Growth, puberty, and final height in children with Type 1 diabetes

Severe growth retardation during carbohydrate restriction in type 1 diabetes mellitus: A case report

Carbohydrate restriction is not typically recommended for children with type 1 diabetes mellitus (T1DM) because of concerns regarding growth retardation, ketoacidosis, severe hypoglycemia, and dyslipidemia. There is no consensus regarding the effects of carbohydrate restriction on the growth of children with T1DM. However, some previously reported cases of T1DM exhibited growth retardation during carbohydrate restriction, whereas others showed no obvious impairment. A female child with T1DM exhibited severe height growth velocity impairment during carbohydrate restriction in early childhood. Her height standard deviation score (SDS) was 1.12 at the initial T1DM diagnosis (2 yr and 11 mo of age) and -1.33 at 4 yr and 8 mo of age. Her height velocity was only 1.7 cm/yr (SDS -7.02). Discontinuing carbohydrate restriction substantially improved her height growth velocity. Implementing a carbohydrate-restricted diet in children with T1DM can negatively affect height growth velocity.

Insulin-like growth factor 1 and sex hormones for assessment of anthropometric and pubertal growth of Egyptian children and adolescents with type 1 diabetes mellitus (single center study)

BACKGROUND

This study aimed to assess the anthropometric measures and pubertal growth of children and adolescents with Type 1 diabetes mellitus (T1DM) and to detect risk determinants affecting these measures and their link to glycemic control.

PATIENTS AND METHODS

Two hundred children and adolescents were assessed using anthropometric measurements. Those with short stature were further evaluated using insulin-like growth factor 1 (IGF-1), bone age, and thyroid profile, while those with delayed puberty were evaluated using sex hormones and pituitary gonadotropins assay.

RESULTS

We found that 12.5% of our patients were short (height SDS < -2) and IGF-1 was less than -2 SD in 72% of them. Patients with short stature had earlier age of onset of diabetes, longer duration of diabetes, higher HbA1C and urinary albumin/creatinine ratio compared to those with normal stature (p < 0.05). Additionally, patients with delayed puberty had higher HbA1c and dyslipidemia compared to those with normal puberty (p < 0.05). The regression analysis revealed that factors associated with short stature were; age at diagnosis, HbA1C > 8.2, and albumin/creatinine ratio > 8 (p < 0.05).

CONCLUSION

Children with uncontrolled T1DM are at risk of short stature and delayed puberty. Diabetes duration and control seem to be independent risk factors for short stature.

Delayed menarche in children and adolescents with type 1 diabetes mellitus: a systematic review and meta-analysis

Several studies have reported an association between age at menarche and the onset of type-1 diabetes mellitus (T1DM). This review compared the age at menarche in patients who had menarche after T1DM diagnosis with that of patients who were healthy and/or had menarche before T1DM diagnosis. Searches were conducted using four databases. The outcome was the age at menarche of patients who had menarche after T1DM diagnosis and patients who were healthy and/or had menarche before T1DM diagnosis. A qualitative analysis was performed using the JBI (Joanna Briggs Institute) Critical Appraisal. Quantitative analysis of the mean differences was performed using Revman 5.4 tool. A total of 1952 studies were obtained from the initial search. The final results were 13 articles that met the inclusion criteria for the qualitative assessment and eight for the quantitative assessment. Eight studies included 1030 patients who had menarche after being diagnosed with T1DM and 1282 patients who were healthy and/or had menarche before T1DM diagnosis. The meta-analysis showed a cumulative effect on a mean difference of 0.87 (95% CI: 0.75; 0.99, p-value < 0.00001), indicating a later age at menarche in patients who had menarche after T1DM diagnosis. The age at menarche was later in patients who had menarche after T1DM diagnosis compared to healthy subjects and those who had menarche beforehand.

Final height in children and adolescents with type 1 diabetes mellitus: A systematic review and meta-analysis

PURPOSE

Considering the high prevalence of type 1 diabetes mellitus (T1DM) together with the importance of improved physical growth and the significance of promoting healthcare quality among T1DM children, this meta-analysis aims to determine mean final height in this population group.

METHODS

We systematically searched PubMed, EMBASE, Web of Science, Scopus, and Cochrane databases for all studies published until May 2023 and reviewed references of published articles. Meta-analytic procedures were used to estimate the effect size (mean final height Z-score) among T1DM children in a random effects model. Significance values, weighted effect sizes, 95% CIs, and tests of homogeneity of variance were calculated. The included studies consisted of data from 3274 patients.

RESULTS

The mean final height Z-score for T1DM children was -0.201 (n = 25 studies, 95% CI: -0.389, -0.013; I2 = 97%), -0.262 in males (n = 20 studies, 95% CI: -0.539, 0.015, I2 = 97.1%), and -0.218 in females (n = 18 studies, 95% CI: -0.436, 0, I2 = 94.2%). The non-significant negative association between age at diagnosis, HbA1c levels, and final height Z-score is suggested by the findings of the univariate meta-regression.

CONCLUSION

Our findings indicated that children with T1DM have impaired linear growth and that monitoring of growth in these patient populations is an important issue in the management of T1DM. Due to a scarcity of studies providing data on the relationship between uncontrolled diabetes (increased HbA1c) and early diagnosis and final height, further investigation is warranted to determine whether there is indeed a correlation. Consequently, any conclusion regarding the association between uncontrolled diabetes (elevated HbA1c), early diagnosis of T1DM, and the increased risk of impaired linear growth or final height remains uncertain.

Assessment of pubertal onset and disorders of puberty in Indian children and youth with type-1 diabetes

OBJECTIVES

Disorders of pubertal development are enlisted as associated conditions in children and adolescents with type-1 diabetes (T1D). We conducted this study with objective (1) To estimate the median age at onset of puberty and luteinizing hormone (LH) and sex-steroid concentrations in Indian adolescents with T1D and (2) To assess the impact of puberty on glycemic control and insulin resistance (IR).

METHODS

This cross-sectional study included 399 children and youth aged 6-23 years with T1D. Demographic, anthropometric, biochemical and pelvic ultrasound data were collected using standard protocols. IR was calculated using estimated glucose disposal rate and puberty was assessed using Tanner staging.

RESULTS

Median age at onset of thelarche, pubarche and menarche were 11.3, 11.4 and 12.8 years in girls and that of gonadarche and pubarche were 10.6 and 12.7 years for boys. The mean LH and sex-steroid concentrations of subjects with T1D were similar to healthy subjects at each stage of puberty. The cut-offs of LH and sex-steroids derived from healthy Indian children yielded high sensitivity and specificity in determining pubertal onset. The prevalence of precocity, delayed puberty, ovarian cysts and polycystic ovaries was 0.9 , 5.1, 5.1 and 8.6 %, respectively. Glycaemic control and insulin sensitivity was poor in pubertal subjects.

CONCLUSIONS

The age at onset of puberty, LH, and sex-steroid concentrations in subjects with T1D were like otherwise healthy Indian children with poor glycemic control and IR in pubertal subjects. Although most complications of T1D are associated with poor glycemic control, pubertal disorders were significantly low despite the less-than-optimal glycemic control.

Puberty in boys with type 1 diabetes mellitus: What has changed?

AIMS

To study the age of pubertal onset and secular trend in boys with Type 1 diabetes mellitus (T1DM) followed in two centers in North Greece.

METHODS

Boys with T1DM visited the Outpatient Clinics of the 1st and 2nd Department of Paediatrics of Aristotle University of Thessaloniki from March until June 2022 were enrolled. Recent anthropometric data were recorded during the follow-up visit whereas previous anthropometric data and demographic data were collected from medical files. A volume of testis > 3 ml was indicative for the onset of puberty.

RESULTS

A total of 46 boys with T1DM with documented pubertal onset after the diagnosis of T1DM were included in the study. Precocious puberty (<9 years old) was recorded in 5 boys (10.2 %), early puberty (<10 years but >9 years) in 10 (20.4 %) and 34 (69.4 %) entered puberty normally. The duration of T1DM was inversely correlated to the likelihood of earlier puberty (P < 0.001). However, no notable year predominance was observed suggesting no COVID-19 effect.

