The goal of attaining good glycaemic control in children with diabetes remains very challenging despite the availability of new insulins, more sophisticated devices and better models of care.
Data from the Epidemiology of Diabetes Interventions and Complications study demonstrated the importance of good glycaemic control in the early years of type 1 diabetes to achieve a reduced risk of complications, increased longevity and a quality of life comparable to people without diabetes (Nathan et al, 2005).
A recent analysis by the Brecon Group (Box 1) looked at changes in glycaemic control in Welsh children with type 1 diabetes from 2001 to 2006 (O’Hagan et al, 2010). A modest improvement was seen, with a reduction in mean HbA1c across Wales from 9.1% to 8.9% (76−74 mmol/mol).
Of the 12 contributing centres, five had appointed a full-time paediatric DSN, having not had one previously. These paediatric clinics had previously relied on support from adult DSNs who had to fit children in among their busy adult clinic commitments. It was the centres with new paediatric DSNs that showed greatest improvement in glycaemic control; in these centres, mean HbA1c reduced from 9.6% to 8.7% (81−72 mmol/mol).
Glycaemic control was generally worse in older children, and greater insulin dose was associated with poorer glycaemic control. The implication, therefore, is that more insulin gets prescribed for worse glycaemic control in adolescents who are probably not taking their prescribed regimen in full.
When the influence of the new paediatric DSNs on the different age groups were compared, it was the older children (aged over 10 years) who showed the greatest improvement, with little change in the younger people. This improvement occurred with no increase in prescribed insulin dose.
Since the DSNs produced better control without more insulin we believe that they generated better adherence in the adolescent population. They achieved this through greater contact with the young people. There were more home and school visits and nurse clinic sessions were established between doctor appointments (O’Hagan et al, 2010).
In other studies, paediatric DSNs have been shown to improve clinic attendance rates and reduce length of stay (Cowan et al, 1997), but there has been little previously published data on their effects on glycaemic control.
In the continuing quest to obtain the specialist nurse staffing that optimum care requires, it is useful to obtain more data to demonstrate the benefits that can be gained, and important to show their impact on the issue of diabetes care in adolescence.