Parental Fear Of Hypoglycemia Research Articles

Evaluation of the possible impact of the fear of hypoglycemia on diabetes management in children and adolescents with type 1 diabetes mellitus and their parents: a cross-sectional study.

Hypoglycemia represents a significant source of anxiety for children with type 1 diabetes mellitus (T1DM) and their caretakers. Fear of hypoglycemia (FoH) was measured in children and adolescents with T1DM as well as in their parents using an established research instrument, the Hypoglycemia Fear Survey (HFS). This is a two-center, cross-sectional study involving 100 children and adolescents aged 6-18 years old diagnosed with T1DM. One parent of each child also participated in the study. The participants, who were recruited from two different pediatric endocrine outpatient clinics, were asked to complete the translated Greek version of the HFS, which includes one version for children (C-HFS) and one for parents (P-HFS). The association of the questionnaire responses with subjects' characteristics, such as current age, age at diagnosis, duration of diabetes, HbA1c levels, and mode of diabetes treatment were assessed. Parents exhibited significantly higher mean HFS scores than their children. No significant correlation was found between the P-HFS or the C-HFS scores and the age of the children, duration of diabetes, HbA1c, or mode of treatment. The finding that parents experience higher levels of FoH compared to their children emphasizes the importance of healthcare providers to screen parental FoH and focus on approaches to support them in order to reduce their psychological burden, thus optimizing children's diabetes management.

Fear of Hypoglycemia in Parents of Young Type 1 Diabetic Patients and Impact on Glycemic Control

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

The Relationship Between Parent Fear of Hypoglycemia and Youth Glycemic Control Across the Recent-Onset Period in Families of Youth with Type 1 Diabetes.

This study aims to examine the relationship between parents' fear of hypoglycemia (FH) over a 1-year period and child glucose metrics in 126 families of youth recently diagnosed with type 1 diabetes (T1D). Parents completed the Hypoglycemia Fear Survey for Parents (HFS-P) and uploaded 14days of glucose data at a baseline, 6-month, and 12-month assessment. Parents' HFS-P total and worry scores increased to a clinically meaningful degree from baseline to 6-month assessment, while multilevel models revealed within- and between-person variability in parents' HFS-P worry and behavior scores over time associated with child glycemia. Specifically, a significant negative relationship for within-person worry scores suggested that when parents reported higher than their average worry scores, their children recorded fewer glucose values in the target range, while within-person behavior scores suggested that when parents reported lower than their average behavior scores, their children recorded more values above the target range. There was also a negative relationship for between-person behavior scores with child glycated hemoglobin and a positive relationship for between-person behavior scores with child glucose values in the target range. In the recent-onset period of T1D, parental FH worry and behavior associated with child glycemia possibly due to changes in parents' perceptions of their child's hypoglycemia risk. The clinically meaningful increases in parent FH in the recent-onset period and the negative association for between-person behavior scores with child glycated hemoglobin suggest that clinics should consider screening parents for FH, especially among parents of children with lower glycemic levels.

Diabetes Technology and Therapy in the Pediatric Age Group.

Diabetes Technology and Therapy in the Pediatric Age Group.

Diabetes Technology and the Human Factor.

Diabetes Technology and the Human Factor.

The effect of do-it-yourself real-time continuous glucose monitoring on psychological and glycemic variables in children with type 1 diabetes: A randomized crossover trial.

BackgroundContinuous glucose monitoring (CGM) decreases fear of hypoglycemia (FOH) and improves glycemic control among those affected by type 1 diabetes (T1D). No studies to date have examined the impact of using do‐it‐yourself real‐time continuous glucose monitoring (DIY RT‐CGM) on psychological and glycemic outcomes.MethodsChild–parent dyads were recruited for a multicentre randomized crossover trial. Children with T1D were current intermittently scanned CGM (isCGM) users and aged 2–13 years. Families received either 6 weeks of DIY RT‐CGM with parental remote monitoring (intervention) or 6 weeks of isCGM plus usual diabetes care (control), followed by a 4‐week washout period, then crossed over. The primary outcome was parental FOH. Secondary outcomes were glycemic control using traditional CGM metrics, as well as a range of other psychosocial measures.FindingsFifty five child–parent dyads were recruited. The child mean age was 9.1 ± 2.8 years. Although, there was no effect on parental FOH, −0.1 (95%CI: −0.3, 0.1, p = 0.4), time‐in‐range (TIR) (%3.9‐10 mmol/L) was significantly higher with DIY RT‐CGM over isCGM (54.3% ± 13.7 vs. 48.1% ± 13.6), mean difference, 5.7% (95%CI 1.8, 9.6, p <0.004). There was no difference for time spent in hypoglycemia. Parent diabetes treatment satisfaction was significantly higher following DIY RT‐CGM compared to isCGM, mean difference 5.3 (95%CI: 2.3, 8.2, p <0.001).ConclusionThe use of DIY RT‐CGM versus isCGM did not improve parental FOH; however, TIR and parental satisfaction with diabetes treatment were significantly improved. This suggests in the short term, DIY RT‐CGM appears safe and may offer families some clinically important advantages over isCGM.

