Pediatric Type 1 Diabetes Research Articles

Underrepresented Voices: Impacts of Social Determinants of Health on Type 1 Diabetes Family Management in Single-Parent, Black Families

ObjectivesSocial determinants of health (SDOH) impact families’ ability to manage chronic illnesses such as type 1 diabetes (T1D). Black, single parents have unique SDOH-related resource needs and concerns when caring for a child with a chronic illness, yet their voices are underrepresented in the pediatric T1D literature. The aim of this qualitative study was to identify and explore the SDOH that influence T1D management in Black, single-parent families. MethodsIn this 2-phase qualitative study we used content analysis to explore themes derived from 3 nominal group technique sessions and semistructured interviews, with 20 self-identified Black, single parents of a child with T1D. ResultsParents encountered various SDOH-related issues that negatively influenced management of their children’s T1D. Six major themes emerged from the parent-generated list of SDOH-related barriers: 1) lack of parent and child emotional and physical support systems, 2) maintaining parent and child’s physical and mental health, 3) pain management with medication administration, 4) clinical team empathy, 5) provider communication, and 6) economic burden of food costs. ConclusionsThese exploratory findings contribute to the knowledge base required to guide development of culturally relevant, individual- and population-level interventions for racially and compositionally minority families, to increase health equity and address racial health disparities in T1D. Routine assessment of family social support context and resources, better integration of community-level social services into clinical health encounters and clinician bias and communication training are advised starting points to address the specific needs of racial and ethnic minority families experiencing the greatest social and clinical challenges.

986-P: Children with Type 2 Diabetes (T2D) Have Altered Arginine Metabolism

To investigate arginine metabolism in pediatric T2D, we measured fasting amino acid levels in 28 children (T2D: n=13, healthy controls [H/C]: n=15) . In the T2D group, the mean HbA1c was 8.5 ± 3.4%, with mean diabetes duration of 2.7 ± 2.4 years, and mean BMI percentile higher (98.5 ± 1) than in H/C (71.5 ± 32.6, p=0.006) . There were no statistical differences between T2D and H/C in age (16.4 ± 0.8 years) , sex (46% female) , race/ethnicity (61% Hispanic, 21% Black, 18% non-Hispanic White) , or protein intake in the preceding day (64 ± 30.5 gram) . We found lower fasting arginine (77 ± 21.9 vs. 97.2 ± 15.9 μmol/L, p=0.01) , citrulline (a precursor of arginine) (21.1 ± 7.3 vs. 27.8 ± 5.5 μmol/L, p=0.01) , and glutamine (a precursor of citrulline) (424.6 ± 64.7 vs. 539.5 ± 76.3, p=<0.001) levels in children with T2D vs. H/C. The difference in fasting arginine levels was even more significant (72.6 ± 15.6 in the T2D group vs. 97.2 ± 15.9 μmol/L in controls, p<0.001) after removal of a T2D group outlier identified by Grubb’s test (outlier: 130 vs. the rest: 72.6 ± 15.6 μmol/L) . There were no differences in ornithine, proline, and ADMA levels between the groups (Figure 1) . In conclusion, children with T2D have a unique metabolomic signature in regard to arginine metabolism. Since arginine plays important roles in regulating both insulin secretion and sensitivity, our findings may provide mechanistic insight into T2D pathophysiology and opportunities for precision therapy. Disclosure M. Tosur: Advisory Panel; Provention Bio, Inc. S. Deen: None. M.J. Redondo: Advisory Panel; Provention Bio, Inc. F. Jahoor: None. A. Balasubramanyam: None. Funding Texas Children's Hospital Pilot Grant

The Genetics of Type 2 Diabetes in Youth: Where We Are and the Road Ahead

The Genetics of Type 2 Diabetes in Youth: Where We Are and the Road Ahead

980-P: Continuous Glucose Monitor Improves Glycemic Control in Youth-Onset Type 2 Diabetes

