{"id":6953,"date":"2018-02-08T20:00:51","date_gmt":"2018-02-08T17:00:51","guid":{"rendered":"http:\/\/prodiab.md\/?p=6953"},"modified":"2018-02-08T20:33:31","modified_gmt":"2018-02-08T17:33:31","slug":"managementul-contemporan-al-diabetului-zaharat-la-copii-si-adolescenti","status":"publish","type":"post","link":"http:\/\/prodiab.md\/ro\/managementul-contemporan-al-diabetului-zaharat-la-copii-si-adolescenti\/","title":{"rendered":"MANAGEMENTUL CONTEMPORAN AL DIABETULUI ZAHARAT LA COPII \u015eI ADOLESCEN\u0162I"},"content":{"rendered":"

<\/p>\n

Managementul contemporan al diabetului zaharat la copii \u015fi adolescen\u0163i<\/strong><\/p>\n

Andrian CHIRIAC, Ina PALII, Sergiu GLADUN, Boris GOLOVIN, Ruxanda GLAVAN, Veaceslav MADONICI, Victoria MORAR, Valeriu E\u015eANU, Veronica E\u015eANU<\/strong><\/p>\n

Summary<\/em><\/strong><\/p>\n

Modern management of diabetes mellitus in children and adolescents<\/em><\/strong><\/p>\n

Diabetes mellitus in children and adolescents is a progressive chronic disease. Its incidence is steadily increasing globally and in our country. In order to achieve the therapeutic targets, as recommended by international guidelines and rational use of resources in accordance with sustainable development goals promoted by the World Health Organization,<\/em> a series of complex measures are required for the correct management at any level of medical assistance. These measures include the use of modern insulins, providing devices for self blood glucose monitoring, access to therapeutic education on proper nutrition, as well as possibilities of rehabilitation in specialized centers.<\/em><\/p>\n

Key-words: <\/em><\/strong>diabetes mellitus, insulin analogs, self blood glucose monitoring, glycated hemoglobine, hypoglycemia.<\/em><\/p>\n

\u0420\u0435\u0437\u044e\u043c\u0435 <\/em><\/strong><\/p>\n

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\u041a\u043b\u044e\u0447\u0435\u0432\u044b\u0435 \u0441\u043b\u043e\u0432\u0430:<\/em><\/strong> \u0441\u0430\u0445\u0430\u0440\u043d\u044b\u0439 \u0434\u0438\u0430\u0431\u0435\u0442, \u0430\u043d\u0430\u043b\u043e\u0433\u0438 \u0438\u043d\u0441\u0443\u043b\u0438\u043d\u0430, \u0441\u0430\u043c\u043e\u043a\u043e\u043d\u0442\u0440\u043e\u043b\u044c \u0433\u043b\u0438\u043a\u0435\u043c\u0438\u0438, \u0433\u043b\u0438\u043a\u043e\u0437\u0438\u043b\u0438\u0440\u043e\u0432\u0430\u043d\u043d\u044b\u0439 \u0433\u0435\u043c\u043e\u0433\u043b\u043e\u0431\u0438\u043d, \u0433\u0438\u043f\u043e\u0433\u043b\u0438\u043a\u0435\u043c\u0438\u044f.<\/em><\/p>\n

Actualitatea temei<\/strong><\/p>\n

Diabetul zaharat la copii \u0219i adolescen\u021bi este una dintre cele mai frecvente patologii cronice \u00eent\u00e2lnit\u0103 la v\u00e2rsta pediatric\u0103. Definit\u0103 printr-o hiperglicemie persistent\u0103 ca urmare a deficitului secre\u0163iei sau ac\u0163iunii insulinei, \u00een lipsa tratamentului adecvat, aceast\u0103 maladie are o evolu\u0163ie progresiv\u0103 \u015fi dezvolt\u0103 complica\u0163ii incompatibile cu via\u0163a. La copii \u015fi tineri se depisteaz\u0103 preponderent Diabetul zaharat de tip 1, caracterizat prin deficit absolut de insulin\u0103. La nivel global sunt \u00eenregistra\u0163i un num\u0103r total de peste 1\u00a0106 200 copii \u015fi adolescen\u0163i \u015fi aproximativ 132 600 cazuri noi sunt depistate anual. La sf\u00e2r\u015fitul anului 2016 \u00een Republica Moldova erau 400 copii cu Diabet zaharat confirmat, iar \u00een primele 11 luni ale anului 2017 s-au depistat primar \u00eenc\u0103 63 de cazuri. Inciden\u0163a maladiei este \u00een continu\u0103 cre\u015ftere \u015fi chiar s-a dublat pe parcursul ultimilor 6 ani, constituind 1,2:10000 locuitori, comparativ cu 0,6:10000 \u00een anul 2010, conform datelor Centrului Na\u0163ional de Management \u00een S\u0103n\u0103tate (anul 2016).<\/p>\n