Sleep Habits of Early School-Aged Children with Type 1 Diabetes and Their Parents: Family Characteristics and Diabetes Management

ABSTRACT Study Objectives School-aged children with type 1 diabetes (T1D) and their parents are at risk for sleep disturbances, yet few studies have used objective measures to assess sleep characteristics in young children with T1D. Methods Forty children (ages 5–9) with T1D and their parents wore actigraph watches and completed sleep diaries for 7 nights. Parents also completed questionnaires about demographic information, diabetes distress, fear of hypoglycemia, and family routines. Children’s clinical data (HbA1c and blood glucose data) were extracted from the medical record. Results Most of the children and their parents obtained insufficient sleep. Based on actigraphy data, children slept an average of 7.9 hours/night and parents slept 6.7 hours/night, below the recommendations of 9–11 and 7–9 hours of sleep, respectively. Shorter child sleep latency was significantly associated with better glycemic levels, and parents’ sleep duration and efficiency were related to child’s glycemic levels. Parental fear of hypoglycemia and lack of family routines were associated with poorer sleep quality in parents and children, and with parental diabetes distress. Conclusions Sleep duration and quality is a modifiable target for potentially improving glycemic levels and parental distress in early school-aged children with T1D.

An Evaluation of Glucagon Injection Anxiety and Its Association with the Fear of Hypoglycemia among the Parents of Children with Type 1 Diabetes

Objective:Hypoglycemia is a common acute complication of type 1 diabetes (T1D), which may cause seizure, loss of consciousness, and temporary motor or sensory impairment. Glucagon administration is an effective way of treating severe hypoglycemia, especially in a free-living setting. Nonetheless, families have difficulties in managing severe hypoglycemia due to their anxiety and challenges with current glucagon administration techniques. The aim of the current study was to explore the associations between parental fear of hypoglycemia (FoH) and their general anxiety level, and in particular, their attitudes towards and thoughts on glucagon administration.Methods:Parents of children with T1D completed questionnaires assessing background and clinical information, FoH, generalized anxiety disorder (GAD) and parental anxiety for glucagon administration (PAGA).Results:Sixty-eight parents participated. Positive correlations were found between parental GAD-7 score and both FoH and the number of night-time blood glucose measurements and there was a negative correlation with the child’s age. Parents mean self-evaluation score of their competence in glucagon administration was 6 (standard deviation±2.9) on a scale of 0 to 10. Unsurprisingly, this score was negatively correlated with the PAGA scores. There was no significant difference between children using continuous glucose monitoring system and self-monitoring of blood glucose in terms of parental FoH, anxiety and misconceptions about glucagon administration.Conclusion:The results showed that parents of children with T1D had anxiety and fear connected with hypoglycemia and glucagon administration. Structured and practical training should be implemented to increase parents’ self-confidence including annual refresher training for home glucagon administration.

Challenges and Considerations for Reducing Diabetes Distress and Fear of Hypoglycemia in Parents of Youth With Type 1 Diabetes During the COVID-19 Pandemic.

Type 1 diabetes management can be challenging for children and their families. To address psychosocial concerns for parents of youth with type 1 diabetes, we developed two parent-focused interventions to reduce their diabetes distress and fear of hypoglycemia. Our team conducted several of these interventions during the early stages of the COVID-19 pandemic and recognized a need to make timely adjustments to our interventions. In this viewpoint article, we describe our experience conducting these manualized treatment groups during the pandemic, the range of challenges and concerns specific to COVID-19 that parents expressed, and how we adjusted our approach to better address parents’ treatment needs.

