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

Perceptions Related to Death in Adolescents and Their Parents During the Management of Type 1 Diabetes: A Thematic Analysis

BACKGROUND

Type 1 diabetes (T1D) is associated with an increased risk of premature death compared to those without T1D, yet perceptions of dying have not been well studied. The purpose of this secondary analysis of existing data was to explore the fears of adolescents with T1D and their parents related to the possibility of death due to T1D.

METHOD

A reflexive thematic analysis was used to examine data from interviews conducted with adolescents with T1D and their parents who participated in a primary grounded theory study of interdependence in T1D management.

FINDINGS

Three themes were generated from the data including: (1) Facing the Reality of Death, (2) Fearing Highs and Lows, and (3) Finding a Way through Fears. Participants indicated they see death as a consequence of failing to optimally manage T1D.

CONCLUSION

Additional investigation is needed to explore the fear of death in adolescents with T1D and any fear their parents may have of their adolescents' mortality.

Psychological variables and lifestyle in children with type1 diabetes and their parents: A systematic review

Diabetes may impact physical and psychosocial well-being; the diabetes incidence has seen a drastic increase globally. There is also a rise in poor mental health and well-being in children with and without chronic illness; problems are being seen at a younger age. The objective of this review was to understand the determinants of these problems in a family context. We conducted a systematic review to investigate what lifestyle and psychological factors influence children with Type 1 diabetes and their parents. A focused literature search was performed using a combination of keywords that covered the relevant terminology for diabetes, target population, and associated emotional distress, using electronic bibliographic databases containing publications until May 2022. Methodological quality was assessed using the Quality Assessment Tools for Quantitative Studies. Twenty articles met the inclusion criteria. Quality scores were weak because of a lack of comparison groups, information about the type of therapy, or adequate sample sizes. Many of the studies included a wide age range in their sample. The majority of the studies reported that parents and their children showed depression symptoms, fear of hypoglycaemia, and higher parenting stress. We conclude that sufficiently powered studies employing appropriate control groups and measures are needed to elucidate the psychological variables associated with Type1 diabetes in children and the effects on parents, especially considering primary-age children who are increasingly reported to suffer from poor mental health, and its implications. This should help to introduce better targeted interventions and improve behavioural outcomes.

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

BACKGROUND

This study aims to examine the relationship between parents' fear of hypoglycemia (FH) over a 1-year period and child glucose metrics in 126 families of youth recently diagnosed with type 1 diabetes (T1D).

METHODS

Parents completed the Hypoglycemia Fear Survey for Parents (HFS-P) and uploaded 14 days of glucose data at a baseline, 6-month, and 12-month assessment.

RESULTS

Parents' HFS-P total and worry scores increased to a clinically meaningful degree from baseline to 6-month assessment, while multilevel models revealed within- and between-person variability in parents' HFS-P worry and behavior scores over time associated with child glycemia. Specifically, a significant negative relationship for within-person worry scores suggested that when parents reported higher than their average worry scores, their children recorded fewer glucose values in the target range, while within-person behavior scores suggested that when parents reported lower than their average behavior scores, their children recorded more values above the target range. There was also a negative relationship for between-person behavior scores with child glycated hemoglobin and a positive relationship for between-person behavior scores with child glucose values in the target range.

CONCLUSIONS

In the recent-onset period of T1D, parental FH worry and behavior associated with child glycemia possibly due to changes in parents' perceptions of their child's hypoglycemia risk. The clinically meaningful increases in parent FH in the recent-onset period and the negative association for between-person behavior scores with child glycated hemoglobin suggest that clinics should consider screening parents for FH, especially among parents of children with lower glycemic levels.

Sense of Coherence as a Resource in Promoting Well-Being and Managing Type 1 Diabetes Mellitus: A Pilot Study

When investigating the feelings of caregivers to patients with T1DM, parental stress, anxiety, and depression are found to be most prevalent, especially in the diagnostic phase and in the first months after diagnosis. In this pilot study, we research various significant elements regarding the well-being of mothers with children between 10 and 15 years of age with a chronic condition. The study focuses on a period of at least three years after the child’s diagnosis. The aims of the study are to describe our sample’s levels of satisfaction (SWLS) and subjective happiness (SHS) and to evaluate possible associations. A sample of 40 mothers was offered a series of assessment tools about psychological skills that could play a role in improving mothers’ well-being: the use of specific coping mechanisms (CISS), the methods of narrating the experience of life with a son/daughter with diabetes, the sense of coherence (SOCS 29), health parameters vs. child’s disease (HbA1c, CBCL), and socio-demographic, such as education and work. The most significant associations with respect to subjective happiness are with the sense of coherence, as a unitary value and as distinct factors, and with task-oriented coping. Sense of coherence is also associated with satisfaction.

