Pediatric Diabetes Research Articles

An exploratory analysis of the impact of the COVID-19 pandemic on pediatric type 1 diabetes mellitus patient outcomes: A single-center study.

The COVID-19 pandemic led to substantial shifts in pediatric diabetes care delivery to virtual and hybrid models. It is unclear if these changes in care delivery impacted short-term patient outcomes. We aimed to explore glycemic control and other diabetes-related outcomes in children living with Type 1 Diabetes Mellitus (T1DM) during the first year of the COVID-19 pandemic at a tertiary pediatric academic center in Canada. Patients <18 years of age with a confirmed diagnosis of T1DM for at least one year were included. This was a retrospective chart review. We compared data from two years pre-pandemic (March 15, 2018-March 14, 2020) to the first year of the pandemic (March 15, 2020-March 14, 2021). The data assessed included glycemic control [Hemoglobin A1c (HbA1c)], diabetic ketoacidosis (DKA), hospital attendance and hospitalizations, hypoglycemia, and hyperglycemia. The generalized estimating equation (GEE) analysis was used to model potential factors affecting the HbA1c and diabetes-related morbidities. Multiple imputations were conducted as a sensitivity analysis. There were 346 eligible patients included in the study. The HbA1c remained stable during the pandemic compared to the pre-pandemic phase (MD-0.14, 95% CI, -0.28, 0.01; p = 0.058). The pandemic saw an increase in the number of newly diagnosed patients (X2 = 16.52, p < 0.001) and a higher number of newly diagnosed patients presenting in DKA (X2 = 12.94, p < 0.001). In patients with established diabetes, there was an increase in hyperglycemia (OR1.38, 95% CI, 1.12,1.71; p = 0.003) and reduced DKA (OR 0.30, 95% CI, 0.12,0.73; p = 0.009) during the pandemic compared to the pre-pandemic phase. Stable rates of hospitalization (OR0.57, 95% CI, 0.31,1.04, p = 0.068) and hypoglycemia (OR1.11, 95% CI, 0.83,1.49; p = 0.484) were noted. These results were retained in the sensitivity analysis. Glycemic control in children with T1DM remained stable during the first year of the pandemic. There were more newly diagnosed patients during the pandemic compared to the pre-pandemic phase, and more of these new patients presented in DKA. The latter presentation was reduced in those with established diabetes during the same period.Further studies are needed to assess the ongoing impact of the COVID-19 pandemic on T1DM care pathways and outcomes to allow children, families, and diabetes teams to personalize choices of care models.

Inequity in access to continuous glucose monitoring and health outcomes in paediatric diabetes, a case for national continuous glucose monitoring funding: a cross-sectional population study of children with type 1 diabetes in New Zealand

Continuous glucose monitoring (CGM) improves glycaemia for people affected by type 1 diabetes (T1D), but is not funded in Aotearoa/New Zealand. This study explores the impact of non-funded CGM on equity of access and associated glycaemic outcomes. Cross-sectional population-based study collected socio-demographic (age, gender, prioritised ethnicity, socioeconomic status) and clinical data from all regional diabetes centres in New Zealand with children <15 years with T1D as of 1st October 2021. De-identified data were obtained from existing databases or chart review. Outcomes compared socio-demographic characteristics between those using all forms of CGM and self-monitoring of blood glucose (SMBG), and association with HbA1c. 1209 eligible children were evaluated: 70.2% European, 18.1% Māori, 7.1% Pacific, 4.6% Asian, with even distribution across socioeconomic quintiles. Median HbA1c was 64mmol/mol (8.0%), 40.2% utilised intermittently scanned (is)CGM, and 27.2% real-time (rt)CGM. CGM utilisation was lowest with Pacific ethnicity (38% lower than Māori) and the most deprived socioeconomic quintiles (quintile 5 vs. 1 adjusted RR 0.69; 95% CI, 0.57 to 0.84). CGM use was associated with regional diabetes centre (P<0.001). The impact of CGM use on HbA1c differed by ethnicity: Māori children had the greatest difference in HbA1c between SMBG and rtCGM (adjusted difference-15.3mmol/mol; 95% CI,-21.5 to-9.1), with less pronounced differences seen with other ethnicities. Inequities in CGM use exist based on prioritised ethnicity and socioeconomic status. Importantly, CGM was independently associated with lower HbA1c, suggesting that lack of CGM funding contributes to health disparity in children with T1D. Australasian Paediatric Endocrine Group (APEG), Canterbury Medical Research Foundation, Starship Foundation.