Deoarece nu exist\u0103 metode de profilaxie primar\u0103, tratamentul cu insulin\u0103, pe m\u0103sur\u0103 ce asigur\u0103 supravie\u0163uirea propriu-zis\u0103 a persoanelor cu Diabet zaharat de tip 1, reprezint\u0103 totodat\u0103 \u015fi o provocare continu\u0103 la ac\u0163iuni din partea pacientului, familiei, comunit\u0103\u0163ii pe de o parte \u015fi a sistemului medical de cealalt\u0103 parte, pentru utilizarea ra\u0163ional\u0103 a resurselor,\u00eendreptate spre pre\u00eent\u00e2mpinarea dezvolt\u0103rii complica\u0163iilor specifice.<\/p>\n

\u00cen Republica Moldova problema Diabetului zaharat este abordat\u0103 la nivel \u00eenalt \u015fi \u00een conformitate cu Conven\u0163iile interna\u0163ionale este elaborat un Program Na\u0163ional, care se actualizeaz\u0103 o dat\u0103 la 5 ani \u015fi se deruleaz\u0103 \u00een a patra edi\u0163ie. Copiii au reprezentat permanent o categorie favorizat\u0103 \u015fi ocup\u0103 o pozi\u0163ie prioritar\u0103 \u00een asigurarea cu servicii medicale \u015fi remedii pentru tratament.<\/p>\n

Cre\u015fterea num\u0103rului de pacien\u0163i, precum \u015fi apari\u0163ia preparatelor noi, mai costisitoare de insulin\u0103 sub form\u0103 de analogi reprezint\u0103 o povar\u0103 economic\u0103 considerabil\u0103 pentru sistemul de s\u0103n\u0103tate din \u0163ara noastr\u0103. Pentru eficientizarea cheltuielilor financiare, Republica Moldova s-a aliniat cu succes \u00een implementarea obiectivelor dezvolt\u0103rii sustenabile promovate de Organiza\u0163ia Mondial\u0103 a S\u0103n\u0103t\u0103\u0163ii.<\/p>\n

Pe parcursul ultimilor 2 ani au fost realizate un \u015fir de m\u0103suri care au ameliorat cu mult situa\u0163ia copiilor cu Diabet zaharat \u015fi impactul acestei maladii asupra familiilor lor. Pentru tratament to\u0163i copiii beneficiaz\u0103 de cele mai moderne preparate de insulin\u0103 sub form\u0103 de analogi eliberate gratuit de la locul de trai \u015fi sunt asigura\u0163i cu glucometre, teste \u015fi lan\u0163ete suficiente pentru 5 analize zilnice. \u00cen sec\u0163ie de endocrinologie a Instititului Mamei \u015fi Copilului, unica de acest fel din \u0163ar\u0103, a fost modernizat\u0103 \u00eentreaga infrastructur\u0103 \u015fi s-au creat toate condi\u0163iile necesare pentru acordarea asisren\u0163ei medicale calificate acestor copii.<\/p>\n

Toate aceste m\u0103suri, \u00eentr-o perioad\u0103 destul de scurt\u0103 de timp, au reu\u015fit s\u0103 demonstreze o ameliorare considerabil\u0103 a gradului compens\u0103rii metabolismului glucidic exprimat printr-o sc\u0103dere \u00een medie cu 0,62% a valorii hemoglobinei glicozilate (HbA1c), de la 11,31% \u00een anul 2014 p\u00e2n\u0103 la 10,69% \u00een anul 2017. Conform rezultatelor renumitului studiu DCCT, reducerea cu 1% a nivelului HbA1c la pacien\u0163ii cu Diabet zaharat de tip 1 este echivalent\u0103 cu reducerea riscului retinopatiei diabetice cu 44%, a nefropatiei cu 25% \u015fi a neuropatiei cu 30%. Reducerea ratei acestor complica\u0163ii se va solda cu economii financiare considerabile pentru bugetul \u0163\u0103rii.<\/p>\n