CONCLUSION

A considerable number of Greek boys with T1DM appear to develop precocious and early puberty, raising thoughts regarding diabetes management and other possible cofactors.

Menstrual Dysfunction in Adolescents with Chronic Illness: A Systematic Review

STUDY OBJECTIVE

Menstrual dysfunction can impact both the physical and emotional health of young people¹. Multiple chronic disease have been associated with menstrual dysfunction in adults², however there is little research in adolescents, despite non adherence and sub-optimal illness control in this group. We aimed to identify the impact chronic illness has on the age of menarche (AAM) and the menstrual cycle in adolescents.

METHODS

Studies were extracted of female adolescents aged 10-19 who had a chronic physical illness. Data included outcomes on age of menarche and/or menstrual cycle quality. Exclusion criteria aimed to exclude diseases where menstrual dysfunction was a known part of the disease pathophysiology i.e. polycystic ovarian syndrome³, or in which medications were used that directly impacted gonadal function⁴. A literature search (to January 2022) was performed on EMBASE, PubMed and Cochrane library databases. Two widely used modified quality analysis tools were used.

RESULTS

Our initial search netted 1451 articles, of which 95 full texts were examined and 43 met inclusion criteria. 27 papers focussed on Type 1 Diabetes (T1D), with 8 papers examining adolescents with cystic fibrosis (CF) and the remaining studying inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), coeliac disease and chronic renal disease. Metanalysis of 933 patients with T1D versus 5244 controls demonstrated a significantly later AAM in T1D (by 0.42 years; p=<0.00001). There was also a significant association between higher HbA1c and insulin dose (IU/kg) and later age of menarche. Eighteen papers reviewed other aspects of menstruation, including dysmenorrhoea, oligomenorrhoea, amenorrhoea and ovulatory function, with variable findings.

CONCLUSION

The majority of studies were small and in single populations. Despite this, there was evidence of delayed menarche and some evidence of irregular menses in those with CF and T1D. Further structured studies are needed to evaluate menstrual dysfunction in adolescents and how it relates to their chronic illness.

Inpatient target discharge weight for early-onset anorexia nervosa: Restoring premorbid BMI percentile to improve height prognosis

OBJECTIVE

Early-onset anorexia nervosa (EO-AN) is characterized by restricted food intake leading to low body weight, emerging before 14 years old. Most patients reaching a target body mass index (BMI) around the 25th percentile at hospitalization discharge display an incomplete prospective height catch-up. A better understanding of height prognosis determinants is required.

METHODS

In 74 children with an EO-AN, we collected height and weight premorbidly, at hospitalization, and at discharge, 6 months, 12 months, and at longer-term follow-up of 36 months. We defined a height prognosis parameter (HPP) as the difference between the height percentile at follow-up times and the premorbid height percentile. We explored the relationship between weight parameters and height catch-up at follow-up with linear regression analyses.

RESULTS

A higher weight suppression (WS) - i.e., difference between premorbid and current BMI - at admission and discharge was associated with lower HPP - i.e., a greater loss of height - at 12 months and 36 months follow-up. Similarly, a higher premorbid BMI percentile was associated with a lower HPP at 12 and 36 months.

CONCLUSION

Target discharge weight for EO-AN patients should be tailored and based on premorbid BMI trajectory to improve height prognosis.

Oral Health Implications and Dental Management of Diabetic Children

Aim

To review the effect of diabetes mellitus (DM) on the oral health status of children.

Background

Diabetes mellitus (DM) is one of the most severe chronic diseases in children and adolescents. It appears as type 1 DM and type 2 DM. Children are mainly diagnosed with type 1 DM. Genetic, as well as environmental factors, contribute to disease risk, indicating a multifactorial etiology. Early symptoms may vary from polyuria to anxiety or depression disorders.

Review results

A variety of signs and symptoms have been reported regarding the oral health of DM children. Both dental and periodontal health is compromised. Qualitative and quantitative changes in saliva have also been reported. Moreover, there is a direct effect of type 1 DM on oral microflora and increased sensitivity to infections. A variety of protocols have been developed regarding the dental treatment of diabetic children.

Conclusion

Children with diabetes, due to the increased risk of periodontal disease and dental caries, are recommended to follow an intensive prevention program and a diet with strict instructions.

Clinical significance

The dental care provided to children with DM should be personalized, and all patients should follow a strict program of reexaminations. Moreover, the dentist may evaluate oral signs and symptoms of inadequately controlled diabetes and, in coordination with the patient's physician, can play a crucial role in maintaining oral and general health.

How to cite this article

Davidopoulou S, Bitzeni-Nigdeli A, Archaki C, et al. Oral Health Implications and Dental Management of Diabetic Children. Int J Clin Pediatr Dent 2022;15(5):631-635.

Impact of Type 1 Diabetes Mellitus on Bone Health in Children

This paper gives an overview of the impact of type 1 diabetes on bone health in children and adolescents. Firstly, we analyse studies using dual X-ray absorptiometry to assess bone mineral content and bone mineral density. Then, we discuss modern, non-invasive techniques including peripheral quantitative computer tomography (pQCT) and high-resolution pQCT for the detailed assessment of bone health aspects including bone mass, bone geometry, bone microarchitecture, and bone strength. Thereafter, we explore some of the mechanisms that are responsible for diabetic bone disease in children, like low bone turnover and high sclerostin levels. Finally, we summarize some of the evidence for the importance of microvascular disease in the pathophysiology of diabetic bone disease.

Growth and development in type 1 diabetes

PURPOSE OF REVIEW

The purpose of this review is to summarize the current literature on the subject of linear growth in children and adolescents with or at risk for type 1 diabetes mellitus (T1DM).

RECENT FINDINGS

Poor glycemic control in T1DM is associated with growth hormone resistance, and improving glycemic control can improve linear growth. Newer reports suggest that the increasingly popular very low carbohydrate diets, may reduce linear growth velocity.

SUMMARY

Linear growth during childhood is a complex process regulated influenced by genetic, hormonal, nutritional and environmental factors. Linear growth may be impaired in children with T1DM, correlating with poor metabolic control; an extreme example is Mauriac syndrome. This decrement in linear growth appears to be driven in part by a reduction in growth hormone responsiveness, leading to low insulin-like growth factor-1 (IGF-1) levels. Improving glycemic control can lead to improved IGF-1 levels and linear growth. Other factors associated with poor linear growth in T1DM include celiac disease and dietary alterations, with early reports suggesting that very low carbohydrate diets, if not carefully managed, may increase risk of attenuated linear growth. This review examines the latest data regarding the associations between T1DM and linear growth in children.

Good glycemic control at puberty in boys with type 1 diabetes is important for final height

BACKGROUND

Poor glycemic control in children with type 1 diabetes (T1D) may hinder sexual development and the associated growth spurt. This study aims to identify factors that may affect the timing of puberty, total pubertal growth (TPG), and final height (F-Ht) in boys with T1D.

METHODS

This was a retrospective longitudinal study of 68 boys diagnosed with T1D during 1996 to 2009, who were prepubertal at diagnosis and had completed puberty at the time of data collection. Data were accessed regarding anthropometric measurements, Tanner stage, and glycosylated hemoglobin (HbA1c) levels from diagnosis to F-Ht. F-Ht was compared to parental height and Israeli National Health Survey data.

RESULTS

The mean F-Ht standard deviation score (F-Ht-SDS) was lower than the mean Ht-SDS at diagnosis (P < .006) but similar to the mean target height SDS (P = .3) and to values from the national survey (P = .12). Mean HbA1c levels in the year preceding pubertal onset were associated with the age at onset of puberty (R = 0.33, P = .009) and inversely with TPG (R = -0.3, P = .03). Mean HbA1c levels during puberty were inversely associated with TPG (R = -0.26, P = .035) and F-Ht (R = -0.28, P = .02). Boys who presented with diabetic ketoacidosis at diagnosis were shorter than those who did not throughout the follow-up.

