Continuous subcutaneous insulin infusion in newly diagnosed diabetic children

In the first century AD Aretaeus of Cappadocia described diabetes as "a wonderful but not very frequent affection among men being a melting down of the flesh and limbs into urine .... , life is short, disgusting and painful, thirst unquenchable, death inevitable". The recognition of this disease with its enormous thirst and massive production of honey sweet urine is very old. Nowadays diabetes is known as a heterogeneous disorder. Insufficient production of biologically active insulin is a common denominator in almost all forms of diabetes. Insulin deficiency results in a variety of metabolic abnormalities (hyperglycaemia, increased lipolysis, increased gluconeogenesis at the cost of amino acids). The NIH National Diabetes Data Group discerns 2 types of diabetes mellitus: insulin dependent diabetes mellitus (IDDM) and noninsulin dependent diabetes mellitus (NIDDM) (National Diabetes Data Group 1979). IDDM frequently starts in childhood. The incidence in the Netherlands is estimated to be 11.0 subjects per 100.000 inhabitants per year in the age group below 20 years (Vaandrager 1984). Since NIDDM seldom occurs in childhood it will be left out of consideration in this study. Insulin is produced by beta cells in the pancreatic islets of Langerhans. In due time after clinical onset there is hardly any beta cell activity evident. An absolute insulin deficiency ensues. As insulin plays a key role in maintaining normal metabolism, this implicates a life-long dependency on exogenous insulin administration. Since insulin is a peptide which can not be administered orally, administration of injections at least once daily is necessary. Ten to 15 years after the onset of the disease severe complications may develop (micro- and macroangiopathy) resulting in a shorter life expectancy and a reduced quality of life (Deckert 1978). It is evident that t~is chronic disease and its consequences also influence life, the psychological wellbeing and development of patients, especially those of child age. The cause of this destructive process, which is specifically directed against the pancreatic beta cells, remains to be elucidated. Current thought is that a hereditary susceptibility in combination with an environmental agent can lead to the development of IDDM (Cahill 1981). Immunological disturbances- cellular as well as humoral - have also been found at the onset of the disease (Bottazzo 1981, Buschard 1980, Lernmark 1981, Maron 1983). Their precise role has not yet been clarified. 3