Insulin treatment in children and adolescents with diabetes

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)

OBJECTIVE

This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

RESEARCH DESIGN AND METHODS

Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

RESULTS

Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (p_trend  < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016.

CONCLUSIONS

There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

Dietary Patterns in Underprivileged Indian Children and Adolescents with Type 1 Diabetes

Background:

Children with diabetes are likely to have different food and nutrient composition due to dietary restrictions. Studies on dietary intakes in Indian underprivileged children with Type1 diabetes are scarce.

Objective:

To study dietary patterns and nutrient intakes of underprivileged children and adolescents with type1 diabetes in comparison with their healthy siblings.

Methods:

Cross-sectional study, diet assessed by 24-h recall on 3-non-consecutive days in 120 children with type1 diabetes (11.2 ± 3.8 yrs) and 65-age-gender matched healthy siblings. Dietary patterns determined by cluster analysis. Nutrient composition was compared by one-way ANOVA.

Results:

Children with diabetes belonged to middle/lower economic class. Mean HbA1C of children with diabetes was 9.7 ± 2.0% with higher intakes of whole cereals, milk, fruits, vegetables and lower intakes of refined cereals, pulses, animal products than healthy siblings (P <0.05). Four diet patterns were characterized on the basis of major foods: i) wheat, ii) millets, iii) rice and pulse and iv) milk and fruits. Though patterns were similar in both groups, significantly higher intakes of vitamin C (35 ± 23 vs. 24.7 ± 16.3 mg/d), zinc (5.6 ± 2 vs. 4.5 ± 2.3 mg/d), thiamin (812 ± 383 vs. 570 ± 254 μg/d), riboflavin (782 ± 341 vs. 352 ± 182 μg/d) and calcium (673 ± 272 vs. 461 ± 253 mg/d) noted in children with diabetes. Total energy, protein and carbohydrate intakes were comparable; fat consumption was significantly lower amongst children with diabetes, though above recommended daily allowance (RDA) 41.6 ± 14.1 gm vs. 47.4 ± 18.9 gm, P=0.029.

Conclusion:

Underprivileged children with diabetes and siblings had similar dietary patterns; children with diabetes consumed healthier diet than siblings, still glycemic control was not optimum. Dietary interventions are needed to improve micronutrient intake and reduce fat intake in underprivileged children with type1 diabetes to improve their glycemic control.

Fear of Self-Injecting and Self-Testing and the Related Risk Factors in Adolescents with Type 1 Diabetes: A Cross-Sectional Study

INTRODUCTION

This study was conducted to investigate the fear of self-injecting and self-testing and its related risk factors among adolescents with type 1 diabetes mellitus (T1DM).

METHODS

From December 2015 to April 2016, a cross-sectional study was performed at the Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia on 142 registered T1DM patients between 13 and 19 years of age. Selection of the respondents was done deliberately and carefully, and the suitable patients were given specific identification numbers. A trained interviewer administered the short Diabetes Fear of Injecting and Self-testing Questionnaire to each patient. It included two subscales estimating the fear of self-injection (FSI) and fear of self-testing (FST). Each patient's age, gender, weight, height, adjusted body mass index (BMI), duration of the diabetic condition, treatment modality, insulin dosage, and glycosylated hemoglobin (HbA1c) were recorded.

RESULTS

The study found that the overall mean score of FSI was 2.44 ± 0.96, whereas that of FST was 2.25 ± 1.04. Adolescents above 16 years of age, treated with multiple daily insulin (MDI), on higher insulin doses, having poor glycemic control, and fewer finger pricks were observed to show significant risk factors for fear of self-injection of insulin, whereas in those patients having a long duration of T1DM, MDI treated, on higher insulin doses, with poor glycemic control, and fewer finger pricks showed significant risk factors for fear of self-testing of blood glucose. From the regression analysis it was evident that the variables of higher age, MDI treatment, and fewer finger pricks were independent risk factors for fear of self-injection of the insulin, whereas a fewer number of finger pricks was an independent risk factor for fear of self-testing the blood glucose.

