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Diabetes control is poor in children in the UK compared with most European countries; only 17% of children achieve HbA1c levels below the target value of 7.5%.1 Historically, we have tended to use insulin regimens requiring twice-daily injections (before breakfast and before the evening meal), meaning that children did not generally require an insulin injection or blood glucose check during the school day. However, the majority of large centres in this country and most in Europe are now using multiple injection therapy (MIT) and continuous subcutaneous insulin infusions (insulin pumps) which are more physiological and have the potential of improving glycaemic control when used intensively. Both require much greater input throughout the day as insulin is required at every meal-time, and, in order to improve control further, the dose of insulin must be related to the carbohydrate content of the meal and to the prevailing blood glucose level.
Diabetes management during the day has thus become far more complex. Parents have learned the new skills well, particularly when these regimens are started from diagnosis, but there are often huge obstacles to setting appropriate support in place in schools. For children over the age of about 10–11 years, who are largely able to carry out their own injections reliably, schools will still have minimal input in most cases. The greater problem comes when doctors and parents wish to use these regimens in children who are too young to perform their own injections and blood glucose testing, even under supervision. So how should we move forward? Do children have the right to help in school or should we adjust the daily regimens so that insulin injections are not required at school?
The landmark Diabetes Control and Complications Trial showed beyond doubt that intensive insulin regimens (and this trial was carried out …
Competing interests: None.
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