ISPAD Clinical Practice Consensus Guidelines 2018
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Chapter 10: Nutritional management 7 D. Maahs This is an excellent and very practical review.  I note that the overall message regarding low carb diets is quite negative and may not adequately address interests of the parents/patients who are using some degree of low carbohydrate intake with good results. The guidelines are not actually inconsistent with recognizing that in the process of individualizing care, some patients may wish to consume fairly low amounts of carbohydrate.  The guidelines  provide all the very appropriate caveats (particularly for young children) but I think could be more effectively presented by recognizing and providing additional specific guidance to ensure appropriate use of such diets in a safe manner, including ranges of carbohydrate intake (e.g., < 20%, 20-30%, 30-40%).
by E. Mayer-Davis
Tuesday, February 20, 2018
Chapter 6: Diabetes Education Locked Topic 3 D. Maahs The forum discussion on Chapter 6: Diabetes Education is now closed. While ISPAD does very much appreciate your feedback, kindly note that any comments posted here after 02/12/2018 will only be taken into account for the 2022 Guidelines! Thank you very much for your understanding.
by D. Maahs
Monday, February 12, 2018
Ch.15:Management of children & adolescents with diabetes requiring surgery 1 D. Maahs Dear authors, I have several comments and suggestions for your consideration.   P.3 Increasing use of glucose monitoring   P.4 … scheduled as the first case of the day on the surgical list … insulin regimen   P.8 Type 2 diabetes “Patients undergoing a major surgical procedure expected to last at least 2 hours should be monitored and started on an IV insulin infusion” Provide more specific instructions about what should be monitored and how frequently.   P. 9 insertion of grommets   P.10 “… all surgery or investigations under anesthesia that are more than minor …” Require BG monitoring before, hourly during, and after the procedure to detect hypo- and hyperglycemia”   P.12 “… despite use of a tight blood glucose control protocol”   Use of “diabetic” is not recommended; diabetic is repeatedly used throughout the manuscript. At least in the USA where I live and work, there is an ongoing campaign to raise awareness that people with diabetes do not want to be referred to as diabetics.  “… poorly controlled individuals with diabetes”   “Since the adult literature shows that outcomes are affected by the state of patients with diabetes before undergoing surgery, these studies allow us to make the following recommendations: …”   There are currently sufficient data (plural) …   P.13 In the discussion about pediatric reports in the critical care setting, the authors should be explicit that these studies were performed in children who did not have diabetes.   P.15 does “electrical equipment” refer to electrcautery?   P.17 “Must be admitted to hospital if receiving general anesthesia” Does this recommendation refer to BEFORE the procedure? In the US, many patients with well controlled diabetes who are scheduled for major procedures arrive in the pre-operative suite early in the AM on the day of the procedure. Health insurance does not pay for admission on the day before surgery in such cases. If the patient has other reasons to be hospital or diabetes is not well controlled, then admission before surgery would be approved.   Insulin regimen   Make a recommendation about how frequently BG should be measured intra-operatively   Why reduce long-acting basal insulin by 50% or basal infusion rate by 20% if the dose has been properly calibrated?   Continue usual basal rate   P.19 Why 80% of the usual correction factor if BG >250 mg/dL? Indicate a target BG to calculate the correction dose. At my institution, we use 150 mg/dL as the correction target in the setting of surgery and anesthesia.   P19 What BOHB concentration defines “significant ketone production”?  see also P.20   “glucose status” – I suspect this means current BG concentration?   P.23 insulin regimen   P.25 Potassium Here, the authors point out that it is potentially dangerous to add potassium to the IV fluids in case there is an urgent need for rapid fluid resuscitation. For clarity, I suggest re-writing the sentence: “Monitor electrolytes pre- and post-operatively.  Only after completion of surgery and when the patient’s vital signs are stable, consider adding potassium chloride 20 mmol/L of intravenous fluid”
by J. Wolfsdorf
Saturday, February 10, 2018
Chapter 12: Hypoglycemia Locked Topic 11 D. Maahs We want to thank all members who provided feedback on the Hypoglycemia chapter.  These comments were used to update the chapter.  Specific responses are provided in the attached PDF.
