Type 1 Diabetes in Children and Adolescents.

Abstract

Key Messages•Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis.•Management of pediatric diabetic ketoacidosis differs from diabetic ketoacidosis in adults because of the increased risk for cerebral edema. Pediatric protocols should be used.•Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise.Key Messages for People with Children and Adolescents with Diabetes•When a child is diagnosed with type 1 diabetes, the role of a caregiver becomes more important than ever. Family life and daily routines may seem more complicated in the beginning but, over time, and with the support of a diabetes team, these improve. Families discover that a child can have a healthy and fulfilling life with diabetes.Note: Unless otherwise specified, the term “child” or “children” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age. •Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis.•Management of pediatric diabetic ketoacidosis differs from diabetic ketoacidosis in adults because of the increased risk for cerebral edema. Pediatric protocols should be used.•Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise. •When a child is diagnosed with type 1 diabetes, the role of a caregiver becomes more important than ever. Family life and daily routines may seem more complicated in the beginning but, over time, and with the support of a diabetes team, these improve. Families discover that a child can have a healthy and fulfilling life with diabetes. Note: Unless otherwise specified, the term “child” or “children” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age. Diabetes mellitus is the most common endocrine disease and one of the most common chronic conditions in children. Type 2 diabetes and other types of diabetes, including genetic defects of beta cell function, such as monogenic and neonatal diabetes, are being increasingly recognized in children and should be considered when clinical presentation is atypical for type 1 diabetes (for additional details see Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome chapter, p. S10). This section addresses those areas of type 1 diabetes management that are specific to children. Children with new-onset type 1 diabetes and their families require intensive diabetes education by an interprofessional pediatric diabetes health-care (DHC) team that should include either a pediatric endocrinologist or pediatrician with diabetes expertise, dietician, diabetes nurse educator, social worker and mental health professional to provide them with the necessary skills and knowledge to manage this disease. The complex physical, developmental and emotional needs of children and their families necessitate specialized care to ensure the best long-term outcomes (1Glasgow A.M. Weissberg-Benchell J. Tynan W.D. et al.Readmissions of children with diabetes mellitus to a children's hospital.Pediatrics. 1991; 88: 98-104PubMed Google Scholar, 2von Sengbusch S. Muller-Godeffroy E. Hager S. et al.Mobile diabetes education and care: Intervention for children and young people with type 1 diabetes in rural areas of northern Germany.Diabet Med. 2006; 23: 122-127Crossref PubMed Scopus (0) Google Scholar). Education topics must include insulin action, administration and dosage adjustment; blood glucose (BG) and ketone monitoring; sick-day management and prevention of diabetic ketoacidosis (DKA); nutrition therapy; physical activity; and prevention, detection and treatment of hypoglycemia. Anticipatory guidance and healthy behaviour counselling should be part of routine care, especially during critical developmental transitions (e.g. daycare, school entry, adolescence). Health-care providers should regularly initiate discussions with children and their families about school, diabetes camp, psychological issues, fear of hypoglycemia, substance use, obtaining a driver's license and career choices. Behavioural interventions that have been applied broadly to clinic-based populations with a focus on improving self-efficacy and self-management skills have shown little benefit on improving glycemic control, but may improve caregiver coping skills and reduce parent-child conflict, emphasizing the need for a continuing programme of education (3Pillay J. Armstrong M.J. Butalia S. et