Household Food Insecurity and Fear of Hypoglycemia in Adolescents and Young Adults With Diabetes and Parents of Youth With Diabetes

OBJECTIVE

To evaluate the relation between household food insecurity (HFI) and fear of hypoglycemia among young adults with type 1 and type 2 diabetes and adolescents with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

We analyzed cross-sectional data of 1,676 young adults with youth-onset diabetes (84% type 1, 16% type 2) and 568 adolescents (<18 years old; mean age 15.1 years) with type 1 diabetes from the SEARCH for Diabetes in Youth study. Adult participants and parents of adolescent participants completed the U.S. Household Food Security Survey Module. Adults, adolescents, and parents of adolescents completed the Hypoglycemia Fear Survey, where answers range from 1 to 4. The outcomes were mean score for fear of hypoglycemia and the behavior and worry subscale scores. Linear regression models identified associations between HFI and fear of hypoglycemia scores.

RESULTS

Adults with type 1 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.22 units higher for behavior, 0.55 units for worry, 0.40 units for total; all P < 0.0001) than those without HFI. No differences by HFI status were found for adolescents with type 1 diabetes. Parents of adolescents reporting HFI had a 0.18 unit higher worry score than those not reporting HFI (P < 0.05). Adults with type 2 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.19 units higher for behavior, 0.35 units for worry, 0.28 units for total; all P < 0.05) than those in food secure households.

CONCLUSIONS

Screening for HFI and fear of hypoglycemia among people with diabetes can help providers tailor diabetes education for those who have HFI and therefore fear hypoglycemia.

Managing the unmanageable through interdependence in adolescents living with type 1 diabetes and their parents: A constructivist grounded theory

BACKGROUND

Management of T1D is complex and requires continuous care and monitoring that place many demands on adolescents with T1D and their parents. The purpose of this study was to explore the nature of interdependence with T1D management with adolescents and their parents.

METHODS

Using a constructivist grounded theory methodology, 32 open-ended interviews were conducted, transcribed, and analyzed from 11 adolescents aged 10-18 years with T1D and eight parents.

FINDINGS

The data were coded using three coding phases: initial, focused, and theroetical and this process continued until theroetical saturation was reached. The substantive theory that emerged from the data describing parents' and adolescents' main concern of Maintaining Optimal Glycemic Control was Managing the Unmanageable through Interdependence. Four related subprocesses were found: Completing T1D Tasks, Attaining Support, Balancing Independence, and Reconciling Reality. These subprocesses occurred within the context of the ever-changing, Nature of the Illness.

DISCUSSION

There is a dynamic relationship associated with interdependence between adolescents with T1D and their parents that varied situationally and by age. Participants also indicated interdependence occurs or they would like it to occur, with others beyond themselves and the health-care team to others willing to be involved.

APPLICATION TO PRACTICE

Interdependence is a dynamic process and requires ongoing evaluation by health-care professionals of its function in the daily management of T1D by parents and adolescents. Additional research into of the roles of health professionals and others in promoting interdependence is needed.

Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review

PROBLEM

Fear of hypoglycemia is a significant concern for parents of children/ adolescents with type 1 diabetes. Although some studies have explained the parental fear of hypoglycemia, the related factors were yet to be determined. This systematic review aims to identify the related factors of fear of hypoglycemia in the parents of children and adolescents with type 1 diabetes and provide a theoretical basis for further intervention.

ELIGIBILITY CRITERIA

PubMed, MEDLINE, EMBASE, Scopus, CINAHL, EBSCO, Web of Science, and Cochrane Library were systematically searched from 2010 to 2021. Studies evaluating the fear of hypoglycemia of parents and its associated factors were included.

SAMPLE

Twenty-three observational articles met the criteria.

RESULTS

Significant associations were found between fear of hypoglycemia and specific factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.

CONCLUSIONS

Understanding parental fear of hypoglycemia can help parents prevent potential problems in diabetes management, thus promoting children's growth. According to current evidence, effective targeted interventions based on modifiable relevant factors can be developed to reduce the fear of hypoglycemia in parents while maintaining optimal blood glucose control in children/ adolescents.

IMPLICATIONS

Health professionals should pay more attention to the mental health of parents, and parents should be involved in the care plan and have the opportunity to discuss their fear of hypoglycemia in the most appropriate way to manage type 1 diabetes.

A user preference analysis of commercial breath ketone sensors to inform the development of portable breath ketone sensors for diabetes management in young people

Background

Portable breath ketone sensors may help people with Type 1 Diabetes Mellitus (T1DM) avoid episodes of diabetic ketoacidosis; however, the design features preferred by users have not been studied. We aimed to elucidate breath sensor design preferences of young people with T1DM (age 12 to 16) and their parents to inform the development of a breath ketone sensor prototype that would best suit their diabetes management needs.

Research designs and methods

To elicit foundational experiences from which design preference ideas could be generated, two commercially available breath ketone sensors, designed for ketogenic diet monitoring, were explored over one week by ten young people with T1DM. Participants interacted with the breath ketone sensing devices, and undertook blood ketone testing, at least twice daily for five days to simulate use within a real life and ambulatory care setting. Semi-structured interviews were conducted post-testing with the ten young participants and their caregivers (n = 10) to elicit preferences related to breath sensor design and use, and to inform the co-design of a breath ketone sensor prototype for use in T1DM self-management. We triangulated our data collection with key informant interviews with two diabetes educators working in pediatric care about their perspectives related to young people using breath ketone sensors.