Molar-incisor hypomineralisation prevalence in a cohort of Australian children with type 1 diabetes

PurposeSystemic diseases or drugs administered early in life may cause a disruption in amelogenesis and contribute to the qualitative defect of enamel described as molar–incisor hypomineralisation (MIH). Therefore, an increase in prevalence of MIH in children with type 1 diabetes (T1D) may be expected as this systemic disorder is commonly diagnosed in early childhood. The aim of this study was to determine the prevalence of MIH in a cohort of children with T1D and investigate diagnosis of MIH with T1D factors.MethodsCross-sectional study of children with T1D recruited from paediatric diabetes clinics at the Women’s and Children’s Hospital (South Australia). A detailed medical history, comprehensive dental and MIH examination according to the European Academy of Paediatric Dentistry (EAPD) long form classification was collected for each child. All upper and lower first permanent molars and central incisors were scored.ResultsA total number of 73 participants; 35 (47.95%) males were examined including 584 teeth. The mean age of the participants was 13.25 ± 2.58 years, with a mean age of diagnosis 7.75 ± 3.58 years, and a mean HbA1c of 8.5 ± 1.6%. 42 out of 73 children (54.8%) had enamel defects on at least one of the teeth examined. However, 19.2% met the criteria for MIH. Univariate and bivariate analyses were conducted but no significant associations were noted between MIH and risk factors including diabetes control (p > 0.1).ConclusionThere was a high prevalence of enamel defects and MIH amongst children with T1D. More research is required to establish association between T1D and MIH.

Psychometric validation of the MIND Youth Questionnaire (MY-Q) to assess quality of life in Spanish patients with type 1 diabetes between 12 and 25 years old

AimValidate in Spanish the Monitoring Individual Needs in Diabetes Youth Questionnaire (MY-Q), a multi-dimensional self-report HRQoL questionnaire designed for paediatric diabetes care. Design and methodsAfter translation, 209 patients diagnosed with type 1 diabetes, between 12 and 25 years old were assessed. The patients belonged to 12 hospitals in Spain. ResultsExploratory factor analysis including one-factor up to seven-factor solutions were tested. The three-factor solution (Negative Impact of Diabetes, Empowerment and Control of Diabetes and Worries) was the most parsimonious model with adequate fit: χ2(723)=568.856 (p<0.001), CFI=0.913, RMSEA=0.072 [0.064, 0.080], SRMR=0.075. The three-factor solution and the grouping of the items followed a clear rationale. Cronbach's alpha was 0.816 for Negative Impact, 0.700 for Empowerment and Control and 0.795 for Worries. The study of the relationship between the MY-Q dimensions and socio-demographics variables show a relationship between age and the MY-Q: F(6,410)=10.873 (p<0.001), η2=0.137. Participants younger than 14 years old showed greater scores on Empowerment and Control when compared to participants between 14 and 17 years old (p=0.021); statistically significant differences were found for the participants 18 years old or older, who showed lower levels of Worries than the younger patients. Concurrent validity found that the dimension of Negative Impact of Diabetes was positively related to WHO-5, and the PedsQL Diabetes Module. ConclusionThe Spanish version of the MY-Q to measure HRQoL in patients with type 1 diabetes between the ages of 12 and 25, has adequate psychometric properties and conceptual and semantic equivalence with the original version in Dutch.

Psychiatric Comorbidities in Pediatric Monogenic Diabetes due to GCK Mutation: Impact on Diabetes-Related Quality of Life.