O premier\u0103 absolut\u0103 pentru Republica Moldova a fost lansarea proiectului de reabilitare a copiilor cu Diabet zaharat. Timp de 2 ani consecutiv, un grup de copii cu v\u00e2rsta de la 2 p\u00e2n\u0103 la 15 ani, \u00een perioada de var\u0103 au beneficiat de un tratament de reabilitare la Centrul de Reabilitare pentru Copii \u201eSergheevca\u201d din Ucraina. Rezultatele tratamentului au fost evaluate \u00een studiul clinic retrospectiv \u015fi prospectiv \u015fi sunt expuse \u00een acest articol.<\/p>\n

Material \u015fi metode<\/strong><\/p>\n

Cu scopul analizei eficacit\u0103\u0163ii metodelor moderne de tratament \u015fi de abordare complex\u0103 a problemei de reabilitare a copiilor \u015fi adolescen\u015filor cu Diabet zaharat, au fost evaluate fi\u015fele medicale a 81 copii care au urmat tratament \u00een Centrul de Reabilitare pentru Copii \u201eSergheevca\u201d \u00een perioada 22.07-08.08.2017.<\/p>\n

Pe toat\u0103 perioada, contingentul de copii a fost supravegheat de 2 medici endocrinologi \u015fi 3 medici pediatri din cadrul Institutului Mamei \u015fi Copilului, iar copiii cu v\u00e2rsta de 2-7 ani au fost interna\u0163i cu unul din p\u0103rin\u0163i. Pentru studiu \u015fi analiza rezultatelor, copiii au fost diviza\u0163i \u00een 3 grupe de v\u00e2rst\u0103: 2-7 ani, 8-12 ani \u015fi 13-15 ani, \u00een total fiind 36 b\u0103ie\u0163i \u015fi 45 fete. Fiecare copil a efectuat minim c\u00e2te 5 glicemii zilnice cu adaptarea dozelor de insulin\u0103 \u00een dependen\u0163\u0103 de rezultate. Conform duratei maladiei, prezen\u0163ei complica\u0163iilor \u015fi a patologiilor concomitente au fost indicate urm\u0103toarele proceduri: aero-helio-talassoterapie-100%, aplica\u0163ii cu n\u0103mol-70%, laseroterapie-65%, masaj-100%, aeroinoterapie-100%, inhala\u0163ii-60%, ap\u0103 mineral\u0103 alcalin\u0103-100%. Copiii \u015fi p\u0103rin\u0163ii lor au fost instrui\u0163i \u00eentr-un ciclu de 5 lec\u0163ii dup\u0103 programul \u201e\u015ecoala diabetului\u201d, iar alimenta\u0163ia lor s-a efectuat conform necesit\u0103\u0163ilor fiziologice, cu oferirea posibilit\u0103\u0163ii de calculare a glucidelor prin metoda c\u00e2nt\u0103ririi bucatelor. \u00cen final s-au analizat nivelul hemoglobinei glicozilate, glicemiile medii pre- \u015fi postprandiale, doza zilnic\u0103 sumar\u0103 de insulin\u0103, frecven\u0163a hipoglicemiilor cu compararea datelor din primele \u015fi ultimele 3 zile de internare. Prelucrarea datelor s-a realizat cu programul Statistica 12.<\/p>\n

Rezultate<\/strong><\/p>\n

Structura grupelor \u015fi caracteristica lor dup\u0103 num\u0103r, v\u00e2rst\u0103, sex, durata \u015fi gradul de compensare a maladiei este redat\u0103 \u00een tabelul 1.<\/p>\n

Tabelul 1<\/strong><\/p>\n

Caracteristica general\u0103 a lotului de pacien\u0163i<\/strong><\/p>\n\n\n\n\n\n\n\n
<\/td>\nNum\u0103rul de copii<\/td>\nV\u00e2rsta medie, ani<\/td>\nSex<\/td>\nDurata bolii, ani<\/td>\nNivelul HbA1c, %<\/td>\n<\/tr>\n
b\u0103ie\u0163i<\/td>\nfete<\/td>\n<\/tr>\n
Grupul 1<\/p>\n

2-7 ani<\/td>\n

20<\/td>\n5,25\u00b11,5<\/td>\n11<\/td>\n9<\/td>\n2,1\u00b11,5<\/td>\n8,43\u00b11,97<\/td>\n<\/tr>\n
Grupul 2<\/p>\n