When Low Blood Sugars Cause High Anxiety: Fear of Hypoglycemia Among Parents of Youth With Type 1 Diabetes Mellitus

ObjectivesHypoglycemia is the most common acute complication of type 1 diabetes (T1D), and the potential short- and long-term sequelae can cause children and parents to develop significant fear of hypoglycemia (FOH). FOH and associated anxiety can be disruptive to activities of daily living and lead to reduced quality of life. We sought to determine the extent of FOH among parents of children with T1D within our clinic and to identify factors associated with greater FOH. MethodsTwo hundred sixty-four parents of youth (2 to 18 years of age; mean ± standard deviation, 12.4±3.5 years) with T1D completed a survey that included demographic and disease-specific questions, the Spielberger State-Trait Anxiety Inventory and the Hypoglycemia Fear Survey---Parent version (HFS-P). ResultsOf the 264 participants, 207 completed the full HFS-P, with a mean score of 67±19 (range, 31 to 119). The most frequent worries related to the child being hypoglycemic while alone or asleep. Higher HFS-P scores were also associated with more frequent and severe hypoglycemic episodes, higher state-trait anxiety scores, use of a continuous glucose monitor and more frequent blood glucose checks. Higher HFS-P scores were also associated with worse parental sleep quality and less parental engagement with treatment plans. ConclusionsParents of children with T1D experience FOH, especially during times of high vulnerability. Moreover, FOH could potentially impact clinical care (with parents being reluctant to administer suggested insulin doses) and quality of life (due to parental/child sleep disruption). Further studies are needed to develop and evaluate interventions aimed at reducing FOH in parents of youth with T1D.

Association between fear of hypoglycemia and physical activity in youth with type 1 diabetes: The SEARCH for diabetes in youth study.

Youth with type 1 diabetes (T1D) are encouraged to participate in physical activity (PA). Studies have identified fear of hypoglycemia (FOH) as a barrier to participating in PA. To examine (a) PA patterns in youth with T1D by age group and (b) the relationship between both parental and youth FOH and youth PA. A cross-sectional analysis from the SEARCH cohort study visit of youth ages 10 to 17 years with T1D (n = 1129) was conducted. Linear regression models estimated the association between self-reported number of days of vigorous PA (VPA) and moderate PA (MPA) and both youth- and parent-reported FOH. Multivariable models were adjusted for age, sex, race, duration of T1D, HbA1c, use of continuous glucose monitoring (CGM), recent severe hypoglycemia, primary insulin regimen, and BMI. Participants were 52% female, had mean (sd) age 14.4 (4.2) years, diabetes duration 7.5 years (1.8), HbA1c 9.2% (1.7). Older youth were less likely to engage in VPA (P < .01), or sports teams (P < .01), but more likely to engage in MPA (P < .01). Higher youth FOH (behavior subscale) was associated with increased levels of VPA (β (se) 0.30 (0.11), P = .01) but not significantly associated with MPA (P = .06). There was no statistically significant association between parental FOH and youth PA. In SEARCH participants with T1D, VPA, and team sports participation declined with age, while MPA increased. We observed that higher scores on the youth FOH behavioral subscale were associated with increased VPA levels, suggesting that FOH may be less of a barrier to PA than previously thought.

Feasibility and Acceptability of Physical Activity Monitoring as an Educational Tool in Management of Pediatric Type 1 Diabetes

ObjectivesThe spontaneous, sporadic and sometimes unpredictable nature of children's physical activity causes fluctuations in blood glucose level and challenges for children with type 1 diabetes. Physical activity monitoring has potential utility. In this study, we explored the perceptions of physical activity monitoring among health-care professionals and assessed the feasibility and acceptability of using it in the management of pediatric type 1 diabetes. MethodsSeven health-care professionals from 1 pediatric diabetes centre in the United Kingdom were involved in a focus group. Data were analyzed thematically. Physical activity monitoring using a wrist-worn monitor was tested for feasibility with 13 children aged 7 to 11 years with type 1 diabetes. The primary outcome was feasibility (i.e. recruitment, adherence, data completion, adverse events and acceptability). Secondary measures were glycemic control, parental self-efficacy for diabetes management and parental fear of hypoglycemia. ResultsHealth-care professionals valued having an awareness of the level, type and intensity of children’s physical activity. They identified unmet training and resource needs that would facilitate them in being able to give physical activity advice to children and families. Recruitment rate was 20%, adherence to the activity monitoring was good and the study completion rate was 62%. No adverse events were reported. Physical activity monitoring was considered acceptable by parents. ConclusionsPhysical activity monitoring could be a feasible part of routine clinical practice, but further research is needed to understand whether health-care professionals are best placed to implement it and what impact it has on health outcomes.

