Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study

Risk predictors of glycaemic control in children and adolescents with type 1 diabetes: A systematic review and meta-analysis

OBJECTIVES

To conduct systematic evaluation of the risk predictors of glycaemic control in children and adolescents with type 1 diabetes mellitus.

METHODS

Cohort studies on risk predictors of glycaemic control in children and adolescents with type 1 diabetes were retrieved from CNKI, PubMed, Web of Science, Embase databases, etc. from the construction of the repository to 3 February 2023. Literature screening was conducted according to inclusion and exclusion criteria, then data extraction of region, sample size, age, follow-up time, risk predictors, outcome indicators, etc., and quality evaluation of The Newcastle-Ottawa Scale were conducted by two researchers while the third researcher makes decisions if there are disagreements. Finally, Revman5.4 and StataMP17 were used for meta-analysis.

RESULTS

A total of 29 studies were included, and the results showed that insulin pump [Weighed mean difference (WMD) = -.48, 95% CI (-.73, -.24), p < .01], high-frequency sensor monitoring, early use of insulin pumps, prospective follow-up male, white race, large body mass index-standardised scoring, conscientiousness, agreeableness of mothers, eicosapentaenoic acid, leucine and protein (p < .05) were beneficial for reducing HbA1c levels in children and adolescents with diabetes. Ketoacidosis [WMD = .39, 95% CI (.28, .50), p < .01], selective admission, higher HbA1c level at one time (p < .01), higher glutamate decarboxylase antibody at 1 month after diagnosis, lower socio-economic status, non-living with biological parents, non-two-parent family, family disorder, family history of diabetes and high carbohydrate intake (p < .05) increased HbA1c levels in children and adolescents with diabetes.

CONCLUSION

For children and adolescents with type 1 diabetes mellitus, the use of insulin pump, high-frequency sensor monitoring, prospective follow-up, good family support and reasonable diet are conducive to blood glucose control, while selective admission and DKA are not. Disease characteristics and demographic characteristics of children are closely related to subsequent blood glucose control, and the relationship between diagnosis age and blood glucose control needs to be further explored.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Insulin Pump-Associated Adverse Events in a Brazilian Reference Center for the Treatment of Diabetes Mellitus: Proposal for a Taxonomy of Device Failures in Adults, Adolescents, and Children

BACKGROUND

Since the introduction of continuous subcutaneous insulin infusion (CSII), the benefits have been numerous. However, adverse events (AEs) are experienced by up to 40% of users per year, exposing them to potentially fatal risks. The available evidence on the variables that trigger AEs associated with CSII remains limited, indicating the importance of studies on the subject.

AIM

To propose a taxonomy based on the prevalent AEs experienced by patients from a reference diabetes mellitus (DM) center in Brazil using different CSII devices.

METHODS

118 patients participated in an online interview and answered the questions of the data collection instrument. Identifying categories and subcategories of analysis contributed to constructing the AEs taxonomy.

RESULTS

The five analysis categories identified were: CSII User Interface (n = 45), CSII Alert System (n = 13), CSII Software and Connection (n = 11), CSII Durability (n = 30), and Electrical and Mechanical System of CSII (n = 60) A total of 159 AEs were identified, including conflicting alert messages and error/warning notification failures, errors resulting from engine malfunctions, data loss, patient interface deficiencies, button problems, and battery failure.

CONCLUSIONS

The study describes in a taxonomic format the AEs directly associated with the use of modern CSIIs that may contribute with additional information to the Food and Drug Administration (FDA) Medical Device Report (MDR) adverse event codes. In addition to guiding educational actions in the treatment of DM and providing information for health professionals and medical device developers, prospective studies examining the frequency of such problems, including the potential psychosocial impact of this technologically advanced therapy, are needed.

Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models

Background

Technology use, including continuous glucose monitoring (CGM) and insulin pump therapy, is associated with improved outcomes in youth with type 1 diabetes (T1D). In 2017 CGM was universally funded for youth with T1D in Australia. In contrast, pump access is primarily accessed through private health insurance, self-funding or philanthropy. The study aim was to investigate the use of diabetes technology across different socioeconomic groups in Australian youth with T1D, in the setting of two contrasting funding models.

Methods

A cross-sectional evaluation of 4957 youth with T1D aged <18 years in the national registry was performed to determine technology use. The Index of Relative Socio-Economic Disadvantage (IRSD) derived from Australian census data is an area-based measure of socioeconomic status (SES). Lower quintiles represent greater disadvantage. IRSD based on most recent postcode of residence was used as a marker of SES. A multivariable generalised linear model adjusting for age, diabetes duration, sex, remoteness classification, and location within Australia was used to determine the association between SES and device use.

Results

CGM use was lower in IRSD quintile 1 in comparison to quintiles 2 to 5 (p<0.001) where uptake across the quintiles was similar. A higher percentage of pump use was observed in the least disadvantaged IRSD quintiles. Compared to the most disadvantaged quintile 1, pump use progressively increased by 16% (95% CI: 4% to 31%) in quintile 2, 19% (6% to 33%) in quintile 3, 35% (21% to 50%) in quintile 4 and 51% (36% to 67%) in the least disadvantaged quintile 5.

Conclusion

In this large national dataset, use of diabetes technologies was found to differ across socioeconomic groups. For nationally subsidised CGM, use was similar across socioeconomic groups with the exception of the most disadvantaged quintile, an important finding requiring further investigation into barriers to CGM use within a nationally subsidised model. User pays funding models for pump therapy result in lower use with socioeconomic disadvantage, highlighting inequities in this funding approach. For the full benefits of diabetes technology to be realised, equitable access to pump therapy needs to be a health policy priority.

Metabolic Outcomes in Pediatric Patients One-Year Post-Total Pancreatectomy with Islet Autotransplantation after Early Pump Initiation

We previously published that insulin pump initiation immediately after IV insulin therapy was associated with improved post-surgical glycemic outcomes compared to multiple daily injections (MDI) in pediatric patients following a total pancreatectomy with islet autotransplantation (TPIAT). We investigated metabolic outcomes of this population at one-year post-TPIAT to assess if the improved outcomes in the early pump group were sustained over time. We retrospectively reviewed 40 patients post-TPIAT previously studied at 10-days post-surgery (15 used MDI and 25 used pump therapy immediately post-ICU, and all were discharged on pump therapy). Data analyzed included: demographics, islet equivalents per kilogram (IEQ/kg) transplanted, exogenous insulin use, and baseline vs. one-year (via mixed meal testing) HbA1c, fasting glucose, insulinogenic index, and the area under the curve (AUC) for insulin and c-peptide. More patients were off insulin at one year in the early pump group compared to the MDI group (45% vs. 13%, p = 0.07). Of all patients off insulin, 100% of the early pump users weaned off by six months post-TPIAT compared to 30% of the MDI users. Two known variables associated with favorable insulin outcomes, lower age and higher IEQ/kg, were not significantly different between groups. Fasting glucose was lower in the early pump group compared to the MDI group (median 97 vs. 122 mg/dL, p = 0.003), while AUC c-peptide was greater in early pump users at one-year post-TPIAT but did not reach significance (median 57.0 vs. 50.3 ng/mL × minutes, p = 0.14). Other metabolic outcomes did not differ between groups. Despite lower median age and higher IEQ/kg in the MDI group, the early pump group had a lower fasting glucose. Younger TPIAT age (p = 0.02) and early pump users (p = 0.04) were significantly associated with insulin independence at one year. This study was limited by sample size. Early pump use may have long-term benefits in post-TPIAT endogenous insulin secretion.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabetic Ketoacidosis at Onset of Type 1 Diabetes and Long-term HbA1c in 7,961 Children and Young Adults in the Australasian Diabetes Data Network