CONCLUSIONS

We found associations of age of pubertal onset, pubertal growth spurt, and F-Ht with target height and glycemic control before and during puberty. Targeted interventions to achieve optimal metabolic control during these time periods are needed for normal, timely puberty and for achieving optimal adult height within the genetic target height.

Integration of Consumer-Based Activity Monitors into Clinical Practice for Children with Type 1 Diabetes: A Feasibility Study

Current technology commonly utilized in diabetes care includes continuous glucose monitors (CGMs) and insulin pumps. One often overlooked critical component to the human glucose response is daily physical activity habits. Consumer-based activity monitors may be a valid way for clinics to collect physical activity data, but whether or not children with type 1 diabetes (T1D) would wear them or use the associated mobile application is unknown. Therefore, the purpose of this study was to test the feasibility of implementing a consumer-based accelerometer directly into ongoing care for adolescents managing T1D. Methods: Adolescents with T1D were invited to participate in this study and instructed to wear a mobile physical activity monitor while also completing a diet log for a minimum of 3 days. Clinical compliance was defined as the number of participants who were compliant with all measures while also having adequate glucose recordings using either a CGM, insulin pump, or on the diet log. Feasibility was defined as >50% of the total sample reaching clinical compliance. Results: A total of 57 children and teenagers between the ages of 7 and 19 agreed to participate in this study and were included in the final analysis. Chi-square results indicated significant compliance for activity tracking (p < 0.001), diet logs (p = 0.04), and overall clinical compliance (p = 0.04). Conclusion: More than half the children in this study were compliant for both activity monitoring and diet logs. This indicates that it is feasible for children with T1D to wear a consumer-based activity monitor while also recording their diet for a minimum of three days.

Characteristics of Selected Somatic and Motor Abilities of Youth Soccer Players with Diabetes Type 1 Treated with Insulin Pump Therapy

Long-term insulin treatment can slow the growth process and decrease physical fitness level in children. In diabetic children, these two developments should be constantly monitored. The aim of the present study was to examine differences in somatic and physical fitness characteristics between soccer-training boys with type 1 diabetes and healthy boys of the same age (reference values based on Polish population norms for somatic and motor parameters). The participants were 94 boys (8–17 years), diagnosed with diabetes, who participated in soccer training on a regular basis and received routine medical care. The study involved (a) anthropometric and body composition measurements, (b) general motor ability assessments, and (c) comparison of those characteristics with the healthy Polish population. The diabetic boys were found to have lower levels of almost all somatic traits and motor abilities as compared with the healthy boys (p ≤ 0.05). Handgrip strength was a variable with the smallest difference between the two groups. The observed differences indicate the necessity to design an appropriate control and assessment system based on simple medical and fitness field tests for diabetic children and adolescents. It will allow optimizing advanced training as well as minimize health risks before, during, or after exercise.

Treatment and long-term follow-up of patients diagnosed with type 1 diabetes mellitus before age 5

OBJECTIVES

This study aimed to determine the effects of continuous subcutaneous insulin infusion (CSII) treatment on anthropometric measurements, mean HbA1c, and insulin dosage in patients diagnosed under 5 years of age and compare with multiple-dose injection therapy (MDI).

METHODS

Children with type 1 diabetes mellitus, diagnosed <5 years since 2000 and their 19-year follow-up were evaluated retrospectively. Weight, height, body mass index (BMI), blood pressure, and HbA1c values were recorded for each visit.

RESULTS

Hundred and five patients (58.1% female, 41.9% male) were included in the study. Sixty-three (60 %) patients were treated by CSII and 42 (40%) by MDI. Mean age at diagnosis was 2.68 ± 1.42 and 3.29 ± 1.30 years respectively. Mean follow-up was 7.42 ± 4.76 and 6.01 ± 4.41 years respectively. For each group, weight standard deviation score (SDS) increased significantly in the first year after the diagnosis (p<0.001), and with the onset of puberty weight SDS decreased significantly (p<0.001). The trend of weight and BMI SDS changes over the years showed similar characteristics in both groups. During follow-up height SDS was similar in both groups except in Tanner stage 5. When puberty was completed, mean height SDS was 0.51 ± 1.03 in CSII and -0.31 ± 0.75 in the MDI group (p: 0.029). Mean HbA1c was significantly lower in the CSII group (7.62 ± 0.82 and 8.17 ± 1.22 respectively). Systolic and diastolic blood pressure change trends during the follow-up were also similar in both groups.

CONCLUSIONS

CSII treatment had positive effects on metabolic control and height SDS in patients with early-onset diabetes without increasing BMI.

Comparison of Continuous Subcutaneous Insulin Infusion and Multiple Daily Injections in Pediatric Type 1 Diabetes: A Meta-Analysis and Prospective Cohort Study

BACKGROUND

The incidence of pediatric type 1 diabetes (T1D) is increasing worldwide, and the appropriate choice of therapy regimens is important for children, especially in developing countries with inadequate resources.

METHODS

We conducted a design combining meta-analysis and prospective cohort study. In meta-analysis, 14 studies involving 69,085 TID cases reported glycosylated hemoglobin (HbA_1c) levels, including 48,363 multiple daily insulin injections therapy (MIT) and 20,722 continuous subcutaneous insulin infusion (CSII). In our prospective cohort study, TID cases were recruited from a tertiary children's hospital, and randomly divided into Group MIT and Group CSII. After the 4-year follow-up, the effects of MDI (n = 112) and CSII (n = 76) therapy on glycemic control, long-term complications, as well as the growth and pubertal development were explored.

RESULTS

Compared to CSII in TID, HbA_1c levels in MDI (WMD = 0.21, 95% CI: 0.20 to 0.23) were increased significantly in meta-analysis. Among 188 clinical cases, mean age at recruitment was 7.55 (SD 2.91) years. Duration of TID was 4.23 (SD 2.61) years. 50.53% (n = 95) of them were boys. The 4-year follow-up showed that children's HbA_1c was 0.67 (95% CI -1.28, -0.05) % lower in children with CSII compared to children with MDI in multivariable regression models with adjustment for potential confounders (children's age at follow-up, duration of TID, gender, birthweight, parity, and delivery method). CSII was associated with 2.31 kg higher in children's weight (95% CI 0.59, 4.04) in the adjusted model. No difference was found in peripheral nerve and fundus consequences as well as the status of obesity and thin and pubertal development between CSII and MIT.

CONCLUSION

CSII might be associated with better glycemic control and better effect for children growth development. No higher risks of long-term complications and delayed pubertal development were observed in CSII. Our findings provided evidence for a better therapy regimen for T1D in children, nevertheless, they need to be validated by a larger sample size study.

Linear Growth in Children and Adolescents with Type 1 Diabetes Mellitus

Ensuring normal linear growth is one of the major therapeutic aims in the management of type one diabetes mellitus (T1DM) in children and adolescents. Many studies in the literature have shown that pediatric patients with T1DM frequently present some abnormalities in their growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis compared to their healthy peers. Data on the growth of T1DM children and adolescents are still discordant: Some studies have reported that T1DM populations, especially those whose diabetes began in early childhood, are taller than healthy pediatric populations at diagnosis, while other studies have not found any difference. Moreover, many reports have highlighted a growth impairment in T1DM patients of prepubertal and pubertal age, and this impairment seems to be influenced by suboptimal glycemic control and disease duration. However, the most recent data showed that children treated with modern intensive insulin therapies reach a normal final adult height. This narrative review aims to provide current knowledge regarding linear growth in children and adolescents with T1DM. Currently, the choice of the most appropriate therapeutic regimen to achieve a good insulin level and the best metabolic control for each patient, together with the regular measurement of growth parameters, remains the most important available tool for a pediatric diabetologist. Nevertheless, since new technologies are the therapy of choice in young children, especially those of pre-school age, it would be of great interest to evaluate their effects on the growth pattern of children with T1DM.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Qualidade de vida e diabetes mellitus: autopercepção de adolescentes de uma cidade do sul do Brasil

Resumo Objetivou-se, neste estudo, avaliar a Qualidade de Vida em Relação à Saúde (QVRS) de adolescentes de 10 a 18 anos, com diagnóstico de diabetes mellitus tipo 1 (DM1), usuários dos serviços de duas unidades de atenção secundária em saúde municipal, no sul do Brasil. Participaram do estudo 20 adolescentes de ambos os sexos, com idades de 10 a 18 anos, sendo os dados coletados através do Questionário KIDSCREEN-52 versão brasileira. Os resultados indicaram que os adolescentes apresentaram ótima percepção de QVRS e que ocorreram poucas diferenças significativas em relação a sexo, classes socioeconômicas, idade e tempo de diagnóstico. Os resultados sugerem que a interferência da DM1 na QVRS deve ser analisada em função do processo de desenvolvimento da adolescência.