Results

Participants acknowledged the non-invasiveness of breath sensors as compared to blood testing. Affordability, reliability and accuracy were identified as prerequisites for breath ketone sensors used for diabetes management. Design features valued by young people included portability, ease of use, sustainability, readability and suitability for use in public. The time required to use breath sensors was similar to that for blood testing. The requirement to maintain a 10-second breath exhalation posed a challenge for users. Diabetes educators highlighted the ease of use of breath devices especially for young people who tended to under-test using blood ketone strips.

Conclusions

Breath ketone sensors for diabetes management have potential that may facilitate ketone testing in young people. Our study affirms features for young people that drive usability of breath sensors among this population, and provides a model of user preference assessment.

Integrating Multiple Inputs Into an Artificial Pancreas System: Narrative Literature Review

Background

Type 1 diabetes (T1D) is a chronic autoimmune disease in which a deficiency in insulin production impairs the glucose homeostasis of the body. Continuous subcutaneous infusion of insulin is a commonly used treatment method. Artificial pancreas systems (APS) use continuous glucose level monitoring and continuous subcutaneous infusion of insulin in a closed-loop mode incorporating a controller (or control algorithm). However, the operation of APS is challenging because of complexities arising during meals, exercise, stress, sleep, illnesses, glucose sensing and insulin action delays, and the cognitive burden. To overcome these challenges, options to augment APS through integration of additional inputs, creating multi-input APS (MAPS), are being investigated.

Objective

The aim of this survey is to identify and analyze input data, control architectures, and validation methods of MAPS to better understand the complexities and current state of such systems. This is expected to be valuable in developing improved systems to enhance the quality of life of people with T1D.

Methods

A literature survey was conducted using the Scopus, PubMed, and IEEE Xplore databases for the period January 1, 2005, to February 10, 2020. On the basis of the search criteria, 1092 articles were initially shortlisted, of which 11 (1.01%) were selected for an in-depth narrative analysis. In addition, 6 clinical studies associated with the selected studies were also analyzed.

Results

Signals such as heart rate, accelerometer readings, energy expenditure, and galvanic skin response captured by wearable devices were the most frequently used additional inputs. The use of invasive (blood or other body fluid analytes) inputs such as lactate and adrenaline were also simulated. These inputs were incorporated to switch the mode of the controller through activity detection, directly incorporated for decision-making and for the development of intermediate modules for the controller. The validation of the MAPS was carried out through the use of simulators based on different physiological models and clinical trials.

Conclusions

The integration of additional physiological signals with continuous glucose level monitoring has the potential to optimize glucose control in people with T1D through addressing the identified limitations of APS. Most of the identified additional inputs are related to wearable devices. The rapid growth in wearable technologies can be seen as a key motivator regarding MAPS. However, it is important to further evaluate the practical complexities and psychosocial aspects associated with such systems in real life.

Fear of hypoglycemia in Italian mothers of children with type 1 diabetes: the mediating role of resilience

Objective

Fear of hypoglycemia for children with diabetes influences parental life and could increase parental stress. The present study aimed to explore the association between resilience, the self-perception of the parental role, and fear of hypoglycemia in mothers of children with type I diabetes (T1DM).

Methods

Ninety mothers (mean age: 44.20 years) of children with a T1DM diagnosis (mean age: 11.48 years) were recruited from an association for parents and completed an online self-report questionnaire packet that includes: Fear of Hypoglycemia Survey, Self-Perception of the Parental Role and Resilience Scale for Adults. Participants were recruited in 2017. Data collection lasted 10 months. Data analysis was performed using the SPSS statistical package, version 22, and the PROCESS macro program by Hayes.

Results

The analysis of the mediation model shows that resilience assumes a mediational role in the relationships between the parental role and preoccupation with hypoglycemia. In particular, the mother's perceived competence and role balance can influence the development and increase of the mother's resilience, which in turn can allow a decrease in the mother's worry about the possible hypoglycemic episode of her child.

Conclusion

The findings suggest that resilience is a significant topic to focus on in interventions designed to increase the self-perception of the parental role and reduce fear of hypoglycemia in mothers.

"Not having a minute of self-distancing during the social distancing is exhausting": a qualitative study on the perspective of caregivers of youth with type 1 diabetes during the COVID-19 pandemic

OBJECTIVE

To investigate the impact of the COVID-19 pandemic on caregivers of youth with type 1 diabetes.

METHODS

We performed a qualitative research based on an open-ended questionnaire that was conducted through an online platform for primary caregivers of children and adolescents with type 1 diabetes. Participants were asked to describe the impact of the COVID-19 outbreak on their caring for youth with diabetes, as well as the emotional burden that it has brought to their personal lives. Interview responses were coded and stratified by youth age: ≤ 12 years (youth aged ≤ 12 years) and between 13 and 18 years (youth aged > 12 years). The connections between the responses were identified based on either positive or negative content of the reported experience. Data were analyzed in accordance with an inductive reasoning methodology.

