Treatment of type 1 diabetes in children and adolescents using modern insulin pumps

An overview of oral insulin delivery strategies (OIDS)

Despite tremendous efforts, the world continues its fight against the common chronic disease-diabetes. Diabetes is caused by elevated glucose levels in the blood, which can lead to several complications like glaucoma, cataract, kidney failure, diabetic ketoacidosis, heart attack, and stroke. According to recent statistics, China, India, and the US rank at the top three positions with regards to the number of patients affected by diabetes. Ever since its discovery, insulin is one of the major therapeutic molecules that is used to control the disease in the diabetic population, worldwide. The most common route of insulin administration has been the subcutaneous route. However, the limitations associated with this route have motivated global efforts to explore alternative strategies to deliver insulin, including pulmonary, transdermal, nasal, rectal, buccal, and oral routes. Oral insulin delivery is the most convenient and patient-centered route. However, the oral route is also associated with numerous drawbacks that present significant challenges to the scientific fraternity. The human physiological system acts as a formidable barrier to insulin, limiting its bioavailability. The present review covers the major barriers against oral insulin delivery and explains formulation strategies that have been adopted to overcome these barriers. The review focuses on oral insulin delivery strategies (OIDS) for increasing the bioavailability of oral insulin, including nanoparticles, microparticles, nano-in-microparticles, hydrogels, tablets, capsules, intestinal patches, and use of ionic liquids. It also highlights some of the notable recent advancements and clinical trials in oral insulin delivery. This formulation based OIDS may significantly improve patient compliance in the treatment of diabetes.

Use of continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes mellitus: a systematic mapping review

BACKGROUND

Among the treatments for type 1 diabetes mellitus (T1DM), Continuous Subcutaneous Insulin Infusion (CSII) is a device that infuses insulin through the subcutaneous tissue in an uninterrupted manner and that comes closest to the physiological secretion of insulin. The use of CSII can provide the family with greater security and children and adolescents have more autonomy in relation to the treatment of T1DM. There is a lack of reviews that systematically gather the mounting evidence about the use of CSII in children and adolescents with T1DM. Therefore, the aim of this review was to group and describe primary and secondary studies on the use of CSII in children and adolescents with T1DM.

METHODS

A systematic mapping review was performed based on searches in the following databases: PubMed, Embase, CINAHL, Lilacs and PsycINFO, using a combination of descriptors and keywords. The screening of the studies was carried out with the aid of the Rayyan software and reading in full was conducted independently by two reviewers. The data extraction of the studies was performed using an extraction tool adapted and validated by researchers specialized in diabetes. The data were analyzed according to the content analysis technique. The map from geocoding of the studies was produced using the ArcGis 10.5 software.

RESULTS

A total of 113 studies were included in the review, including primary studies, literature reviews and gray literature publications. The content analysis of the results of the studies allowed for the identification of four categories: 1) metabolic control; 2) support networks; 3) benefits of using CSII; and 4) challenges of using CSII, each category having its respective subcategories. The review also made it possible to conduct a rigorous mapping of the literature on the use of CSII considering the location of development and the design of the studies.

CONCLUSIONS

The use of CSII should be indicated by health professionals able to prepare children, adolescents, and their families for the treatment of T1DM, and, despite being a technological device, it may not be suitable for the entire pediatric population.

The SWEET Project 10-Year Benchmarking in 19 Countries Worldwide Is Associated with Improved HbA1c and Increased Use of Diabetes Technology in Youth with Type 1 Diabetes

Objective: The international SWEET registry (NCT04427189) was initiated in 2008 to improve outcomes in pediatric diabetes. A 10-year follow-up allowed studying time trends of key quality indicators in 22 centers from Europe, Australia, Canada, and India in youth with type 1 diabetes (T1D). Methods: Aggregated data per person with T1D <25 years of age were compared between 2008-2010 and 2016-2018. Hierarchic linear and logistic regression models were applied. Models were adjusted for gender, age-, and diabetes duration groups. Results: The first and second time periods included 4930 versus 13,654 persons, 51% versus 52% male, median age 11.3 [Q1; Q3: 7.9; 14.5] versus 13.3 [9.7; 16.4] years, and T1D duration 2.9 [0.8; 6.4] versus 4.2 [1.4; 7.7] years. The adjusted hemoglobin A1C (HbA1c) improved from 68 (95% confidence interval [CI]: 66-70) to 63 (60; 65) mmol/mol (P < 0.0001) or 8.4 (95% CI: 8.2-8.6) to 7.9 (7.6; 8.1) % (P < 0.0001). Across all age groups, HbA1c was significantly lower in pump and sensor users. Severe hypoglycemia declined from 3.8% (2.9; 5.0) to 2.4% (1.9; 3.1) (P < 0.0001), whereas diabetic ketoacidosis events increased significantly with injection therapy only. Body mass index-standard deviation score also showed significant improvements 0.55 (0.46; 0.64) versus 0.42 (0.33; 0.51) (P < 0.0001). Over time, the increase in pump use from 34% to 44% preceded the increase in HbA1c target achievement (<53 mmol/mol) from 21% to 34%. Conclusions: Twice yearly benchmarking within the SWEET registry was associated with significantly improved HbA1c on a background of increasing pump and sensor use for 10 years in young persons with T1D. Trial Registration: NCT04427189.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Oral insulin delivery: existing barriers and current counter-strategies

