Metabolic Control in Children with Diabetes Mellitus Who are Younger than

6 Years at Diagnosis: Continuous Subcutaneous Insulin Infusion as a First

Line Treatment?
Veronique Sulmont, MD, Pierre-Francois Souchon, MD, Cecile Gouillard-Darnaud, MD, Anna Fartura, MD,
Anne-Sophie Salmon-Musial, MD, Emeric Lambrecht, MD, Pierre Mauran, MD, PhD, and Michel Abely, MD, PhD
Objective To assess long-term metabolic outcomes in children with diabetes mellitus that was diagnosed when
they were <6 years old.

Study design A cohort of 66 children with diabetes mellitus that had a duration of at least 5 years and was diagnosed before they were 6 years old. Thirty-four children were treated at diagnosis with multiple daily subcutaneous
insulin injections (MDI), and all these children, except 3, were switched to continuous subcutaneous insulin infusion
(CSII; group A). Thirty-two children received CSII as initial treatment (group B).
Results Hemoglobin A1c values were significantly lower in patients receiving CSII than MDI during all the 8 years
of follow-up except one (year 1: 6.9%  0.9% versus 7.6%  1%, P = .011 ; year 4: 7.4%  0.8% versus 8.1% 
0.9%, P = .006; year 7: 7.6%  0.5% versus 8.3%  0.8%, P = .001). The incidence of severe hypoglycemia was
greatly decreased for the CSII group (9.8 versus 22.3 episodes/100 patient-years, P = .016). In group A, hemoglobin
A1c values increased during the study period, and in group B, they increased only during the first 2 years and remained constant thereafter. Only 9.1% of patients did not use or abandoned CSII.
Conclusion CSII in children <6 years of age enables better long-term metabolic control and lowers the risk of
severe hypoglycemia better than MDI, especially when initiated at diagnosis. (J Pediatr 2010;157:103-7).

nly 10 years ago, continuous subcutaneous insulin infusion (CSII) therapy was being used in children with type 1 diabetes mellitus as a last resort when adequate metabolic control could not be established, despite intensification of multiple daily subcutaneous insulin injections (MDI) regimens, or in patients with repeated episodes of severe hypoglycemia.
Technological improvements in the pumps and infusion sets have provided ease-of-use and comfort of CSII use. Numerous clinical studies have demonstrated safety and efficacy of CSII on short-term glycemic control evidenced by reduction in hemoblobin
(Hb) A1c levels,1,2 reduced frequency of severe hypoglycemia,3 and improved quality of life in adolescents, adults, and children.4,5
Insulin pumps are now widely accepted, and, in many countries, their cost is reimbursed for patients whose diabetes mellitus
remains insufficiently controlled with MDI. However, the use of insulin pumps as a first-line treatment at time of diagnosis remains poorly documented, and long-term results of such an approach remain scarce, especially in very young children.

Methods
This report describes the metabolic outcomes of 66 patients with type 1 diabetes mellitus with a duration of at least 5 years that
was diagnosed before the age of 6 years after 1995 who were observed at our institution. Thirty-four children received initial
treatment with MDI (group A), either because their diabetes mellitus was diagnosed in our unit before 1999 when CSII became
a first-line treatment (n = 16, 47%), or because they were referred to us by other hospitals after initial MDI treatment (n = 18,
53%). Initial insulin treatment consisted of 2 to 4 subcutaneous daily injections with regular and Neutral Protamine Hagedorn
insulin, mainly via pens. Some patients (n = 15) switched to rapid and long-acting insulin analogs after they became available.
All patients except 3 switched from MDI to CSII because of elevated HbA1c levels (>8%), despite an increase in the number of
daily insulin injections (n = 18), severe or frequent hypoglycemic episodes (n = 2), fear or weariness of performing the injections (n = 6), desire for greater flexibility in treatment (n = 2), food-induced behavioral problem (n = 1), or unstable diabetes
mellitus (n = 2). Thirty-two children were treated with CSII from the time of diagnosis, which in 1999, within our unit, became
the standard approach for all children <6 years of age (group B). After initial use
of regular insulin, patients were switched to rapid-acting insulin analog when
they reached 7 or 8 years of age.
From the Department of Pediatrics, American Memorial
Hospital, University Hospital of Reims, Reims, France