RESULTS

A total of 318 participants (mean age of 40.3 ± 8.1 years old) were included, representing caregivers of youth aged 11.7 ± 4.3-year-old with diabetes duration of 5.1 ± 3.8 years. The preponderance of negative feelings was noteworthy. Regarding diabetes care, more than 80% of participants reported concern and anxiety about the changes in habits that accompanied the pandemic. Also, more than half of caregivers regretted the isolation of their youth, factors that were associated with greater difficulty in achieving good glycemic control. Regarding the personal burden experienced, the negative impact of uncertainties and concerns about the COVID-19 were present in almost all participants.

CONCLUSION

The period of pandemic may lead to exhaustion in caregivers of youths with type 1 diabetes, which reflects the need for mental health support strategies to help those families.

Psychosocial factors affecting the etiology and management of type 1 diabetes mellitus: A narrative review

Type 1 diabetes (T1D) is one of the most common chronic diseases in children and adolescents worldwide. Its etiopathogenesis results from the interplay of genetic and environmental variables. Among the latter, psychological stress has been implicated in disease onset as well as disease management. Various studies, including large population-based studies, have highlighted the role of stressful life events in the etiopathogenesis of T1D. In this article, we also emphasize the importance of attachment in the early child-caregiver relationship, which can be seen as a measure of the quality of the relationship and is crucial for stress and emotional regulation. It serves as a model for all subsequent relationships in one's life. We summarize some of the few studies performed in the field of attachment and T1D etiopathogenesis or management. T1D management demands a lifelong therapeutic regimen to prevent acute and chronic complications. In addition to psychological stress, psychological factors such as family functioning, developmental adjustment, autonomy, mental health problems and other factors have been found to relate to metabolic control. Psychological factors need to be understood not as a single directional causality-based principle but as a dynamic bi- or multidirectional system that is affected by the normal developmental transitions of childhood and adolescence.

Can Innovative Technologies Overcome HbA1c Disparity for African-American Youth with Type 1 Diabetes?

Achieving normal or near-normal glycemic control as reflected by HbA1c levels in patients with type 1 diabetes (T1D) is important for preventing the development and progression of chronic complications. Despite delineation and dissemination of HbA1c management targets and advances in insulin pharmacology, insulin delivery systems, and glucose monitoring, the majority of children with T1D do not achieve HbA1c goals. In particular, African Americans are more likely not to reach HbA1c goals and have persistently higher HbA1c than Non-Hispanic Whites. Availability of pumps and other technology has not eliminated the disparity in HbA1c. Multiple factors play a role in the persisting racial disparity in HbA1c outcome. The carefully designed application and deployment of new technology to help the patient/family and facilitate the supportive role of the diabetes management team may be able to overcome racial disparity in glycemic outcome and improve patient quality of life.

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

OBJECTIVE

Hypoglycemia is a common acute complication of type 1 diabetes (T1D), which may cause seizure, loss of consciousness, and temporary motor or sensory impairment. Glucagon administration is an effective way of treating severe hypoglycemia, especially in a free-living setting. Nonetheless, families have difficulties in managing severe hypoglycemia due to their anxiety and challenges with current glucagon administration techniques. The aim of the current study was to explore the associations between parental fear of hypoglycemia (FoH) and their general anxiety level, and in particular, their attitudes towards and thoughts on glucagon administration.

METHODS

Parents of children with T1D completed questionnaires assessing background and clinical information, FoH, generalized anxiety disorder (GAD) and parental anxiety for glucagon administration (PAGA).

RESULTS

Sixty-eight parents participated. Positive correlations were found between parental GAD-7 score and both FoH and the number of night-time blood glucose measurements and there was a negative correlation with the child’s age. Parents mean self-evaluation score of their competence in glucagon administration was 6 (standard deviation±2.9) on a scale of 0 to 10. Unsurprisingly, this score was negatively correlated with the PAGA scores. There was no significant difference between children using continuous glucose monitoring system and self-monitoring of blood glucose in terms of parental FoH, anxiety and misconceptions about glucagon administration.

CONCLUSION

The results showed that parents of children with T1D had anxiety and fear connected with hypoglycemia and glucagon administration. Structured and practical training should be implemented to increase parents’ self-confidence including annual refresher training for home glucagon administration.

Associations Between Depressive Symptoms, Fear of Hypoglycemia, Adherence to Management Behaviors and Metabolic Control in Children and Adolescents with Type 1 Diabetes

We examined the relationship between two malleable risk factors, depressive symptoms and fear of hypoglycemia, in children and adolescents with Type 1 diabetes and their relationship to two important outcomes, adherence behaviors and metabolic control. To assess this relationship, we used a multidimensional measure of adherence, assessing frequency of both blood glucose monitoring and healthy behaviors including diet and exercise. We predicted that higher levels of depressive symptoms and higher levels of fear of hypoglycemia would be associated with worse metabolic control as mediated by poor adherence. Eighty-three children and adolescents ages 8 to 20 (M = 13.87, SD 3.21) were recruited from March 2014 to October 2014 at an outpatient diabetes clinic in a moderately sized Southeastern city within the USA. Nested models were evaluated using structural equation modeling. Adherence significantly mediated the relationship between depressive symptoms and metabolic control with more depressive symptoms leading to worse metabolic control. Adherence marginally mediated the relationship between fear of hypoglycemia and metabolic control; however, less fear of hypoglycemia was associated with worse metabolic control. In a combined model, adherence continued to significantly mediate the relationship between depressive symptoms and metabolic control, while also independently significantly mediating the relationship between fear of hypoglycemia and metabolic control. This finding was also contrary to the predicted relationship with less fear of hypoglycemia leading to worse metabolic control. The results indicate that youth with fewer depressive symptoms and more fear of hypoglycemia had better adherence to their treatment regimen, which was associated with better metabolic control. The results of this study highlight the importance of screening for depression and fear of hypoglycemia during routine clinic visits to optimize adherence and metabolic control.