Objectives

The chronic and progressive nature of diabetes is usually associated with micro- and macrovascular complications where failure of pancreatic β-cell function and a general condition of hyperglycaemia is created. One possible factor is failure of the patient to comply with and adhere to the prescribed insulin due to the inconvenient administration route. This review summarizes the rationale for oral insulin administration, existing barriers and some counter-strategies trialled.

Key findings

Oral insulin mimics the physiology of endogenous insulin secreted by pancreas. Following the intestinal absorption of oral insulin, it reaches the liver at high concentration via the portal vein. Oral insulin on the other hand has the potential to protect pancreatic β-cells from autoimmune destruction. Structural modification, targeting a particular tissue/receptor, and the use of innovative pharmaceutical formulations such as nanoparticles represent strategies introduced to improve oral insulin bioavailability. They showed promising results in overcoming the hurdles facing oral insulin delivery, although delivery is far from ideal.

Summary

The use of advanced pharmaceutical technologies and further research in particulate carrier system delivery predominantly nanoparticle utilization would offer useful tools in delivering insulin via the oral route which in turn would potentially improve diabetic patient compliance to insulin and the overall management of diabetes.

Initiation of insulin pump therapy in children at diagnosis of type 1 diabetes resulted in improved long-term glycemic control

BACKGROUND

Insulin pump therapy (IPT) is increasingly used in children and young people with type 1 diabetes. There are limited studies evaluating the optimal time to start IPT.

OBJECTIVE

The aim of this study was to determine if early initiation of IPT in children with type 1 diabetes leads to improved glycaemic control and quality of life (QOL) compared with the later introduction of IPT.

SUBJECTS

There were 38 subjects in the early pump group (EPG) (age 12.6 + 4.9 yr, 23 male) and 37 in the later pump group (LPG) (age 13.1 + 4.1 yr, 19 male).

METHODS

Hemoglobin A1c (HbA1c), rate of severe hypoglycemia, and diabetic ketoacidosis (DKA) were collected retrospectively over a 48-month period. Eligible subjects and/or their parents completed both a Paediatric and Paediatric Diabetes-specific Quality of Life Inventory.

RESULTS

HbA1c measurements were lower in the EPG (6.8%; 51 mmol/mol) compared to the LPG (7.9%; 63 mmol/mol), across the 48 months of the study (p < 0.0001). There was no significant difference in the rate (per patient years) of severe hypoglycaemia (0.02; 0.07) p = 0.075 between the two groups. There were no episodes of DKA in either group. There was no significant difference in QOL between the groups with both having high satisfaction rates.

CONCLUSIONS

Initiation of IPT at diagnosis of type 1 diabetes in children resulted in consistently lower HbA1c with no apparent change in hypoglycemia, DKA, or QOL.

Fear of needles in children with type 1 diabetes mellitus on multiple daily injections and continuous subcutaneous insulin infusion

OBJECTIVE

To assess the prevalence of fear of needles and its effect on glycemic control in children with type 1 diabetes mellitus (T1DM) on multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII).

METHODS

Patients aged 6 to 17 years with T1DM on MDI or CSII (n = 150) were enrolled. All caregivers and patients aged ≥11 years completed a "Diabetes Fear of Injecting and Self-testing Questionnaire" (D-FISQ). Needle phobia was defined as a score ≥6 for fear of self-testing (FST), fear of injections (FI), and fear of infusion-site changes (FISC).