Background: Youth with type 2 diabetes (T2D) develop early treatment failure. Most patients do not self-monitor blood glucose (SMBG) levels at recommended frequency. Continuous glucose monitor (CGM) has been shown to improve glycemic control in pediatric T1D and adult T2D. Its feasibility and efficacy in youth-onset T2D is unknown. Hypothesis: Participants who wear the CGM >85% of the time will lower their HbA1c by at least 0.5%. Methods: T2D patients prescribed insulin were eligible to participate if their HbA1c was at least 8%. Participants were randomized to 3-months of SMBG or Dexcom G6 CGM, followed by 3 months of washout (SMBG) and 3-month crossover to the other treatment arm. Participants and their clinical providers agreed to not start new diabetes medications but could adjust insulin dosing or add on rapid-acting insulin if HbA1c >9% at follow-up. A nurse care manager provided coaching for the first 30 days of CGM use. The CGM-SAT satisfaction survey was administered at the end of CGM wear. Student t-test and Fisher’s exact test were used to compare differences in continuous and categorical variables between groups, respectively. A 5% level of significance was used. Results: out of 14 participants completed the study. Our cohort was 55% female. At enrollment, mean age was 17.4±2.0 years, diagnosis duration was 4.0±2.8 years, and HbA1c was 11.5±2.5%. The percentage of days with CGM data trended from 89% down to 73% between the 1st and 3rd month of CGM use (not statistically significant) . CGM use lowered HbA1c by 2.8% for the cohort (SMBG: -0.1%, CGM: -3.1%, P=0.005) and by 3.8% for those who wore the CGM >85% of the time (P=0.01) . The mean CGM item score was 3.7 ± 0.5, comparable to prior results reported in T1D youth. Conclusion: Consistent CGM use improves glycemic control in youth-onset type 2 diabetes in this pilot study. Not all patients experienced an improvement in HbA1c. A larger study is warranted to validate the findings of this study and to identify patients who are most likely to benefit from CGM use. Disclosure N.T.Chang: None. J.Smith: None. L.Chao: None. Funding Dexcom

1250-P: Identifying Pediatric A-ß+ Ketosis-Prone Diabetes (KPD)

KPD is characterized by diabetic ketoacidosis (DKA) in persons lacking the phenotype of autoimmune type 1 diabetes. The validated "Aβ" system classifies 4 KPD subgroups in adults, one of which (A-β+ KPD) is an atypical form that otherwise resembles type 2 diabetes (T2D) . Although recognized in children, better understanding of the prevalence and characteristics of pediatric A-β+ KPD is needed. The Rare and Atypical Diabetes Network (RADIANT) has modified the criteria for A-β+ KPD to: DKA within 6 months of diagnosis (dx) , not on SGLT2i, off insulin within 6 months of DKA with HbA1c <7% on oral agents alone, and negative islet autoantibodies. We compared clinical characteristics of pediatric T2D with and without DKA at dx, and in the former group estimated the prevalence of A-β+ KPD. A retrospective chart review identified 716 children with T2D over 3 years at Texas Children’s Hospital. Mean age at dx was 13.7 ± 2.4 yr; 63% females; 59% Hispanic, 29% African American (AA) , 9% non-Hispanic white, 3% others. Of them, 57 (8%) presented with DKA with negative antibodies. Children with DKA at dx, vs. those without it, were more often AA (45% vs. 28%, p=0.008) , male (60% vs. 35%, p=<0.001) and older (14.4 vs. 13.6 y/o, p=0.02) ; had lower random C-peptide (1.4 vs. 4.23 ng/mL, p<0.001) , higher glucose (375 vs. 240 mg/dL, p<0.001) , higher BMI-z score (2.38 vs. 2.25, p=0.02) and higher HbA1c (12.1 vs. 9.4%, p<0.001) at dx. In a multivariable model with age, sex, race, C-peptide, glucose, HbA1c and BMI z-score at dx, older age (p=0.004) , lower C-peptide (p<0.0001) , higher glucose (p=0.003) and BMI z-score (p=0.004) remained significantly associated with DKA. Eight children with DKA (14%) met all RADIANT criteria for A-β+ KPD. Most of the other children with DKA failed KPD criteria because they remained on insulin treatment for >6 months. Children with T2D and DKA at dx were more likely to be older, had lower C-peptide and higher glucose and BMI-z score at dx. Of them, 14% met all RADIANT A-β+ KPD criteria and are eligible for enrollment in RADIANT. Disclosure E.A.Kubota-mishra: None. M.Tosur: Advisory Panel; Provention Bio, Inc. Radiant study group: n/a. X.C.Huang: None. C.G.Minard: None. M.Astudillo: None. A.K.Refaey: None. G.Montes: None. S.Sisley: Speaker's Bureau; Rhythm Pharmaceuticals, Inc. A.Balasubramanyam: None. M.J.Redondo: Advisory Panel; Provention Bio, Inc.