Monogenic diabetes caused by mutation in the glucokinase gene (GCK-MD) is a rare disorder manifesting in childhood as mild, prevalent hyperglycemia. By consensus, it is managed by dietary supervision and infrequent consultations. However, its impact on the mental health of the affected children is largely unknown. To estimate the prevalence of psychiatric comorbidities in children with monogenic glucokinase-related diabetes (GCK-MD) and evaluate their association with quality of life (QoL). The study invited children with GCK-MD aged 5-18 years identified in the Central National Registry and treated in 3 pediatric diabetes centers in Poland. The control group comprised children with type 1 diabetes (T1D, the most common diabetes type in youth) matched for age and family history of diabetes. Participants underwent a semistructured clinical interview diagnostic for psychiatric comorbidities, questionnaires assessing behavioral problems, depressive symptoms, parental stress, and measuring general and diabetes-related QoL (PedsQl). We included 35 patients with GCK-MDMD and 199 with T1D. Eight (22.9%) GCK-MD patients were diagnosed with psychiatric disorder in their lifetime, compared with 16 (8.1%) in the T1D group (odds ratio 3.4 [95% confidence interval: 1.3-8.7]). Patients with GCK-MD showed better parent-reported general QoL (87.1±11.9 vs 82.0±14.0, P= 0.0060) and higher diabetes-related QoL in both parental (84.5±13.8 vs 74.1±15.2, P < 0.0001) and child's perspective (87.6±10.9 vs 77.3±13.9, P < 0.0001). Psychiatric disorders (+P) were associated with worse child-reported diabetes QoL (T1D+P 66.6±16.7, T1D-P 78.2±13.3, GCK-MD+P 79.6±16.3, GCK-MD-P 90.1±7.5, P= 0.0002). High prevalence of psychiatric disorders in children with GCK-MD and lower QoL emphasizes the need for psychologic surveillance in those otherwise mildly-treated patients.

LBODP084 Bilateral Cataracts In A 15-year-old Girl With New-onset Type 1 Diabetes Mellitus

Abstract Background Cataracts secondary to Type 1 or Type 2 Diabetes is not uncommon in adults, however, it is a rare finding in pediatrics patients with Type 1 Diabetes. Clinical Case A 15-year-old girl presented with progressively worsened bilateral vision for 6 months, however, vision rapidly deteriorated over the previous month, prompting visit to optometrist. No history of weight loss, however, did report 1.5 years of polydipsia, polyuria, and polyphagia. Outside optometrist reported concerns for cataracts. She presented to our Ophthalmology department one week later, who found bilateral cataracts with haziness in all layers and swollen lenses. Labs were done due to findings, glucose was 668 mg/dL with HbA1C &amp;gt;20%. She presented next day to ER, reported no symptoms other than blurry vision but was found to be in mild DKA with a venous pH of 7.285, Ketones 5.41 mmol/L, Glucose 480 mg/dL, and C-peptide 0.32 pmol/mL. Patient was started on insulin infusion at 0.1u/kg/hour and transitioned quickly to subcutaneous insulin. Pancreatic antibodies were significant for positive GAD65 and ZnT8 antibodies. She had cataract surgery for her left eye 1 week after presentation, found to have intumescent white cataract with "hand motion" vision. Vision in left eye is now 20/20 with plans to operate on the right eye in the near future. Literature Review: The prevalence of early diabetic cataracts in the pediatric population can range from 0.7%- 3.4% (1); and more common in female patients (2). Pathophysiology includes defect in the polyol pathway, combined with oxidative stress, leading to increased fluid retention (3). Treatment involves cataract surgery and improved glycemic control. Current ISPAD guidelines recommend initial evaluation for cataracts, and subsequent surveillance concomitant with diabetic retinopathy monitoring biennially with those with good glycemic control (4). Conclusion Diabetic cataracts are extremely rare in the pediatric population. However, diabetes should be considered as an etiology for juvenile cataracts. Given the rapid formation and severity of onset of bilateral cataracts for this patient, early and frequent ophthalmologic surveillance should be recommended for Type 1 diabetes pediatric population. Reference: 1. Šimunović, M, et al (2018). Cataract as early ocular complication in children and adolescents with type 1 diabetes mellitus. International Journal of Endocrinology, 2018, 1–6. 2. Lu, W. -L, et al (2020). High risk of early cataracts in young type 1 diabetes group: A nationwide cohort study. International Journal of Endocrinology, 2020, 1–8. 3. Pollreisz, A, et al (2010). Diabetic cataract pathogenesis, epidemiology and treatment. Journal of Ophthalmology, 2010, 1–8. 4. Donaghue, KC, et al (2018). ISPAD Clinical Practice Consensus Guidelines 2018: Microvascular and macrovascular complications in children and adolescents. Pediatric Diabetes, 19, 262–274. Presentation: No date and time listed

