Moderator White: The most important age periods in the management of the juvenile diabetic patient are infancy and adolescence. Some physicians dread the management of diabetes when the patient is under five years of age. The condition sometimes seems difficult to handle and it places extreme strain on the morale of the patients. Dr. Guest, what is your advice in regard to the diabetic infant?
Dr. Guest: In my opinion diabetic infants are not necessarily more difficult to manage than older children. I should say that the age of adolescence is a much more difficult period than that of infancy, but then of course, other problems are involved. As most of you know, I recommend the so-called “free-diet-glycosuric” regime which is a subject of continuing debate. (See editorials in Diabetes: 1:487–89, Nov.-Dec. 1952.) In our clinic we have eighteen diabetic infants with onset of diabetes under the age of two years. Of these, eight were under one year of age when symptoms were first recognized. The youngest started glycosuria at nine days of age. The diagnosis was made by the astute mother because she had another diabetic child then aged one and onehalf years. When she noted the new infant was passing a lot of urine, she tested it and found sugar. On admission to the hospital, the baby's blood sugar was 350 mg. per 100 cc. The urinalysis showed 3-plus glycosuria but no ketonuria. During twenty-four hours we determined the blood sugar every two hours and found it fluctuating between 300 and 500. Because there was no ketonuria, we felt that a period of observation before starting insulin would do no harm. After that brief period of observation the baby was given an initial dose of three units of protamine zinc insulin. During the next twenty-four hours the blood sugar fell progressively (determined at two-hour intervals) to 150 and then 100. Again, three units of protamine zinc insulin kept the blood sugar within normal range. (Let me stress the necessity for microchemical methods for following blood chemical changes in infants, whether diabetic or nondiabetic.) The baby was sent home on the fifth day, receiving two units of protamine zinc insulin daily. He was breast fed for ten months, on a demand schedule, with the dosage of protamine zinc varying from one to three units daily and solid foods offered at usual ages. (Please note that breast feeding is the ultimate in “free diet”, while it lasts!) That child is now seven years of age and has not suffered any illness that required hospitalization. His urine is rarely free of sugar, but excessive glycosuria with polyuria is likewise rare. Transient ketonuria has occurred occasionally during intercurrent infections, but has always cleared up promptly with the administration of extra doses of quick-acting insulin. The insulin requirement increased slowly with age and increasing body weight, from five units a day at one year of age, to thirty-five units (globin insulin) a day at the present time.