CSII
Hb
MDI

Continuous subcutaneous insulin infusion

Hemoglobin
Multiple daily subcutaneous insulin injections

Supported in part by Les amis de lAmerican Memorial

Hospital association and Champagne Ardenne Reseau
Diabe`te association. The authors declare no conflicts of
interest.
0022-3476/$ - see front matter. Copyright 2010 Mosby Inc.
All rights reserved. 10.1016/j.jpeds.2009.12.034

103

THE JOURNAL OF PEDIATRICS

www.jpeds.com

Vol. 157, No. 1

Table. Characteristics of the study cohort

Group

n
Initial therapy
Age at diagnosis (years)
HbA1c at diagnosis (%)
Ketoacidosis at diagnosis
Duration of diabetes mellitus (years)*

34
MDI
3.8  1.6
11.2  2
38%
9.6  2.9

32
CSII
3.2  1.5
10.3  1.1
36%
6.9  2.1

*P < .0001.

Data on basal and bolus insulin doses, height, weight, cutaneous reactions, severe hypoglycemia, hyperglycemia with
ketonemia, technical problems, illnesses, hospitalizations,
treatment satisfaction, patients and parents experiences,
and the wish to continue with the treatment were collected
from patients medical records.
In the case of patients wishing to change their treatment
modality, the reasons were recorded. In 2004, a survey was
carried out to evaluate the satisfaction of families after 5 years
experience of CSII in our unit. The families were asked about
their daily life with CSII (pump wearing, infusion set management, physical activity, school, childcare, and reactions
of the environment).
At each consultation, capillary blood samples were taken
and HbA1c levels were measured with the DCA 2000 analyzer
(Bayer, West Haven, Connecticut; reference range, 4.2%6.3%). The mean annual HbA1c level was calculated for
each year of diabetes mellitus duration. Analyses were performed to compare annual mean HbA1c levels when the
child received either MDI or CSII treatment and on 2 subgroups according to the first-line treatment they received at
time of diagnosis: MDI (group A) versus CSII (group B).
HbA1c levels measured during the 2 months after the switch
were not included in the mean calculation when MDI or CSII
periods were compared.
Data analysis was performed with XLStat 2007 software
(Addinsoft, Paris, France) and Epi Info software version
3.5.1 (Centers for Disease Control and Prevention, Atlanta,
Georgia). Continuous variables are displayed as arithmetical
means plus or minus SD; categorical variables are displayed
as frequencies or percentages. The incidence of acute events
is expressed as the number of events divided by cumulative
years of follow-up (episodes per 100 patient-years). Paired
t tests were used to analyze changes in continuous variables
with time. Differences between outcomes of subgroups
were tested with the student t test (2-tailed) and repeated
measures analysis of variance. The Mann-Whitney/Wilcoxon
2-sample test (Kruskal-Wallis test for 2 groups) was used
when the analysis of variance test was not appropriate.
A P level #.05 determined statistical significance.

Results
The 2 subgroups, A and B, were not significantly different at
diagnosis in age, HbA1c levels, and the proportion of ketoacidosis. Group A had a significantly longer diabetes mellitus
104

Figure 1. HbA1c levels according to duration of diabetes

mellitus and insulin treatment regimen for all patients. Values
are presented as means  SD. *P < .05.

history (Table). The 31 children who switched to CSII

treatment after initial treatment with MDI did so after an
average of 3.9  2.7 years of therapy, at an average age of
7.6  3.3 years.
Five boys and 1 girl (9.1%) abandoned CSII because of
a refusal to wear the system (n = 4), inability to manage treatment constraints (n = 1), or infusion set intolerance (n = 1).
CSII dropout rates were similar in groups A and B.
Mean annual HbA1c levels were significantly lower in patients treated with CSII compared with children treated with
MDI during the 8 years of follow-up, except in year 3 (P =
.054; Figure 1). During the first year, significantly more
children treated with CSII had a mean HbA1c level <6.5%,
compared with children receiving MDI (37% and 11%,
respectively; P = .046), with no significant difference in
total insulin dosage (0.63  0.2 IU/kg/d). During the
second year, mean HbA1c levels in patients in group B
were significantly lower than those in patients in group A
who had not yet switched to CSII (7.1%  0.8% versus
7.9%  1.1%, P = .011). Patients receiving MDI in group
A experienced significant increases in HbA1c levels in the
entire study period after the second year of diabetes
mellitus duration (r = 0.31, P = .003), and HbA1c values of
patients receiving CSII in group B remained constant
(Figure 2). Within group A, HbA1c values tended to be
lower in patients who changed to CSII compared with
patients who continued with MDI. The HbA1c reduction
reached statistical significance during years 4 (P = .015),
5 (P = .010), and 7 (P = .025) of diabetes mellitus duration
(Figure 2).
In the whole study population, pump treatment was associated with lower rates of severe hypoglycemia than MDI
(P = .016). In group A, the incidence of severe hypoglycemia
decreased from 22.3 episodes per 100 patient-years during the
MDI period to 12 episodes per 100 patient-years after
Sulmont et al