CONCLUSION

Fear of self-injecting and fear of self-testing are common among adolescents with T1DM. Therefore, it is essential to ensure comprehensive multidisciplinary diabetes education to lower the risk factor of fear of injections.

Impact of disease-management programs on metabolic control in patients with type 1 diabetes mellitus: A cohort study in Shantou, China

The aim of this study is to evaluate the effect of diabetes disease management program (DMP) on glycemic control in type 1 diabetes mellitus (T1DM) patients in Shantou China.A sample of 240 participants recruited from 3C study Shantou subgroup was followed up in DMP for 3 years. The DMP provided self-management education, individualized therapy plan, diabetes complications screening, and laboratory examination periodical according to clinical practice guidelines. Primary outcomes were changes in hemoglobin A1C (HbA1c).Two hundred one of the participants completed the follow-up. There was a significant decrease in the HbA1c levels after DMP implemented. The mean (± SD) pre- and post-intervention HbA1c levels were 10.26% ± 3.30% and 8.57% ± 1.57% respectively with a P value <0.001. General linear mixed model analyse demonstrated that changes in glycemic control were associated with insulin treatment regimen, frequency of Self-Monitoring of Blood Glucose (SMBG), diabetes diet adherence, physical activity, and duration of diabetes.DMP helped to improve glycemic control and should be general implemented in China's T1DM. Individuals with basal-bolus regimen (multiple daily injections or pump therapy), more frequency of SMBG, following a diabetes diet, more physical activity, shorter diabetes duration may derive greater benefits from DMP.

A randomised, open-labelstudy of insulin glargine or neutral protamine Hagedorn insulin in Chinese paediatric patients with type 1 diabetes mellitus

BACKGROUND

We aimed to describe the safety and efficacy of insulin glargine in Chinese paediatric patients with type 1 diabetes mellitus (T1DM). Neutral protamine Hagedorn (NPH) insulin was the reference therapy.

METHODS

This open-label, randomised, Phase III study was conducted at 10 sites in China. Children aged ≥6 to <18 years with T1DM were randomised (2:1) to insulin glargine or NPH insulin asbasal insulinfor a 24-week treatment period. For all patients, insulin aspart was given as bolus insulin. The primary endpoint was absolute change in glycated haemoglobin(HbA1c) from baseline to Week 24. Secondary endpoints included the percentage of patients reaching HbA1c <7.5% (<58.5 mmol/mol), and safety. The study was registered at clinicaltrials.gov (NCT01223131).

RESULTS

In total,196 patients were screened, and 162 were randomised (107 and 55 patients were randomised to insulin glargine and NPH insulin, respectively). The mean ± SD of absolute change in HbA1c was-0.25 ± 1.68% (-2.69 ± 18.32 mmol/mol) in the insulin glargine group and -0.54 ± 1.67% (-5.55 ± 20.32 mmol/mol) in the NPH insulin group. At Week 24, 18.7 and 21.6% of patients in the insulin glargine and NPH insulin groups achieved HbA1c <7.5% (<58.5 mmol/mol). Both treatments were generally well tolerated. A numerically lower rate of symptomatic hypoglycaemia per patient year was observed for insulin glargine versus NPH insulin (24.3 ± 45.8 versus32.3 ± 43.2); severe hypoglycaemia was rare (<2%).

CONCLUSIONS

Initiation of insulin glargine can aid Chinese paediatric patients with T1DM to safely reduce their HbA1c levels.

Case Studies in Pediatric Endocrinology: An Interactive Learning Module

INTRODUCTION

Pediatrics is an exciting field because it requires having a background in physiology that evolves as the patient ages. As a subspecialty, pediatric endocrinology encompasses a wide range of disease processes both acute and chronic. This module was created to provide a review of endocrine physiology, promote understanding of the biopsychosocial model of children diagnosed with an endocrine disorder, and utilize simulated case studies to become familiar with patient management.