8-12 ani<\/td>\n

39<\/td>\n10,2\u00b11,2<\/td>\n17<\/td>\n22<\/td>\n3,7\u00b12,3<\/td>\n9,16\u00b11,93<\/td>\n<\/tr>\n
Grupul 3<\/p>\n

13-15 ani<\/td>\n

22<\/td>\n13,7\u00b10,9<\/td>\n8<\/td>\n14<\/td>\n3,9\u00b12,8<\/td>\n9,61\u00b12,64<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00cen studiu au fost inclu\u015fi doar copiii cu diagnostic de Diabet zaharat de tip 1\u015fi to\u0163i au urmat tratament cu analogi de insulin\u0103 Glargin, Detemir, Aspart \u015fi Glulisin dup\u0103 schema intensiv\u0103 cu corec\u0163ia dozelor \u00een dependen\u0163\u0103 de tabloul glicemic.<\/p>\n

Concomitent, din num\u0103rul total de copii, s-au apreciat complica\u0163ii ale Diabetului zaharat sub form\u0103 de lipodistrofie local\u0103 la 28 pacien\u021bi, nefropatie diabetic\u0103 \u00een faze incipiente la 3 copii, retinopatie diabetic\u0103 neproliferativ\u0103 la 2 copii, atropatie diabetic\u0103 la 2 \u015fi maladii asociate sub form\u0103 de tiroidit\u0103 autoimun\u0103 la 18 copii, boala celiac\u0103 la 1 pacient, astm bron\u015fic – 1 copil, infec\u0163ii respiratorii frecvente la 12 copii.<\/p>\n

\u00cen total pe parcursul a 18 zile s-au efectuat 8548 glicemii. Analiza indicatorilor din primele \u015fi ultimele 3 zile de tratament a demonstrat o sc\u0103dere a valorilor glicemiei \u00een medie cu 1 mmol\/l, de la 9,91\u00b11,94 mmol\/l p\u00e2n\u0103 la 8,98\u00b12,23 mmol\/l (p<0,01).<\/p>\n

Cele mai bune rezultate au fost ob\u0163inute \u00een grupa de v\u00e2rst\u0103 2-7 ani, unde valorile glicemiei medii au sc\u0103zut cu 1,6 mmol\/l de la 9,81\u00b11,91mmol\/l p\u00e2n\u0103 la 8,28\u00b12,03 mmol\/l (p<0,01), inclusiv a glicemiei \u201ea jeune\u201d de la 8,4 p\u00e2n\u0103 la 6,6 mmol\/l (p<0,01) \u015fi a glicemiilor postprandiale de la 8.9 p\u00e2n\u0103 la 7,4 mmol\/l (p<0,01) (Fig.1).<\/p>\n

Figura 1<\/p>\n

Evolu\u0163ia tabloului glicemic, v\u00e2rsta 2-7 ani<\/strong><\/p>\n

\"\"<\/a><\/p>\n

Acela\u015fi tablou a fost remarcat \u015fi \u00een grupul de copii cu v\u00e2rsta de 13-15 ani, la care s-a atestat o sc\u0103dere a glicemiei medii de la 8,54\u00b11,61 mmol\/l p\u00e2n\u0103 la 7,61\u00b11,85 mmol\/l (p<0,01), mai pu\u0163in a glicemiei \u201ea jeune\u201d \u015fi mai mult a glicemiilor postprandiale (Fig.2).<\/p>\n

Figura 2<\/p>\n

Evolu\u0163ia tabloului glicemic, v\u00e2rsta 13-15 ani<\/strong><\/p>\n

\"\"<\/a><\/p>\n

De\u015fi valorile glicemiei \u00een grupul de v\u00e2rst\u0103 medie la fel au sc\u0103zut de la 10,71\u00b11,69 mmol\/l p\u00e2n\u0103 la 10,35\u00b11,92 mmol\/l (p<0,01), aceast\u0103 tendin\u0163\u0103 a fost \u00eens\u0103 mai modest\u0103, dar \u00een schimb a sc\u0103zut comparativ mai mult fa\u0163\u0103 de celelalte grupe glicemia \u201ea jeune\u201d – de la 11,29 p\u00e2n\u0103 la 9,0 mmol\/l (p<0,05) (fig.3).<\/p>\n