ORIGINAL ARTICLES

July 2010

Figure 2. HbA1c levels according to duration of diabetes

mellitus, insulin treatment regimen (MDI or CSII), and initial
treatment (group A or B). Values are presented as means 
SD. *P < .05.

changing to CSII. The incidence of severe hypoglycemia was

9.8 episodes per 100 patient-years in group B. The incidence
of ketoacidosis was not significantly different in the 2 groups
(3.4 and 2.4 episodes per 100 patient-years in groups A and B,
respectively) and remained comparable before and after
pump therapy in group A (3.9 for CSII and 2.8 episodes per
100 patient-years for MDI). Hospitalizations, mainly for
acute gastroenteritis, were recorded for 53% of MDI patients
and for 25% of CSII patients.
Twenty-two families participated in a diabetes mellitus
therapy survey in 2004. Only 5% of parents expressed difficulties in learning to use the pump, and 10% reported difficulties related to infusion set insertion. Ten percent of
families reported technical problems during school time
and physical activities. Twenty-five percent of families
found the pump unsightly, and 12% found it to be cumbersome. Twenty-five percent reported some degree of embarrassment surrounding CSII. CSII did not deter parents from
entrusting their children to friends or relatives for temporary care.

Discussion
Published randomized comparisons of CSII and MDI have
reported controversial results about metabolic control,6,7
and other studies tend to favor CSII in the incidence of severe
hypoglycemia and on various aspects of quality-of-life.8 Several observational or cohort studies have shown CSII to be
one of the strongest predictors of low HbA1c levels.9-12 In recent years, clinical trials investigating CSII in preschool-aged
children with diabetes mellitus have been numerous.13-18
However, these studies have been of relatively short duration,
and very few studies have dealt with CSII when initiated at

diagnosis.19-22 This study reports long-term metabolic control in patients with type 1 diabetes mellitus that was diagnosed before they were 6 years of age, depending on
whether initial treatment was with MDI or CSII.
Our findings reflect real-life progression of diabetes mellitus in an unselected cohort of young children. Group A (children initially treated with MDI) is heterogeneous in
treatment modality and reflects the historical use of CSII as
a last resort when other treatments failed. In contrast, group
B is a homogeneous group composed of 32 children <6 years
old in whom diabetes mellitus was consecutively diagnosed
and who were started on CSII treatment at the time of diagnosis. Our results show that the use of CSII as a first-line
treatment in young children is feasible in clinical practice
without patient selection and is well accepted by patients
and their parents. Few patients who began with CSII switched
to MDI. These data support earlier studies that reported that
no child refused CSII when this option was given at the time
of diagnosis and that no child chose to discontinue CSII during the 12- to 24-month study period.19,20 CSII as a first-line
treatment is an increasingly viable option in many countries,
especially for very young children, in whom it appears to be
safe and effective.23 In randomized parallel group studies of
children and adolescents with newly diagnosed type 1 diabetes mellitus, patients in the CSII treatment group showed
a greater treatment satisfaction when compared with MDI
treatment in 24 months.22,24 However, long-term data about
treatment satisfaction and disease perception are missing
when CSII is used at time of diagnosis compared with
MDI, especially in very young children, in particular at the
time of their adolescence.
In our cohort, we observed better HbA1c levels during the
first 2 years of diabetes mellitus in patients initially treated
with CSII than in similar patients who were started on
MDI. Our findings corroborate the study of De Beaufort et
al,21 but are in contrast with the studies of Pozzilli et al20
and Skogsberg et al,22 who showed no difference in metabolic
control between CSII and MDI treatment groups. This discrepancy could be explained by the difference in the modalities of the MDI treatment during the first 2 years (number of
injections, kind of insulin used). However, the children included in our study are younger, and consequently, most patients receiving MDI at time of diagnosis received 2 to 3
subcutaneous daily injections with ordinary and NPH insulin
because of clinical and regulatory limitations for more advanced regimens. After these first 2 years of diabetes mellitus,
the HbA1c levels in our patients using CSII at time of diagnosis did not significantly increase during the 6 following years.
In contrast, the metabolic control of patients with MDI treatment deteriorated, as shown by HbA1c levels that increased
with diabetes mellitus duration.10,25 Our findings suggest
that the transition from MDI to CSII treatment in group A
could have a long-term beneficial effect on patients HbA1c
levels. However, our data do not have sufficient power to
confirm it at all times of the study period. Further studies
are needed to investigate the hypothesis that the patients
and familys adaptation and confidence with CSII could be