2251-PUB: Assessment of Fear of Hypoglycemia in a Large, Clinical Sample of Fathers of Children with Type 1 Diabetes

The Hypoglycemia Fear Survey-Parent (HFS-P) is the most commonly used questionnaire to assess parental worries and behaviors about low blood glucoses occurring in their children with T1D. The purpose of this study was to provide descriptive statistics on the HFS-P’s three subscales using a large clinical sample of fathers, data that are notably absent from the extant literature. As part of their child’s routine T1D clinic visits, 302 fathers completed the HFS-P, which comprises three subscales: Maintaining High Blood Glucose (BG), Worry/Helplessness About Low BG, and Worry About Negative Social Consequences. Higher scores indicate greater fear/worry about hypoglycemia. Child demographic and medical variables were extracted from medical records. Child characteristics were: 43% female; mean age = 15.1±3.3 yrs (range 10-22); mean A1C = 8.7±1.9%. Fathers’ were more likely to engage in maintaining high BG behaviors with younger children (r=-0.17, p&amp;lt;0.01). Fathers’ mean Maintaining High BG scores were significantly higher in 10-12 year olds (4.1±2.5) then in 13-17 year olds (3.4±2.6) and 18-22 years olds (3.2±2.6; F=3.01; p&amp;lt;0.05). There were no differences in mean Worry/Helplessness About Low BG or Worry About Negative Social Consequences scores by age group (ps=0.14 and 0.68, respectively). None of the three subscales was significantly correlated with glycemic control (ps&amp;gt;0.15). This is the first study to provide normative data for the three subscales comprising the HFS-P derived from a large clinical sample as all other studies have used research samples. Clinicians using the HFS-P to monitor worries and behaviors associated with hypoglycemia can use these data to assess fathers’ progress. These data also support other studies showing that glycemic control and fear of hypoglycemia are not related; although findings are generally mixed. This study adds to a growing body of literature on the importance of assessing fear of hypoglycemia in parents of children with T1D. Disclosure D.J. Amburgey: None. H. ODonnell: None. T. Gomer: None. T. Reznick-Lipina: None. S. Majidi: Advisory Panel; Self; Companion Medical. K.A. Driscoll: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (7K23DK091558-05)

1292-P: Continuous Glucose Monitor Use Protects against the Negative Impact of Fear of Hypoglycemia on Sleep Parameters in Adolescents with Type 1 Diabetes

Background: Adolescents with type 1 diabetes (T1D) are vulnerable to sleep difficulties that may negatively affect mental health and glycemic control. Fear of hypoglycemia (FOH) may contribute to these sleep problems. Although parental FOH has been associated with poor sleep quality in children with T1D, little is known about the relationship between adolescent FOH and sleep outcomes. Objective: To examine the association between adolescent FOH and sleep parameters and assess how continuous glucose monitor (CGM) use influences these relationships. Methods: Adolescents ages 14-18 years with T1D completed questionnaires evaluating FOH (Child Hypoglycemia Fear Survey) and sleep parameters (Pittsburgh Sleep Quality Index). Meaningful CGM use was defined as reporting using the device ≥ 50% of the time. Analyses included linear regression and T-tests. Results: One hundred adolescents (56 female) with a median (IQR) age of 16.3 (15.3,17.6) years and duration of T1D of 5.7 (2.5, 9.5) years completed surveys, and 45 used CGM. FOH was inversely associated with sleep duration (r=0.25, p=0.01) and quality (r=0.22 p=0.03), and positively associated with sleep disturbances (r=0.24, p=0.01). A stratified analysis showed that the inverse relationship between FOH and sleep duration (r=0.29, p=0.03), as well as the association with sleep disturbances (r=0.31, p=0.02) was only significant among those not using CGM. Furthermore, average sleep duration was longer in those using CGM [7.5 hours with CGM vs. 6.8 hours without, p=0.02] and the associations between FOH and sleep duration or disturbance were not significant among CGM users. Conclusions: Among adolescents with T1D, FOH is associated with reduced sleep duration, poor sleep quality and increased sleep disturbance. Our findings suggest that CGM use could mitigate the negative contribution of FOH on various sleep parameters in this population, a previously unrecognized benefit. Disclosure T.A. Hitt: None. J. Smith: None. E.L. Forth: None. P. Garren: None. D. Olivos-Stewart: None. M. De La Vega: None. F. Stuart: None. C.P. Hawkes: None. S.M. Willi: Advisory Panel; Self; Boehringer Ingelheim International GmbH. Research Support; Self; Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Tolerion, Inc. Other Relationship; Self; Caladrius Biosciences, Inc. J. Gettings: None.