Evaluating Health Disparities in a Pediatric Population With Type 1 Diabetes

We sought to determine the association between SES and glycemic control in children with type 1 diabetes (T1D) followed at the Montreal Children’s Hospital (MCH), and whether insulin pump use, processes of care and depression modified the association. Using MCH’s Pediatric Diabetes Database, we conducted a retrospective cohort study of children ages 0 to 18 years diagnosed with T1D for at least a year with a visit between November 2019 and October 2020. Our outcome was mean glycated hemoglobin (HbA1c) in the following year.

Paediatric diabetes practice overview at a DGH hospital of east midlands deanery

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

Type 2 diabetes mellitus in children and young people; Single UK paediatric diabetes centre experience

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

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

Using language to empower joint diabetes decision making in the paediatric diabetes clinic

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

Recognising and raising safeguarding and child protection issues in childrens diabetes. Early findings from a qualitative study exploring specialist paediatric diabetes healthcare professionals' experiences

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

Diabete hi-tech

Recently, technological innovations have radically changed diabetes care. Insulin pumps and continuous glucose monitoring systems have significantly improved diabetes outcomes in both children and adults with Type 1 diabetes. For this reason, the major international associations recommend the use of technology in the management of Type 1 diabetes. The limitations of glycemic self-monitoring have prompted research to develop alternative techniques, favouring the expansion of continuous blood glucose monitoring systems (CGMs). CGM measures interstitial glucose through tiny sensors inserted in the subcutaneous tissue. Sensors can provide information in real time on the current glucose level and its trend. These data can be uploaded to the cloud and checked any time by doctors, patients and their caregivers. CGM can be combined with multiple daily injections (MDI) therapy or continuous subcutaneous insulin infusion (CSII). With CSII, basal insulin is supplied in the form of a continuous infusion and pre-meal bolus doses are calculated based on the meals’ carbohydrate content. A variety of insulin pumps is available, some of which can communicate with specific CGM devices, helping the patient to make better decisions about insulin dosing. This approach is known as sensor-augmented insulin pump therapy and it is the gold standard for the treatment of Type 1 diabetes in children and young adults, as recommended by the Italian Association of Paediatric Endocrinology and Diabetology. In the most recent systems, basal insulin delivery can be automatically modified through algorithms, based on CGM results, target glucose and the amount of active insulin, even though the patients still have to set the pre-meal insulin bolus manually. This system is defined as a partially hybrid closed-loop system, also known as artificial pancreas. Compared to MDI, CSII is associated with better control of blood glucose - measured by haemoglobin A1c and glycemic variability -, reduction of daily insulin requirement and an improvement of the quality of life. Psychophysical disabilities, language barriers or socio-economic disadvantage should not be considered limitations of CSII treatment as long as the caregiver is able to manage the therapy. Nowadays, MDI is recommended as first line therapy exclusively for those patients who do not want to use insulin pumps due to physical discomfort. The aim of this article is to provide updated information on the management of paediatric diabetes with modern technological devices for glucose monitoring and insulin delivery.