Metabolic Control in Children with Diabetes Mellitus Who are Younger Than 6 Years at Diagnosis: Continuous
Subcutaneous Insulin Infusion as a First Line Treatment?

105

THE JOURNAL OF PEDIATRICS

www.jpeds.com

more difficult when it follows a long period of treatment

failures.26
We also observed fewer episodes of severe hypoglycemia in
the CSII group than in the MDI group, as observed by
Berghaeuser et al.23 In contrast, no difference in the incidence
of severe hypoglycemic events was found in randomized
studies performed in older children.21,22 The prevention of
such events through the use of effective therapeutic tools
from the time of diagnosis could play an important role in
the confidence and ability of parents to correctly adapt the
childs insulin dose without fear of causing hypoglycemia.27,28
In our practice, parents are educated to use the CSII with
flexibility for insulin dosage and number of boluses according to the variations in the childs appetite, or to correct hyperglycemia. This can play a role in maintenance of longterm good metabolic control and reductions in the frequency
of hospitalizations for intercurrent illness in children treated
with CSII. n
We thank all the pediatric team members for their assistance with this
work and for the care they provide to children and their families. We
thank Dr Fabien Vitry for providing statistical analysis advice and
Dr Barney Welsh and Christine Heslop for their assistance in editing
the manuscript for English. Finally, this study would not have been possible without the support of all patients and their families.
Submitted for publication May 3, 2009; last revision received Nov 3, 2009;
accepted Dec 17, 2009.
Reprint requests: Veronique Sulmont, MD, Service de pediatrie A American
memorial hospital, CHU Reims 49, rue Cognacq-Jay, F51092 Reims cedex,
France. E-mail: vsulmont@chu-reims.fr.

References
1. Plotnick LP, Clark LM, Brancati FL, Erlinger T. Safety and effectiveness
of insulin pump therapy in children and adolescents with type 1 diabetes.
Diabetes Care 2003;26:1142-6.
2. Colquitt JL, Green C, Sidhu MK, Hartwell D, Waugh N. Clinical and
cost-effectiveness of continuous subcutaneous insulin infusion for diabetes. Health Technol Assess 2004;8:iii, 1-171.
3. Boland EA, Grey M, Oesterle A, Fredrickson L, Tamborlane WV.
Continuous subcutaneous insulin infusion. A new way to lower
risk of severe hypoglycemia, improve metabolic control, and enhance
coping in adolescents with type 1 diabetes. Diabetes Care 1999;22:
1779-84.
4. Julusson PB, Graue M, Wentzel-Larsen T, Svik O. The impact of continuous subcutaneous insulin infusion on health-related quality of life in
children and adolescents with type 1 diabetes. Acta Paediatr 2006;95:
1481-7.
5. Jeitler K, Horvath K, Berghold A, Gratzer TW, Neeser K, Pieber TR, et al.
Continuous subcutaneous insulin infusion versus multiple daily insulin
injections in patients with diabetes mellitus: systematic review and metaanalysis. Diabetologia 2008;51:941-51.
6. Doyle EA, Weinzimer SA, Steffen AT, Ahern JAH, Vincent M,
Tamborlane WV. A randomized, prospective trial comparing the efficacy of continuous subcutaneous insulin infusion with multiple daily injections using insulin glargine. Diabetes Care 2004;27:1554-8.
7. Weintrob N, Benzaquen H, Galatzer A, Shalitin S, Lazar L, Fayman G,
et al. Comparison of continuous subcutaneous insulin infusion and
multiple daily injection regimens in children with type 1 diabetes: a randomized open crossover trial. Pediatrics 2003;112:559-64.
106