OBJECTIVE

The relationship between diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes and long-term glycemic control varies between studies. We aimed, firstly, to characterize the association of DKA and its severity with long-term HbA1c in a large contemporary cohort, and secondly, to identify other independent determinants of long-term HbA1c.

RESEARCH DESIGN AND METHODS

Participants were 7,961 children and young adults diagnosed with type 1 diabetes by age 30 years from 2000 to 2019 and followed prospectively in the Australasian Diabetes Data Network (ADDN) until 31 December 2020. Linear mixed-effect models related variables to HbA1c.

RESULTS

DKA at diagnosis was present in 2,647 participants (33.2%). Over a median 5.6 (interquartile range 3.2, 9.4) years of follow-up, participants with severe, but not moderate or mild, DKA at diagnosis had a higher mean HbA1c (+0.23%, 95% CI 0.11,0.28; [+2.5 mmol/mol, 95% CI 1.4,3.6]; P < 0.001) compared with those without DKA. Use of continuous subcutaneous insulin infusion (CSII) was independently associated with a lower HbA1c (-0.28%, 95% CI -0.31, -0.25; [-3.1 mmol/mol, 95% CI -3.4, -2.8]; P < 0.001) than multiple daily injections, and CSII use interacted with severe DKA to lower predicted HbA1c. Indigenous status was associated with higher HbA1c (+1.37%, 95% CI 1.15, 1.59; [+15.0 mmol/mol, 95% CI 12.6, 17.4]; P < 0.001), as was residing in postcodes of lower socioeconomic status (most vs. least disadvantaged quintile +0.43%, 95% CI 0.34, 0.52; [+4.7 mmol/mol, 95% CI 3.4, 5.6]; P < 0.001).

CONCLUSIONS

Severe, but not mild or moderate, DKA at diagnosis was associated with a marginally higher HbA1c over time, an effect that was modified by use of CSII. Indigenous status and lower socioeconomic status were independently associated with higher long-term HbA1c.

Insulin Pump Therapy Efficacy and Key Factors Influencing Adherence in Pediatric Population-A Narrative Review

Objective: we aimed to highlight the state of the art in terms of pediatric population adherence to insulin pumps. This study intends to underline the significance of identifying and minimizing, to the greatest extent feasible, the factors that adversely affect the juvenile population's adherence to insulin pump therapy. Materials and methods: articles from PubMed, Embase, and Science Direct databases were evaluated using the following search terms: adherence, pump insulin therapy, children, pediatric population, and type 1 diabetes, in combination with several synonyms such as compliance, treatment adherence, pump adherence, patient dropouts, and treatment refusal. Results: A better glycemic control is connected to a better adherence to diabetes management. We identify, enumerate, and discuss a number of variables which make it difficult to follow an insulin pump therapy regimen. Several key factors might improve adherence to insulin pump therapy: efficient communication between care provider and patients (including home-based video-visits), continuous diabetes education, family support and parental involvement, as well as informational, practical assistance, and emotional support from the society. Conclusions: every cause and obstacle that prevents young patients from adhering to insulin pumps optimally is an opportunity for intervention to improve glycemic control and, as a result, their quality of life.

Diabetestechnologie bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1

Die Behandlung des Diabetes mellitus Typ 1 (T1D) im Kindes- und Jugendalter ist komplex und stellt eine Herausforderung für die betroffenen Kinder und Jugendlichen, deren Familien und das ganze Umfeld (Schule/Kindergarten) dar. Das Ziel der Diabetestherapie besteht darin, eine möglichst normoglykämische Blutzuckerkontrolle zu erreichen, um akuten und chronischen Komplikationen vorzubeugen. Laut Registerstudien können die metabolischen Therapieziele derzeit noch nicht erreicht werden, weswegen ein Risiko für Akut- und Spätkomplikationen besteht. Weitere Therapieziele sind eine normale Entwicklung, Inklusion, Flexibilität im Alltag sowie eine hohe Lebensqualität. Abgesehen von neueren Insulinanaloga gingen auch die Entwicklungen in der Diabetestechnologie in den letzten Jahren mit großen Veränderungen und Verbesserungen in der Behandlung und Lebensqualität der betroffenen Familien einher. Die Insulinpumpentherapie, die kontinuierliche Glukosemessung sowie die automatische Insulindosierung (AID) führten zu einer signifikanten Verbesserung der metabolischen Einstellung sowie einer Reduktion der schweren Hypoglykämien und Ketoazidosen. Die Diabetestechnologie entwickelt sich ständig weiter und erfordert eine umfassende Schulung und Fortbildung der betroffenen Familien, der Betreuungseinrichtungen sowie auch des multidisziplinären Behandlungsteams. Ziel sind eine Reduktion der glykämischen Variabilität und damit ein besseres Langzeitoutcome der jungen Menschen mit T1D. Die AID ist zunehmend die Therapie der Wahl bei Kindern und Jugendlichen mit T1D. Mit weiteren Innovationen im Bereich der Diabetestechnologie ist in naher Zukunft zu rechnen.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh

Objectives

Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).

Methods

Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children's hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).

Results

A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value  < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).

Conclusion

Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Three-variate trajectories of metabolic control, body mass index, and insulin dose: Heterogeneous response to initiation of pump therapy in youth with type 1 diabetes

OBJECTIVE

Continuous subcutaneous insulin infusion (CSII) in youths with type 1 diabetes (T1D) is often associated with lower HbA1c, lower total daily insulin dose (TDD), and lower body mass index (BMI) compared with multiple daily injections (MDI). Individual responses to CSII are diverse. The aim was to identify unique three-variate patterns of HbA1c, BMI standard deviation score (SDS), and TDD after switching to CSII.

METHODS

Five thousand one hundred and thirty-three youths (≤20 years; 48% boys; median age at pump start 12.5 years) with T1D duration ≥3 years at CSII initiation were selected from the multicenter DPV registry. We applied group-based multitrajectory modeling to identify groups of individuals following similar trajectories. Measurements were aggregated quarterly during a 3-year follow-up period. Trajectory variables were changes of HbA1c, BMI-SDS, and TDD from baseline (delta = quarterly aggregated values at each time point [i] minus the respective baseline value).