al.Behavioral programs for type 1 diabetes mellitus: A systematic review and meta-analysis.Ann Intern Med. 2015; 163: 836-847Crossref PubMed Google Scholar, 4Price K.J. Knowles J.A. Fox M. et al.Effectiveness of the Kids in Control of Food (KICk-OFF) structured education course for 11–16 year olds with Type 1 diabetes.Diabet Med. 2016; 33: 192-203Crossref PubMed Scopus (4) Google Scholar, 5Basarir H. Brennan A. Jacques R. et al.Cost-effectiveness of structured education in children with type-1 diabetes mellitus.Int J Technol Assess Health Care. 2016; 32: 203-211Crossref PubMed Scopus (0) Google Scholar). Children with new-onset diabetes who present with DKA require a short period of hospitalization to stabilize the associated metabolic derangements and to initiate insulin therapy. Outpatient education for children with new-onset diabetes has been shown to be less expensive than inpatient education and associated with similar or slightly better outcomes when appropriate interprofessional resources to provide outpatient education on basic diabetes management are available (6Clar C. Waugh N. Thomas S. Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus.Cochrane Database Syst Rev. 2006; (CD004099)Google Scholar, 7Tonyushkina K.N. Visintainer P.F. Jasinski C.F. et al.Site of initial diabetes education does not affect metabolic outcomes in children with T1DM.Pediatr Diabetes. 2014; 15: 135-141Crossref PubMed Scopus (3) Google Scholar). Improved metabolic control reduces both the onset and progression of diabetes-related complications in adults and adolescents with type 1 diabetes (8The Diabetes Control and Complications Trial Research GroupThe effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.N Eng J Med. 1993; 329: 977-986Crossref PubMed Google Scholar, 9Diabetes Control and Complications Trial Research GroupEffect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes control and complications trial.J Pediatr. 1994; 125: 177-188Abstract Full Text Full Text PDF PubMed Scopus (1246) Google Scholar). Knowledge of glycemic targets by the child with diabetes and parents and consistent target setting by the diabetes health-care team have been shown to be associated with improved metabolic control (10Swift P.G. Skinner T.C. de Beaufort C.E. et al.Target setting in intensive insulin management is associated with metabolic control: The Hvidoere childhood diabetes study group centre differences study 2005.Pediatr Diabetes. 2010; 11: 271-278Crossref PubMed Scopus (62) Google Scholar). Aggressive attempts should be made to reach the recommended glycemic target outlined in Table 1; however, clinical judgement is required to determine which children can reasonably and safely achieve these targets without severe or recurrent hypoglycemia. Results from a large multicentre observational study found that glycated hemoglobin (A1C) targets of ≤7.5% can be safely achieved without an increase in the risk of severe hypoglycemia in children less than 6 years of age (11Maahs D.M. Hermann J.M. DuBose S.N. et al.Contrasting the clinical care and outcomes of 2,622 children with type 1 diabetes less than 6 years of age in the United States T1D Exchange and German/Austrian DPV registries.Diabetologia. 2014; 57: 1578-1585Crossref PubMed Scopus (0) Google Scholar). In some follow-up studies, episodes of severe hypoglycemia have been associated with poorer cognitive function, such as with memory and learning, whereas other studies have found that chronic hyperglycemia and glycemic variability in young children (ages 4 to 10 years) are associated with white matter structural changes and poorer overall cognitive performance (12Aye T. Barnea-Goraly N. Ambler C. et al.White matter structural differences in young children with type 1 diabetes: A diffusion tensor imaging study.Diabetes Care. 2012; 35: 2167-2173Crossref PubMed Scopus (26) Google Scholar, 13Barnea-Goraly N. Raman M. 