METHODS

The material and case studies presented are based on firsthand experiences in a pediatric clinic and diabetes camp, as well as an extensive literature review. The information in this resource teaches interview questions and problem-solving techniques and ensures that the learner understands the basic equipment used by the patients. Implementation of this module will advance students' and residents' efficacy in caring for this pediatric population. The approximate time to complete this module is 3 to 5 hours. To evaluate the effectiveness of this module, pre- and postmodule surveys were administered to medical students. Factors analyzed included overall user satisfaction, utility of the module, comfort in approaching pediatric endocrine patients, and suggestions for improvement.

RESULTS

A cohort of medical students (N = 26) completed both surveys and the module, with an equal distribution of first- and second-year students to third- and fourth-year students. The surveys showed a general trend of improvement in self-reported comfort with both basic science and clinical skills components.

DISCUSSION

This module would be most beneficial to a medical student who may rotate with a pediatric endocrinologist during the clinical years. The target audience can be broadened to include not only medical students but also physician assistant students, nursing/nurse practitioner students, pediatric residents, and pediatric endocrinology fellows.

20 Years of Pediatric Benchmarking in Germany and Austria: Age-Dependent Analysis of Longitudinal Follow-Up in 63,967 Children and Adolescents with Type 1 Diabetes

BACKGROUND

To investigate changes in diabetes treatment over the last two decades in three age-groups of children and adolescents with type 1 diabetes (T1D) from Germany and Austria.

METHODS

63,967 subjects (<18yr) with T1D documented between 1995 and 2014 from the DPV-database were included and stratified according to age (0.5-<6, 6-<12, 12-<18yr). Regression models were applied for insulin regimens (<3 and ≥4 injection time points/day, or continuous subcutaneous insulin infusion (CSII)), use of rapid- and long acting insulin analogues, NPH insulin, and frequency of self-monitoring of blood glucose (SMBG)/day. Models were adjusted for sex, diabetes duration, and migration background. P-value for trend was given.

FINDINGS

The number of subjects with <3 injection time points/day decreased from 1995 to 2014 to <5% in all age-groups (p<0.0001). Proportion of patients with ≥4 injections/day increased until the early 2000s, and then declined until 2014. This trend was not found in 6-<12yr olds (p = 0.3403). CSII increased in all age-groups (p<0.0001) with the highest increase in children <6 years (from 0.4% to 79.2%), and the lowest increase in 12-<18 year olds (from 1.0% to 38.9%). NPH insulin decreased in all age-groups (p<0.0001). Insulin analogues, especially rapid-acting, became more frequent in all age-groups (p<0.0001), accounting for 78.4% in 2014 for all subjects. The highest use was found in the youngest children (in 2014: 85.6%), the lowest use in 6-<12 year olds (in 2014: 72.9%). The number of SMBG/day increased from 2.2 to 6.4 with a similar rise in all age-groups (p<0.0001). Frequency was highest in subjects <6yr.

CONCLUSIONS

In all age-groups, T1D treatment was intensified over the last 20 years. Age-specific differences in trends were particularly observed in the number of patients on CSII, in the number of patients with 4 or more injections/day, and in the frequency of SMBG/day.

A novel tool to predict youth who will show recommended usage of diabetes technologies

BACKGROUND AND OBJECTIVE

Controversy exists regarding which individuals will benefit most from commencement of diabetes technologies such as continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring systems (CGMS), such as 'real-time' sensor-augmented pumping (SAP). Because higher usage correlates with haemoglobin A1c (HbA1c) achieved, we aimed to predict future usage of technologies using a questionnaire-based tool.

SUBJECTS

The tool was distributed to two groups of youth with type 1 diabetes; group A (n = 50; mean age 12 ± 2.5 yr) which subsequently commenced 'real-time' CGMS and group B (n = 47; mean age 13 ± 3 yr) which commenced CSII utilisation.

METHODS

For the CGMS group, recommended usage was ≥5 days (70%) per week [≥70% = high usage (HU); <70% = low usage (LU)], assessed at 3 months. In the CSII group, HU was quantified as entering ≥5 blood sugars per day to the pump and LU as <5 blood sugars per day, at 6 months from initiation. Binary logistic regression with forward stepwise conditional was used to utilise tool scales and calculate an applied formula.