RESULTS

Four groups of diverging Delta-HbA1c, Delta-BMI-SDS, and Delta-TDD patterns were identified. All showed improvements in HbA1c during the first 3 months. Group 1 (12%) was characterized by modest HbA1c increase thereafter, TDD reduction, and stable BMI-SDS. In Group 2 (39%), increasing HbA1c, decreasing BMI-SDS, and stable TDD were found. By contrast, sustainably improved HbA1c, increasing BMI-SDS, and stable TDD were observed in Group 3 (32%). Group 4 (17%) was characterized by increasing levels for HbA1c, BMI-SDS, and TDD. Between-group differences in baseline HbA1c, BMI-SDS, TDD as well as in sex ratio, age at diabetes onset and at pump start were observed.

CONCLUSIONS

Definite trajectories of glycemic control, BMI, and TDD over 3 years after CSII initiation were identified in youths with T1D allowing a more personalized treatment recommendation.

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.

14. Children and Adolescents: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Association of the use of diabetes technology with HbA1c and BMI-SDS in an international cohort of children and adolescents with type 1 diabetes: The SWEET project experience

OBJECTIVE

To examine the association between the use of diabetes technology (insulin pump [CSII], glucose sensor [CGM] or both) and metabolic control (HbA1c) as well as body adiposity (BMI-SDS) over-time in a cohort of children and adolescents with type 1 diabetes (T1D), that have never used these technologies before.

SUBJECTS AND METHODS

Four thousand six hundred forty three T1D patients (2-18 years, T1D ≥1 year, without celiac disease, no CSII and/or CGM before 2016) participating in the SWEET prospective multicenter diabetes registry, were enrolled. Data were collected at two points (2016; 2019). Metabolic control was assessed by glycated hemoglobin (HbA1c) and body adiposity by BMI-SDS (WHO). Patients were categorized by treatment modality (multiple daily injections [MDI] or CSII) and the use or not of CGM. Linear regression models, adjusted for age, gender, duration of diabetes and region, were applied to assess differences in HbA1c and BMI-SDS among patient groups.

RESULTS

The proportion of patients using MDI with CGM and CSII with CGM significantly increased from 2016 to 2019 (7.2%-25.7%, 7.8%-27.8% respectively; p < 0.001). Linear regression models showed a significantly lower HbA1c in groups that switched from MDI to CSII with or without CGM (p < 0.001), but a higher BMI-SDS (from MDI without CGM to CSII with CGM p < 0.05; from MDI without CGM to CSII without CGM p < 0.01).

CONCLUSIONS

Switching from MDI to CSII is significantly associated with improvement in glycemic control but increased BMI-SDS over-time. Diabetes technology may improve glucose control in youths with T1D although further strategies to prevent excess fat accumulation are needed.

Felix dies natalis, insulin… ceterum autem censeo "beta is better"

One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.

Declining Frequency of Acute Complications Associated with Tubeless Insulin Pump Use: Data from 2,911 Patients in the German/Austrian Diabetes Patienten Verlaufsdokumentation Registry

Objective: To characterize patients with diabetes treated with a tubeless insulin pump (Omnipod^® Insulin Management System; Insulet Corp., Acton, MA), and to evaluate the frequency of acute complications with long-term use of the system. Methods: This retrospective analysis of the German/Austrian Diabetes Patienten Verlaufsdokumentation (DPV) registry included data from 3657 patients with diabetes (n = 3582 type 1, n = 25 type 2, n = 50 latent autoimmune diabetes in adults/other) treated with a tubeless insulin pump. Hemoglobin A1c (HbA1c) levels and frequency of diabetic ketoacidosis (DKA) and severe hypoglycemia (SH) were compared between 1 year pre- and 1 year (n = 2911) or up to 3 years (n = 1311) post-tubeless insulin pump initiation and compared with a contemporary cohort on multiple daily injections (MDI) with 3-year data (n = 1874). Results: Patients using tubeless insulin pump therapy had a median age of 13.7 years [interquartile range 10.8, 17.3], diabetes duration 3.7 years [1.7, 8.0], and HbA1c 7.5% [6.9, 8.2]. In patients with 3 years of follow-up data (n = 1311), the percentage with ≥1 episode of DKA, SH (Level 3, requiring assistance), and SH (coma) event with prior treatment was 6.3%, 5.5%, and 1.7%, respectively. After 3 years of tubeless insulin pump therapy, the frequency of DKA, SH (Level 3), and SH (coma) decreased to 2.2%, 4.1%, and 0.5%, respectively. Both DKA and SH remained significantly lower compared with MDI after adjustment in multiple regression analysis. High treatment retention rates (>90%) were observed. Conclusion: Real-world registry data document that tubeless insulin pump therapy is associated with good glycemic control and a low frequency of DKA and SH in an age group prone to acute complications.

Marked improvements in glycaemic outcomes following insulin pump therapy initiation in people with type 1 diabetes: a nationwide observational study in Scotland

AIMS/HYPOTHESIS

Our aim was to assess the use of continuous subcutaneous insulin infusion (CSII) in people with type 1 diabetes in Scotland and its association with glycaemic control, as measured by HbA_1c levels, frequency of diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH), overall and stratified by baseline HbA_1c.

METHODS

We included 4684 individuals with type 1 diabetes from the national Scottish register, who commenced CSII between 2004 and 2019. We presented crude within-person differences from baseline HbA_1c over time since initiation, crude DKA and SHH event-rates pre-/post-CSII exposure. We then used mixed models to assess the significance of CSII exposure, taking into account: (1) the diffuse nature of the intervention (i.e. structured education often precedes initiation); (2) repeated within-person measurements; and (3) background time-trends occurring pre-intervention.

RESULTS

HbA_1c decreased after CSII initiation, with a median within-person change of -5.5 mmol/mol (IQR -12.0, 0.0) (-0.5% [IQR -1.1, 0.0]). Within-person changes were most substantial in those with the highest baseline HbA_1c, with median -21.0 mmol/mol (-30.0, -11.0) (-1.9% [-2.7, -1.0]) change in those with a baseline >84 mmol/mol (9.8%) within a year of exposure, that was sustained: -19.0 mmol/mol (-27.6, -6.5) (-1.7% [-2.5, -0.6]) at ≥5 years. Statistical significance and magnitude of change were supported by the mixed models results. The crude DKA event-rate was significantly lower in post-CSII person-time compared with pre-CSII person-time: 49.6 events (95% CI 46.3, 53.1) per 1000 person-years vs 67.9 (64.1, 71.9); rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.61 (95% credible interval [CrI] 0.47, 0.77; posterior probability of reduction pp = 1.00). The crude overall SHH event-rate in post-CSII vs pre-CSII person-time was also lower: 17.8 events (95% CI 15.8, 19.9) per 1000 person-years post-exposure vs 25.8 (23.5, 28.3) pre-exposure; rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.67 (95% CrI 0.45, 1.01; pp = 0.97).