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Treatment goals and strategies must be tailored to each child, with consideration given to individual risk factors.Table 1Recommended glycemic targets for children and adolescents with type 1 diabetesAge (years)A1C (%)Fasting/ preprandial PG (mmol/L)2-hour postprandial PG*Postprandial monitoring is rarely done in young children except for those on continuous subcutaneous insulin infusion (CSII) therapy for whom targets are not available. (mmol/L)Considerations<18≤7.54.0–8.05.0–10.0Caution is required to minimize severe or excessive hypoglycemia. Consider preprandial targets of 6.0–10.0 mmol/L as well as higher A1C targets in children and adolescents who have had severe or excessive hypoglycemia or have hypoglycemia unawareness.A1C, glycated hemoglobin; PG, plasma glucose.* Postprandial monitoring is rarely done in young children except for those on continuous subcutaneous insulin infusion (CSII) therapy for whom targets are not available. Open table in a new tab A1C, glycated hemoglobin; PG, plasma glucose. Insulin therapy is the mainstay of medical management of type 1 diabetes. A variety of insulin regimens can be used, but few have been studied specifically in children with new-onset diabetes. The choice of insulin regimen depends on many factors, including the child's age, duration of diabetes, family lifestyle, school support, socioeconomic factors, and family, patient, and physician preferences. Regardless of the insulin regimen used, all children should be treated to meet glycemic targets. The honeymoon period, which can last up to 2 years after diagnosis, is characterized by target glycemic control and low insulin requirements (<0.5 units/kg/day). At the end of this period, more intensive management may be required to continue meeting glycemic targets. Two methods of intensive diabetes management have been used: basal-bolus regimens (long-acting basal insulin analogues and rapid-acting bolus insulin analogues) and continuous subcutaneous insulin infusion (CSII) therapy. Basal-bolus therapy has resulted in improved control over traditional twice-daily neutral protamine Hagedorn (NPH) and rapid-acting bolus analogue therapy in some but not all studies (17Robertson K.J. Schoenle E. Gucev Z. et al.Insulin detemir compared with NPH insulin in children and adolescents with Type 1 diabetes.Diabet Med. 2007; 24: 27-34Crossref PubMed Scopus (0) Google Scholar, 18Chase H.P. Arslanian S. White N.H. et al.Insulin glargine versus intermediate-acting insulin as the basal component of multiple daily injection regimens for adolescents with type 1 diabetes mellitus.J Pediatr. 2008; 153: 547-553Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 19Pihoker C. Badaru A. Anderson A. et al.Insulin regimens and clinical outcomes in a type 1 diabetes cohort: The SEARCH for Diabetes in Youth study.Diabetes Care. 2013; 36: 27-33Crossref PubMed Scopus (32) Google Scholar). CSII is safe and effective and can be initiated at any age (20Phillip M. Battelino T. Rodriguez H. et al.Use of insulin pump therapy in the pediatric age-group: Consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes.Diabetes Care. 2007; 30: 1653-1662Crossref PubMed Scopus (200) Google Scholar, 21Levy-Shraga Y. Lerner-Geva L. Modan-Moses D. et al.Benefits of Continuous Subcutaneous Insulin Infusion (CSII) therapy in preschool children.Exp Clin Endocrinol Diabetes. 2013; 121: 225-229Crossref PubMed Scopus (7) Google Scholar, 22McMahon S.K. Airey F.L. Marangou D.A. et al.Insulin pump therapy in children and adolescents: Improvements in key parameters of diabetes management including quality of life.Diabet Med. 2005; 22: 92-96Crossref PubMed Scopus (0) Google Scholar). A Cochrane review found that CSII resulted in slightly improved metabolic control over basal-bolus therapy (23Misso M.L. Egberts K.J. Page M. et al.Continuous Subcutaneous Insulin Infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus.Cochrane Database Syst Rev. 2010; (CD005103)PubMed Google Scholar). Some clinic-based studies of CSII in school-aged children and adolescents have shown a significant reduction in A1C with reduced hypoglycemia 12 to 24 months after initiation of CSII when compared to pre-CSII levels (24Weinzimer S.A. Sikes K.A. Steffen A.T. et al.Insulin pump treatment of childhood type 1 diabetes.Pediatr Clin North Am. 2005; 52: 1677-1688Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar) or in the longer term when compared to controls on injections (25Johnson S.R. Cooper M.N. Jones T.W. et al.Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study.Diabetologia. 