by D. Maahs
Monday, January 29, 2018
Chapter 3: Type 2 Diabetes 2 D. Maahs Excellent, comprehensive coverage of this topic!  Some comments and suggestions for the authors' consideration Page 4 bullet 3 Highlight that this should be a FASTING lipid profile? 3aii (1) states fasting   Page 7 2nd line from bottom of page: typo ethnic/racial   Page 8 so as not to offend our Canadian colleagues, include Canadian First Nation youth in the list of high risk populations   Page 9 3rd line from bottom of page typo: autoimmune-mediated T1D   Page 9 The most recent report from SEARCH for Diabetes in Youth study indicated that in youth with T2D, DKA at presentation decreased from 11.7% 2002-2003 to 5.7% in 2008-2010. Dabelea, D et al Pediatrics 2014;133(4):e938-45     Page 10 Because measurement of diabetes autoantibodies may not be available or cost may be prohibitive, one us has to rely on clinical criteria. The article by Julia von Oettingen in Pediatric Diabetes 2016;17(6):416-425 provides a simple clinical scoring system (weight Z-score, age and race) that may be useful in these circumstances (low resource settings).   Page 11 … as the insulin resistance of puberty wanes   Page 24 Indicate whether the goals levels refer to fasting or non-fasting samples… or does it matter? Fasting samples more difficult to obtain in clinical practice. May require patent returning to clinic on another day and this adds to the patient’s burden (inconvenient, cost of travel, time off work, missed school, etc.).
by J. Wolfsdorf
Sunday, January 28, 2018
Chapter 9: Insulin Locked Topic 6 D. Maahs Dear all, Than you for the nice Guideline. In comment to fergus I would like to add, that the aim of the JAMA paper comparing CSII and MDI was to Show that we see fewer adverse Events like DKA and sever hypoglycemia in the real world Setting outside a RCT. I agree that the difference in HbA1c is not very high however taking into account that most patients/families on CSII additionally have a better quality of live (Müller-Godeffroy E, Treichel S, Wagner VM; German Working Group for Paediatric Pump Therapy.Diabet Med. 2009 May;26(5):493-501. doi: 10.1111/j.1464-5491.2009.02707.x.) I would suggest there is still some evidence favoring CSII.Howevere the treatement decission is allways an indiviual decission taking into accoutn all familiar and Patient related arguments. I know I am to late but I wanted to comment on the discussionBW Thomas Kapellen
by T. Kapellen
Friday, January 26, 2018
Chapter 5: Management of cystic fibrosis-related diabetes 1 D. Maahs There is a study comparing insulin Treatment with Repaglinide at the beginning of CFRD (Lancet Diabetes Endocrinol. 2017 Nov 30. Repaglinide versus insulin for newly diagnosed diabetes in patients with cystic fibrosis: a multicentre, open-label, randomised trial.Ballmann M1, Hubert D2, Assael BM3, Staab D4, Hebestreit A5, Naehrlich L6, Nickolay T7, Prinz N8, Holl RW8; CFRD Study Group.) This study should urgently be added because it shows some evidence for oral antidiabetic treatement especiallay at the beginning of the disease.There are some limitations in this Trial (high drop Outs in the repaglinide arm) however the Trial should be added to the refernces and be carefully discussed in the Guidelines.
by T. Kapellen
Friday, January 26, 2018
Chapter 11: Diabetic ketoacidosis and hyperglycemic hypersmolar state Locked Topic 4 D. Maahs The forum discussion on Chapter 11: Diabetic ketoacidosis and hyperglycemic hypersmolar state is now closed. While ISPAD does very much appreciate your feedback, kindly note that any comments posted here after 25/01/2018 will only be taken into account for the 2022 Guidelines! Thank you very much for your understanding.
by D. Maahs
Thursday, January 25, 2018
Chapter 17: Adolescence Locked Topic 3 D. Maahs The forum discussion on Chapter 17: Adolescence is now closed. While ISPAD does very much appreciate your feedback, kindly note that any comments posted here after 25/01/2018 will only be taken into account for the 2022 Guidelines! Thank you very much for your understanding.
by D. Maahs
Thursday, January 25, 2018

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