CONCLUSIONS/INTERPRETATION

CSII therapy was associated with marked falls in HbA_1c especially in those with high baseline HbA_1c. CSII was independently associated with reduced DKA and SHH rates. CSII appears to be an effective option for intensive insulin therapy in people with diabetes for improving suboptimal glycaemic control.

Improved Glycemic Outcomes with Early Initiation of Insulin Pump Therapy in Pediatric Postoperative Total Pancreatectomy with Islet Autotransplantation

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure for patients with chronic pancreatitis and poor quality of life. Euglycemia is critical for islet cell survival and engraftment. We reviewed clinical care practice and hypothesized that early in-hospital transition from intravenous insulin to insulin pump therapy, managed by an endocrine unit trained on post-surgical care, would improve glucose control and impact the length of hospital stay. We completed a retrospective analysis of 40 pediatric patients who underwent TPIAT. Comparative hospitalized postoperative groups included those who received insulin intravenously, followed by multiple daily injections, subsequently managed by pump therapy (n = 14), versus those who received insulin intravenously followed by early pump therapy provided on the endocrine unit trained to manage post-surgical patients (n = 26). The outcomes analyzed included percentage of blood glucoses in target (4.44–6.66 mmol/L (80–120 mg/dL)), hypoglycemia (<3.33 mmol/L (<60 mg/dL)) and hyperglycemia (>7.77 mmol/L (>140 mg/dL)), blood glucose variability, and length of hospital unit stay post-ICU. Hospitalized patients with early transition to pump therapy on a specialized endocrine unit had a higher proportion of glucose values in the target range (61% vs. 51%, p = 0.0003), a lower proportion of hyperglycemia (15% vs. 19%, p = 0.04), and a lower proportion of hypoglycemia, though not statistically significant (3.4% vs. 4.4%, p = 0.33). Early pump users also had lower variability in glucose values over 10 days post-intravenous insulin (p = 0.001), and the post-transition median length of stay was shorter by 5 days (median: 11.5 vs. 16.5 days, p = 0.005). Early in-hospital pump therapy managed by the specialized endocrine unit improved glucose outcomes and reduced the duration of in-unit stay.

Benefits and Challenges of Current Closed-Loop Technologies in Children and Young People With Type 1 Diabetes

Recent advances in diabetes technology have led to the development of closed-loop insulin delivery systems for the management of type 1 diabetes. Several such systems are now commercially available for children and young people. While all available systems have been shown to improve glycaemic control and quality of life in this population, qualitative data also highlights the challenges in using closed-loop systems, which vary among different pediatric age-groups. Very young children require systems that are able to cope with low insulin doses and significant glycaemic variability due to their high insulin sensitivity and unpredictable eating and exercise patterns. Adolescents' compliance is often related to size and number of devices, usability of the systems, need for calibrations, and their ability to interact with the system. Given the speed of innovations, understanding the capabilities and key similarities and differences of current systems can be challenging for healthcare professionals, caregivers and young people with type 1 diabetes alike. The aim of this review is to summarize the key evidence on currently available closed-loop systems for children and young people with type 1 diabetes, as well as commenting on user experience, where real-world data are available. We present findings on a system-basis, as well as identifying specific challenges in different pediatric age-groups and commenting on how current systems might address these. Finally, we identify areas for future research with regards to closed-loop technology tailored for pediatric use and how these might inform reimbursement and alleviate disease burden.

Twenty-Four Hour Fasting (Basal Rate) Tests to Achieve Custom-Tailored, Hour-by-Hour Basal Insulin Infusion Rates in Patients With Type 1 Diabetes Using Insulin Pumps (CSII)

BACKGROUND

Twenty-four hour fasting periods are being used to scrutinize basal insulin infusion rates for pump-treated patients with type 1 diabetes.

METHODS

Data from 339 consecutive in-patients with adult type 1 diabetes on insulin pump therapy undergoing a 24-hour fast as a basal rate test were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations within, below, or above arbitrarily defined target ranges were assessed for periods of the day of special interest (eg, 01:00-07:00 am, "dawn" period, 04:00-07:00 pm, and "dusk" period). Statistics: χ²-tests, paired t-tests were used.

RESULTS

Basal rates (mean: 0.90 ± 0.02 IU/h) showed circadian variations with peaks corresponding to "dawn" (1.07 ± 0.02 IU/h from 01:00 to 07:00 am) and, less prominently, "dusk" (0.95 ± 0.02 IU/h from 03:00 to 07:00 pm). Individual mean plasma glucose concentrations averaged 6.6 ± 0.1 mmol/L, with 53.1% in the predefined "strict" (4.4-7.2 mmol/L) target range. Interestingly, during the "dawn" period, plasma glucose was significantly higher (by 0.5 ± 0.1 mmol/L [95% confidence interval: 0.3-0.8 mmol/L; P < .0001]) and the odds ratio for hypoglycemia was significantly lower compared to the reference period.

INTERPRETATION

Twenty-four hour fasting periods as basal rate tests frequently unravel periods with inappropriate basal insulin infusion rates potentially responsible for fasting hyper- or hypoglycemia. Notably, the higher basal insulin infusion rate found during the "dawn" period seems to be justified and may need to be accentuated.

The Evolution of Hemoglobin A1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence

The American Diabetes Association 2020 Standards of Medical Care in Diabetes (Standards of Care) recommends a hemoglobin A1c (A1C) of <7% (53 mmol/mol) for many children with type 1 diabetes (T1D), with an emphasis on target personalization. A higher A1C target of <7.5% may be more suitable for youth who cannot articulate symptoms of hypoglycemia or have hypoglycemia unawareness and for those who do not have access to analog insulins or advanced diabetes technologies or who cannot monitor blood glucose regularly. Even less stringent A1C targets (e.g., <8%) may be warranted for children with a history of severe hypoglycemia, severe morbidities, or short life expectancy. During the "honeymoon" period and in situations where lower mean glycemia is achievable without excessive hypoglycemia or reduced quality of life, an A1C <6.5% may be safe and effective. Here, we provide a historical perspective of A1C targets in pediatrics and highlight evidence demonstrating detrimental effects of hyperglycemia in children and adolescents, including increased likelihood of brain structure and neurocognitive abnormalities, microvascular and macrovascular complications, long-term effects, and increased mortality. We also review data supporting a decrease over time in overall severe hypoglycemia risk for youth with T1D, partly associated with the use of newer insulins and devices, and weakened association between lower A1C and severe hypoglycemia risk. We present common barriers to achieving glycemic targets in pediatric diabetes and discuss some strategies to address them. We aim to raise awareness within the community on Standards of Care updates that impact this crucial goal in pediatric diabetes management.

[Long-term follow-up of efficacy of insulin pump in the treatment of children with type 1 diabetes mellitus]

OBJECTIVE

To study the clinical effect of continuous subcutaneous insulin infusion (CSⅡ) versus multiple daily injection (MDI) on blood glucose control in children with type 1 diabetes mellitus (T1DM).