Paediatric Type1 Diabetes Management and Mothers' Emotional Intelligence Interactions

The functioning of the parents' emotional sphere is very important to a child's mental and physical health. This study focused on investigating the association between mothers' emotional intelligence (EI) and paediatric type I diabetes (T1DM) disease management in their children. We hypothesized that mothers' EI is associated with T1DM outcomes. Mothers of children with T1DM aged 6-12 years were surveyed. One hundred and thirty-four mothers, the main caregivers of their diabetic children, provided measures of EI and completed a demographic questionnaire. The primary indicator of diabetes management was haemoglobin A1c (HbA1c; the main form of glycosylated haemoglobin). EI scales and subscales were associated with glycaemic management indices. Logistic regression analysis was applied for the assessment of the association between parents' EI and their paediatric with T1DM disease management. The analysis demonstrated a statistically significant correlation between T1DM management and mothers' ability to understand and control own emotions, to transform their own negative emotions into positive and to control own negative emotions. Mothers' EI scales and subscales of understanding and regulating their own emotions, subscales of transforming their own negative emotions into positive ones and controlling their own negative emotions were statistically reliable predictors of glycaemic control in children with T1DM.

Experiences of Young People and Their Caregivers of Using Technology to Manage Type 1 Diabetes Mellitus: Systematic Literature Review and Narrative Synthesis

BACKGROUND

In the last decade, diabetes management has begun to transition to technology-based care, with young people being the focus of many technological advances. Yet, detailed insights into the experiences of young people and their caregivers of using technology to manage type 1 diabetes mellitus are lacking.

OBJECTIVE

The objective of our study was to describe the breadth of experiences and perspectives on diabetes technology use among children and adolescents with type 1 diabetes mellitus and their caregivers.

METHODS

This systematic literature review used integrated thematic analysis to guide a narrative synthesis of the included studies. We analyzed the perspectives and experiences of young people with type 1 diabetes mellitus and their caregivers reported in qualitative studies, quantitative descriptive studies, and studies with a mixed methods design.

RESULTS

Seventeen articles met the inclusion criteria, and they included studies on insulin pump, glucose sensors, and remote monitoring systems. The following eight themes were derived from the analysis: (1) expectations of the technology prior to use, (2) perceived impact on sleep and overnight experiences, (3) experiences with alarms, (4) impact on independence and relationships, (5) perceived usage impact on blood glucose control, (6) device design and features, (7) financial cost, and (8) user satisfaction. While many advantages of using diabetes technology were reported, several challenges for its use were also reported, such as cost, the size and visibility of devices, and the intrusiveness of alarms, which drew attention to the fact that the user had type 1 diabetes mellitus. Continued use of diabetes technology was underpinned by its benefits outweighing its challenges, especially among younger people.

CONCLUSIONS

Diabetes technologies have improved the quality of life of many young people with type 1 diabetes mellitus and their caregivers. Future design needs to consider the impact of these technologies on relationships between young people and their caregivers, and the impact of device features and characteristics such as size, ease of use, and cost.

Psychological Well-Being of Parents of Very Young Children With Type 1 Diabetes - Baseline Assessment

BACKGROUND

Type 1 diabetes in young children is a heavy parental burden. As part of pilot phase of the KIDSAP01 study, we conducted a baseline assessment in parents to study the association between hypoglycemia fear, parental well-being and child behavior.

METHODS

All parents were invited to fill in baseline questionnaires: hypoglycemia fear survey (HFS), WHO-5, Epworth Sleepiness Scale and Strength and Difficulties Questionnaire (SDQ).

RESULTS

24 children (median age: 5-year, range 1-7 years, 63% male, mean diabetes duration: 3 ± 1.7 years) participated. 23/24 parents filled out the questionnaires. We found a higher score for the hypoglycemia fear behavior 33.9 ± 5.6 compared to hypoglycemia worry 34.6 ± 12.2. Median WHO-5 score was 16 (8 - 22) with poor well-being in two parents. Median daytime sleepiness score was high in five parents (>10). For six children a high total behavioral difficulty score (>16) was reported. Pro social behavior score was lower than normal in six children (<6). Parental well-being was negatively associated with HFS total (r = - 0.50, p <.05) and subscale scores (r = - 0.44, p <.05 for HFS-Worry and HFS-Behavior), child behavior (r = - 0.45, p = .05) and positively with child age and diabetes duration (r = 0.58, p <.01, r = 0.6, p <.01). HFS, parental well-being nor daytime sleepiness are associated with the HbA1c.