Vol. 157, No. 1

8. Pickup JC, Sutton AJ. Severe hypoglycaemia and glycaemic control in
type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med
2008;25:765-74.
9. Danne T, Battelino T, Kordonouri O, Hanas R, Klinkert C, Ludvigsson J,
et al. A cross-sectional international survey of continuous subcutaneous
insulin infusion in 377 children and adolescents with type 1 diabetes
mellitus from 10 countries. Pediatr Diabetes 2005;6:193-8.
10. Springer D, Dziura J, Tamborlane WV, Steffen AT, Ahern JH,
Vincent M, et al. Optimal control of type 1 diabetes mellitus in youth receiving intensive treatment. J Pediatr 2006;149:227-32.
11. Hanas R, Adolfsson P. Insulin pumps in pediatric routine care improve
long-term metabolic control without increasing the risk of hypoglycemia. Pediatr Diabetes 2006;7:25-31.
12. Jakisch BI, Wagner VM, Heidtmann B, Lepler R, Holterhus P,
Kapellen TM, et al. Comparison of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) in paediatric Type 1
diabetes: a multicentre matched-pair cohort analysis over 3 years. Diabet
Med 2008;25:80-5.
13. Eugster EA, Francis G. Position statement: continuous subcutaneous insulin infusion in very young children with type 1 diabetes. Pediatrics
2006;118:e1244-9.
14. Wilson DM, Buckingham BA, Kunselman EL, Sullivan MM,
Paguntalan HU, Gitelman SE. A two-center randomized controlled
feasibility trial of insulin pump therapy in young children with diabetes.
Diabetes Care 2005;28:15-9.
15. Alemzadeh R, Palma-Sisto P, Holzum M, Parton E, Kicher J. Continuous
subcutaneous insulin infusion attenuated glycemic instability in preschool children with type 1 diabetes mellitus. Diabetes Technol Ther
2007;9:339-47.
16. Fox LA, Buckloh LM, Smith SD, Wysocki T, Mauras N. A randomized
controlled trial of insulin pump therapy in young children with type 1
diabetes. Diabetes Care 2005;28:1277-81.
17. DiMeglio LA, Pottorff TM, Boyd SR, France L, Fineberg N, Eugster EA. A
randomized, controlled study of insulin pump therapy in diabetic preschoolers. J Pediatr 2004;145:380-4.
18. Berhe T, Postellon D, Wilson B, Stone R. Feasibility and safety of insulin
pump therapy in children aged 2 to 7 years with type 1 diabetes: a retrospective study. Pediatrics 2006;117:2132-7.
19. Ramchandani N, Ten S, Anhalt H, Sinha S, Ching J, Finkelstein A, et al.
Insulin pump therapy from the time of diagnosis of type 1 diabetes. Diabetes Technol Ther 2006;8:663-70.
20. Pozzilli P, Crino` A, Schiaffini R, Manfrini S, Fioriti E, Coppolino G, et al.
A 2-year pilot trial of continuous subcutaneous insulin infusion versus
intensive insulin therapy in patients with newly diagnosed type 1 diabetes (IMDIAB 8). Diabetes Technol Ther 2003;5:965-74.
21. de Beaufort CE, Houtzagers CM, Bruining GJ, Aarsen RS, den Boer NC,
Grose WF, et al. Continuous subcutaneous insulin infusion (CSII) versus conventional injection therapy in newly diagnosed diabetic children:
two-year follow-up of a randomized, prospective trial. Diabet Med 1989;
6:766-71.
22. Skogsberg L, Fors H, Hanas R, Chaplin JE, Lindman E, Skogsberg J. Improved treatment satisfaction but no difference in metabolic control
when using continuous subcutaneous insulin infusion vs. multiple daily
injections in children at onset of type 1 diabetes mellitus. Pediatr Diabetes 2008;9:472-9.
23. Berghaeuser MA, Kapellen T, Heidtmann B, Haberland H, Klinkert C,
Holl RW. Continuous subcutaneous insulin infusion in toddlers starting
at diagnosis of type 1 diabetes mellitus. A multicenter analysis of 104 patients from 63 centres in Germany and Austria. Pediatr Diabetes 2008;9:
590-5.
24. Slijper FM, De Beaufort CE, Bruining GJ, De Visser JJ, Aarsen RS, Kicken
DA, et al. Psychological impact of continuous subcutaneous insulin infusion pump therapy in non-selected newly diagnosed insulin dependent
(type 1) diabetic children: evaluation after two years of therapy. Diabetes
Metab 1990; 16:273277.
25. Gerstl E, Rabl W, Rosenbauer J, Grobe H, Hofer SE, Krause U, et al. Metabolic control as reflected by HbA1c in children, adolescents and young

Sulmont et al

ORIGINAL ARTICLES

July 2010
adults with type-1 diabetes mellitus: combined longitudinal analysis including 27,035 patients from 207 centers in Germany and Austria during
the last decade. Eur J Pediatr 2008;167:447-53.
26. Levine BS, Anderson BJ, Butler DA, Antisdel JE, Brackett J, Laffel LM.
Predictors of glycemic control and short-term adverse outcomes in
youth with type 1 diabetes. J Pediatr 2001;139:197-203.