Social Determinants of Health Associated With Patient Portal Use in Pediatric Diabetes

ObjectivesSocial determinants of health (SDOH) are associated with type 1 diabetes (T1D) outcomes. Patient portal (PP) use can improve care quality. Therefore, equitable PP access is essential. Associations between SDOH and PP access have not been reported in pediatric T1D. The purpose of this study was to determine whether PP access and use are associated with SDOH in pediatric T1D. MethodsThis work was a cross-sectional study of patients <18 years of age with T1D who were seen in a diabetes clinic at a tertiary care centre between April 1, 2020, and March 31, 2021. Patient postal code, PP activation status and use, and characteristics were collected from electronic health records on April 1, 2021. SDOH were assessed using patient postal code linked to the Ontario Marginalization Index (ON-Marg) to determine quintile score across 4 dimensions of deprivation. Statistical analysis tested for an association between PP activation status and ON-Marg quintile. ResultsData were obtained for 634 patients with a mean age of 12.8±3.8 years; 53% were male and mean glycated hemoglobin was 8.4±2.0%. In the last year, 334 patients (53%) were PP active and 332 (52%) used the PP. The odds of inactive PP status were higher for those with the highest degree of material deprivation (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.62 to 5.36) and residential instability (OR, 3.49; 95% CI, 1.86 to 6.70). PP activation status was not associated with dependency or ethnic concentration. ConclusionsIn our pediatric T1D population, inactive PP status is associated with greater material deprivation and residential instability. How these factors impact PP activation and how to improve equitable access requires further study.

Changes in Type 2 Diabetes Trends in Children and Adolescents During the COVID-19 Pandemic.

PURPOSETo examine whether trends in new-onset pediatric type 2 diabetes (T2D) -- inclusive of patients requiring hospitalization and patients managed outpatient -- were impacted during the COVID-19 pandemic, and to compare patient characteristics prior to and during COVID-19.METHODSA retrospective single-center medical-record review was conducted in a hospital which cares for 90% of Alabama’s pediatric T2D patients. Patients with new-onset T2D referred from March 2017-March 2021 were included. Counts of patients presenting per month (“monthly rates”) were computed. Linear regression models were estimated for the full sample and stratified by Medicaid and non-Medicaid insurance status. Patient characteristics prior to versus during COVID-19 were compared.RESULTS642 patients presented with new-onset T2D over this period. Monthly rates were 11.1 ± 3.8 prior to COVID-19,19.3 ± 7.8 during COVID-19 (p=0.004). Monthly rates for Medicaid patients differed prior to and during COVID-19 (7.9 ± 3.4 vs 15.3 ± 6.6, p = 0.003) but not for non-Medicaid patients (3.3 ± 1.7 vs 4.0 ± 2.4, p=0.33). Regression results showed significant increases in monthly rates during COVID-19 for the full sample (β=, p<0.05) and for Medicaid enrollees (β=, p<0.05) Hospitalization-rate, severity of obesity, and hemoglobin A1c remained similar prior to and during COVID-19, though the proportion of male patients increased from 36.8% to 46.1% (p=0.021).CONCLUSIONSA rise in new-onset T2D was observed among Alabama’s youth during the COVID-19 pandemic, a burden that disproportionately affected Medicaid enrollees and males. Future research should explore the pathways through which the pandemic impacted pediatric T2D.

Multimodal neuroimaging in pediatric type 1 diabetes: a pilot multisite feasibility study of acquisition quality, motion, and variability.