RESULTS

Of the CGMS group, using gender, baseline HbA1c, and two subscales of the tool generated a formula which predicted both high and low usage with 92% accuracy. Twelve (24%) showed HU vs. 38 who exhibited LU at 3 months. Of the CSII group, 32 (68%) exhibited HU vs. 15 who exhibited LU at 6 months. Four tool items plus gender predicted HU/LU with 95% accuracy.

CONCLUSIONS

This pilot study resulted in successful prediction of individuals who will and those who will not go on to show recommended usage of CSII and CGMS.

Efficacy and safety of switching from insulin glargine to insulin degludec in young people with type 1 diabetes

We evaluated the efficacy and safety of switching to insulin degludec (IDeg) from insulin glargine (IGlar) as basal-bolus therapy in young people with type 1 diabetes. The subjects were 36 patients, 21.3±1.0 years of age, with type 1 diabetes. IGlar had previously been injected once daily in 25 patients and twice daily in 11. They were then switched from IGlar to once-daily injection of IDeg. Both fasting plasma glucose (FPG) and HbA1c levels decreased significantly from 134±3.9 mg/dL and 7.9±0.2% at baseline to 116±2.2 mg/dL and 7.4±0.2% at 12 months after starting IDeg (P<0.0001 and P≤0.001, respectively). Overall and nocturnal hypoglycemia (PG<70 mg/dL) frequencies also decreased significantly from 4.9±0.7 and 2.0±0.3 times/month to 2.4±0.3 and 0.4±0.1 times/month at 12 months after starting IDeg (P≤0.005 and P<0.0005, respectively). The daily basal insulin dose was significantly reduced from 0.48±0.04 units/kg/day at baseline to 0.38±0.03 units/kg/day at the end of the study period (P<0.0001), which corresponded to 79.2% of the baseline value. Trends were similar in patients receiving the once-daily injection and those given twice-daily injections, but basal-insulin value reductions from baseline were more marked in patients receiving twice-daily injections of basal insulin (76.0% vs. 82.6% of the baseline value). These results suggest that switching from IGlar to an appropriate dose of IDeg may effectively control hyperglycemia while reducing the frequency of hypoglycemia episodes in young Japanese people with type 1 diabetes.

Does treatment with an insulin pump improve glycaemic control in children and adolescents with type 1 diabetes? A retrospective case-control study

OBJECTIVE

To investigate long-term effects on glycaemic control, ketoacidosis, serious hypoglycaemic events, insulin requirements, and body mass index standard deviation scores (BMI-SDS) in children and adolescents with type 1 diabetes starting on continuous subcutaneous insulin infusion (CSII) compared with children and adolescents treated with multiple daily injections (MDI).

METHODS

This retrospective case-control study compares 216 patients starting CSII with a control group on MDI (n = 215), matched for glycated hemoglobin (HbA1c), sex, and age during a 2-yr period. Variables collected were gender, age, HbA1c, insulin requirement, BMI, BMI-SDS, ketoacidosis, and serious hypoglycaemic events.

RESULTS

In the CSII group there was an improvement in HbA1c after 6 and 12 months compared with the MDI group. For boys and girls separately the same effect was detected after 6 months, but only for boys after 12 months. The incidence of ketoacidosis was higher in the CSII group compared with the MDI group (2.8 vs. 0.5/100 person-yr). The incidences of severe hypoglycaemic episodes per 100 person-yr were three in the CSII group and six in the MDI group (p < 0.05). After 6, 12, and 24 months, the insulin requirement was higher in the MDI group.

CONCLUSIONS

This study shows that treatment with CSII resulted in an improvement in HbA1c levels up to 1 yr and decreased the number of severe hypoglycaemic events, but the frequency of ketoacidosis increased. The major challenge is to identify methods to maintain the HbA1c improvement, especially among older children and teenagers, and reduce the frequency of ketoacidosis.