METHODS

A retrospective analysis was performed on the medical data of 91 children with T1DM who were treated with CSⅡ for more than 1 year and 75 children with T1DM who were treated with MDI. The two groups were compared in terms of glycosylated hemoglobin (HbA1C) and the recurrence of diabetic ketoacidosis (DKA) to evaluate the difference in the efficacy during the 3-year follow-up. A survey was conducted for the children in the CSⅡ group and their family members to investigate the degree of satisfaction with insulin pump.

RESULTS

There was no significant difference in age, sex, and course of diabetes between the CSⅡ and MDI groups at disease onset and in the first year, the second year, and the third year of follow-up (P > 0.05). There was no significant difference in the HbA1C level between the two groups at disease onset (P > 0.05), but in the first year of follow-up, the CSⅡ group had a significantly lower HbA1C level than the MDI group (P=0.04). There was no significant difference in the HbA1C level between the two groups in the second year and the third year of follow-up (P > 0.05). The CSⅡ group had a higher proportion of children with HbA1C < 7.5% than the MDI group in the first year, the second year, and the third year of follow-up (P > 0.05). Within the 3 years of follow-up, 2 children in the CSⅡ group and 8 in the MDI group experienced the recurrence of DKA. In the third year of follow-up, there was no significant difference in blood pressure and blood lipids between the CSⅡ and MDI groups (P > 0.05). Most children and their family members (87%) were satisfied with CSⅡ treatment.

CONCLUSIONS

Children with T1DM treated with CSⅡ have a better control of blood glucose than those treated with MDI, and children and their family members are satisfied with CSⅡ treatment. Therefore, it holds promise for clinical application.

Accuracy of a Low-Cost Continuous Subcutaneous Insulin Infusion Pump Prototype: In Vitro Study Using Combined Methodologies

Considering that infusion devices are safety-critical systems, the main goal of this paper is to evaluate the infusion accuracy and precision of a low-cost insulin infusion pump prototype, using two different methodologies. The first one used a microgravimetric method adapted from IEC60601-2-24, and the second estimated the displacement of the syringe plunger in response to programmed infusions. The low-cost prototype resulted in a compact and functional device with good accuracy. The prototype infused the programmed fluid doses with an average error of 2.2%. The percentage of infusions within ± 5% accuracy was 42.50 and of 84.17% for the ± 15% limit. The developed miniaturized mechanical system presented functionality, precision, and accuracy when coupled to the electronic system, responded well to repeatability tests. Additionally, the results from in vitro tests demonstrated that the performance of the device is satisfactory and comparable to commercial continuous insulin infusion pumps. This study presents a low-cost prototype as a candidate to be used by type 1 diabetic patients in Brazil and developing countries, especially in the context of public health.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Clinical Outcome and Cost-Effectiveness Analysis of CSII Versus MDI in Children and Adolescent With Type 1 Diabetes Mellitus in a Public Health Care System of China

OBJECTIVES

To evaluate the clinical and economic consequences of continuous subcutaneous insulin infusion (CSII) vs. multiple daily injections (MDI) in children and adolescents with type 1 diabetes mellitus (T1DM) from a public health care system in developed areas of developing country, considering changes in glycemic Control, daily insulin requirements, lipid profile, body mass index (BMI), frequency of severe hypoglycemia and Diabetic Ketoacidosis (DKA) and diabetic complications.

METHODS

This was a retrospective cohort study of children and adolescents with T1DM. Data were collected at baseline and the end of every year including glycated hemoglobin (HbA1c), insulin dose, lipid profile, blood pressure, and adverse events (severe hypoglycemia and DKA). The Cost-effectiveness analysis was performed using the IQVIA CORE Diabetes Model (CDM) to simulate diabetes progression by utilizing the clinical data obtained from the two groups. The main outcome measures were Life Expectancy, Quality adjusted life years (QALYs), Total Costs and Incremental Costs and Effectiveness Ratio (ICER) of CSII compared with MDI in Chinese pediatric patients with T1DM in Qingdao City (60 years).

RESULTS

Mean HbA1c values and daily insulin doses were significantly lower in those receiving CSII therapy throughout follow-up. Mean direct lifetime costs were ¥ 67,137 higher with CSII treatment than with MDI for pediatric patients. Treatment with CSII was associated with an improvement in life expectancy of 0.41 years for pediatric patients compared with MDI based on CORE diabetes model simulation. The corresponding gains in QALYs were 0.42. These data produced corresponding ICER is ¥ 161,815 per QALY for pediatric T1DM patients in Qingdao. Sensitivity analyses suggested that our base-case assumptions were mostly robust.

CONCLUSIONS

CSII is associated with improved long-term clinical outcomes compared with MDI. Based on this model analysis, CSII appears to be more cost-effective for the Qingdao TIDM pediatric population and health care system.

Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions

PURPOSE OF REVIEW

This review highlights challenges associated with weight management in children and adolescents with type 1 diabetes (T1D). Our purpose is to propose potential solutions to improve weight outcomes in youth with T1D.

RECENT FINDINGS

A common barrier to weight management in T1D is reluctance to engage in exercise for fear of hypoglycemia. Healthcare practitioners generally provide limited guidance for insulin dosing and carbohydrate modifications to maintain stable glycemia during exercise. Adherence to dietary guidelines is associated with improved glycemia; however, youth struggle to meet recommendations. When psychosocial factors are addressed in combination with glucose trends, this often leads to successful T1D management. Newer medications also hold promise to potentially aid in glycemia and weight management, but further research is necessary. Properly addressing physical activity, nutrition, pharmacotherapy, and psychosocial factors while emphasizing weight management may reduce the likelihood of obesity development and its perpetuation in this population.

Effects of Continuous Subcutaneous Insulin Infusion on Glycaemic Control and Acute Complications in Young People with Type 1 Diabetes in Bangladesh

<b><i>Objective:</i></b> The objective of this study was to assess the effects of continuous subcutaneous insulin infusion (CSII) therapy on glycaemic control and acute complications in children, adolescents, and young adults with type 1 diabetes mellitus (T1DM). <b><i>Methods:</i></b> The prospective observational study was done in patients on multiple daily injection (MDI) switching to pump system. All patients were followed at the Paediatric Diabetes Clinic at BIRDEM Hospital. They were trained on carbohydrates counting and started on continuous basal insulin infusion in addition to meal and high blood glucose correction insulin boluses. They were followed on insulin pump therapy for a 6-month period. <b><i>Results:</i></b> Twenty patients were analysed, from baseline to visit 2 after 6 months. The patients included in the study had T1DM for a mean duration of 4.7 ± 3.1 years. The age ranged from 3 to 25 years (mean 13.7 ± 6.1). There was 1% reduction in haemoglobin A1c (HbA1c) after 6 months, though it did not reach the statistical significance (<i>p</i> = 0.084). There was significant reduction of mean fasting blood glucose level 13.4 ± 7.0 versus 6.9 ± 1.6 mmol/L (<i>p</i> = 0.001), total insulin requirement (<i>p</i> = 0.043), frequency of hypoglycaemic episodes (<i>p</i> = 0.006), and diabetic ketoacidosis (<i>p</i> = 0.002) events during CSII therapy. <b><i>Conclusion:</i></b> In our study, we found that switching young T1DM patients from MDI to insulin pump had been effective with achievement of a reduction in fasting blood glucose, HbA1c, and acute complications.