The influence of treatment, age at onset, and metabolic control on height in children and adolescents with type 1 diabetes-A SWEET collaborative study

OBJECTIVE

To describe the association between height, demographics, and treatment in youths with type 1 diabetes participating in an international network for pediatric diabetes centers (SWEET).

METHODS

Data were collected from 55 centers with documented patients' height. All subjects below 20 years of age, diabetes duration >1 year, and without celiac disease were included. World Health Organization growth charts were used to calculate height and body mass index z-scores. Multiple hierarchic regression models adjusting for known confounders were applied.

RESULTS

Data on 22 941 subjects (51.8% male) were analyzed with a median and interquartile range for age 14.8 years (11.2, 17.6), diabetes duration 5.6 years (3.1, 8.9), and height z-score 0.34 (-0.37, 1.03). Children were taller in the youngest age groups: adjusted height z-scores of 0.31 (±0.06) and 0.39 (±0.06), respectively; with shorter diabetes duration (<2 years: 0.36 [±0.06]; 2-<5 years: 0.34 [±0.06]; ≥5 years: 0.21 [±0.06]) and if they were pump users: 0.35 ± 0.05 vs 0.25 ± 0.05 (>three injections/day and 0.19 ± 0.06 [0-3 injections daily]), respectively. High hemoglobin A1c (HbA1c) and low to normal weight were associated with a lower height z-score. Trends were identical in all models except for gender. No gender differences were found except in the final height model where females exhibited higher z-score than males.

CONCLUSION

For youths treated at centers offering modern diabetes management, major growth disturbances are virtually eliminated. For children with a young age at onset, high HbA1c, injections, and/or non-intensive diabetes, treatment still requires attention in order to attain normal growth.

The association of insulin-like growth factor-1 standard deviation score and height in Chinese children with type 1 diabetes mellitus

Assessing the relationship between IGF-1 and height in type 1 diabetes children. Seventy-two type 1 diabetes children and 190 controls were recruited. The height standard deviation score of type 1 diabetes children was significantly higher than controls. The height standard deviation score was higher than the target height standard deviation score in both type 1 diabetes and controls. Serum IGF-1 levels and the IGF-1 standard deviation score were significantly lower in type 1 diabetes patients compared with controls. There was a significant difference in IGF-1 standard deviation score between the good glycemic control group and control group. The height standard deviation score was significantly correlated with C-peptide and IGF-1 levels. Furthermore, the IGF-1 standard deviation score was significantly correlated with glycemic control and C-peptide. The growth hormone/IGF-1 axis is impaired in type 1 diabetes, but height with good or poor glycemic control is not impaired.

High Prevalence of Polycystic Ovary Syndrome in Type 1 Diabetes Mellitus Adolescents: Is There a Difference Depending on the NIH and Rotterdam Criteria?

BACKGROUND

Polycystic ovary syndrome (PCOS) is more frequently observed in type 1 diabetes mellitus (T1DM) adult women than in nondiabetic women. No such prevalence has yet been studied in adolescent girls with T1DM.

AIM

The aim of this study was to evaluate the prevalence of PCOS in adolescent girls with T1DM and to determine the clinical and hormonal features associated with the disorder.

METHODS

A cross-sectional study of 53 adolescent girls (gynecological age >2 years) referred for routine evaluation for T1DM was conducted. We diagnosed PCOS using the National Institutes of Health (NIH) and Rotterdam criteria.

RESULTS

26.4 and 47.9% of adolescents had PCOS according to NIH (NIH-PCOS) and Rotterdam (Rotterdam-PCOS) criteria. 66.7% of NIH-PCOS adolescents had a complete phenotype associated with hyperandrogenism, oligomenorrhea, and polycystic ovarian morphology, unlike only 33.3% of the Rotterdam-PCOS adolescents. A family history of type 2 diabetes mellitus (T2DM) was more frequent in PCOS than in non-PCOS girls, whichever criteria were used. Late pubertal development and a T1DM diagnosis close to puberty were factors associated with NIH-PCOS.

CONCLUSION

Adolescents with T1DM had a high prevalence of PCOS. More differences between PCOS and non-PCOS patients were found using the NIH criteria, suggesting that clinical characteristics might be more accurate for diagnosing PCOS in girls with T1DM. A family history of T2DM is associated with a high risk of PCOS.

Resveratrol attenuates reproductive alterations in type 1 diabetes-induced rats

The progression of diabetes mellitus leads to several complications including overproduction of reactive oxygen species and reproductive alterations. As resveratrol (RES) is a powerful anti-oxidant and an anti-apoptotic compound, we hypothesized that side effects of type-1 diabetes (DM1) on male reproduction could be reduced by the RES treatment. Eighty-four prepubertal male rats were distributed into seven groups: sham-control (SC), RES-treated (R), resveratrol-vehicle-treated (RV), diabetic (D), diabetic-insulin-treated (DI), diabetic-RES-treated (DR), diabetic-insulin and RES-treated (DIR). DM1 was induced by a single intraperitoneal streptozotocin (STZ) injection (65 mg/kg) on the 30th day postpartum (dpp). Animals of DR, DIR and R groups received 150 mg/day of RES by gavage for 43 consecutive days (from the 33 to 75 dpp). DI and DIR rats received subcutaneous injections of insulin (1 U/100 g b.w./day) from 5th day after the DM1 induction. The blood glucose level was monitored. At 75 dpp, the euthanasia was performed for morphometric and biometric testicular analyses, spermatic evaluation and hormonal doses. In the D group, the blood glucose level was higher than in the DR, DI and DIR groups. Besides morphometric testicular measurements, testosterone and estradiol doses were lower in D group than in DR and DIR groups; LH dose was also lower than in DR. The preputial separation age was delayed in diabetes-induced groups. The DR and DIR groups showed an improvement in sperm mitochondrial activity, epididymal sperm counts and the frequency of morphologically normal sperms. RES treatment improved glycaemic level, sperm quantitative and qualitative parameters and the hormonal profile in DM1-induced rats and seems to be a good reproductive protector.

Perspectives in Pediatric Pathology, Chapter 22. Testicular Involvement in Systemic Diseases

Normal testicular physiology requires appropriate function of endocrine glands and other tissues. Testicular lesions have been described in disorders involving the hypothalamus-hypophysis, thyroid glands, adrenal glands, pancreas, liver, kidney, and gastrointestinal tract. Testicular abnormalities can also associate with chronic anemia, obesity, and neoplasia. Although many of the disorders that affect the above-mentioned glands and tissues are congenital, acquired lesions may result in hypogonadism in children and adolescents.