RESULTS

Positive FST scores were noted in 10.0% and positive FI or FISC scores in 32.7% (caregivers' responses). Patients aged 6 to 10 years on CSII had greater fear (FISC) than those on MDI (FI) (P = .010). FST was inversely related to the number of daily blood sugar checks (P = .003). Patients with positive scores for FI/FISC or FST had significantly higher glycated hemoglobin (HbA1c) levels than those without. An inverse association was noted between positive FI/FISC scores and age of the patient (P = .029). Based on patient responses, FST severity was directly related to the age of the patient (P = .013).

CONCLUSION

Needle phobia is common in children with T1DM. Although FI/FISC are more common in younger children, especially in those on CSII, FST is more often encountered in older patients. Patients with a more intense fear of needles have higher HbA1c levels and less frequent blood sugar monitoring. Identifying these patients may help improve glycemic control.

Analysis of insulin pump settings in children and adolescents with type 1 diabetes mellitus

AIM

To characterize current insulin pump settings used in young patients with type 1 diabetes mellitus (T1DM) and to assess their relationship to glycemic control.

METHODS

This retrospective study included patients aged <18 yr old with T1DM >1 yr using a Medtronic pump device. Pump data including number of blood glucose (BG) tests per day, basal and bolus insulin parameters, carbohydrate ratio (CR), and insulin sensitivity factors (ISFs) were averaged over 14 d for statistical analyses. Anthropometric data and recent glycosylated hemoglobin A1c (HbA1c) were recorded.

RESULTS

A total of 292 patients (144 males and 148 females) were included in the study. Participants had a median age (interquartile range, IQR) of 12.9 yr (10.0-15.1 yr) and pump duration of 2.8 yr (1.5-4.2 yr). No significant differences in median HbA1c (IQR) were observed in preschool [n = 14; HbA1c 7.8% (7.3-8.3%)], prepubertal [n = 105; HbA1c 8.1% (7.7-8.9%)], and adolescent subjects [n = 173; HbA1c 8.4% (7.7-9.0%)]. Adolescents took significantly fewer boluses and BG tests per day compared with younger children (p < 0.05). Age-specific diurnal variation in basal insulin delivery was noted. Additionally, stronger carbohydrate cover and weaker corrections were used in real-life compared with theoretical 500 and 100 rules, respectively. Lower HbA1c was associated with higher number of daily boluses, greater number of BG tests per day, lower average CR/500 rule ratio, and higher average ISF/100 rule ratio adjusted for age (R(2) = 0.22; p < 0.01).

CONCLUSION

Insulin pump therapy requires continuous adjustments and glycemic targets are achieved by a minority. We believe this is the first study in pediatric cohort looking at association between CR and ISF with glycemic control.

A Comparison of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Insulin Injection in Children with Type I Diabetes in Kuwait: Glycemic Control, Insulin Requirement, and BMI

OBJECTIVE

Continuous subcutaneous insulin infusion (CSII) and multiple daily insulin injections (MDI) are two methods currently used to manage type I diabetes mellitus (T1DM). Here we compare our experiences with CSII and MDI in a large cohort of pediatric patients in Kuwait.

METHODS

Data on 326 patients with T1DM who were started on CSII between 2007 and 2012 were retrospectively compared with those of 326 patients on MDI. They were matched for sex, age at diagnosis, T1DM duration, glycemic control, insulin requirement, and body mass index (BMI). Data were collected at baseline and every three months and included glycated hemoglobin (HbA1c), insulin dose, and adverse events (severe hypoglycemia, diabetic ketoacidosis, and skin problems).

RESULTS

The main reason for switching to CSII was to achieve better glycemic control (37%), followed by reducing hypoglycemia, and improving the quality of life (13.3% each). Although HbA1c decrease was most significant in the first year, it continued to be significantly lower in the CSII group compared to the MDI throughout the study period. Total daily insulin requirements were significantly lower in the CSII group. BMI increased in both groups, but the difference was significant only at the end of the fifth year. There was no significant change in the rate of diabetic ketoacidosis in either group. The CSII patients had more severe hypoglycemic episodes at baseline; however, it significantly decreased throughout the study period. Only five patients discontinued CSII therapy and two of these restarted within three months.

CONCLUSION

CSII is a safe intensive insulin therapy in youngsters with T1DM and achieved markedly fewer severe hypoglycemic episodes and lower daily insulin requirements.

Management of a patient with diabetic ketoacidosis in the emergency department

Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency department (ED). Technological advances are leading to changes in outpatient management of diabetes. The ED physician needs to be aware of the new technologies in the care of diabetic children and comfortable managing patients using continuous subcutaneous insulin infusions. This article reviews the ED management of diabetic ketoacidosis and its associated complications, as well as the specific recommendations in caring for patients using the continuous subcutaneous insulin infusion, serum ketone monitoring, and continuous glucose monitoring.