Classifying insulin regimens--difficulties and proposal for comprehensive new definitions

Modern insulin regimens for the treatment of type 1 diabetes are highly individualized. The concept of an individually tailored medicine accounts for a broad variety of different insulin regimens applied. Despite clear recommendations for insulin management in children and adolescents with type 1 diabetes there is little distinctiveness about concepts and the nomenclature is confusing. Even among experts similar terms are used for different strategies. The aim of our review--based on the experiences of the Hvidoere Study Group (HSG)--is to propose comprehensive definitions for current insulin regimens reflecting current diabetes management in childhood and adolescence. The HSG--founded in 1994--is an international group representing 24 highly experienced pediatric diabetes centers, from Europe, Japan, North America and Australia. Different benchmarking studies of the HSG revealed a broad variety of insulin regimens applied in each center, respectively. Furthermore, the understanding of insulin regimens has been persistently different between the centers since more than 20 yr. Not even the terms 'conventional' and 'intensified therapy' were used consistently among all members. Besides the concepts 'conventional' and 'intensified', several other terms for the characterization of insulin regimens are in use: Basal Bolus Concept (BBC), multiple daily injections (MDI), and flexible insulin therapy (FIT) are most frequently used, although none of these expressions is clearly or consistently defined. The proposed new classification for insulin management will be comprehensive, simple, and catchy. Currently available terms were included. This classification may offer the opportunity to compare therapeutic strategies without the currently existing confusion on the insulin regimen.

Insulin glargine metabolite 21(A) -Gly-human insulin (M1) is the principal component circulating in the plasma of young children with type 1 diabetes: results from the PRESCHOOL study

BACKGROUND AND AIMS

Insulin glargine metabolite 21(A) -Gly-human insulin (M1) is the principal component circulating in plasma of adults with type 1 diabetes. The objective of this study was to confirm this finding in young children and to rule out accumulation of parent insulin glargine.

DESIGN AND METHODS

Children with type 1 diabetes from the PRESCHOOL study, aged 2-6 yr, were treated with insulin glargine for 24 wk (n = 62). Blood samples were drawn at weeks 1, 2, and 4 approximately 24 h after the last dose and analyzed for glargine, M1, and Thr(30B) -des-M1 (M2) using immunoaffinity purification and liquid chromatography with mass spectrometry. The lower limit of quantification was 33 pmol/L for all analytes.

RESULTS

M1 was the principal active component circulating in plasma. Mean (SD) plasma Ctrough values were 101 (138), 80 (122), and 79 (102) pmol/L following glargine doses of 0.33 (0.02), 0.34 (0.02), and 0.38 (0.03) U/kg at weeks 1, 2, and 4, respectively. Parent insulin glargine and M2 concentrations were below the level of quantification. These results are in line with those observed in adults and indicate no accumulation of the parent compound in this patient population.

CONCLUSION

In young children with type 1 diabetes, the principal component circulating in plasma after subcutaneous injection of insulin glargine is M1, the pharmacologically active component. No accumulation of the parent insulin glargine was observed. These data provide additional evidence on the safety profile of insulin glargine in young children (Clinical trial identifier: NCT00993473).

Parents' experiences of managing their child's diabetes using an insulin pump: a qualitative study

AIMS

Continuous subcutaneous insulin infusion delivered via a pump is increasingly recommended for younger children with Type 1 diabetes. Our aims were: to understand the impact on parents who care for young children using insulin pumps; to help interpret psychological outcomes reported in quantitative research; and to inform provision of support to future parents.

METHODS

We conducted in-depth interviews with 19 parents of children (aged ≤ 12 years) with Type 1 diabetes who used an insulin pump. Data were analysed thematically.

RESULTS

Parents reported multiple benefits from using insulin pumps, including: no longer having to administer painful injections; fewer restrictions on the frequency, timing and carbohydrate contents of snacks and meals; and improvements in family life and their child's glycaemic control. Parents liked and felt less anxious about using bolus calculators to determine insulin doses; however, parents also described undertaking additional and unanticipated work to manage their child's diabetes using a pump. This included performing more blood glucose tests to calculate insulin doses for snacks and to address their concerns that the pump increased their child's risk of hypoglycaemia. Some parents reported doing additional blood glucose checks because they could adjust pump settings to better manage hypo- and hyperglycaemia.