Closed-loop control in insulin pumps for type-1 diabetes mellitus: safety and efficacy

INTRODUCTION

Type 1 diabetes is a lifelong disease with high management burden. The majority of people with type 1 diabetes fail to achieve glycemic targets. Algorithm-driven automated insulin delivery (closed-loop) systems aim to address these challenges. This review provides an overview of commercial and emerging closed-loop systems.

AREAS COVERED

We review safety and efficacy of commercial and emerging hybrid closed-loop systems. A literature search was conducted and clinical trials using day-and-night closed-loop systems during free-living conditions were used to report on safety data. We comment on efficacy where robust randomized controlled trial data for a particular system are available. We highlight similarities and differences between commercial systems.

EXPERT OPINION

Study data shows that hybrid closed-loop systems are safe and effective, consistently improving glycemic control when compared to standard therapy. While a fully closed-loop system with minimal burden remains the end-goal, these hybrid closed-loop systems have transformative potential in diabetes care.

[Study of the quality of life and adherence to treatment in patients from 2 to 16 years-old with type 1 diabetes mellitus in Andalusia, Spain]

INTRODUCTION

Diabetes mellitus 1 is the second most frequent chronic disease, and the most frequent endocrine-metabolic disorder in childhood. The estimated prevalence is between 1.1 and 1.4 / 1000 children under 15 years years-old. In Andalusia the prevalence is higher (1.7 per thousand). The objective of the study is to evaluate health-related quality of life (HRQoL) and adherence to treatment, specifically in the paediatric population of Andalusia.

METHODS

A multicentre cross-sectional observational analytical study was conducted on a sample of 178 patients from six hospitals with a Paediatric Endocrinology Unit. Each patient received two questionnaires; quality of life (PedsQL version 3.0) and adherence to the self-care recommendations (SCI-R) treatment. The demographic, clinical, metabolic control data, and possible complications were also collected.

RESULTS

High levels were obtained in both adherence and health-related quality of life (HRQoL). Adherence was inversely related to age and HbA1c. The health-related quality of life (HRQoL) was associated with the use of a continuous real-time glucose monitoring system (MCG-TR) combined with continuous subcutaneous insulin infusion (CSII), as well as with a lower number of severe hypoglycaemia and renal complications. The mean HbA1c was 7.1%. 12,9% of patients used ISCI. 83.2% used capillary glycemia exclusively, while 16.8% used some interstitial glucose monitoring device.

CONCLUSIONS

This is the first study in Andalusia that analyzes the health-related quality of life (HRQoL) of pediatric patients. The results show high levels of adherence and health-related quality of life (HRQoL), as well as good metabolic control.

Diabetes-Specific Self-Compassion: A New Measure for Parents of Youth With Type 1 Diabetes

OBJECTIVE

Given the high daily demands of managing type 1 diabetes (T1D), parents of youth with T1D can experience high levels of emotional distress, burden, and self-criticism, with implications for parent and child well-being and parent self-efficacy for managing diabetes. Diabetes-specific self-compassion (SC), or being kind to oneself when facing challenges related to managing diabetes, may serve as protective for parents. This study aimed to create and assess the psychometric properties of a new tool, the diabetes-specific Self-Compassion Scale (SCS-Dp), to assess diabetes-specific SC in parents of youth with T1D.

METHODS

We adapted a parent diabetes-specific SC measure; surveyed parents (N = 198; parent: 88% female; 95% non-Hispanic White; M age = 44 ± 8.9; child: 46% female; M age = 13 ± 3.4, range 2-18 years; 83% insulin pump users; 40% continuous glucose monitor (CGM) users; HbA1c from clinic data available for 76 participants: M HbA1c = 8.1 ± 1.3%) and conducted confirmatory factor analysis, and reliability and construct validity analyses. Validity measures included diabetes distress, diabetes empowerment, diabetes numeracy, and HbA1c.

RESULTS

A bifactor structure provided the best fit, with one general factor and two wording-related group factors (positively and negatively worded items). The final 19-item SCS-Dp demonstrated excellent internal consistency (α =.94; range of item-total correlations: .52-.81) and good construct validity. As predicted, greater SC was associated with lower distress (r = -.68, p < .001) and greater empowerment (r = .43, p < .001) and was not associated with diabetes numeracy (p = .61). Diabetes-specific Self-Compassion Scale was not associated with HbA1c (p = .28).

CONCLUSIONS

Results provide initial evidence of good reliability and validity of the SCS-Dp to assess diabetes-specific SC in parents.

Factors associated with glycemic control in type 1 diabetes patients in China: A cross-sectional study

Aims/Introduction

Glycemic control in type 1 diabetes can be challenging, and is influenced by many factors. This study aimed to investigate glycemic control and its associated factors in Chinese people with type 1 diabetes.

Materials and Methods

This cross‐sectional study included 779 participants with type 1 diabetes selected from hospital records review, outpatient clinics and inpatient wards. Data were collected through face‐to‐face interviews, medical records and venous blood samples. Multiple logistic regression analysis was carried out to determine factors associated with glycemic control.

Results

Among 779 participants, 49.2% were male. The median age was 24 years (interquartile range 14–36 years). The median age at diagnosis of diabetes was 17 years (interquartile range 10–28 years) and the median duration of diabetes was 4 years (interquartile range 1–8 years). The mean ± standard deviation hemoglobin A1c was 9.1 ± 2.5%. Nearly 80% of participants had inadequate glycemic control (hemoglobin A1c ≥7.0%). Multivariable analysis showed that age at diagnosis of diabetes ≤20 years, living in a rural location, low household income, low intake of fruit and vegetables, low level of physical activity, low adherence to insulin, and low utilization of insulin pump were independent risk factors for poor glycemic control (hemoglobin A1c ≥9.0%).

Conclusions

Inadequate glycaemic control is common among people with type 1 diabetes in China. Efforts should be made to control the modifiable risk factors, which include low intake of fruit and vegetables, low level of physical activity, and low adherence to insulin for the improvement of glycemic control. Appropriate use of insulin pump among type 1 diabetes should be encouraged.