Skeletal growth and bone mineral acquisition in type 1 diabetic children; abnormalities of the GH/IGF-1 axis

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases diagnosed in childhood. Childhood and adolescent years are also the most important period for growth in height and acquisition of skeletal bone mineral density (BMD). The growth hormone (GH)/insulin like growth factor -1 (IGF-1) axis which regulates growth, is affected by T1DM, with studies showing increased GH and decreased IGF-1 levels in children with T1DM. There is conflicting data as to whether adolescents with TIDM are able to achieve their genetically-determined adult height. Furthermore, data support that adolescents with T1DM have decreased peak BMD, although the pathophysiology of which has not been completely defined. Various mechanisms have been proposed for the decrease in BMD including low osteocalcin levels, reflecting decreased bone formation; increased sclerostin, an inhibitor of bone anabolic pathways; and increased leptin, an adipocytokine which affects bone metabolism via central and peripheral mechanisms. Other factors implicated in the increased bone resorption in T1DM include upregulation of the osteoprotegerin/ receptor-activator of the nuclear factor-κB ligand pathway, elevated parathyroid hormone levels, and activation of other cytokines involved in chronic systemic inflammation. In this review, we summarize the clinical studies that address the alterations in the GH/IGF-I axis, linear growth velocity, and BMD in children and adolescents with T1DM; and we review the possible molecular mechanisms that may contribute to an attenuation of linear growth and to the reduction in the acquisition of peak bone mass in the child and adolescent with T1DM.

Delay in sexual maturation in perinatally HIV-infected youths is mediated by poor growth

OBJECTIVE

To evaluate the association between HIV infection and sexual maturation, and mediation of this association by HIV effects on growth.

DESIGN

Pooled data were analyzed from two longitudinal cohort studies, the International Maternal Pediatric Adolescent AIDS Clinical Trials P219/219C Study (1993-2007) and the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol (2007-2015), including perinatally HIV-infected (PHIV) and HIV-exposed uninfected (PHEU) youths.

METHODS

We evaluated age at sexual maturity among 2539 PHIV and PHEU adolescents based on annual physician-assessed pubertal staging measures. Interval-censored regression models were used to evaluate associations of HIV infection with age at maturity. Mediation analyses accounting for height and BMI Z-scores at specific ages were used to estimate direct and indirect effects of HIV infection on age at sexual maturity.

RESULTS

Mean ages at sexual maturity for PHIV girls (n = 1032) were 15.5 years for both female breast and pubic hair and 15.9 and 15.8 years for PHIV boys (n = 1054) for genitalia and pubic hair, respectively. PHIV youths matured approximately 6 months later on average than PHEU (n = 221 girls and 232 boys), and this difference persisted after adjustment for race/ethnicity and birth cohort. BMI and height Z-scores mediated the association between HIV infection and later maturation in girls, accounting for up to 74% of the total HIV effect. Only height Z-scores mediated the effect of HIV on male age at maturity, accounting for up to 98% of the HIV effect.

CONCLUSION

PHIV youths attain sexual maturity later on average than PHEU youths. Much of this difference may be attributable to deficient growth, suggesting directions for future interventions.

Growth in patients with type 1 diabetes

PURPOSE OF REVIEW

As the incidence of type 1 diabetes (T1DM) continues to rise, complications including impairment of childhood growth remain a major concern. This review provides an overview of alterations in growth patterns before and after the onset of T1DM.

RECENT FINDINGS

Recent advances in this field include several prospective investigations of height and weight trajectories in children leading up to the development of islet autoimmunity and T1DM as well as evaluations of larger cohorts of T1DM patients to better assess predictors of altered growth. In addition, genetic and metabolic investigations have improved our understanding of the more rare severe growth impairment of Mauriac Syndrome.

SUMMARY

Despite advances in medical care of children with T1DM, growth remains suboptimal in this population and likely reflects ongoing metabolic derangement linked with classic microvascular diabetic complications.

Interaction of Pubertal Development and Metabolic Control in Adolescents with Type 1 Diabetes Mellitus

BACKGROUND

In T1DM, delayed pubertal development and reduced final height are associated with inadequate metabolic control.

OBJECTIVE

To assess whether T1DM affects pubertal growth spurt and whether metabolic control during puberty is gender-related.

METHODS

Using a large multicentre database, longitudinal data from 1294 patients were analysed. Inclusion criteria: complete records of height and HbA1c from the age of seven to 16 years. Exclusion criteria: other significant chronic diseases and medications, T1DM duration less than three months, and initial BMI < 3rd or >97th percentile.

RESULTS

Growth velocity (GV) was impaired with a significant reduction of peak GV by 1.2 cm in boys. HbA1c increase during male puberty was lower except for a period of 1.5 years. The highest HbA1c increase in boys coincided with maximum growth spurt. In girls, the highest HbA1c increase was observed during late puberty. Even though there is impaired GV, both sexes reach a height at 16 years of age which corresponds to the background population height.

CONCLUSION

Worsening of metabolic control is sex-discordant and associated with gender-specific alterations of GV. However, the vast majority of boys and girls with T1DM seems to reach normal height at the age of 16 years.

Myopia in young patients with type 1 diabetes mellitus

INTRODUCTION

This study aimed to evaluate the proportion of young patients with type 1 diabetes mellitus (T1DM) who have myopia, as well as the risk factors associated with myopia in this group.

METHODS

In this cross-sectional study, patients aged < 21 years with T1DM for ≥ 1 year underwent a comprehensive eye examination. Presence of parental myopia, and average hours of near-work and outdoor activity were estimated using a questionnaire. Annualised glycosylated haemoglobin (HbA1c), defined as the mean of the last three HbA1c readings taken over the last year, was calculated. Multivariate analysis using genetic, environmental and diabetes-related factors was done to evaluate risk factors associated with myopia.

RESULTS

Of the 146 patients (mean age 12.5 ± 3.6 years) recruited, 66.4% were Chinese and 57.5% were female. Myopia (i.e. spherical equivalent [SE] of -0.50 D or worse) was present in 96 (65.8%) patients. The proportion of patients with myopia increased from 25.0% and 53.6% in those aged < 7.0 years and 7.0-9.9 years, respectively, to 59.2% and 78.4% in those aged 10.0-11.9 years and ≥ 12.0 years, respectively. Higher levels of SE were associated with lower parental myopia (p = 0.024) and higher annualised HbA1c (p = 0.011).

CONCLUSION

Compared to the background population, the proportion of myopia in young patients with T1DM was higher in those aged < 10 years but similar in the older age group. Myopia was associated with a history of parental myopia. Environmental risk factors and poor glycaemic control were not related to higher myopia risk.

Ovarian aging in women with diabetes: An overview

Type 2 diabetes is a global epidemic, and the prevalence and incidence of type 1 diabetes are increasing. The negative effects of diabetes on kidneys, nerves, and vessels are well established. The effect of diabetes on reproductive function is less well understood, but important to characterize, given the increasing numbers of young women with diabetes. In this review, we summarize the available literature on how women with diabetes experience ovarian aging, from menarche to menopause. We report that women with type 1 diabetes appear more likely to have ovarian dysfunction, manifested by delayed menses, menstrual irregularities, and possibly earlier menopause. Studies of women with type 2 diabetes are inconsistent but suggest increased anovulation and earlier menopause. Differences in reproductive aging between women with type 1 and type 2 diabetes raise questions about potential differences in the mechanisms contributing to ovarian aging. Although there is shared glycemic dysregulation, fundamental differences in insulin presence and processing distinguish the two diseases. This review suggests that insulin, age at diagnosis, and weight play a role in ovarian dysfunction. More long-term studies are needed to evaluate the multitude of factors that may disrupt hypothalamic, pituitary, and ovarian function in women with diabetes.

Effects of intraperitoneal insulin versus subcutaneous insulin administration on sex hormone-binding globulin concentrations in patients with type 1 diabetes mellitus

AIMS

Elevated sex hormone-binding globulin (SHBG) concentrations have been described in patients with type 1 diabetes mellitus (T1DM), probably due to low portal insulin concentrations. We aimed to investigate whether the route of insulin administration, continuous intraperitoneal insulin infusion (CIPII), or subcutaneous (SC), influences SHBG concentrations among T1DM patients.

METHODS

Post hoc analysis of SHBG in samples derived from a randomized, open-labeled crossover trial was carried out in 20 T1DM patients: 50% males, mean age 43 (±13) years, diabetes duration 23 (±11) years, and hemoglobin A1c (HbA1c) 8.7 (±1.1) (72 (±12) mmol/mol). As secondary outcomes, testosterone, 17-β-estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were analyzed.