1349-P: Sociodemographic and Clinical Factors Associate with Parental Fear of Hypoglycemia: Italian Nationwide Cross-Sectional Survey

Aim of this study was to evaluate the association of socio-demographic and clinical factors, including technologies used for diabetes management, and parental fear of hypoglycaemia (FOH) in parents of children (&amp;lt;18y) with T1D. A cross-sectional, nationwide electronic survey, supported by the Italian Society of Paediatric Endocrinology and Family Associations of children with diabetes, was conducted during September-November 2018. The Hypoglycaemia Fear Survey for Parents (HFS-P), a 25-item questionnaire, was used to assess FOH. Quintile regression analysis was performed to estimate factors associated to FOH. Out of 1450 questionnaires, 1106 (873 mothers) reported a complete HFS-P in both the worry and behavior subscales. Children median age was 11 y (IQR: 8-14), median diabetes duration 6 y (IQR: 3-10); median HbA1c 7.2% (IQR: 6.7-7.8). Glucose Sensor (including CGM and FGM) was used in 79% of patients and insulin pump in 45%. Median HFS-P worry score was 36 (IQR: 29-46), behavior score 29 (IQR: 24-33). Parental FOH was associated with parental modifiable and non-modifiable factors (Table 1). The use of insulin pump does not seem to impact worries and behaviors, while glucose sensor do influence parental behaviors. As the use of diabetes-advanced technologies is today increasingly widespread, the impact on parental FOH requires more analyses. Disclosure V. Cherubini: None. D. Pjetraj: None. R. Bonfanti: Advisory Panel; Self; Abbott, Lilly Diabetes, Medtronic, Novo Nordisk A/S, Roche Diabetes Care, Sanofi. M. Marino: None. A. Iannilli: None. F. Carle: None. R. Gesuita: None.

Camp-based multi-component intervention for families of young children with type 1 diabetes: A pilot and feasibility study

Managing type 1 diabetes mellitus (T1DM) in preschool-aged children has unique challenges that can negatively impact glycemic control and parental coping. To evaluate the impact of a camp-based multi-component intervention on glycated hemoglobin A1c (HbA1c) in young children with T1DM and psychosocial measures for their parents. Two separate cohorts of 18 children (ages 3-5 years) and their families participated in a camp-based intervention that included didactic and interactive parent education, child-centered education and family-based recreational activities. In Camp 1.0, measures of HbA1c, parental fear of hypoglycemia, mealtime behaviors and quality of life (QOL) were compared before and after an initial session (I) and follow-up booster session (II) 6 months later. Based on these results, the intervention was consolidated into 1 session (Camp 2.0) and repeated with additional measures of parental stress and parental self-efficacy with diabetes management tasks. Participants in Camp 2.0 exhibited a significant decrease in mean HbA1c level (-0.5%, P = .002) before and after camp. Mothers exhibited a significant improvement in diabetes-specific QOL (Camp 1.0/Session I and Camp 2.0) and reduction in stress as measured on the Pediatric Inventory for Parent (PIP) assessment (Camp 2.0). The booster session in Camp 1.0 showed no added benefit. A family centered, camp-based multi-component intervention in young children with T1DM improved HbA1c and perceived QOL and stress in their mothers.