Glycemic control and self-rated health among ethnically diverse adolescents with type 1 diabetes

OBJECTIVE

Patient-reported outcomes have received increased attention as treatment outcomes and indicators of wellbeing. A1c has been criticized as lacking patient-centered relevance because individuals are often unaware of their A1c, and studies also often fail to show a benefit of intensive control on quality of life. The goal of the present study was to examine self-rated health (SRH) in relation to diabetes self-care behaviors, socioeconomic factors, treatment regimen characteristics, and glycemic control among predominately Hispanic and African American adolescents with type 1 diabetes (T1D).

METHODS

Adolescents with T1D (N = 84) were recruited for a cross-sectional study evaluating psychosocial factors and identity development. SRH, self-care behaviors, treatment regimen, and demographic variables were collected through self-report while glycemic control (A1c) was determined through chart review.

RESULTS

Participants were predominantly racial and ethnic minorities (48% Hispanic, 27% African American; 52% female, M age 15.9, M diabetes duration 6.8, M A1c 10% [86 mmol/mol]). Significant bivariate relationships emerged between SRH and sex, A1c, self-care behavior, and insulin delivery method. Covariate-adjusted regression models showed only A1c was significantly and independently related to SRH. Mediation analyses illustrated a significant indirect effect for A1c between self-care and SRH.

CONCLUSION

These findings suggest glycemic control is associated with self-ratings of health among ethnically diverse adolescents with T1D. SRH appears to be an appropriate patient-reported outcome that is sensitive to glycemic control in this population.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes

Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.

Examination of Psychosocial and Physiological Risk for Bulimic Symptoms in Youth With Type 1 Diabetes Transitioning to an Insulin Pump: A Pilot Study

Objectives

This study tested hypotheses drawn from a risk model positing that psychosocial risk plus disease-related and treatment factors contribute to bulimic symptoms in youth with type 1 diabetes (T1D) transitioning to an insulin pump. The goal of this study was to examine whether disease-related factors, particularly disease- and treatment-based disruption in hunger and satiety, contribute to report of bulimic symptoms in youth with T1D after accounting for psychosocial risk factors.

Methods

43 youth (ages 10-17, 54% female) with established T1D were recruited before transition from multiple daily injections to insulin-pump therapy from three tertiary pediatric diabetes centers. Participants completed measures of bulimic symptoms, depressive symptoms dietary restraint, and the Diabetes Treatment and Satiety Scale, a diabetes-specific questionnaire assessing hunger and satiety cues and eating behavior in response to blood glucose levels and treatment.

Results

Hierarchical multiple regression was used to assess contributions of psychosocial and disease-based risk to report of bulimic symptoms. After assessing the contributions of body mass index, body image dissatisfaction, and dietary restraint, a significant 2-way interaction emerged between depression and diabetes-related uncontrollable hunger related to bulimic symptoms (β = 1.82, p < .01).

Conclusions

In addition to psychosocial risk, disease- and treatment-based hunger and satiety dysregulation appear to be important factors contributing to report of bulimic symptoms in youth with T1D. These preliminary findings have significant treatment implications for bulimic symptoms in youth with T1D.

Hospital-based home care for young children newly diagnosed with type 1 diabetes: Assessing expectations and obstacles in families and general practitioners

AIMS

This study aimed to evaluate whether hospital-based home care was desired by the parents of children diagnosed with type 1 diabetes (T1D) under the age of 5 years and their general practitioners, and to identify the main expectations and obstacles to its implementation.

METHODS

This descriptive bicentric study in France was performed between November 2016 and November 2017. Data were collected by interviewing 57 families of children diagnosed with diabetes before the age of 5 years and the corresponding 30 general practitioners. The primary endpoint was the families' or general practitioners' acceptance of home-based care after diagnosis.

RESULTS

A high proportion of families and physicians (86% and 93%, respectively) expressed a wish for hospital-based home care, most of whom considered it essential (79% and 87%, respectively). Low-income families were less likely to accept this care pathway (P<0.001). The families' expectations regarding home care were help with social care, the management of emergencies, and return to school. The physicians' main request was improved interprofessional collaboration.

CONCLUSION

Hospital-based home care seems to be an acceptable transition after conventional care for children just diagnosed with T1D. Multidisciplinary support, personalized social care, and access to welfare benefits may improve acceptance rates, especially among low-income families.

Clinical Use of Degludec in Children and Adolescents with T1D: A Narrative Review with Fictionalized Case Reports

The use of insulin in children and adolescents with type 1 diabetes (T1D) is a challenge because of the heterogeneity of these patients and their lifestyles, with consequent unpredictability in blood glucose levels. A new ultra-long-acting basal insulin, insulin degludec (degludec), has the potential to mitigate some of these challenges, notably variability in the glucose-lowering action of the basal insulin component of an insulin regimen, and consequent risks of hypo- and hyperglycemia. However, the protracted half-life and steady state pharmacokinetics of degludec potentially bring some new challenges. In particular, the adjustment of therapy in response to commonly encountered clinical situations might require a different approach when degludec is used in place of other currently used basal insulins in this challenging patient population. The purpose of this article is to guide clinicians through a series of case histories in the use of this insulin. These include, but are not limited to, how to initiate, titrate, switch from other basal insulin or pump therapy; how to alleviate difficulties arising as a result of unpredictable lifestyle/habits; and how to maintain treatment following diabetic ketoacidosis. The guidance presented in this review illustrates that degludec is a good option for a diverse range of children and adolescents with T1D, providing much needed flexibility in the treatment of this challenging patient population.Funding Novo Nordisk.

Using insulin pump with a remote-control system in young patients with diabetes improves glycemic control and enhances patient satisfaction

Background

Insulin delivery triggered by a remote control is an advanced feature offered by newer insulin pump systems. These remote-integrated pump systems might further improve glycemic control and patient satisfaction. This study aims at assessing the effects of advanced insulin pump system on patients with type 1 diabetes mellitus (T1DM).

Methods

The prospective, observational study in two centers addressed patients on multiple daily injection (MDI) switching to an integrated pump system (primary: adolescents and young adults, secondary: school-children). Treatment and patient satisfaction parameters were recorded at baseline and at two visits at 12 and 24 weeks.

Results

Thirty-eight patients were analyzed; primary n = 24 (mean-age 16) and secondary n = 14 (mean-age 9). From baseline to visit2, the mean decrease of HbA1c was 1.09% (p = 0.00009) and 0.79% (p = 0.09) for the primary and secondary group, respectively. Patient satisfaction rate was favorable. Exploratory analyses revealed patients favoring the use of the remote control achieved best reductions in HbA1c (p = 0.0174). Safety was encouraging with no adverse events in the period from visit1 to visit2.

Conclusions

Switching young T1DM patients from MDI to a remote control-integrated pump system achieved a reductions in HbA1c and insulin dose. Positive attitude towards remote operating enhanced these effects. Patient satisfaction has markedly improved.

Electronic supplementary material

The online version of this article (10.1186/s40842-019-0081-z) contains supplementary material, which is available to authorized users.