2013; 56: 2392-2400Crossref PubMed Scopus (0) Google Scholar). Young age, A1C at CSII initiation and number of daily boluses may be associated with improved or sustained near-normal metabolic outcome (26Overgaard Ingeholm I. Svensson J. Olsen B. et al.Characterization of metabolic responders on CSII treatment amongst children and adolescents in Denmark from 2007 to 2013.Diabetes Res Clin Pract. 2015; 109: 279-286Abstract Full Text Full Text PDF PubMed Google Scholar). The Sensor-Augmented Pump Therapy for A1C Reduction (STAR) 3 study demonstrated that sensor-augmented insulin-pump therapy was more effective in lowering A1C levels than multiple daily injections (MDI) in children with poorly controlled type 1 diabetes mellitus (27Bergenstal R.M. Tamborlane W.V. Ahmann A. et al.Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes.N Engl J Med. 2010; 363: 311-320Crossref PubMed Scopus (508) Google Scholar). Most, but not all, pediatric studies of the long-acting basal insulin analogues (detemir, glargine and degludec) have demonstrated improved fasting blood glucose (FBG) levels and fewer episodes of nocturnal hypoglycemia with a reduction in A1C (17Robertson K.J. Schoenle E. Gucev Z. et al.Insulin detemir compared with NPH insulin in children and adolescents with Type 1 diabetes.Diabet Med. 2007; 24: 27-34Crossref PubMed Scopus (0) Google Scholar, 28Alemzadeh R. Berhe T. Wyatt D.T. 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Karges B. et al.Improved metabolic control in children and adolescents with type 1 diabetes: A trend analysis using prospective multicenter data from Germany and Austria.Diabetes Care. 2011; 35: 80-86Crossref PubMed Scopus (109) Google Scholar). Insulin therapy should be individualized to reach A1C targets, minimize hypoglycemia and optimize quality of life. Self-monitoring of blood glucose (SMBG) is an essential part of management of type 1 diabetes, and increased frequency has been associated with better clinical outcomes (35Formosa N. Blood glucose monitoring in children and adolescents with type 1 diabetes mellitus.MMJ. 2013; 25: 31-35Google Scholar, 36Nordly S. Mortensen H.B. Andreasen A.H. et al.Factors associated with glycaemic outcome of childhood diabetes care in Denmark.Diabet Med. 2005; 22: 1566-1573Crossref PubMed Scopus (0) Google Scholar, 37Miller K.M. Beck R.W. Bergenstal R.M. et al.Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D exchange clinic registry participants.Diabetes Care. 2013; 36: 2009-2014Crossref PubMed Scopus (145) Google Scholar). Evidence of a strong association between frequency of SMBG and hemoglobin A1C levels has been found in T1D Exchange Clinic Registry participants (37Miller K.M. Beck R.W. Bergenstal R.M. et al.Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D exchange clinic registry participants.Diabetes Care. 2013; 36: 2009-2014Crossref PubMed Scopus (145) Google Scholar). Subcutaneous continuous glucose sensors allow detection of asymptomatic hypoglycemia and hyperglycemia. In some studies, use of continuous glucose monitoring (CGM) has resulted in improved glycemic control with less hypoglycemia (38Mauras N. Fox L. Englert K. et al.Continuous glucose monitoring in type 1 diabetes.Endocrine. 2013; 43: 41-50Crossref PubMed Scopus (44) Google Scholar, 39Rachmiel M. Landau Z. Boaz M. et al.The use of continuous glucose monitoring systems in a pediatric population with type 1 diabetes mellitus in real-life settings: The AWeSoMe Study Group experience.Acta Diabetol. 2015; 52: 323-329Crossref PubMed Scopus (8) Google Scholar, 40Hommel E. Olsen B. Battelino T. et al.Impact of continuous glucose monitoring on quality of life, treatment satisfaction, and use of medical care resources: analyses from the SWITCH study.Acta Diabetol. 