Sleep in children with type 1 diabetes and their parents in the T1D Exchange

ObjectivesSleep has physiological and behavioral impacts on diabetes outcomes, yet little is known about the impact of sleep disturbances in children with type 1 diabetes. The current study sought to characterize sleep in children with type 1 diabetes and in their parents and to examine the associations between child sleep, glycemic control and adherence, parent sleep and well-being, parental fear of hypoglycemia, and nocturnal caregiving behavior. MethodsSurveys were emailed to parents of 2- to 12-year-old participants in the Type 1 Diabetes (T1D) Exchange clinic registry. Clinical data were obtained from the registry for the 515 respondents. ResultsIn our sample, 67% of children met criteria for poor sleep quality. Child sleep quality was related to glycemic control (HbA1c of 7.9% [63 mmol/mol] in children with poor sleep quality vs 7.6% [60 mmol/mol] in children with non-poor sleep quality; P < 0.001) but not mean frequency of blood glucose monitoring (BGM) (7.6 times/day vs 7.4 in poor/non-poor quality; P = 0.56). Associations were similar for sleep duration. Children with poor sleep quality were more likely to experience severe hypoglycemia (4% in children with poor sleep quality vs 1% in children with non-poor sleep quality; P = 0.05) and more likely to experience DKA (7% vs 4%, respectively; P < 0.001). Poorer child sleep quality was associated with poorer parental sleep quality, parental well-being, and fear of hypoglycemia (P < 0.001 for all). Child sleep was not related to the use of diabetes-related technology (CGM, insulin pump). ConclusionsSleep may be a modifiable factor to improve glycemic control and reduce parental distress.

Fear of Hypoglycemia, Parenting Stress, and Metabolic Control for Children with Type 1 Diabetes and Their Parents.

This study sets out to extend current knowledge of parenting stress and fear of hypoglycemia (FoH) in parents of children with type 1 diabetes mellitus (T1DM). We examined if the relationship between parental and children's FoH and metabolic control, as reflected by HbA1c, is mediated by parenting stress. A total of 63 parents and children with T1DM were recruited during their routine physician's appointment. Parents completed questionnaires on parenting stress and FoH. Children eight years and older also completed a questionnaire on FoH. HbA1c values were obtained from all children. Mediation analysis revealed an indirect association between parental FoH and HbA1c values through parenting stress (Sobel's z = 2.42, p = .02), but no indirect association between children's FoH and HbA1c. We concluded that parental FOH has an indirect association with the child's metabolic control that is mediated by parenting stress. More simply, fear of hypoglycemia predicts parent stress, which in turn, predicts metabolic control.

Fear of hypoglycemia, anxiety, and subjective well-being in parents of children and adolescents with type 1 diabetes.

This study explored the association between parental fear of hypoglycemia, anxiety, and subjective well-being in parents of children and adolescents with type 1 diabetes. A total of 120 mothers and 79 fathers participated. Mothers' and fathers' fear of hypoglycemia was significantly associated with anxiety and negative affect as well as with worse glycemic control in child. Paired-samples t-test showed that mothers were more involved in diabetes management and reported more fear and anxiety compared to fathers, but they did not differ in worries about hypoglycemia. The findings suggest screening for fear of hypoglycemia and subjective well-being in all parents regardless of whether their child experienced severe hypoglycemia.

Fear of hypoglycemia in parents of children with type 1 diabetes.

The aim of this study is to determine if parental hypoglycaemia fear is associated with worse glycaemic control and increased resource utilisation and to identify risk factors for increased hypoglycaemia fear. Parents of children with diabetes completed a modified Hypoglycaemia Fear Survey. Demographic data, phone contacts and mean glycosylated haemoglobin A1c (HbA1c) were also recorded over a 1 year study period. A total of 106 parents participated. Mean patient age was 11.1 years, and duration of diabetes was 4.8 years. Fifty-two per cent were male, and 48% were on insulin pump therapy. Fear of hypoglycaemia was highest among parents of 6- to 11-year-olds. Parents of children with HbA1c less than 7.5% had less hypoglycaemia fear. Previous seizures and increased frequency of phone calls to the diabetes team were not associated with increased fear. Fear of hypoglycaemia is associated with worse glycaemic control. It is highest among parents of 6- to 11-year-olds but is not affected by previous severe hypoglycaemia or associated with increased contact with the diabetes team.