Risk factors for discontinuation of insulin pump therapy in pediatric and young adult patients

BACKGROUND

Previous studies have shown that only a small number of pediatric and young adult patients discontinue pump therapy, but risk factors for discontinuation are unclear.

OBJECTIVE

To identify characteristics of pediatric and young adult patients with pump therapy which are associated with discontinuation of treatment.

SUBJECTS AND METHODS

Retrospective cohort study using a representative nationwide database (LRx; IMS Health) in Germany covering >80% of all prescriptions to members of statutory health insurances in 2008-2011. All patients (age group <25 years) with new prescriptions of insulin pumps were identified (2009-2010) and were followed for 12 months.

RESULTS

Overall, 2452 new pump users were identified, of whom 177 (7.2%) switched to other forms of insulin therapy within 12 months. In multivariate logistic regression, younger age (<6 years; reference 18 to <25 years: Odds ratio, OR, 95% CI: 0.36; 0.17-0.74) and use of teflon needles (reference steel needles: OR, 95% CI: 0.59; 0.41-0.83) were related to a lower odds of pump discontinuation. A non-significant trend was found for male sex (OR, 95% CI: 0.75; 0.52-1.08). Prescriptions of thyroid therapeutics (ATC H03A: OR, 95% CI: 1.79; 1.23-2.61) and antiepileptics (N03: OR, 95% CI: 3.14; 1.49-6.59) were significantly associated with discontinuation of pump therapy.

CONCLUSIONS

About 93% of pediatric and young adult patients maintained insulin pump therapy within 12 months. Age <6 years, male sex and teflon needle use were associated with a lower risk of discontinuation. Thyroid therapy (indicating autoimmunity) and antiepileptic drug prescriptions were associated with a higher likelihood for discontinuation of insulin pump treatment.

High prevalence of depressive symptoms in well-controlled adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND

Researchers report co-morbid depressive symptoms in children with poorly controlled type 1 diabetes (T1D). However, excellent diabetes control may be associated with emotional distress as well. The aim of this study was to evaluate the prevalence of depressive symptoms in T1D children with HbA1c <7.5% and ≥ 7.5% treated with insulin pump.

METHODS

A total of 372 children (186 girls) with a mean age of 14.2 ± 2.0 years and mean diabetes duration of 5.3 ± 3.5 years were included. All subjects were treated for T1D for a minimum of 1 year. Children filled out a Polish version of the Children's Depression Inventory (CDI) and answered questions in the Quality of Life Questionnaire. Statistical analysis was made using Student's t-test, Mann-Whitney U-test, Fisher's exact test and Spearman's rank correlation.

RESULTS

Eighteen per cent (31/177) of participants with HbA1c <7.5% and 21% (41/195) with HbA1c ≥ 7.5% reported depressive symptoms (CDI scores ≥ 13). Adolescents with HbA1c <7.5% and CDI ≥ 13 had higher total insulin dose (p = 0.039) and longer diabetes duration (p = 0.043) than subjects with CDI < 13. There was no difference in prevalence of depressive symptoms among patients with HbA1c ≥ 7.5% and HbA1c <7.5% (odds ratio [1.25 95% confidence interval (CI) 0.75-2.11], p = 0.432). In both groups, adolescents with CDI ≥ 13 had worse quality of life than those with CDI < 13 (p < 0.0001).

CONCLUSIONS

In both groups, one in five adolescents with either good or poor glycemic control had depressive symptoms compared with <7% in subjects without diabetes. Long-lasting T1D significantly increased the risk of depressive symptoms in well-controlled youth. Depressive symptoms strongly affected the quality of life regardless of diabetes control.

Management of type 1 diabetes in children and adolescents

Type 1 diabetes (T1D) is estimated to have a prevalence of approximately 1 in 5000 among Indian children. Living with T1D is a challenge for the child and the family because of the significant burden of treatment in terms of regular injections and monitoring of blood sugar, and risk of acute and long term complications that this condition imposes. Optimal glycemic control in T1D requires a meticulous balance of insulin therapy with diet and exercise. With the earlier insulin regimens this required lot of discipline in the eating and activity pattern, which led to significant curtailment of the lifestyle. Now, with availability of better insulins, delivery and monitoring devices, greater flexibility in lifestyle has become possible. The ultimate breakthrough in terms of therapy of T1D shall be easy availability of accurate and affordable closed loop systems, and 'cure' through islet or stem cell transplant. A review of the ambulatory management of T1D in children and adolescents and the upcoming therapeutic advances is being presented in this paper.

