Dear Editor,

We read the valuable comments and observations of Dr. Mahmood Al-Mendalawi about our paper1 with interest and thank him for his contribution to the discussion.

We agree with the comments about body mass index and the fact that the proper use of growth charts, especially using a population-based formula, are essential in conducting studies related to growth. In our study, the aim was to look for weight gain, which is expected with the use of multiple daily injections (MDIs). We used the World Health Organization growth charts because of the lack of local data.1

MDI has well documented favorable outcome on metabolic control of children with type 1 diabetes mellitus (T1DM) and even younger children.2,3 We mentioned in our study that despite all the benefits of the MDI insulin regimen, proper patient and family education was crucial in order to achieve better outcomes.1 This includes providing information on how lifestyle, feeding habits and the school environment can be modified.

Diabetes management needs a multidisciplinary approach for optimum care. The team should consist of a specialist physician, a diabetes nurse, a diabetic educator, a dietitian, a social worker, a podiatrist, and a psychiatrist.4 This team should have a proper and effective communication network within the health care system and the community. Most of the time, this team approach does not exist because of lack of human resources or unavailability of the services.

The confounding factors that can affect the introduction of the MDI regime in patients are noted and must be assessed before its introduction, but this should not deter the diabetologist from introducing the concept of MDIs to all families and assessing its suitability individually.

Typically, newly diagnosed children with T1DM have needle phobia; however, they usually overcome that fear with time. Using the smallest size lancet needles helps with this. Twice daily injections are associated with more fluctuations and excursions of blood glucose and poor glycated hemoglobin (HbA1c). Frequent blood glucose monitoring reinforces positive behaviors, such as meal planning and dosage adjustments, with less glycemic variability and optimum HbA1c target.5

Disclosure

No conflicts of interest, financial or otherwise, were declared by the author.

references

1. Sharef SW, Ullah I, Al-Shidhani A, Al-Farsi T, Al-Yaarubi S. Switching to multiple daily insulin injections in children and adolescents with type 1 diabetes: revisiting benefits from oman. Oman Med J 2015 Mar;30(2):83-89.
2. Vasudevan AR, Burns A, Fonseca VA. The effectiveness of intensive glycemic control for the prevention of vascular complications in diabetes mellitus. Treat Endocrinol 2006;5(5):273-286.
3. Reduced hypoglycemic episodes and improved glycemic control in children with type 1 diabetes using insulin glargine and neutral protamine Hagedorn insulin. J Pediatr 2003. Dec;143(6):737-740.
4. Alyaarubi S. Diabetes Care in Oman: Obstacles and solutions. Sultan Qaboos Univ Med J 2011. Aug;11(3):343-348
5. Davery B, Segal DG. Self monitoring of blood glucose measurements and glycemic control in a managed care paediatric type1 diabetes practice. S Afr Med J 2015;105(5):405-407.