27. Tupola S, Rajantie J, Akerblom HK. Experience of severe hypoglycaemia

may influence both patients and physicians subsequent treatment policy of insulin-dependent diabetes mellitus. Eur J Pediatr 1998;157:625-7.
28. Fanelli CG, Porcellati F, Pampanelli S, Bolli GB. Insulin therapy and hypoglycaemia: the size of the problem. Diabetes Metab Res Rev 2004; 20
Suppl 2S32S42.

50 Years Ago in THE JOURNAL OF PEDIATRICS

The Right Word in Search of a Doctor
White PJ. J Pediatr 1960;57:149-50

ark White, a pediatrician at Washington University School of Medicine, bemoaned the trend in medicine of mispronounced and misused words, outrageous conflicts between singular and plural, and other random linguistic sins. Whites examples seem quaint compared with current medico-literary catastrophes. Because medical training
involves much oral teaching and learning entitles one to teach, carrying the perfectionism essential to good medicine
into the realm of self-expression seemed logical to White in 1960, but is essential in our 21st century of shared care
and safety-first medicine.
Mispronounced words (eg, con-c
o-mittant, tympanic for tympanitic, heter-ah-ge-nous, gentamiacin) make one
wince. But rampant use of jargon and verbal pauses makes one worry about essential perfectionism. Consider this
Morning Report recitation, The kid wasnt peeing and was like really having trouble breathing. So we bolused
and CTed him. When the kid hit the floor, we rapid-responsed him and sent him to the unit.1 Could we have
confidence that this physician considered the possible causes of decreased urine output, such as oliguric renal failure,
inappropriate secretion of anti-diuretic hormone, or congestive myocardopathy before administering fluids, or excluded supraglottic airway obstruction or a compressive mediastinal mass before the patient was sedated, laid flat,
and lost to physician observation while in the radiology suite, or acted through good decision-making skills before
relinquishing responsibility to a critical-care team? Longs rule for language use is simpleif the word wouldnt
appear in a Case Record of The New England Journal of Medicine, dont use it. There are no kids in The New England
Journal of Medicine, nor do they pee, puke, or poop.
Verbal pauses, seemingly subcortical utterances (sleeping quietly in mothers arms, normocephalic, atraumatic,
99% in room air, pulmonary-wise, crackles not appreciated), are distracting and inefficient, but frequently are
admixed with important findings as if merely a courtroom recorders recitation. Please wake the sleeping baby to see
whether he is arousable and interactive, then report just that. Was the head circumference measured and is it normal?
Does the patient spend 1% of her time in something other than room air? Appreciate fine wine or music, report
cracklesyes or no. Chatter is related inversely to the presenters or listeners capability of deducing the few cardinal
features of the case.
The Kings English was demanded of us by our grade school teachers, families, and mentors. We are charged with
teaching physicians who will teach other physicians what we do or do not teach them. We seek clean English, not
erudition. When young physicians are prodded into the discipline of precise communication, the discipline of precise
thinking often is co-opted. To quote White, Of course when we are.sick, we should prefer to be in the care of the
doctor who knows most about etiology, diagnosis and therapy, however lacking he may be in syntax and orthoepy. But
surely it is not amiss to plead for graduates in medicine who will not be found careless in use of the language, any more
than in use of stethoscope, head mirror or electrocardiogram. or, we believe, of medical information, a diagnostic
test, device, or advice.
Sarah S. Long, MD
Daniel V. Schidlow, MD
Department of Pediatrics
St. Christophers Hospital for Children
Philadelphia, Pennsylvania
10.1016/j.jpeds.2010.01.051

Reference
1. DeGroot LJ, Siegler M. The morning-report syndrome and medical search. N Eng J Med 1979;301:1285-7.

Metabolic Control in Children with Diabetes Mellitus Who are Younger Than 6 Years at Diagnosis: Continuous
Subcutaneous Insulin Infusion as a First Line Treatment?

107