Type 1 diabetes (T1D) affects over 200,000 children and is associated with an increased risk of cognitive dysfunction. Prior imaging studies suggest the neurological changes underlying this risk are multifactorial, including macrostructural, microstructural, and inflammatory changes. However, these studies have yet to be integrated, limiting investigation into how these phenomena interact. To better understand these complex mechanisms of brain injury, a well-powered, prospective, multisite, and multimodal neuroimaging study is needed. We take the first step in accomplishing this with a preliminary characterization of multisite, multimodal MRI quality, motion, and variability in pediatric T1D. We acquire structural T1 weighted (T1w) MRI, diffusion tensor MRI (DTI), functional MRI (fMRI), and magnetic resonance spectroscopy (MRS) of 5-7 participants from each of two sites. First, we assess the contrast-to-noise ratio of the T1w MRI and find no differences between sites. Second, we characterize intervolume motion in DTI and fMRI and find it to be on the subvoxel level. Third, we investigate variability in regional gray matter volumes and local gyrification indices, bundle-wise DTI microstructural measures, and N-acetylaspartate to creatine ratios. We find the T1-based measures to be comparable between sites before harmonization and the DTI and MRS-based measures to be comparable after. We find a 5-15% coefficient of variation for most measures, suggesting ~150-200 participants per group on average are needed to detect a 5% difference across these modalities at 0.9 power. We conclude that multisite, multimodal neuroimaging of pediatric T1D is feasible with low motion artifact after harmonization of DTI and MRS.

IDF21-0544 Artificial Intelligence in Diabetes Care

Background: Artificial intelligence (AI) is making a paradigm shift in traditional diabetes care in terms of target achieving efficacy, excellent safety, best quality care, effective monitoring and improved quality of life for both patients with Type-1 diabetes (T1D) and Type-2 diabetes (T2D). All guidelines for adult and pediatric T1D suggest that target Glycated hemoglobin (HbA1c) should be less than 53 mmol/mol (7%) but very less percent population with T1D can achieve this target due to many factors namely individual variability of insulin requirements, fear of hypoglycemia, errors in insulin dose calculations, etc. These lead to poor glycemic control, diabetes complications and a major source of stress for families and care givers especially in pediatric populations. All these affects quality of life (QoL), mental well-being and productivity of patients. So, the emergence of AI in diabetes care has revolutionized the management of diabetes care in optimizing the glycemic control by extending the ‘Target In Range’ (TIR), reducing ‘Target Above Range’ (TAR), ‘Target Below Range’ (TBR) and minimizing severe hypoglycemia. Glucose monitoring by Self Monitoring Blood Glucose (SMBG) using smart glucometer or Ambulatory glucose profile (AGP), Continuous Glucose Monitoring System (CGMS), to name a few. AI is being used in delivering insulin by smart pens, Continuous Subcutaneous Insulin Infusion (CSII), recently introduced Hybrid Artificial Pancreas and with prolonged CGMS. Smart insulin pens namely InPen, Novo Pen 6, Novo Pen Echo Plus, etc. can calculate the bolus dose considering current glucose reading, target, carb intake, probable exercise, etc. by algorithm. Furthermore, it can record the amount and timing of each insulin dose, display the last dose and insulin onboard, and wirelessly transmit the information via Bluetooth to a dedicated mobile application and transfers data automatically on the cloud for sharing with health care professionals as well. Novo Pen 6 and Novo Pen Echo Plus use near-field communication technology. CGMS uses sensor to monitor blood glucose continuously for 14 days and shows results in real-time without using a needle which made the life of young children much comfortable. It calculates TIR, TAR, TBR and probable HbA1c in a graphic presentation. Now new models are in pipeline for much longer duration. Smart glucometers are incorporated with bolus advisors to calculate insulin dosages, algorithm-driven message response to each glucose reading. The Hybrid Close Loop artificial pancreas is the new generation of CSII which automatically determines the basal rates, can determine the bolus dose as per CGMS but this feature is still under trial and having other old generation basic and advanced features. The ongoing trials results will guide further improvements and eventually will lead complete AI based diabetes management. Aim: To see the scope, feasibility and critical role of AI in diabetes care. Method: Contemporary literature is being searched to get the latest information on AI use in diabetes care. Results: PubMed, MEDLINE, CINAHL Plus, EMBASE, Cochrane and Google Scholar is being searched with search words 'Artificial Intelligence AND Diabetes', 'Artificial Pancreas', Close Loop system', 'Smart Insulin Pen'. 312 articles were found and finally 34 were selected.

