correlated with HbA 1 levels only in the group that achieved near normal HbA1 values. These data suggest that problems with SBGM may impede achievement of strict glycemic control during intensive treatment of insulin-dependent diabetes.

The psychosocial effects of recent advances in the management of diabetes mellitus are unknown and could conceivably be adverse, particularly during the critical period of adolescence. Seven teenagers were evaluated by standard psychosocial scales and a detailed questionnaire before and on completion of a 6-mo intensive management program utilizing home glucose monitoring and multiple injections or the insulin infusion pump. All achieved improved metabolic control with inpatient glucose values (during 24-h monitoring) falling from 244 +/- 58 to 108 +/- 10 mg/dl, glycosylated hemoglobin levels falling from 11.8 +/- 2.9% to 8.4 +/- 1.7%, and home glucose levels averaging 121 +/- 16 mg/dl. Standardized scales evaluating depression, diabetic adjustment, self-esteem, and social adjustment indicated no deterioration in psychosocial functioning. There was a statistically significant increase in locus of control scores, suggesting an improved sense of internal control of life events. The program questionnaire revealed a positive response to both the program and the control devices used. This study suggests that the positive metabolic benefits of intensive diabetic management during adolescence are not offset by adverse psychosocial effects and indeed positive psychosocial benefits may result.

Recent studies indicate that glucose control may be improved in adult diabetics with intensive insulin (II) Rx (using either infusion pumps or multiple injections) and home blood glucose monitoring. To examine the efficacy of these Rx strategies in children, we examined whether near normal glucose levels could be achieved in 8 young (age 10-15 yrs) diabetics given II Rx (6 pump, 2 multiple injections) for 2-6 mos. Control was assessed by HbA1 (nl 5-8%) and glucose measurements of blood samples mailed from home (HG). Glycemic excursions (MAGE) were determined from inpatient glucose profiles (IG). Effect of II Rx on glucose levels (mg/dl) is shown below (¶ p < 0.01). HbA1 levels fell significantly after 2 wks (12.7±1.0 to 9.3±0.7%) and was further reduced by 4-8 wks.(7.6±0.1%, p<0.005). Glycosuria was virtually eliminated (81±20 vs 3±1 gm/day). Insulin dose increased by 50% with II Rx (to 1.4 U/kg/day). However, hypoglycemia symptoms were mild and none required IV glucose. Conclusions: Near normal glucose control can be achieved in the outpatient management of children and adolescents with diabetes. The comparative efficacy of insulin pump vs multiple injections needs to be determined.