RESULTS

Estimated mean change in SHBG was -10.3nmol/L (95% CI: -17.4, -3.2) during CIPII and 3.7nmol/L (95% CI: -12.0, 4.6) during SC insulin treatment. Taking the effect of treatment order into account, the difference in SHBG between therapies was -6.6nmol/L (95% CI: -17.5, 4.3); -12.7nmol/L (95% CI: -25.1, -0.4) for males and -1.7nmol/L (95% CI: -24.6, 21.1) for females, respectively. Among males, SHBG and testosterone concentrations changed significantly during CIPII; -15.8nmol/L (95% CI: -24.2, -7.5) and -8.3nmol/L (95% CI: -14.4, -2.2), respectively. The difference between CIPII and SC insulin treatment was also significant for change in FSH 1.2U/L (95% CI: 0.1, 2.2) among males.

CONCLUSIONS

SHBG concentrations decreased significantly during CIPII treatment. Moreover, the difference in change between CIPII and SC insulin therapy was significant for SHBG and FSH among males. These findings support the hypothesis that portal insulin administration influences circulating SHBG and sex steroids.

[Pediatric patients with type 1-diabetes: growth and growth failure associated factors]

BACKGROUND

Type 1 diabetes (T1D) usually occurs in the pediatric age and affects the growth of children. The aim of this work was to describe growth and growth failure associated factors in a population of children with T1D in a tertiary level pediatric hospital.

METHODS

A case-control nested in a cohort study was conducted. We included patients with TD1 under 16 years of age with a minimum follow-up of 12 months. Data as age at T1D diagnosis, anthropometry, glycosylated hemoglobin (HbA1c), as well as the pubertal development (Tanner stage) were collected at the time of diagnosis and during 4 years of follow-up. At the end of the follow-up, patients with growth failure and without it were compared, matched by sex, age at TD1 diagnosis. Univariate and multivariate analyses were performed.

RESULTS

On the first year of follow-up, 95 patients were gathered, 88 patients were still followed by the second year, 56 patients were kept for the third year, and 46 patients were still followed-up by the fourth year. Median age was 9.5 years and 50% were preadolescents. During their evolution, 50% had growth failure. According to the multivariate analysis, the factor associated with growth failure was the HbA1c in the first year post-diagnosis (OR 4.08; 95% CI 1.34-12.42).

CONCLUSIONS

In the first year post-diagnosis of children with T1D, HbA1c was associated with growth failure.

Pediatric diabetic retinopathy: experience of a tertiary hospital in Ethiopia

BACKGROUND

Diabetic retinopathy is one of the micro vascular complications of diabetes mellitus. To date there are no studies that show the magnitude of diabetic retinopathy in the pediatric population of Ethiopia with only very few in Africa. The purpose of this study was to determine the prevalence of diabetic retinopathy in children and adolescents at a tertiary center in Ethiopia.

METHODS

This cross-sectional hospital based descriptive study included children aged between 9 and 17 years attending the endocrine follow-up clinic of Tikur Anbesa Specialized Hospital. A structured questionnaire was used for evaluating sociodemographic data and information pertinent to diabetes. The prevalence of diabetic retinopathy was determined by fundus photography of each eye.

RESULTS

A total of 86 patients were examined with a mean age of 13.7 (SD = 1.8) years. At onset of diabetes, 95.6% of children presented with diabetic ketoacidosis(DKA); 22 children (25.6%) had at least two episodes of DKA, and 45 children (52.3%) had poor glycemic control. Background retinopathy was present in four children (4.7%) with a mean age of 14.25 (SD = 1.89) years and two of them also had maculopathy.

CONCLUSION

Although there are some methodological limitations, this study highlights the difficulties of achieving good glycemic control and the early occurrence of diabetic retinopathy in Ethiopian diabetic children.

The Relationship between Metabolic Control and Growth in Children with Type I Diabetes Mellitus in Southwest of Iran

Background. Metabolic control is an important factor in growth of children with type I diabetes. This study assessed the relationship between growth and metabolic control in such children. Materials and Methods. 83 children with diabetes were studied. They were examined for weight and height gain and HbA1C was quantified every 3 months for one year. The growth process was studied in patients who were divided into 3 groups according to their HbA1C amounts, consisting of good, intermediate, and poor metabolic control. Results. Mean age of cases was 7.6 ± 2. The presenting sign at the onset of disease was diabetic ketoacidosis in 44.6%. The average HbA1C amount was 8.89%. The average weight SDS at diagnosis was -0.18 and at the end of the study was 0.45 (P<0.001). The average height SDS at diagnosis was -0.04 and at the end of the study was -0.07 (P=0.64). A significant difference in weight SDS changes was only seen between patients with good and poor metabolic control (P=0.04). Conclusion. Poor metabolic control can decrease height growth but has minimal influence on weight. Metabolic control was not the only predictive factor of physical growth in children with diabetes.

Diabetes IN develOpment (DINO): the bio-psychosocial, family functioning and parental well-being of youth with type 1 diabetes: a longitudinal cohort study design

Background

Strict glycemic control during adolescence decreases the risk of developing complications later in life, even if this level of control is not maintained afterwards. However, the majority of adolescents with type 1 diabetes (T1D) are in poor control and so far medical or psychological interventions have shown limited success. Adolescence is characterized by major biological, psychosocial, cognitive and parent–child relationship changes and the complex interaction between these developmental trajectories, and its impact on health outcomes is still poorly understood. A specific topic of interest in this context is the timing of diagnosis. The longitudinal study DINO (Diabetes IN develOpment) aims to examine:

If and how the onset of T1D before vs. during puberty results in different outcomes of glycemic control, self-management, psychological functioning and diabetes-related quality of life.

The timing of onset of disturbed eating behavior, its risk factors and its prospective course in relation to glycemic and psychological consequences.

If and how the onset of T1D before vs. during puberty results in different family functioning and parental well-being.

If and how the cognitive development of youth with T1D relates to glycemic control and diabetes self-management.

Methods/design

DINO, a longitudinal multi-center cohort study is conducted in youth with T1D in the age range 8–15 years at baseline. Participants will be divided into two subgroups: pre-pubertal and pubertal. Both groups will be followed for 3 years with assessments based on a bio-psychosocial model of diabetes, scheduled at baseline, 12 months, 24 months and 36 months examining the biological, psychosocial -including disturbed eating behaviors- and cognitive development, family functioning and parental well-being.

Discussion

A better understanding of how the different trajectories affect one another will help to gain insight in the protective and risk factors for glycemic outcomes and in who needs which support at what moment in time. First results are expected in 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0400-1) contains supplementary material, which is available to authorized users.

Growth disorders in type 1 diabetes: an Indian experience

Though children with type 1 diabetes mellitus (T1DM) are often tall at the time of diagnosis, they may experience growth retardation, pubertal delay or both, which may be due to poor glycemic control, associated diseases or chronic complications. Factors affecting growth include: gender, genetic environment, age at diagnosis, diabetes duration, puberty, metabolic control, and status of growth hormone (GH), insulin-like growth factors (IGFs), and IGF binding proteins (IGFBPs). Insulin regulates expression of hepatic GH receptors, affects IGFs and IGFBPs synthesis by modulating GH postreceptor events, and significantly increases IGF-I bioactivity. Low portal insulin seen in T1DM leads to GH hypersecretion, low circulating IGF-I and IGFBP-3, and high circulating IGFBP-1. Newly diagnosed T1DM patients have decreased GHBP which can be restored with insulin therapy. Growth velocity should be appropriate for the age of the child/adolescent, and the mid-parental height. Height, weight and blood pressure (BP) should be measured and plotted on a growth chart at least 2-3 times a year. Puberty should also be assessed annually. Following precautions are to be taken in T1DM children: checking for pubertal onset and ensuring it is not delayed, testing early when growth falters (hypothyroidism/celiac disease/puberty/other conditions), aiming for best possible metabolic control (multidose regimens, regardless of type of insulin), and encouraging dietary calcium and protein, exposure to sunlight, Vitamin D supplements and exercise.