Increased anxiety symptoms in pediatric type 1 diabetes during the acute phase of COVID-19 lockdown.

The prevalence of mental health issues has increased at an alarming rate during the COVID-19 pandemic. Furthermore, an exacerbated psychosocial burden in populations with chronic disease is observed. This cross-sectional study evaluated the psychosocial factors of pediatric type 1 diabetes (T1D) during the COVID-19 pandemic. During April 2020, 15min phone interviews were performed for pediatric T1D group (n=100) and healthy comparison group (n=93) to assess psychosocial functioning during the acute lockdown phase of the pandemic. Thepatient health questionnaire-4 was utilized to assess anxiety and depressive symptoms. An additional questionnaire to assess specific concerns related to T1D and COVID-19 was administered to the T1D group to explore potential causes for increased psychosocial burden. T1D was associated with a five-times higher risk of anxiety symptoms. Increased anxiety symptoms in T1D group appear to be, at least in part, due to fear of higher risk of severe COVID-19 infection and uncertainty regarding access to diabetes supplies. This study provides a snapshot of mental well-being in a diverse population of patients with T1D in the acute phase of a crisis and underscores the need for timely, accurate medical information and distribution of medical resources for pediatric T1D population.

Moderate and severe diabetic ketoacidosis at type 1 diabetes onset in children over two decades: A population-based study of prevalence and long-term glycemic outcomes.

To investigate in a population-based pediatric cohort: prevalence of moderate-severe diabetic ketoacidosis (DKA) at type 1 diabetes (T1D) diagnosis over two decades and its association with long-term glycemic control. Children <16 years diagnosed with T1D in Western Australia 2000-2019 were included and followed up for ≤14 years. Moderate-severe DKA at diagnosis was defined as serum pH < 7.2 or bicarbonate<10 mmol/L with hyperglycemia and ketosis. HbA1c was measured ~3-monthly. Trend in prevalence of moderate-severe DKA at diagnosis was investigated using a logistic regression model adjusting for sex, age, socioeconomic status, and area of residence. Long-term glycemic control associated with DKA at diagnosis was investigated using linear mixed models adjusting for the same variables and also for visit frequency, CGM and pump use. Moderate-severe DKA occurred in 534 of 2111 (25.3%) participants. Odds of presenting with moderate-severe DKA increased by 4.1% (95% CI: 2.3, 5.9; p< 0.001) per year. Patients with moderate-severe DKA at diagnosis had higher HbA1c levels than other patients initially; the groups were similar between 2 and 6 years duration; from 7 years HbA1c levels tracked higher in the group with moderate-severe DKA at diagnosis with significant differences at 8 and 12 years (p< 0.05). The increasing prevalence of DKA at diagnosis of pediatric T1D is concerning and highlights the need for early detection programs. Unlike a similar US study, this study did not find a consistent, clinically significant relationship between DKA at diagnosis and long-term HbA1c, raising important questions about the influence of other factors on long-term glycemic outcomes.

Pediatric Diabetes on the Rise: Trends in Incident Diabetes During the COVID-19 Pandemic.

ContextThe effects of the coronavirus disease 2019 (COVID-19) pandemic on the incident cases of pediatric type 1 diabetes (T1D) and type 2 diabetes (T2D) are not clear.ObjectiveTo identify trends in incidence and presentation of pediatric new-onset T1D and T2D during the COVID-19 pandemic.MethodsA retrospective chart review was conducted. Demographics, anthropometrics, and initial laboratory results from patients ages 0 through 21 years who presented with new-onset diabetes to a pediatric tertiary care center were recorded.ResultsDuring the pandemic, incident cases of pediatric T1D increased from 31 in each of the prior 2 years to 46; an increase of 48%. Incident cases of pediatric T2D increased by 231% from 2019 to 2020. The number of incident cases of pediatric T2D increased significantly more than the number of incident cases of pediatric T1D (P = 0.009). Patients with T2D were more likely to present in diabetic ketoacidosis (DKA), though this was not statistically significant (P = 0.093). Severe DKA was higher compared with moderate DKA (P = 0.036) in incident cases of pediatric T2D. During the pandemic, for the first time, incident cases of T2D accounted for more than one-half of all newly diagnosed pediatric diabetes cases (53%).ConclusionsThere were more incident pediatric T1D and T2D cases as well as an increase in DKA severity in T2D at presentation during the COVID-19 pandemic. More importantly, incident T2D cases were higher than the incident T1D during the pandemic. This clearly suggests a disruption and change in the pediatric diabetes trends with profound individual and community health consequences.