2014; 51: 845-851Crossref PubMed Scopus (0) Google Scholar). In 1 larger randomized controlled trial of 322 adults and children, use of CGM was associated with improved glycemic control in adults but not in children and adolescents (41Tamborlane W.V. Beck R.W. Bode B.W. et al.The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study GroupContinuous glucose monitoring and intensive treatment of type 1 diabetes.N Engl J Med. 2008; 359: 1464-1476Crossref PubMed Scopus (826) Google Scholar). Glycemic benefit correlated with duration of sensor use, which was much lower in children and adolescents (42Matsuda E. Brennan P. The effectiveness of continuous glucose monitoring for type 1 diabetic adolescents using continuous subcutaneous insulin infusion pumps: A systematic review.JBI Database System Rev Implement Rep. 2014; 12: 88-120Crossref Scopus (0) Google Scholar). Recently, a built-in algorithm in an available CSII device with low glucose suspend feature has been shown to significantly lower overnight hypoglycemia (43Buckingham B.A. Raghinaru D. Cameron F. et al.Predictive low-glucose insulin suspension reduces duration of nocturnal hypoglycemia in children without increasing ketosis.Diabetes Care. 2015; 38: 1197-1204Crossref PubMed Scopus (57) Google Scholar, 44Maahs D.M. Calhoun P. Buckingham B.A. et al.A randomized trial of a home system to reduce nocturnal hypoglycemia in type 1 diabetes.Diabetes Care. 2014; 37: 1885-1891Crossref PubMed Scopus (65) Google Scholar). The closed-loop pancreas system, also known as the artificial or bionic pancreas system, is one of the most rapidly evolving areas of clinical care for type 1 diabetes. It couples the use of an insulin pump with infusion of 1 or more hormones (insulin +/- glucagon), a glucose sensor and an algorithm for glucose control. The closed-loop system allows for decreasing excursions in blood glucose levels while reducing the overall burden of self-care. However, the system must ensure patient safety as well as prevent the occurrence of severe hypo- and hyperglycemia, as well as DKA. Results from several studies are promising for outcomes combining a lowering of the number of hypoglycemic events while optimizing per cent time in target range for glucose, fasting blood glucose and mean sensor glucose (45Thabit H. Tauschmann M. Allen J.M. et al.Home use of an artificial beta cell in type 1 diabetes.New Engl J Med. 2015; 373: 2129-2140Crossref PubMed Scopus (0) Google Scholar). However, most studies are short term and assessed the closed-loop system in different clinical settings. Larger randomized clinical trials in adults and youth are currently underway. All children with type 1 diabetes should receive counselling from a registered dietitian experienced in pediatric diabetes. Children with diabetes should follow a healthy diet as recommended for children without diabetes in Eating Well with Canada's Food Guide (46Health Canada Eating well with Canada's food guide.http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/order-commander/eating_well_bien_manger-eng.phpDate: 2011Google Scholar). This involves consuming a variety of foods from the 4 food groups (grain products, vegetables and fruits, milk and alternatives, and meat and alternatives). Children with diabetes have been found to consume a diet that is similar to children without diabetes, one that is higher in fat and lower in fibre than guidelines recommend for healthy eating (47Mehta S.N. Volkening L.K. Quinn N. et al.Intensively managed young children with type 1 diabetes consume high-fat, low-fiber diets similar to age-matched controls.Nutr Res. 2014; 34: 428-435Crossref PubMed Google Scholar). Carbohydrate counting is a commonly used method of matching insulin to carbohydrate intake that allows increased flexibility in diet, although fat and protein content also influence postprandial glucose levels. There is no strong evidence that one form of nutrition therapy is superior to another in attaining age-appropriate glycemic targets. Nutrition therapy should be individualized (based on the child's nutritional needs, eating habits, lifestyle, ability and interest) and must ensure normal growth and development without compromising glycemic control. This plan should be evaluated regularly and at least annually. Features suggestive of eating disorders and of celiac disease should be systematically sought out (48Markowitz J.T. Butler D.A. Volkening L.K. et al.Brief screening tool for disordered eating in diabetes: Internal consistency and external validity in a contemporary sample of pediatric patients with type 1 diabetes.Diabetes Care. 2010; 33: 495-500Crossref PubMed Scopus (75) Google Scholar). Hypoglycemia is a major obstacle for children with type 1 diabetes and can affect their ability to achieve glycemic targets. Children with early-onset diabetes are at greatest risk for disruption of cognitive function and neuropsychological skills, but the respective roles of hypoglycemia and hyperglycemia in their development are still questioned (16Gaudieri P.A. Chen R. Greer T.F. et al.Cognitive function in children with type 1 diabetes: A meta-analysis.Diabetes Care. 2008; 31: 1892-1897Crossref PubMed Scopus (140) Google Scholar, 49Naguib J.M. Kulinskaya E. Lomax C.L. et al.Neuro-cognitive performance in children with type 1 diabetes–a meta-analysis.J Pediatr Psychol. 