Figura 3<\/p>\n

Evolu\u0163ia tabloului glicemic, v\u00e2rsta 8-12 ani<\/strong><\/p>\n

\"\"<\/a><\/p>\n

A fost remarcabil faptul c\u0103 \u00een toate grupele de v\u00e2rst\u0103 a sc\u0103zut frecven\u0163a episoadelor hipoglicemice \u015fi cel mai pronun\u0163at aceast\u0103 tendin\u0163\u0103 s-a \u00eenregistrat la copiii de 8-12 ani, la care s-au redus aproximativ de 2 ori episoadele totale de hipoglicemie \u015fi de 10 ori cele nocturne (Fig.4 \u015fi 5).<\/p>\n

Figura 4<\/p>\n

Frecven\u0163a episoadelor totale de hipoglicemie<\/strong><\/p>\n

\"\"<\/a><\/p>\n

Figura 5<\/p>\n

Frecven\u0163a episoadelor nocturne de hipoglicemie<\/strong><\/p>\n

\"\"<\/a><\/p>\n

Doza sumar\u0103 de insulin\u0103 s-a redus \u00een medie cu 19,2% la 38 copii, s-a majorat cu 13,8% la 26 copii \u015fi a r\u0103mas neschimbat\u0103 la 14 copii.<\/p>\n

Discu\u0163ii<\/strong><\/p>\n

Diabetul zaharat are un impact deosebit asupra copiilor, adolescen\u0163ilor \u015fi familiilor lor. Asigurarea cu servicii medicale de calitate \u015fi remedii pentru tratament nu rezolv\u0103 toate problemele cu care se confrunt\u0103 aceste persoane. Necesit\u0103\u0163ile de comunicare, instruire \u015fi suport psihologic sunt la fel de importante pentru ei \u00een \u00eencercarea de integrare \u00een societate.<\/p>\n

Este cunoscut c\u0103 \u00een r\u00e2ndul copiilor \u015fi tinerilor cu Diabet zaharat se remarc\u0103 cre\u015fterea frecven\u0163ei depresiei, anxiet\u0103\u0163ii, tulbur\u0103rilor psihice \u015fi de comportament alimentar [1], iar de ace\u015fti factori depinde \u00een primul r\u00e2nd aderen\u0163a la tratament. Pentru sistemul de s\u0103n\u0103tate este foarte important\u0103 utilizarea ra\u0163ional\u0103, cu maximum de eficien\u0163\u0103, a resurselor financiare, iar costurile preparatelor moderne de insulin\u0103, \u00eempreun\u0103 cu mijloacele de monitorizare a glicemiei, sunt pe deplin justificate doar odat\u0103 cu sporirea gradului de autoimplicare a copiilor \u015fi p\u0103rin\u0163ilor \u00een managementul propriei maladii.<\/p>\n

Toate aceste aspecte ale problemei Diabetului zaharat sunt imposibil de abordat \u00een deplin\u0103 m\u0103sur\u0103 la oricare din etapele acord\u0103rii asisten\u0163ei medicale. Anume din aceste considerente, mai multe organiza\u0163ii diabetologice locale \u015fi na\u0163ionale au creat centre pentru reabilitarea copiilor \u015fi adolescen\u0163ilor cu Diabet zaharat [2, 3]. Aceste centre, sus\u0163inute de profesioni\u015fti \u00een domeniul diabetologiei, \u00eentr-un mediu favorabil \u015fi sigur, ofer\u0103 copiilor \u015fi adolescen\u0163ilor, dar \u015fi p\u0103rin\u0163ilor lor, posibilitatea de comunicare cu semenii \u015fi \u00eencurajeaz\u0103 dezvoltarea responsabilit\u0103\u0163ii \u015fi independen\u0163ei \u00een rezolvarea problemelor zilnice.<\/p>\n

Metodele fizice de tratament \u00een majoritatea studiilor au demonstrat doar o influen\u0163\u0103 nesemnificativ\u0103 asupra nivelului hemoglobinei glicozilate [4-6], fiind efective doar pentru o perioad\u0103 scurt\u0103 de timp [7], ceea ce a fost demonstrat \u015fi \u00een studiul nostru. \u00cen cazul \u00een care devin o practic\u0103 regulat\u0103, metodele tratamentului de reabilitare, \u015fi-au demonstrat eficacitatea asupra sc\u0103derii hemoglobinei glicozilate, f\u0103r\u0103 cre\u015fterea riscului de hipoglicemii [8], la fel ca \u015fi \u00een studiul expus de noi.<\/p>\n