Metabolic control during the SARS-CoV-2 lockdown in a large German cohort of pediatric patients with type 1 diabetes: Results from the DPV initiative.

To assess if metabolic control worsened during the SARS-CoV2 lockdown in spring 2020 in youth with type 1 diabetes (T1D) in Germany. Data from 19,729 pediatric T1D patients from the diabetes prospective follow-up (DPV) registry were available. Data sets from four time-periods between January 1 and June 30, 2020, were compared with data from the whole year 2019 in the same patient; differences were adjusted for seasonality, increasing age, and longer diabetes duration. HbA1c values from laboratory measurements and estimates derived from continuous glucose monitoring (CGM) were aggregated into a combined glucose indicator (CGI), expressed in analogy to HbA1c. Based on regression models adjusted for differences of sex, age, diabetes duration, and migratory background between the four time-periods, CGI values in 2020 were slightly higher than in 2019, for example, by 0.044% (0.042-0.046) (median [95% CI]) in the second lockdown month, time-period 3. Insulin dose and BMI-SDS were also marginally higher. In 2020, there were fewer hospitalizations (e.g., incidence risk ratio in time-period 3 compared with 2019: 0.52 [95% CI: 0.46-0.58]). In a subgroup of patients reporting CGM data in both years, metrics in 2020 improved: time in target increased, and mean sensor glucose fell, for example, by 2.8% (2.7-2.9), and by 4.4mg/dl (4.3-4.6) in time-period 3. Before, during, and after the lockdown in spring 2020, metabolic control in youth with T1D in Germany did not differ significantly from the preceding year. Further effects of the ongoing pandemic on pediatric T1D patients need to be evaluated.

Could I-FABP Be an Early Marker of Celiac Disease in Children with Type 1 Diabetes? Retrospective Study from the Tertiary Reference Centre.

Patients with type 1 diabetes (T1D) are at higher risk of celiac disease (CD). Recently, intestinal fatty acid binding protein (I-FABP) has been shown to be a serological biomarker of impaired intestinal barrier in CD. Thus, the aim of this study was to verify whether I-FABP could be an early marker of CD in pediatric T1D patients. I-FABP was measured in sera of patients with T1D (n = 156), active CD (n = 38), T1D with active CD (T1D-CD, n= 51), and age-matched healthy children (n = 55). Additionally, I-FABP was determined in T1D patients with negative CD serology at least one year before CD diagnosis (T1D-CD-1, n = 22), in CD patients on a gluten-free diet (CD-GFD, n = 36), and T1D-CD patients on GFD (T1D-CD-GFD, n = 39). Sera were tested using immunoenzymatic assay. Significantly increased levels of I-FABP were found in the T1D, active CD, and T1D-CD groups (1153 ± 665, 1104 ± 916, and 1208 ± 878, respectively) in comparison to healthy with controls (485 ± 416, p < 0.05). GFD induced a significant decrease in I-FABP levels in CD and T1D-CD groups (510 ± 492 and 548 ± 439, respectively). Interestingly, in T1D-CD-1 and T1D, I-FABP levels were comparable (833 ± 369 vs. 1153 ± 665), and significantly increased in relation to healthy controls and T1D-CD values on GFD. The results indicate that the epithelial barrier is disrupted in T1D patients independently of CD development; therefore, I-FABP cannot serve as an early marker of CD in T1D patients. Although GFD can improve epithelial recovery, the question remains as to whether GFD could exert beneficial effects on the intestinal barrier in early stages of T1D.