CONCLUSION

Regular screening of parental well-being, hypoglycemia fear and child behavior should be part of routine care to target early intervention.

Mothers and Fathers Parenting Stress and Their Perception of Children's Psychosocial Functioning in Paediatric Diabetes: A Pilot Study

(1) Background: In the context of a child with Type 1 Diabetes Mellitus (T1DM), the rearrangement of the family’s lifestyle can account for an increased risk of experiencing psychosocial problems for both child and parents. Those few studies on pediatric diabetes, which focused on parents’ perception of children’s psychological strengths and weaknesses, reported significantly higher rates of children’s emotional and conduct problems associated with an imbalance in the Hemoglobin A1c (HbA1c). The main aim of this paper was to assess the role of parental perception of children’s psychosocial symptoms as a mediator of the perceived parenting stress, considering mother and father separately. (2) Methods: The study involved 12 parent couples (Mothers M_age = 40.25, SD = 6.58; Fathers M_age = 42.5, SD = 6.38) of children with T1DM aged between 7 and 11 years (M_age = 8.8, SD = 0.996). Parents completed questionnaires such as the Strengths and Difficulties Questionnaire for parents and their perspective of their child, and the Parenting Stress Index–Short Form. (3) Results: Mothers and fathers had significant differences in the perception of their child’s internalizing symptoms. Specifically, mothers present a greater perception of the mentioned symptoms compared to fathers. Mediation models showed that only for fathers’ perception of the child conduct problems has a significant role between the fathers’ perception of dysfunctional interaction with the child and the HbA1c. (4) Conclusions: The current study provides useful evidence also for clinical settings, suggesting that an interesting interplay between parenting stress, perception of children’s symptoms and glucometabolic control should be taken into consideration.

Mindfulness, Worries, and Parenting in Parents of Children With Type 1 Diabetes

OBJECTIVE

Parents of children with type 1 diabetes (T1D) often experience distress and worries, which may negatively impact their parenting behaviors. The current study investigates parental mindfulness (i.e., an enhanced attention to and awareness of current experiences or present reality) as a resilience mechanism. Using a daily diary approach, the predictive role of parental mindfulness for daily diabetes-related worries was examined, its impact upon protective parenting behaviors, and its buffering role in the relationship between daily worries and protective parenting behaviors.

METHODS

Participants were 56 parents of 40 children with T1D (2-12 years). Trait mindfulness was assessed with the Mindful Attention Awareness Scale. Subsequently, parents completed a diary for 14 consecutive days, assessing parental worries about hypo- and hyperglycemia and general and diabetes-specific parental protective behavior.

RESULTS

Multilevel analyses showed that parental diabetes-related worries fluctuated substantially across days and positively predicted daily protective behavior. Higher levels of parental mindfulness predicted less daily worries about hypoglycemia and lower engagement in general protective behavior and hypoglycemia avoidance behavior. In addition, the relationship between worries about hyperglycemia and general protective behavior was moderated by parental mindfulness.

CONCLUSIONS

The present findings highlight the importance of daily parental worries in explaining parental protective behaviors on a daily basis. Mindfulness emerged as a promising resilience factor in parents of children with T1D, resulting in less daily worries and protective parenting. These results have important clinical implications and point to the promising role of mindfulness interventions in this context.

Comparison of flash glucose monitoring with real time continuous glucose monitoring in children and adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion

AIMS

In 2016 intermittently scanned continuous glucose monitoring (isCGM) became the first reimbursed CGM system in Belgium. Many children with type 1 diabetes (T1D) treated with multiple daily injections as well as with continuous subcutaneous insulin infusion (CSII) switched from self-monitoring of blood glucose to isCGM to monitor their treatment. In 2017 the Enlite® real-time CGM (rtCGM) system was reimbursed enabling its use with the Minimed® 640G insulin pump with integrated SmartGuard technology. In this study we compared the metabolic control during CSII with isCGM with that during rtCGM. Patient's satisfaction and side effects of the rtCGM system were also evaluated.

METHODS

20 children with T1D, aged 5-16 years, were included. Metabolic control during the last month of isCGM use was compared to that during the 3rd and 6th month of rtCGM.

RESULTS

Three patients stopped early rtCGM mainly due to calibration burden. The HbA1c level and the mean glucose value in the other patients did not change after switching to the rtCGM system. Glucose variability was smaller (46.2% vs 38.4% and 36.4%, p = 0.000). Time in hypoglycemia (<70 mg/dl) was lower (7.4% vs 1.6% and 1.5%, p = 0.000). The main patient inconvenience was the sensor calibration.

CONCLUSIONS

Our data show that during Enlite® rtCGM with the Minimed® 640G pump system glucose variability was smaller and the patients spent less time in hypoglycemia than during isCGM. The need for timely calibrations is considered as the main drawback of the system.

Evaluating fear of hypoglycemia, pediatric parenting stress, and self-efficacy among parents of children with type 1 diabetes and their correlation with glycemic control

Background: This study was designed to determine the level of fear of hypoglycemia (FoH), pediatric parenting stress and selfefficacy in parents of children with type 1 diabetes (T1D).