Current status of diabetes management, glycemic control and complications in children and adolescents with diabetes in Egypt. Where do we stand now? And where do we go from here?

THE AIM

of this study was to use the Diabetes Registry of the Pediatric Diabetes Clinic, Ain Shams University Hospital to examine risk factors related to poor glycemic control and to provide data to health professionals for planning, evaluation and optimizing diabetes care.

SUBJECTS AND METHODS

Data from 600 children and adolescents with diabetes with information in the registry provide information on current clinical status, metabolic control, acute and long-term complications, presence of concomitant autoimmune diseases, and psychiatric aspects of patients.

RESULTS

Mean age of patients was 13.3±5.1 years, mean duration of diabetes was 6.4±3.6 years, mean HbA1c was 8.8±4.6% [73±27 mmol/mol], and 71% had poor glycemic control. Acute complications included ketoacidosis in 19.7% and severe hypoglycemia in 2.8%. Chronic complications including peripheral neuropathy, retinopathy, and persistent microalbuminuria were present in 6.3%, 1.8%, and 6.8%, respectively. The majority (97.2%) were on intensive insulin therapy. Patients with poor glycemic control had higher disease duration, DKA frequency and diabetic microvascular complications. However, regular education lecture attendance and regular SMBG were associated with better glycemic control.

CONCLUSIONS

These registry data indicate that although the majority of the patients were on intensive insulin therapy, poor glycemic control was common and diabetic microvascular complications were observed. These findings will provide potential avenues to improve quality of care and could be the first step in the development of a national registry for diabetes in Egypt.

Growth attainments of Indian children with type 1 diabetes: a mixed longitudinal study

OBJECTIVE

To evaluate distance and velocity growth of children with Type 1 Diabetes (T1D) and quantify the magnitude of gender differences in anthropometric parameters.

METHODS

Children with T1D, without any coexisting condition that could affect growth were measured at half yearly intervals for body weight, height, occipito-frontal circumference (OFC), chest circumference (CC), mid upper arm circumference (MUAC), triceps skinfold thickness (TSFT), biceps skinfold thickness (BSFT) and subscapular skinfold thickness (SSSFT) using standardized techniques. Comparison of these growth parameters was made between the 2 genders as well as with the published norms.

RESULTS

Of the 115 children studied, there were no significant gender differences in weight at different age points. Boys measured taller than girls but the gender differences in height were significant only at 7 and 10 y. There was a tendency of higher BMIs in girls. In comparison to WHO standards and normal Indian children, boys had lower weight initially but became heavier later. The girls showed close similarity to their normal Indian counterparts but remained lighter than their WHO counterparts. After the initial lower height, an acceleratory trend was noted in boys but girls remained shorter throughout the study as compared to WHO peers. Boys, in general had higher CC, OFC, MUAC and MUAMC. The skinfold thicknesses recorded inconsistent growth patterns in both sexes. Growth velocities for various body parameters except skinfold thicknesses were similar in boys and girls.

CONCLUSIONS

Initial weight and height loss followed by catch up growth was noted in boys. The values of MUAC, MUAMC and skinfold thicknesses as compared to data from developed countries, were lower in present patients.

Assessment of skeletal and dental ages of children and adolescents with type 1 diabetes mellitus

The present study aimed to assess the skeletal and dental ages of type 1 diabetes mellitus (T1DM) patients. Therefore, panoramic and hand-wrist radiographs of 82 patients, aged between 5 and 15 years, were collected and divided into case and control groups. The case group consisted of 41 panoramic and 41 hand-wrist radiographs of T1DM patients, whereas the control group consisted of 41 panoramic and 41 hand-wrist radiographs of patients without T1DM. Skeletal age was assessed according to the method of Greulich and Pyle (1999), whereas dental age was assessed according to the method of Nolla (1960). Chi-square tests revealed no statistically significant differences between skeletal and dental ages between the case and control groups (p > 0.05). However, in the case group, the skeletal age of females was greater than that of age-matched males (p = 0.005). Considering that skeletal and dental growth of the case and control groups were closely related, clinical interventions involving orthodontics and dentomaxillofacial orthopedics should be equally performed both for healthy and specific patient groups, such as those with T1DM.

Future challenges for pediatric diabetes management in developing countries: lessons from Africa

In this review, we describe the epidemiology of diabetes mellitus in children and adolescents in Africa, noting that there is a paucity of data with regard to the burden of disease, prevalence of undiagnosed diabetes, healthcare and acute and chronic complications. Furthermore, access to care remains an issue of great concern. Our view is that in the next 5 years, more research will be undertaken on the burden of the disease and on interventions to provide better access to care. While the majority of African countries still have a low incidence of diabetes in children, it is predicted that the incidence will increase and it is therefore essential that governments develop sustainable policies to deal with such increases.

Physical Growth and Body Composition of Controlled Versus Uncontrolled Type 1 Egyptian Diabetic Children

BACKGROUND: Type 1 Diabetes Mellitus (T1DM) is one of the most common chronic endocrine disorders of childhood. Data on growth parameters of diabetic children is scarce.AIM: To assess growth and body composition in a group of diabetic children.SUBJECTS AND METHODS: 427 T1DM children (age 2-10 years) were recruited from Diabetic Paediatric Unit, outpatients' clinic of Abou El-Rish Hospital. Anthropometric and body composition parameters were taken and HbA1c was measured for all subjects.RESULTS:  Highly significant difference was detected between controlled and uncontrolled groups as regard to weight/age z-score, height/age z-score, BMI z-score, triceps skin fold thickness, subscapular skin fold thickness, midupper arm circumference, fat mass, fat %, lean mass, and body water (p < 0.001). All values are higher in the controlled group than in the uncontrolled group. Uncontrolled subjects were significantly more at risk of being underweight and short, with odds ratio of 15.131 and 16.877 and 95% confidence interval 1.972-116.130 and 3.973-71.694 respectively. However, controlled subjects were significantly more at risk of being obese than the uncontrolled with an odds ratio 0.116 and 95% confidence interval 0.045-0.302.CONCLUSION: Growth was compromised in uncontrolled T1DM children. This is of utmost importance since most of the clinical features are reversible with better glycemic control and appropriate insulin management.

Sexual dimorphism in growth and insulin-like growth factor-I in children with type 1 diabetes mellitus

OBJECTIVE

Impaired linear growth and reduced IGF-I levels in children with type 1 diabetes (T1DM) have been related to poor metabolic control. The aim of this study was to identify additional factors which may negatively affect growth and IGF system in patients with T1DM.

DESIGN

Ninety-one T1DM children (54 males, age=: 11.73±3years, disease duration=5.6±2.1years) were studied. All children were on intensive insulin therapy: 62 children were on multiple injection therapy (MI) and 29 children on continuous subcutaneous insulin infusion (CSII).

RESULTS

Height velocity (HV) SDS and IGF-I levels were higher in females and in pubertal children [HV SDS: females=0.6±2.4 vs males=-0.45±2.3 (p=0.04); IGF-I SDS: females=-1.09±0.58 vs males=-1.4±0.6 (p=0.02); IGF-I/IGFBP-3 molar ratio: females=0.25±0.1 vs males=0.21±0.08 (p=0.04); IGF-I SDS: pre-pubertal=-1.58±0.46 vs pubertal=-1.15±0.65 (p<0.001); IGF-I/IGFBP-3 molar ratio: pre-pubertal=0.16±0.08 vs pubertal=0.26±0.09 (p<0.001)]. No differences between children on CSII or MI therapy were found. IGF-I SDS was positively related to C peptide level (p<0.001), puberty (p<0.001) and female gender (p=0.02) and negatively related to HbA1c (p=0.04). IGF-I/IGFBP-3 molar ratio was positively affected by C peptide level (p<0.001), puberty (p<0.001) and daily insulin dose (p<0.001).

CONCLUSIONS

Our results indicate that despite intensive insulin therapy, T1DM still negatively affects IGF-I secretion and linear growth. Growth impairment is more severe in males and primarily related to poor glycemic control and loss of the residual beta cell mass.