Adolescent Immigration and Type-2 Diabetes.

Type-2 diabetes (T2D) in children and adolescents has become an increasingly important public health concern, currently accounting for nearly half of all diabetes cases in this age group in some countries. With immigration growing worldwide, immigrants as a subpopulation warrant special attention. Although the association of immigration and T2D has been explored in older persons, few studies have examined it in adolescent immigrants. Of 64 studies, only 8 were relevant and elaborated on in this review. Our findings show that adolescent immigrants to Western countries seem to benefit an overall favorable metabolic profile that is associated with lower odds to dysmetabolism. However, this protective effect wanes over time with longer years of residency and plateaus at approximately a decade from arrival. As immigration becomes a global phenomenon, pediatric T2D in these special populations has major public health and socioeconomic implications. Improving immigrants' access to healthcare, healthcare education and utilization, and specific cultural programs for prevention and treatment of T2D are important to ensure the accessibility of preventive medical services to young immigrants. Further research should be considered to help identify at-risk youth.

Pediatric Diabetic Retinopathy: Updates in Prevalence, Risk Factors, Screening, and Management.

Diabetic retinopathy (DR) is a microvascular complication of diabetes mellitus and a major cause of vision loss worldwide. The purpose of this review is to provide an update on the prevalence of diabetic retinopathy in youth, discuss risk factors, and review recent advances in diabetic retinopathy screening. While DR has long been considered a microvascular complication, recent data suggests that retinal neurodegeneration may precede the vascular changes associated with DR. The prevalence of DR has decreased in type 1 diabetes (T1D) patients following the results of the Diabetes Control and Complications Trial and implementation of intensive insulin therapy, with prevalence ranging from 14-20% before the year 2000 to 3.7-6% after 2000. In contrast, the prevalence of diabetic retinopathy in pediatric type 2 diabetes (T2D) is higher, ranging from 9.1-50%. Risk factors for diabetic retinopathy are well established and include glycemic control, diabetes duration, hypertension, and hyperlipidemia, whereas diabetes technology use including insulin pumps and continuous glucose monitors has been shown to have protective effects. Screening for DR is recommended for youth with T1D once they are aged ≥ 11years or puberty has started and diabetes duration of 3-5years. Pediatric T2D patients are advised to undergo screening at or soon after diagnosis, and annually thereafter, due to the insidious nature of T2D. Recent advances in DR screening methods including point of care and artificial intelligence technology have increased access to DR screening, while being cost-saving to patients and cost-effective to healthcare systems. While the prevalence of diabetic retinopathy in youth with T1D has been declining over the last few decades, there has been a significant increase in the prevalence of DR in youth with T2D. Improving access to diabetic retinopathy screening using novel screening methods may help improve detection and early treatment of diabetic retinopathy.

Temporal Trends for Diabetes Management and Glycemic Control Between 2010 and 2019 in Korean Children and Adolescents with Type 1 Diabetes.

Purpose: There is increasing use of modern devices in the management of patients with type 1 diabetes (T1D). We investigated temporal trends for diabetes management and outcomes in Korean pediatric T1D patients over 10 years. Methods: We retrospectively collected the data from 752 participants (boys: 311, 41.4%) diagnosed with T1D and aged ≤18 years, with ≥1 year of follow-up between 2010 and 2019 in any of the seven study hospitals in Korea. Results: Over the 10-year study period, use of continuous glucose monitoring (CGM) increased from 1.4% to 39.3%. From 2010 to 2019, there was an increased use of multiple daily insulin injections (MDI; 63.9%-77.0%, respectively) and continuous subcutaneous insulin infusion (CSII; 2.1%-14.0%, respectively), but decreased use of conventional insulin therapy (CIT, 33.9%-9.0%, respectively). Mean glycated hemoglobin (HbA1c) decreased from 8.56% to 8.01% (P < 0.001) and was lower in younger patients, boys, and CGM users (P < 0.001). MDI and CSII users had lower mean HbA1c levels than CIT users (P = 0.003). Regarding the acute complications of T1D, CGM use was associated with lower incidences of diabetic ketoacidosis (P = 0.015); CSII users were likely to experience less severe hypoglycemia (P = 0.008). Conclusions: The use of CSII and CGM increased ∼7- and 30-fold, respectively, over the 10-year study period. The glycemic control of pediatric T1D patients in Korea improved from 2010 to 2019, probably because of increased use of T1D technologies.