Insulin pump therapy, pre-pump hemoglobin A1c and metabolic improvement in children with type 1 diabetes at a tertiary Canadian children's hospital

BACKGROUND AND OBJECTIVES

Indications for insulin pump therapy (IPT) in children with type 1 diabetes (T1D) are relatively non-specific and therefore subject to provider discretion. Health professionals' perceptions of which people will have difficulty with IPT, for example, those with higher hemoglobin A_1c (HbA_1c ), may not be correct. This study examined the effect of IPT on HbA_1c , and the role of pre-pump HbA_1c on this effect.

METHODS

All children with T1D started on IPT at British Columbia Children's Hospital from January 2011 through June 2016 were included if they had HbA_1c values available both before and after IPT (n = 125). Generalized estimating equations was used to estimate the effects of IPT on HbA_1c , stratified by pre-pump HbA_1c levels (good: <7.5% [<58 mmol/mol], moderate: 7.5%-9.0% [58-75 mmol/mol], poor: >9.0% [>75 mmol/mol]).

RESULTS

After adjusting for potential confounders, mean HbA_1c decreased by 0.48% [5.2 mmol/mol] (95% confidence interval: -0.64, -0.33% [-7.0, -3.6 mmol/mol]; P < 0.0001) after IPT initiation. The adjusted mean HbA_1c decreased by 0.14% [1.5 mmol/mol] (-0.35, 0.07% [-3.8, 0.8 mmol/mol]; P = 0.188), 0.54% [5.9 mmol/mol] (-0.74, -0.34% [-8.1, -3.7 mmol/mol]; P < 0.0001), and 1.08% [11.8 mmol/mol] (-1.69, -0.46% [-18.5, -5.0 mmol/mol]; P = 0.0006) after pump initiation in the good, moderate, and poor pre-pump metabolic control groups, respectively.

CONCLUSIONS

Pre-pump HbA_1c appears to play a significant role in the effects of IPT on HbA_1c , with the largest decrease in HbA_1c seen in the poor pre-pump HbA_1c group. Eligibility and consideration for IPT should be expanded to routinely include these children.

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13-year-old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller-Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (-0.18 to -0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller-Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes-related quality of life and reduced care giver burden, were reported. Further high-quality randomised controlled trials and long-term data are required to assess the benefits of CSII over MDI and the longevity of these methods.

Comparing Insulin Pump Devices in Real Life: The AWeSoMe Study Group Prospective Experience

BACKGROUND

The use of insulin pumps in pediatric patients with type 1 diabetes (T1D) has expanded; however, data comparing devices remain scarce. We compared glycemic control, technical difficulties, and quality of life (QOL) between pump devices of three companies.

METHODS

This prospective observational trial is based on clinical data retrieved during 12 months of follow-up of pediatric patients who started pump therapy as part of their clinical care in four medical centers. The devices fully reimbursed by the national health insurance are as follows: MiniMed™ 640G, MiniMed^® Veo™, Animas^® Vibe^®, and Abbott OmniPod^®. Parameters investigated included discontinuation rate, glycated hemoglobin (HbA1c), mean self-monitoring of blood glucose (SMBG), total daily dose of insulin (TDD), pump setting parameters, body mass index (BMI), frequency of technical difficulties, significant skin reactions, and QOL.

RESULTS

Of 113 children (mean age 9.1 ± 4.1 years, 46% females), 68 (60%) used Medtronic devices, 33 (29%) OmniPod, and 12 (11%) Animas devices. Twelve percent of the cohort stopped using the pump during the study period, with no difference according to device. There were no differences between groups regarding mean SMBG values (P = 0.86), insulin TDD (P = 0.24), BMI (P = 0.87), level of insertion site pain or local reaction (P = 0.51), technical problems (P = 0.66), and QOL (P = 0.38). Changes in HbA1c from study initiation to end were also not statistically significant for any of the devices: from 7.99% ± 1.14% to 7.93% ± 0.99% for Medtronic, from 7.71% ± 1.29% to 7.92% ± 1.38% for OmniPod, and from 8.75% ± 1.3% to 7.70% ± 1.33% for Animas (P = 0.63).

CONCLUSIONS

Pump devices were comparable regarding glycemic control, weight gain, and satisfaction among pediatric patients with T1D.

Efficacy and Safety of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Injections on Type 1 Diabetes Children: A Meta-Analysis of Randomized Control Trials

OBJECTIVE

This meta-analysis was performed to evaluate the efficacy and safety of continuous subcutaneous insulin infusion (CSII) vs. multiple daily injections (MDI) in children with type 1 diabetes.

METHODS

A literature search was conducted on databases including PubMed and Embase up to June 2017. The pooled weighted mean difference or risk ratio as well as 95% confidence intervals were calculated using RevMan 5.3 software.

RESULTS

Eight studies involving 310 children with type 1 diabetes were included. Results showed that HbA1c (%) was significantly lower (p=0.007) after CSII compared with MDI in children with type 1 diabetes. In addition, there was no significant difference between groups in HbA1c (%) change, total daily insulin doses, change of total daily insulin doses and incidence of ketoacidosis and severe hypoglycemia. However, subgroup analyses indicated that age, treatment duration and study design were influenced the efficacy of CSII and MDI in children with type 1 diabetes.

CONCLUSION

CSII is associated with lower HbA1c levels in children with type 1 diabetes but appears to have no effect on insulin requirement or incidence of ketoacidosis and severe hypoglycemia.

Real-world outcomes of insulin pump compared to injection therapy in a population-based sample of children with type 1 diabetes

BACKGROUND

Long-term glycemic outcomes in people with type 1 diabetes (T1D) on insulin pump therapy (continuous subcutaneous insulin infusion [CSII]) with appropriate control data are limited. Randomized controlled studies of technology in diabetes care are generally limited in duration and likely to have a selection bias. Hence, evaluation of population-based data provides a robust alternative evaluation of the benefits of insulin pump therapy.

AIM

To investigate the outcomes of insulin pump therapy, as compared to injection therapy, in children with T1D attending a state-wide diabetes service in Western Australia.

METHODS

Patients using insulin pump therapy between January 1999 and July 2016 were matched to patients on injection therapy on the basis of age, date of diagnosis, and hemoglobin A1C (HbA1c) at the start of pump therapy.

RESULTS

A total of 513 pump-injection matches were identified. The pump cohort had a significantly lower mean HbA1c for the first 6 years of follow-up. The difference in HbA1c between the cohorts was observed by 6 months (3 mmol/mol [0.3%], standard error of the mean (SEM) 0.05, N = 463 matched pairs, P < 0.001) and was sustained with the greatest difference in HbA1c at 6 years (4 mmol/mol [0.4%], SEM 0.21, N = 112 matched pairs, P = 0.04). Beyond 6 years of follow-up, the HbA1c was not significantly lower in the pump cohort (N < 70 matched pairs).

CONCLUSIONS

Patients using insulin pump therapy had a better long-term glycemic control relative to the matched injection therapy cohort. Large population-based cohort studies using real-world data provide a valuable perspective on evaluation of new technologies in children with T1D.