Methods: In this cross-sectional study, 61 families of children with T1D who had been diagnosed for at least 6 months recruited from "Gabric Diabetes Education Association" in Tehran. Sixty mothers and 41 fathers of 61 children (26 girls, age: 6.0-12.7 years) were assessed using the Hypoglycemia Fear Survey-Parent (HFS-P), Pediatric Inventory for Parents (PIP) and Self-Efficacy for Diabetes Scale-Parent (SED-P) questionnaires. Pearson correlation analysis was used to compute the correlation between HFS-P, PIP and SEDP scores separately for mother and fathers.

Results: Only 8.3% of children had controlled diabetes. Internal reliability of the Persian version of all questionnaires was good. FoH were higher for mothers. Mothers whose children had diabetes for less than two years had significantly lower mean HFS-Behavior subscale (HFS-B) scores than mothers whose children had diabetes for more than two years. There was a positive correlation between fathers’ mean HFS-B score and children’s total insulin dose per day. Parents' FoH score was positively correlated with increased pediatric parenting stress. Findings also showed considerable emotional distress in 51% of mothers and 29.7% of fathers. Frequency of selfmonitoring blood glucose tests (SMBG) correlated negatively with HbA1c.

Conclusion: We concluded that parents with high levels of FoH and stress may benefit from diabetes education. Important implications for education are considering psychological adjustment, recognizing diabetes-related fear and stress in parents, encouraging fathers to become actively involved in the child’s diabetes management and emphasizing the importance of SMBG.

Adjusting Insulin Delivery to Activity (AIDA) clinical trial: Effects of activity-based insulin profiles on glucose control in children with type 1 diabetes

BACKGROUND

Increased daytime activity in children with type I diabetes mellitus (T1DM) is associated with increased risk of hypoglycemia.

OBJECTIVE

To determine whether an automated weekly review of accelerometer, continuous glucose monitoring (CGM), and insulin pump data, could be used to identify children with increased risk of nighttime hypoglycemia and preemptively adjust the nighttime basal insulin profile according to daytime activity.

RESEARCH AND DESIGN METHODS

Clinical trial of children with T1DM on insulin pump and CGM therapy. Subjects at risk of nighttime hypoglycemia were identified from regression analysis of daytime step count vs nighttime nadir glucose. If the regression slope was significantly different from zero (P < 0.05) subjects were managed with different algorithm derived nighttime basal insulin profiles following high and low activity days.

RESULTS

Twenty children (median age: 12; range: 7-17 years) were enrolled. Regression slopes were significant in 10 children. In these children, baseline nighttime nadir glucose level was lower following high activity days (120 [110-139] vs 152 [130-162] mg/dL, P = 0.004). Use of activity-based nighttime basal profiles produced similar nighttime nadir glucose levels following high and low activity days (136 [123-175] vs 140 [108-180] mg/dL, P = 0.73) with fewer nighttime interventions to correct hypoglycemia (0 [0-0.16] vs 0.15 [0.13-0.22] per night, P = 0.008).

CONCLUSION

Children with lower nighttime glucose levels following high daytime activity can be identified using step count data obtained from readily available accelerometers and the nighttime glucose control improved using different activity-based basal profiles.

In-Clinic Evaluation of the MiniMed 670G System "Suspend Before Low" Feature in Children with Type 1 Diabetes

BACKGROUND

The Medtronic predictive low-glucose management (PLGM) algorithm automatically stops insulin delivery when sensor glucose (SG) is predicted to reach or fall below a preset low-glucose value within the next 30 min, and resumes delivery after hypoglycemia recovery. The present study evaluated the PLGM algorithm performance of the MiniMed™ 670G system SmartGuard™ "suspend before low" feature in children aged 7-13 years with type 1 diabetes (T1D).

METHOD

Participants (N = 105, mean ± standard deviation of 10.8 ± 1.8 years) underwent an overnight in-clinic evaluation of the "suspend before low" feature with a preset low limit of 65 mg/dL. After exercise, frequent sample testing (FST) was conducted every 5 min if values were <70 mg/dL; every 15 min if 70-80 mg/dL; and every 30 min if >80 mg/dL. First-day performance of the Guardian™ Sensor 3 glucose sensor and continuous glucose monitoring system was also evaluated.

RESULTS

Activation of the "suspend before low" feature occurred in 79 of the 105 participants, 79.7% (63/79) did not result in SG falling below 65 mg/dL. Mean glucose at activation was 102 ± 19 mg/dL and the initial insulin suspension duration was 87.5 ± 32.7 min. Four hours after insulin resumption, mean reference glucose was 130 ± 42 mg/dL. Mean absolute relative difference between the FST reference glucose and SG values on the first day of sensor wear was 11.4%. For the 26 participants in whom the "suspend before low" feature did not activate, none involved a reference glucose value ≤65 mg/dL, suggesting that the PLGM algorithm performed as intended.

CONCLUSION

In children aged 7-13 years with T1D, the "suspend before low" feature of the MiniMed 670G system demonstrated a hypoglycemia prevention rate of nearly 80% after exercise and did not involve rebound hyperglycemia. There were no events of severe hypoglycemia during the evaluation.

