XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiag- nosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pedi- atric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interven- tions focused on healthy attachment and parent-child relationships. Pediatrics 2010;126:1032-1039 BACKGROUND Maternal and paternal depression affect the whole family. 1 This report will specifically focus on the impact of maternal depression on the young infant and the role of the primary care clinician in recognizing perinatal depression. Perinatal depression is a major/minor depres- sive disorder with an episode occurring during pregnancy or within the first year after birth of a child. A family history of depression, alcohol abuse, and a personal history of depression increase the risk of perinatal depression. 2 The incidence of perinatal depression varies with the population sur- veyed, but estimated rates for depression among pregnant and post- partum women have ranged from 5% to 25%. Studies of low-income mothers and pregnant and parenting teenagers have reported rates of depressive symptoms at 40% to 60%. In general, as many as 12% of all pregnant or postpartum women experience depression in a given year, and for low-income women, the prevalence is doubled.1 The rate of major and minor depression varies during pregnancy from 8.5% to 11.0%, and in the first year after birth of a child, the rate ranges from

/pdf/incorporating-recognition-and-management-of-perinatal-and-1ls0qzxrsz.pdf

Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

Type 2 diabetes in adolescents and young adults

In children with type 1 diabetes (T1DM), parents are ultimately responsible for daily management of T1DM, which has a significant impact on family life. Daily management of T1DM is time-consuming and requires a change to many well-established family routines. Although technological advances have greatly enhanced the ability of parents to monitor and manage T1DM in youth,1 the responsibility of T1DM management can contribute to parental stress, distress, and diminished quality of life. Understanding the experience of parenting a child with T1DM can provide insight into the challenges and needs of parents, thus informing the development of parental and/or family interventions. Considerable research has been undertaken to examine aspects of the parenting experience; however, there is a need to synthesize this literature to inform future research and clinical work.

Caring for a child with T1DM has been described as an overwhelming experience, requiring constant vigilance.2 Parents must come to terms with having a child with a life-threatening illness and carrying out a labor-intensive and complicated daily regimen.3 Parents live with constant worry about hypoglycemia or hyperglycemia, heightened feelings of responsibility for their child’s health, and the desire to promote optimal growth and development.4 At different developmental phases, new issues arise that require a complete reevaluation of previously established and effective management strategies.5 The ongoing stress and worry manifest in elevated rates of parents’ perception of stress and increased risk for depression and anxiety.

There is considerable research on the prevalence of parental psychological distress and the impact of such distress on child and family outcomes. Although the majority of parents of children with T1DM adjust well, approximately 20% to 30% of parents report clinically significant distress, which has been defined as stress (life stress or parenting stress) and symptoms of anxiety, depression, and/or posttraumatic stress.6–8 Parental psychological distress at the time of diagnosis has been found to predict later parental distress.9 In addition, parental psychological distress has health implications for the parent, the child with T1DM, and the overall functioning of the family.10 In parents of children with T1DM, psychological distress has been shown to affect family communication,11 increase family conflict,12 decrease the ability to parent effectively,13 negatively affect child psychological adjustment,9 and contribute to poor parental mental and physical health.14

Greater understanding of the relationship of parental psychological responses to having a child with T1DM is needed to guide clinical practice and future research. Thus, the purpose of this systematic mixed-studies review is to synthesize the research on the parental experience of having a child with T1DM, focusing on parental psychological adjustment. The aims are to describe the prevalence of psychological distress in parents of children with T1DM, the relationship between parental psychological distress and health outcomes, and the parental experience of having a child with T1DM. Clinical and research implications will also be presented.

/pdf/psychological-experience-of-parents-of-children-with-type-1-4vadbpo6uq.pdf

Psychological Experience of Parents of Children With Type 1 Diabetes A Systematic Mixed-Studies Review

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

https://pediatrics.aappublications.org/content/pediatrics/early/2015/06/23/peds.2015-1517.full.pdf

Telemedicine: Pediatric Applications

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10- to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child's age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

/pdf/management-of-newly-diagnosed-type-2-diabetes-mellitus-t2dm-4x7tjfxwbk.pdf

Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents

OBJECTIVES. The goals were (1) to determine the feasibility and yield of maternal depression screening during all well-child visits, (2) to understand how pediatricians and mothers respond to depression screening information, and (3) to assess the time required for discussion of screening results. METHODS. Implementation of brief depression screening of mothers at well-child visits for children of all ages was studied in 3 rural pediatric practices. Two screening trials introduced screening (1 month) and then determined whether screening could be sustained (6 months). Screening used the 2-question Patient Health Questionnaire. Practices tracked the proportions of visits screened and provided data about the screening process. RESULTS. Practices were able to screen in the majority of well-child visits (74% in trial 1 and 67% in trial 2). Of 1398 mothers screened, 17% had 1 of the depressive symptoms and 6% (n 88) scored as being at risk for a major depressive disorder. During discussion, 5.7% of all mothers thought they might be depressed and 4.7% thought they were stressed but not depressed. Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms. Pediatrician actions included discussion of the impact on the child, a follow-up visit or call, and referral to an adult primary care provider, a mental health clinician, or community supports. Pediatrician time needed to discuss screening results decreased in the second trial. Prolonged discussion time was uncommon (5–10 minutes in 3% of all well-child visits and 10 minutes in 2%). CONCLUSIONS. Routine, brief, maternal depression screening conducted during wellchild visits was feasible and detected mothers who were willing to discuss depression and stress issues with their pediatrician. The discussion after screening revealed additional mothers who felt depressed among those with lesser symptoms. The additional discussion time was usually brief and resulted in specific pediatrician actions.

Brief maternal depression screening at well-child visits

OBJECTIVE: Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, “Management of Type 2 Diabetes Mellitus in Children and Adolescents,” and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline’s recommendations. METHODS: A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM’s comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist. RESULTS: Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information.

https://pediatrics.aappublications.org/content/pediatrics/131/2/e648.full.pdf

Greg E. Prazar

Papers

Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents

Brief maternal depression screening at well-child visits

Management of Type 2 Diabetes Mellitus in Children and Adolescents