The regulation of reproductive neuroendocrine function by insulin and insulin-like growth factor-1 (IGF-1)

The mammalian reproductive hormone axis regulates gonadal steroid hormone levels and gonadal function essential for reproduction. The neuroendocrine control of the axis integrates signals from a wide array of inputs. The regulatory pathways important for mediating these inputs have been the subject of numerous studies. One class of proteins that have been shown to mediate metabolic and growth signals to the CNS includes Insulin and IGF-1. These proteins are structurally related and can exert endocrine and growth factor like action via related receptor tyrosine kinases. The role that insulin and IGF-1 play in controlling the hypothalamus and pituitary and their role in regulating puberty and nutritional control of reproduction has been studied extensively. This review summarizes the in vitro and in vivo models that have been used to study these neuroendocrine structures and the influence of these growth factors on neuroendocrine control of reproduction.

The contribution of glycemic control to impaired growth during puberty in young people with type 1 diabetes and microalbuminuria

BACKGROUND

In adults with type 1 diabetes (T1D), short stature has been associated with risk for cardiovascular disease and nephropathy. However, there are no available data on the potential relationship between growth patterns during puberty and the development of vascular complications. Our aim was to assess whether pubertal growth is impaired in young people with T1D who develop microalbuminuria (MA).

METHODS

Repeated height measurements performed during adolescence were available for 206 young people (107 boys) with T1D followed in the Oxford Regional Prospective Study. Longitudinal data on albumin-creatinine ratios and hemoglobin A1c (HbA1c) were also collected from the study participants. Height standard deviations score (SDS) was compared between subjects with (MA+; n = 66) and without MA (MA-; n = 140).

RESULTS

In the group as a whole, mean [95% CI] height SDS progressively declined during puberty, from 0.145 [0.015; 0.274] to -0.003 [-0.145; 0.138], p < 0.001. However, the decline in height SDS was significantly different between the MA+ and MA- groups (p = 0.023), with a mean difference in final height of 4.29 [1.87; 6.72] cm, p = 0.001. Final height was inversely associated with MA (HR [95%CI]: 0.942 [0.908; 0.979], p = 0.002), although this association was no longer significant after adjusting for HbA1c, which was higher in the MA+ group.

CONCLUSION

In this study, we found a significant impairment in growth during puberty in young people with T1D, particularly in those developing MA. Poor glycemic control as well as other genetic or environmental factors could explain these associations.

Testicular function during adolescence in boys with type 1 diabetes mellitus (T1D): absence of hypogonadism and differences in endocrine profile at the beginning and end of puberty

AIM

Conflicting results regarding testicular function in adults with type 1 diabetes (T1D) have been reported, but little is known about Leydig and Sertoli cell function during puberty in boys treated with multiple daily insulin doses. Our aim was to assess testicular function in boys with T1D.

METHODS

Pubertal boys with T1D (n = 71) and healthy control boys (Control group; n = 104) who were 10-18 years were studied. Both groups were matched by pubertal stage, age, and BMI. Total testosterone (TT), calculated free testosterone (cfT), SHBG, inhibin B, AMH, and gonadotropin levels were determined.

RESULTS

At the beginning of puberty, the T1D group had higher levels of SHBG (p = 0.003) and similar androgen levels than the Control group. At the end of puberty, higher TT, and cfT were observed in T1D compared to the Control group (p < 0.01 and p < 0.001, respectively). Gonadotropins and AMH were similar in both groups. Regression analysis showed that T1D was a significant factor, even after adjusting for Tanner stage and BMI-SDS, affecting TT, cFT, and SHBG levels. BMI-SDS was a significant factor affecting TT and SHBG levels. Higher HbA1c had a negative effect on total testosterone and cFT and a positive effect on SHBG levels in T1D boys.

CONCLUSION

Adolescents with T1D do not exhibit hypogonadism, as shown by normal gonadotropin, testosterone, inhibin B, and AMH levels. However, in T1D boys, HbA1c and BMI-SDS had a negative association with testosterone levels. Elevated testosterone levels are observed during late puberty, which were not present earlier.

[Growth and body composition of a cohort of children and adolescents with type 1 diabetes]

OBJECTIVE

To evaluate the growth and body composition of children and adolescents with type 1 diabetes mellitus (T1DM).

SUBJECTS AND METHODS

A cohort of 44 patients with T1DM were followed up for approximately four years and compared with a control group. Weight, height, body mass index (BMI), body fat percentage (BF%), fat mass index, waist circumference (WC) and waist-height ratio were determined.

RESULTS

In females, in the first evaluation, BF% was lower in patients than in controls, while in the second evaluation, mean WC was higher in patients than in controls. In males, height of the patients was lower in the first evaluation, while body mass index (BMI) was higher in the second one. We did not find any differences among the changes in height, weight and BMI z-scores and BF% or in the distribution of those z-scores between the two evaluations, in both groups. Multiple regression analysis found differences in BMI and waist-height ratio in both sexes and also in WC in females.

CONCLUSION

The patients had adequate growth but showed discrepancy in their body composition during the study.

Current clinical status, glucose control, and complication rates of children and youth with type 1 diabetes in Rwanda

OBJECTIVE

To describe the clinical status of youth and adolescents (≤ 25 yr) in the Rwanda Life For A Child (LFAC) program who had their first HbA1c measure in 2009 or 2010, and to identify factors which may relate to glycemic control (HbA1c) and complication status.

RESEARCH DESIGN AND METHODS

Data were collected from June 2009 to November 2010 for the LFAC program in Rwanda and comprise clinical data from when participants' first HbA1c reading was obtained.

RESULTS

From June 2009 to November 2010, 286 youth aged ≤25 yr had their first HbA1c. Mean age, duration, and age at diagnosis were 18.6 ± 4.5 yr, 3.4 ± 3.1 yr and 15.1 ± 4.8 yr, respectively. Mean HbA1c was 11.2 ± 2.7% with 15.7% (n = 45) having HbA1c <8%, while 30.8% (n = 88) had HbA1c >14%. Five (2.1%) had either abnormal tuning fork vibratory sensation or monofilament response, 21% (n = 31) had microalbuminuria (MA, A/C ratio >30 mg/g) and 5% (n = 7) had nephropathy (A/C ratio >300 mg/g). Diabetes duration and insulin dose/kg were positively associated with higher HbA1c, while residing in the southern province was associated with lower HbA1c. Duration, diastolic blood pressure, and HbA1c were positively associated with developing MA, while age was protective.

CONCLUSIONS

These data from the LFAC program for 2009-2010 show that there is a urgent need for dramatically improved care, as many patients have greatly elevated HbA1c measures, often >14%. We have identified correlates of better control (e.g., living in the Southern province) and MA (e.g., diastolic blood pressure), which provide potential avenues to improved quality of care.

Delayed puberty but normal fertility in mice with selective deletion of insulin receptors from Kiss1 cells

Pubertal onset only occurs in a favorable, anabolic hormonal environment. The neuropeptide kisspeptin, encoded by the Kiss1 gene, modifies GnRH neuronal activity to initiate puberty and maintain fertility, but the factors that regulate Kiss1 neurons and permit pubertal maturation remain to be clarified. The anabolic factor insulin may signal nutritional status to these neurons. To determine whether insulin sensing plays an important role in Kiss1 neuron function, we generated mice lacking insulin receptors in Kiss1 neurons (IR(ΔKiss) mice). IR(ΔKiss) females showed a delay in vaginal opening and in first estrus, whereas IR(ΔKiss) males also exhibited late sexual maturation. Correspondingly, LH levels in IR(ΔKiss) mice were reduced in early puberty in both sexes. Adult reproductive capacity, body weight, fat composition, food intake, and glucose regulation were comparable between the 2 groups. These data suggest that impaired insulin sensing by Kiss1 neurons delays the initiation of puberty but does not affect adult fertility. These studies provide insight into the mechanisms regulating pubertal timing in anabolic states.