Evaluation of the FreeStyle® Libre Flash Glucose Monitoring System in Children and Adolescents with Type 1 Diabetes

BACKGROUND/AIMS

The FreeStyle® Libre Flash Glucose Monitoring System (FGM, Abbott) measures glucose concentrations in the interstitial fluid for up to 14 days. It has been approved for use in children aged > 4 years in January 2016. Experience in children is still limited. We evaluated the accuracy and usability of the FGM in children with type 1 diabetes mellitus (DM).

METHODS

67 children with type 1 DM (35 girls), aged 4-18 years, were included. Subjects wore a sensor on the back of their upper arm. For the first 14 days, they regularly measured capillary blood glucose (BG) with their usual BG meter (Accu-Chek® Mobile [ACM], Roche [n = 24]; Contour® Next Link [CNL], Bayer [n = 26]; OneTouch® Verio® IQ [OTV], LifeScan [n = 17]) followed by a sensor glucose (SG) scanning. SG readings were compared to BG measurements by consensus error grid (CEG) analysis; the mean difference (MD), the mean relative difference (MRD), the mean absolute difference (MAD), and the mean absolute relative difference (MARD) were calculated. After 14 days, subjects were asked to fill in a questionnaire on the usability of the FGM.

RESULTS

2,626 SG readings were paired with BG results. FGM readings were highly correlated with BG (r = 0.926, p < 0.001). 80.3% of the data pairs were in zone A (= no effect on clinical action) and 18.4% were in zone B (= altered clinical action with little or no effect on the clinical outcome) of the CEG. Overall MD was +7.5 mg/dL; MD varied with the BG meter: ACM +10.4 mg/dL, CNL +14.2 mg/dL, OTV -3.6 mg/dL (p < 0.001). Overall, MARD was 16.7%. We observed a large interindividual variability in the accuracy parameters. MD and MRD were inversely related to BMI (r = -0.261 [p < 0.05]; r = -0.266 [p < 0.05], respectively). MARD was inversely related to age (r = -0.266 [p < 0.05]). Twenty-nine patients (43.3%) reported sensor problems, mainly early detachment of the sensor. Nonetheless, the usability questionnaire indicated high levels of satisfaction.

CONCLUSIONS

Our results showed a reasonable agreement between the FGM SG readings and capillary BG measurements in children. There was, however, a large interindividual variability. The wearing of the sensor requires special attention. Further studies in children are imperative in order to document the accuracy and safety of the FGM in the paediatric population.

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

BACKGROUND

Managing type 1 diabetes mellitus (T1DM) in preschool-aged children has unique challenges that can negatively impact glycemic control and parental coping.

OBJECTIVE

To evaluate the impact of a camp-based multi-component intervention on glycated hemoglobin A1c (HbA1c) in young children with T1DM and psychosocial measures for their parents.

SUBJECTS AND METHODS

Two separate cohorts of 18 children (ages 3-5 years) and their families participated in a camp-based intervention that included didactic and interactive parent education, child-centered education and family-based recreational activities. In Camp 1.0, measures of HbA1c, parental fear of hypoglycemia, mealtime behaviors and quality of life (QOL) were compared before and after an initial session (I) and follow-up booster session (II) 6 months later. Based on these results, the intervention was consolidated into 1 session (Camp 2.0) and repeated with additional measures of parental stress and parental self-efficacy with diabetes management tasks.

RESULTS

Participants in Camp 2.0 exhibited a significant decrease in mean HbA1c level (-0.5%, P = .002) before and after camp. Mothers exhibited a significant improvement in diabetes-specific QOL (Camp 1.0/Session I and Camp 2.0) and reduction in stress as measured on the Pediatric Inventory for Parent (PIP) assessment (Camp 2.0). The booster session in Camp 1.0 showed no added benefit.

CONCLUSIONS

A family centered, camp-based multi-component intervention in young children with T1DM improved HbA1c and perceived QOL and stress in their mothers.

Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents

OBJECTIVE

The primary objective of this trial was to evaluate the feasibility, safety, and efficacy of a predictive hyperglycemia and hypoglycemia minimization (PHHM) system vs predictive low glucose suspension (PLGS) alone in optimizing overnight glucose control in children 6 to 14 years old.

RESEARCH DESIGN AND METHODS

Twenty-eight participants 6 to 14 years old with T1D duration ≥1 year with daily insulin therapy ≥12 months and on insulin pump therapy for ≥6 months were randomized per night into PHHM mode or PLGS-only mode for 42 nights. The primary outcome was percentage of time in sensor-measured range 70 to 180 mg/dL in the overnight period.

RESULTS

The addition of automated insulin delivery with PHHM increased time in target range (70-180 mg/dL) from 66 ± 11% during PLGS nights to 76 ± 9% during PHHM nights (P<.001), without increasing hypoglycemia as measured by time below various thresholds. Average morning blood glucose improved from 176 ± 28 mg/dL following PLGS nights to 154 ± 19 mg/dL following PHHM nights (P<.001).

CONCLUSIONS

The PHHM system was effective in optimizing overnight glycemic control, significantly increasing time in range, lowering mean glucose, and decreasing glycemic variability compared to PLGS alone in children 6 to 14 years old.