Efectul pozitiv al m\u0103surilor de reabilitare nu se reduce doar la \u00eembun\u0103t\u0103\u0163irea controlului glicemic, dar permite \u015fi un control mai bun al masei corporale, scade riscul cardiovascular \u015fi amelioreaz\u0103 starea general\u0103 [9-13]. La fel aceste metode de tratament sunt efective \u015fi pentru sc\u0103derea glicemiilor postprandiale [14], efect remarcat \u015fi de noi.<\/p>\n

Spre deosebire de alte studii asem\u0103n\u0103toare, studiul dat a reu\u015fit s\u0103 caracterizeze efectul tratamentului asupra copiilor de diferite v\u00e2rste. Se pare c\u0103 grupul de copii cu v\u00e2rsta \u00eentre 8 \u015fi 12 ani a avut mai pu\u0163in de beneficiat \u00een plan de sc\u0103dere a valorilor glicemiei, unica explica\u0163ie fiind adaptarea mai dificil\u0103 a acestor copii, dac\u0103 men\u0163ion\u0103m c\u0103 ei au fost interna\u0163i f\u0103r\u0103 p\u0103rin\u0163i.<\/p>\n

Sc\u0103derea dozei sumare de insulin\u0103 la majoritatea dintre copii, care la fel a fost studiat\u0103, \u00een paralel cu sc\u0103derea glicemiei medii, este un indicator suplimentar de eficacitate a tratamentului complex administrat.<\/p>\n

Concluzii:<\/strong><\/p>\n

    \n
  1. Utilizarea analogilor de insulin\u0103 \u00een tratamentul copiilor cu Diabet zaharat a permis \u00eembun\u0103t\u0103\u0163irea gradului de compensare a maladiei exprimat prin sc\u0103derea nivelului HbA1c \u00een medie cu 0,62% pe parcursul ultimilor 2 ani.<\/li>\n
  2. Tratamentul de reabilitare este benefic pentru copiii cu Diabet zaharat \u015fi poate fi indicat \u00een faza de compensare \u015fi subcompensare a maladiei, observ\u00eendu-se o dinamic\u0103 pozitiv\u0103 a parametrilor controlului glicemic exprimat prin sc\u0103derea glicemiei medii de la 9,91\u00b11,94 mmol\/l p\u00e2n\u0103 la 8,98\u00b12,23 mmol\/l, f\u0103r\u0103 cre\u015fterea riscului de hipoglicemie \u015fi cu o sc\u0103dere a dozei sumare de insulin\u0103 \u00een medie cu 19,2% comparativ cu doza ini\u0163ial\u0103.<\/li>\n
  3. Copiii de v\u00e2rst\u0103 mic\u0103, \u00eenso\u0163i\u0163i de p\u0103rin\u0163i \u015fi copii cu v\u00e2rsta mai mare de 12 ani s-au adaptat mai u\u015for \u015fi au avut un rezultat mai bun la tratament, demonstr\u00e2nd o sc\u0103dere a glicemiei medii cu 1,6 \u015fi respectiv 0,93 mmol\/l, iar pentru copiii cu v\u00e2rsta 8-12 ani, cu dificult\u0103\u0163i de adaptare la fel este oportun\u0103 internarea \u00eempreun\u0103 cu unul din p\u0103rin\u0163i.<\/li>\n
  4. Prezen\u0163a echipei multidisciplinare alc\u0103tuit\u0103 din speciali\u015fti endocrinologi, pediatri, psihologi, pedagogi \u015fi asisten\u0163i medicali este esen\u0163ial\u0103 pentru sporirea eficacit\u0103\u0163ii asisten\u0163ei acordate copiilor cu Diabet zaharat.<\/li>\n
  5. Astfel, ac\u021biunile \u00eentreprinse \u00een Republica Moldova \u00een ultimii 2 ani \u00een domeniul Diabetului zaharat la copii \u2013 asigurarea cu preparate de insulin\u0103 sub form\u0103 de analogi, asigurarea cu glucometre, teste \u015fi lan\u0163ete suficiente pentru 5 analize zilnice eliberate gratuit; renovarea infrastructurii \u015fi crearea condi\u0163iilor necesare pentru acordarea asisten\u0163ei medicale calificate, precum \u0219i lansarea proiectului de reabilitare a acestor copii sunt \u00een corespundere cu recomand\u0103rile OMS.<\/li>\n<\/ol>\n