An update on the pharmacotherapy options for pediatric diabetes

INTRODUCTION

Diabetes mellitus is a frequent endocrine disease during childhood and adolescence. Achieving a good glycemic control is of paramount importance to avoid short- and long-term complications and to allow a normal growth and quality of life.

AREAS COVERED

This review offers an update on current available treatment strategies for type 1 and type 2 diabetes approved for use in children and adolescents.

EXPERT OPINION

Although many progresses have been made in the field of diabetes management in children and adolescents, there are still several problems to deal with. With regard to type 1 diabetes, insulin remains the main and essential therapeutic strategy. However, the main issue is to develop a system that allows more physiological insulin coverage and reduces the risk of hypoglycemia and weight gain. Adjunct therapies would be invaluable for patients struggling to achieve an acceptable glycemic control. Treatment of type 2 diabetes is based on lifestyle interventions and metformin is the first-line drug for children older than 10 years. As for type 1 diabetes, there is a strong need for developing new drugs to be used alone or in combination.

A multicentre randomized controlled trial of an empowerment-inspired intervention for adolescents starting continuous subcutaneous insulin infusion--a study protocol

Background

Continuous subcutaneous insulin infusion (CSII) treatment among children with type 1 diabetes is increasing in Sweden. However, studies evaluating glycaemic control in children using CSII show inconsistent results. The distribution of responsibility for diabetes self-management between children and parents is often unclear and needs clarification. There is much published support for continued parental involvement and shared diabetes management during adolescence. Guided Self-Determination (GSD) is an empowerment-based, person-centred, reflection and problem solving method intended to guide the patient to become self-sufficient and develop life skills for managing difficulties in diabetes self-management. This method has been adapted for adolescents and parents as Guided Self-Determination-Young (GSD-Y). This study aims to evaluate the effect of an intervention with GSD-Y in groups of adolescents starting on insulin pumps and their parents on diabetes-related family conflicts, perceived health and quality of life (QoL), and metabolic control. Here, we describe the protocol and plans for study enrolment.

Methods/design

This study is designed as a randomized, controlled, prospective, multicentre study. Eighty patients between 12–18 years of age who are planning to start CSII will be included. All adolescents and their parents will receive standard insulin pump training. The education intervention will be conducted when CSII is to be started and at four appointments in the first 4 months after starting CSII. The primary outcome is haemoglobin A1c levels. Secondary outcomes are perceived health and QoL, frequency of blood glucose self-monitoring and bolus doses, and usage of carbohydrate counting. The following instruments will be used: Disabkids, ‘Check your health’, the Diabetes Family Conflict Scale and the Swedish Diabetes Empowerment Scale. Outcomes will be evaluated within and between groups by comparing data at baseline, and at 6 and 12 months after starting treatment.

Discussion

In this study, we will assess the effect of starting an CSII together with the model of GSD to determine whether this approach leads to retention of improved glycaemic control, QoL, responsibility distribution and reduced diabetes-related conflicts in the family.

Trial registration

Current controlled trials: ISRCTN22444034

Why do few food-allergic adolescents treat anaphylaxis with adrenaline?--Reviewing a pressing issue

Food allergic adolescents are at higher risk of fatal anaphylaxis than other children. Both allergen avoidance and maintaining access to adrenaline auto-injectors (AAI) are key goals in effective food allergy management, for which written guidance is often supplied. However, adolescents are rarely sufficiently prepared to use adrenaline during anaphylaxis. It is likely that further didactic education would bring limited improvement in management in this population. Focused discussion of each adolescent's perspectives and current management practice may allow more effective behavioural strategies to be adopted. Key areas for appraisal include subjects' experiences after previous allergen exposure with reference to worst response, recognising specific symptoms requiring AAI administration, and appropriate priority being given to timeliness of administering adrenaline. Behavioural strategies should be discussed to increase AAI accessibility. Rigor of allergen avoidance should not be compromised by false reassurance of proximity to emergency medication or medical services. Food allergic adolescents are motivated by the psychological impact of their condition, which often makes them feel different to their peers and may result in bullying. Methods of appropriately empowering adolescents may be considered, such as involvement of close friends and lay organisations to support appropriate management. Open discussion is crucial in engaging with adolescents' reasoning for adopting their chosen management strategies. Further research is warranted to identify cognitive patterns associated with high-risk behaviour, and to design appropriate interventions for the augmentation of adolescent self-management skills.