Prolonged lapses between pediatric and adult care are associated with rise in HbA1c and inpatient days among patients with type 1 diabetes

AimTo quantify the association between the duration of the pediatric-to-adult care transfer with glycemic control among patients with type 1 diabetes (T1D). MethodsThis retrospective cohort study included patients with T1D who completed transfer between pediatric and adult diabetes clinics at a single academic medical center between 2004 and 2020. The primary exposure was time from the last pediatric to first adult diabetes care encounter. The primary outcome was the average HbA1c in the first year after entry into adult care. ResultsA total of 449 patients (mean age at transfer 19.8yrs, 51.7 % male) were included for analysis. Transfer required a median of nearly 5 months (196 days; IQR:93–251) and in adjusted and unadjusted models was strongly associated with increased HbA1c within 1 year of transfer (0.19 %, 2 mmol/mol; 95 %CI:0.04 %-0.33 %) for each 6 months of latency. In secondary analyses, transfer latency also exhibited a significant association with days spent hospitalized (IRR 1.23 per 6 months; 95 %CI:1.08–1.33). ConclusionsOur findings isolate and quantify the impact of prolonged lapses in care associated with the pediatric-to-adult care transfer. These findings underscore the need for providers and healthcare systems to improve this care transition in order to improve outcomes for this vulnerable patient population.

21.2 Endocrinologist’s Perspective on the Integration of Behavioral Health Into a Pediatric Diabetes Center

Patients with chronic medical illness have a higher burden of psychiatric comorbidity. They also have more frequent visits with their subspecialist than with their primary care provider. As a result, the subspecialty practice has an opportunity to perform more frequent psychosocial assessments and also to provide more tailored support.

Diabetes-related antibody-testing is a valuable screening tool for identifying monogenic diabetes – A survey from the worldwide SWEET registry

AimsTo evaluate access to screening tools for monogenic diabetes in paediatric diabetes centres across the world and its impact on diagnosis and clinical outcomes of children and youth with genetic forms of diabetes. Methods79 centres from the SWEET diabetes registry including 53,207 children with diabetes participated in a survey on accessibility and use of diabetes related antibodies, c-peptide and genetic testing. Results73, 63 and 62 participating centres had access to c-peptide, antibody and genetic testing, respectively. Access to antibody testing was associated with higher proportion of patients with rare forms of diabetes identified with monogenic diabetes (54 % versus 17 %, p = 0.01), lower average whole clinic HbA1c (7.7[Q1,Q2: 7.3–8.0]%/61[56–64]mmol/mol versus 9.2[8.6–10.0]%/77[70–86]mmol/mol, p < 0.001) and younger age at onset (8.3 [7.3–8.8] versus 9.7 [8.6–12.7] years p < 0.001). Additional access to c-peptide or genetic testing was not related to differences in age at onset or HbA1c outcome. ConclusionsClinical suspicion and antibody testing are related to identification of different types of diabetes. Implementing access to comprehensive antibody screening may provide important information for selecting individuals for further genetic evaluation. In addition, worse overall clinical outcomes in centers with limited diagnostic capabilities indicate they may also need support for individualized diabetes management.Trial Registration: NCT04427189.

Monogenic diabetes clinic (MDC): 3-year experience

AimIn the pediatric diabetes clinic, patients with type 1 diabetes mellitus (T1D) account for more than 90% of cases, while monogenic forms represent about 6%. Many monogenic diabetes subtypes may respond to therapies other than insulin and have chronic diabetes complication prognosis that is different from T1D. With the aim of providing a better diagnostic pipeline and a tailored care for patients with monogenic diabetes, we set up a monogenic diabetes clinic (MDC).MethodsIn the first 3 years of activity 97 patients with non-autoimmune forms of hyperglycemia were referred to MDC. Genetic testing was requested for 80 patients and 68 genetic reports were available for review.ResultsIn 58 subjects hyperglycemia was discovered beyond 1 year of age (Group 1) and in 10 before 1 year of age (Group 2). Genetic variants considered causative of hyperglycemia were identified in 25 and 6 patients of Group 1 and 2, respectively, with a pick up rate of 43.1% (25/58) for Group 1 and 60% (6/10) for Group 2 (global pick-up rate: 45.5%; 31/68). When we considered probands of Group 1 with a parental history of hyperglycemia, 58.3% (21/36) had a positive genetic test for GCK or HNF1A genes, while pick-up rate was 18.1% (4/22) in patients with mute family history for diabetes. Specific treatments for each condition were administered in most cases.ConclusionWe conclude that MDC maycontribute to provide a better diabetes care in the pediatric setting.