Demographic and diagnostic markers in new onset pediatric type 1 and type 2 diabetes: differences and overlaps.

PurposeType 1 diabetes (T1D) is the most common type of diabetes in children, but the frequency of type 2 diabetes (T2D) is increasing rapidly. Classification of diabetes is based on a constellation of features that vary by type. We aimed to compare demographic, clinical, and laboratory characteristics at diagnosis of pediatric T1D and T2D.MethodsWe studied children who visited a large academic hospital in Houston, Texas (USA) with a new diagnosis of T2D (n=753) or T1D (n=758). We compared age, sex, race/ethnicity, presence of obesity, glucose, hemoglobin A1c, islet autoantibody positivity, C-peptide, and presence of diabetic ketoacidosis (DKA) at diabetes diagnosis.ResultsAt diagnosis, children with T2D, compared with those with T1D, were older (13.6 years vs. 9.7 years), more likely female (63.2% vs. 47.8%), of racial/ethnic minority (91.1% vs. 42.3%), and obese (90.9% vs. 19.4%) and were less likely to have DKA (7.8% vs. 35.0%) and diabetes autoantibodies (5.5% vs. 95.4%). Children with T2D also had significantly lower glucose, lower hemoglobin A1c and lower C-peptide level (all comparisons, P<0.0001). In multiple logistic regression analysis, older age, racial/ethnic minority, obesity, higher C-peptide, and negative islet autoantibodies were independently associated with T2D (all, P<0.05), while sex, glucose, hemoglobin A1c, and DKA were not (model P<0.0001).Conclusions There are important demographic, clinical, and laboratory differences between T1D and T2D in children. However, none of the characteristics were unique to either diabetes type, which poses challenges to diabetes classification at diagnosis.

Diabetes Technology Use in Remote Pediatric Patients with Type 1 Diabetes Using Clinic-to-Clinic Telemedicine.

Background: Clinic-to-clinic telemedicine can increase visit frequency in pediatric patients with type 1 diabetes (T1D) living far from a diabetes specialty clinic, but the impact on adoption of diabetes technology is unclear. Materials and Methods: Pediatric patients with T1D in Colorado and surrounding states who received diabetes care using clinic-to-clinic telemedicine were enrolled. Medical records and surveys were reviewed to ascertain technology use, and data were compared to patients from the main clinic population. Results: Patients (N = 128, baseline mean age 12.4 ± 4.2 years, median T1D duration 3.3 years [IQR 1.4-7.7], mean A1c 8.9% ± 1.8%, 60% male, 75% non-Hispanic white, 77% private insurance) who utilized telemedicine were included. Technology use among telemedicine patients was not associated with gender, T1D duration, insurance, distance from the main clinic or rural designation but was associated with ethnicity and A1c. Compared to the main clinic cohort (N = 3636), continuous glucose monitor (CGM) use and pump/CGM combination use was lower among patients participating in clinic-to-clinic telemedicine (CGM: 29.7% vs. 56.0%, P < 0.001; CGM/pump combination: 27.3% vs. 40.3%, P = 0.004). Technology use was associated with lower A1c regardless of cohort. Conclusions: Compared to patients attending in-person clinic, pediatric T1D patients who use clinic-to-clinic telemedicine due to their distance from the main clinic, have lower CGM and combination CGM/pump use. For both telemedicine and main clinic patients, CGM and CGM/pump combination was associated with lower A1c. Additional research is needed to explore reasons for this discrepancy and find methods to improve CGM use in this population.

Type 1 diabetes prevalence and incidence rates in the pediatric population of Veneto Region (Italy) in 2015–2020

The prevalence of Type 1 Diabetes (T1D) in the Veneto Region (Italy) in the 2015–2020 years was 152.5/100,000 subjects and the incidence 19.7/100,000 person-years. Accordingly, Veneto Region can be defined as a high-risk area for pediatric T1D.