    Bibliografie<\/strong><\/p>\n

      \n
    1. Delamater AM. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium: psychological care of children and adolescents with diabetes. Pediatric Diabetes 2009: 10 (Suppl. 12): 175\u2013184.<\/li>\n
    2. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium \/\/ Pediatric Diabetes. \u2014 2014. \u2014 Vol. 15, Suppl. 20. 1- 290 p.<\/li>\n
    3. Eiser C, Flynn M, Green E et al. Coming of age with diabetes: patients\u2019 views of a clinic for under-25 year olds. Diabet Med 1993: 10: 285\u2013289.<\/li>\n
    4. Roberts L, Jones TW, Fournier PA. Exercise training and glycemic control in adolescents with poorly controlled type 1 diabetes mellitus. J Pediatr Endocrinol 2002:15: 621\u2013627.<\/li>\n
    5. Sarnblad S, Ekelund U, Aman J. Physical activity and energy intake in adolescent girls with type 1 diabetes. Diabet Med 2005: 22: 893\u2013899.<\/li>\n
    6. Ligtenberg PC, Blans M, Hoekstra JB, van der Tweel I, Erkelens DW. No effect of long-term physical activity on the glycemic control in type 1 diabetes patients: a cross-sectional study. Neth J Med 1999: 55: 59\u201363.<\/li>\n
    7. Ruzic L, Sporis G, Matkovic BR. High volume-low intensity exercise camp and glycemic control in diabetic children. J Paediatr Child Health 2008: 44: 122\u2013128.<\/li>\n
    8. Herbst A, Bachran R, Kapellen T, Holl RW. Effects of regular physical activity on control of glycemia in pediatric patients with type 1 diabetes mellitus. Arch Pediatr Adolesc Med 2006: 160: 573\u2013577.<\/li>\n
    9. Santiprabhob J, Likitmaskul S, Sriwij itkamol A et al. Improved glycemic control among Thai children and young adults with type 1 diabetes participating in the diabetes camp. J Med Assoc Thai 2005: 88 (Suppl. 8): S38\u2013S43.<\/li>\n
    10. Post EM, Moore JD, Ihrke J, Aisenberg J. Fructosamine levels demonstrate improved glycemic control for some children attending a diabetes summer camp. Pediatr Diabetes 2000: 1: 204\u2013208.<\/li>\n
    11. Strickland AL, McFarland KF, Murtiashaw MH, Thorpe SR, Baynes JW. Changes in blood protein glycosylation during a diabetes summer camp. Diabetes Care 1984: 7: 183\u2013185.<\/li>\n
    12. Braatvedt GD, Mildenhall L, Patten C, Harris G. Insulin requirements and metabolic control in children with diabetes mellitus attending a summer camp. Diabet Med 1997: 14: 258\u2013261.<\/li>\n
    13. Miller AR, Nebesio TD, DiMeglio LA. Insulin dose changes in children attending a residential diabetes camp. Diabet Med 2011: 28: 480\u2013486.<\/li>\n
    14. Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet 2007: 369: 1481\u20131489.<\/li>\n<\/ol>\n

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Its incidence is steadily increasing globally and…<\/p>\n","protected":false},"author":1,"featured_media":6958,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"ngg_post_thumbnail":0},"categories":[6,5],"tags":[],"yoast_head":"\nMANAGEMENTUL CONTEMPORAN AL DIABETULUI ZAHARAT LA COPII \u015eI ADOLESCEN\u0162I - PRODIAB<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"http:\/\/prodiab.md\/ro\/managementul-contemporan-al-diabetului-zaharat-la-copii-si-adolescenti\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"MANAGEMENTUL CONTEMPORAN AL DIABETULUI ZAHARAT LA COPII \u015eI ADOLESCEN\u0162I - PRODIAB\" \/>\n<meta property=\"og:description\" content=\"Managementul contemporan al diabetului zaharat la copii \u015fi adolescen\u0163i Andrian CHIRIAC, Ina PALII, Sergiu GLADUN, Boris GOLOVIN, Ruxanda GLAVAN, Veaceslav MADONICI, Victoria MORAR, Valeriu E\u015eANU, Veronica E\u015eANU Summary Modern management of diabetes mellitus in children and adolescents Diabetes mellitus in children and adolescents is a progressive chronic disease. 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