Effect of Educational Intervention on Pediatric Diabetes self Care Practices

Effect of Educational Intervention on Pediatric Diabetes self Care Practices

The COVID-19 Pandemic Affects Seasonality, With Increasing Cases of New-Onset Type 1 Diabetes in Children, From the Worldwide SWEET Registry.

To analyze whether the coronavirus disease 2019 (COVID-19) pandemic increased the number of cases or impacted seasonality of new-onset type 1 diabetes (T1D) in large pediatric diabetes centers globally. We analyzed data on 17,280 cases of T1D diagnosed during 2018-2021 from 92 worldwide centers participating in the SWEET registry using hierarchic linear regression models. The average number of new-onset T1D cases per center adjusted for the total number of patients treated at the center per year and stratified by age-groups increased from 11.2 (95% CI 10.1-12.2) in 2018 to 21.7 (20.6-22.8) in 2021 for the youngest age-group, <6 years; from 13.1 (12.2-14.0) in 2018 to 26.7 (25.7-27.7) in 2021 for children ages 6 to <12 years; and from 12.2 (11.5-12.9) to 24.7 (24.0-25.5) for adolescents ages 12-18 years (all P < 0.001). These increases remained within the expected increase with the 95% CI of the regression line. However, in Europe and North America following the lockdown early in 2020, the typical seasonality of more cases during winter season was delayed, with a peak during the summer and autumn months. While the seasonal pattern in Europe returned to prepandemic times in 2021, this was not the case in North America. Compared with 2018-2019 (HbA1c 7.7%), higher average HbA1c levels (2020, 8.1%; 2021, 8.6%; P < 0.001) were present within the first year of T1D during the pandemic. The slope of the rise in pediatric new-onset T1D in SWEET centers remained unchanged during the COVID-19 pandemic, but a change in the seasonality at onset became apparent.

Poor glycemic control and associated factors among pediatric diabetes mellitus patients in northwest Ethiopia, 2020: facility-based cross sectional retrospective study design

Diabetes mellitus is a global public health problem. Glycemic control is a major public health problem. Diabetes results from elevated levels of glycaemia such as increased glucose and glycated hemoglobin, and controlling glycaemia is an integral component of the management of diabetes. Glycemic control in children is particularly difficult to achieve. Identifying determinants of poor glycemic control is important for early modification of diabetic related end organ damages. This study was aimed to assess the status of glycemic control and associated factors among pediatric diabetes mellitus patients in northwest Ethiopia. Facility-based cross sectional retrospective cohort study design was used and this study was conducted from September, 2015 to February, 2018. Simple random sampling was used to select 389 samples. Data were collected using an extraction checklist. Data were entered into Epi-data − 4.6, and analyzed using Stata-16. Finally, multivariable binary logistic regression was done. Poor glycemic control was more common among pediatric patients 39.3% (95% CI 34.6, 44.3). Treatment discontinuation (AOR 2.42, 95% CI 1.25, 4.69), age (AOR 1.15, 95% CI 1.03, 1.28) and treatment dose (AOR 0.96, 95 CI 0.92, 0.99) were significantly associated with poor glycemic control. Prevalence of poor glycemic control was high. Patient’s age, history of treatment discontinuation and dose of treatment were the significant contributing factors to poor glycemic control. These need to be addressed to attain the objective of adequate glycemic control.