2009; 34: 271-282Crossref PubMed Scopus (0) Google Scholar). Significant risk of hypoglycemia often necessitates less stringent glycemic goals, particularly for younger children. There is no evidence in children that one insulin regimen or mode of administration is superior to another for resolving nonsevere hypoglycemia. As such, treatment must be individualized (50Garg S. Moser E. Dain M.P. et al.Clinical experience with insulin glargine in type 1 diabetes.Diabetes Technol Ther. 2010; 12: 835-846Crossref PubMed Scopus (0) Google Scholar). Frequent use of CGM in a clinical care setting may reduce episodes of hypoglycemia (51Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study GroupEffectiveness of continuous glucose monitoring in a clinical care environment: Evidence from the Juvenile Diabetes Research Foundation Continuous Glucose Monitoring (JDRF-CGM) trial.Diabetes Care. 2010; 33: 17-22Crossref PubMed Scopus (143) Google Scholar). Severe hypoglycemia should be treated with pediatric doses of intravenous dextrose in the hospital setting or glucagon in the home setting. In children, the use of mini-doses of glucagon has been shown to be useful in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate. A dose of 10 micrograms (mcg) per year of age (the equivalent of 1 unit on the syringe per year of age) (minimum dose 20 mcg (2 units), maximum dose 150 mcg (15 units)) is effective at treating and preventing hypoglycemia, with an additional doubled dose given if the BG has not increased in 20 minutes (52Hartley M. Thomsett M.J. Cotterill A.M. Mini-dose glucagon rescue for mild hypoglycaemia in children with type 1 diabetes: The Brisbane experience.J Paediatr Child Health. 2006; 42: 108-111Crossref PubMed Scopus (0) Google Scholar, 53Haymond M.W. Schreiner B. Mini-dose glucagon rescue for hypoglycemia in children with type 1 diabetes.Diabetes Care. 2001; 24: 643-645Crossref PubMed Google Scholar). Treatment of mild hypoglycemia is described in Table 2.Table 2Examples of carbohydrates for treatment of mild-to-moderate hypoglycemiaPatient age<5 yrs5 to 10 yrs>10 yrsAmount of carbohydrate5 g10 g15 gCarbohydrate Source Glucose tablet (4 g)12 or 34 Dextrose tablet (3 g)235 Apple or orange juice; regular soft drink; sweet beverage (cocktails)40 mL85 mL125 mL Open table in a new tab A careful multidisciplinary assessment should be undertaken for every child with chronically poor metabolic control (e.g. A1C >10%) to identify potential causative and associated factors, such as depression (54Kongkaew C. Jampachaisri K. Chaturongkul C.A. et al.Depression and adherence to treatment in diabetic children and adolescents: A systematic review and meta-analysis of observational studies.Eur J Pediatr. 2014; 173: 203-212Crossref PubMed Scopus (0) Google Scholar), eating disorders (55Young V. Eiser C. Johnson B. et al.Eating problems in adolescents with type 1 diabetes: A systematic review with meta-analysis.Diabet Med. 2013; 30: 189-198Crossref PubMed Scopus (0) Google Scholar), lower socioeconomic status, lower family support and higher family conflict (56Neylon O.M. O'Connell M.A. Skinner T.C. et al.Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: A systematic review.Diabetes Metab Res Rev. 2013; 29: 257-272Crossref PubMed Scopus (13) Google Scholar, 57Drotar D. Ittenbach R. Rohan J.M. et al.Diabetes management and glycemic control in youth with type 1 diabetes: Test of a predictive model.J Behav Med. 2013; 36: 234-245Crossref PubMed Scopus (15) Google Scholar), and to identify and address barriers to improved glycemic control. Use of a standardized measure of risk factors has been shown to identify those at high risk for poor control, emergency room visits and DKA (58Schwartz D.D. Axelrad M.E. Anderson B.J. A psychosocial risk index for poor glycemic control in children and adolescents with type 1 diabetes.Pediatr