CONCLUSIONS

Parents liked and perceived benefits for their child and themselves from using an insulin pump; however, parents would benefit from being made aware of the additional work involved in using a pump and also from education and support to address concerns about hypoglycaemia. Better measures to evaluate parents' experiences are also recommended.

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.

Differential sequential patterns supporting insulin therapy of new-onset type 1 diabetes

Background

In spite of numerous research efforts on supporting the therapy of diabetes mellitus, the subject still involves challenges and creates active interest among researchers. In this paper, a decision support tool is presented for setting insulin therapy in new-onset type 1 diabetes.

Methods

The concept of differential sequential patterns (DSPs) is introduced with the aim of representing deviations in the patient’s blood glucose level (BGL) and the amount of insulin injections administered. The decision support tool is created using data mining algorithms for discovering sequential patterns.

Results

By using the DSPs, it is possible to support the physician’s decisionmaking concerning changing the treatment (i.e., whether to increase or decrease the insulin dosage). The other contributions of the paper are an algorithm for generating DSPs and a new method for evaluating nocturnal glycaemia. The proposed qualitative evaluation of nocturnal glycaemia improves the generalization capabilities of the DSPs.

Conclusions

The usefulness of the proposed approach was evident in the results of experiments in which juvenile diabetic patients actual data were used. It was confirmed that the proposed DSPs can be used to guide the therapy of numerous juvenile patients with type 1 diabetes.

Intensive diabetes management and goal setting are key aspects of improving metabolic control in children and young people with type 1 diabetes mellitus

Diabetes control in children remains poor in spite of advances in treatment for last 10 years. The aim of this review was to look at various aspects of intensive therapy in the management of type 1 diabetes such as insulin regimes, role of target setting, psycho-educational approaches and self-management. To achieve good metabolic control, clear goal setting with adequate support for self-management are essential. Psycho-educational and behavioural interventions aimed at specific areas of management have shown significant improvement in quality of life and diabetes control.

Insulin glargine in pediatric patients with type 1 diabetes in Japan

BACKGROUND

We evaluated the safety and effectiveness of insulin glargine in Japanese pediatric patients with type 1 diabetes in clinical settings based on post-marketing surveillance data.

METHODS

Clinical data were collected from Japanese pediatric patients with type 1 diabetes for 24 weeks after initiation of glargine treatment. Baseline characteristics, hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), previous/concomitant medication, height, bodyweight, and adverse events were analyzed.

RESULTS

One-hundred and thirteen patients were enrolled from 20 medical institutions in Japan in 2003 and 2004. Of these patients, 73 were included in the safety analysis, and 70 of these patients were also included in the efficacy analysis. The 73 patients included 28 boys and 45 girls, with a mean age of 11.8 years at entry. Hypoglycemia occurred in three patients (three events) and was severe in two patients (two events); all patients recovered. In the efficacy evaluation, HbA1c at baseline and final assessment was 9.10% and 8.09% (P < 0.001) in all patients; 8.96% and 7.85% (P < 0.001) in patients aged 7-12 years (Group 1); and 9.28% and 8.37% (P = 0.010) in patients aged 13-15 years (Group 2). FPG significantly decreased in all patients and in Group 1. No significant changes were observed in body mass index or degree of obesity during the study.

CONCLUSIONS

Glargine therapy for Japanese pediatric patients with type 1 diabetes resulted in good glycemic control in terms of HbA1c and FPG as well as good safety in clinical settings. Glargine had little effect on the physical build of patients.

An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings

BACKGROUND

Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.

METHOD

Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings.

RESULTS

Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.

CONCLUSION

This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.

Changes in insulin therapy regimens over 10 yr in children and adolescents with type 1 diabetes attending diabetes camps

OBJECTIVE

To describe the changes in insulin therapy regimens of children and adolescents with type 1 diabetes over 10 yr and their correlation with hemoglobin A1c (HbA1c).

RESEARCH DESIGN AND METHODS

The study included 7206 children and adolescents (age 12.8 ± 2.7 yr, more than 1 yr of diabetes duration) admitted in summer camps between 1998 and 2007 (707-896/yr). Based on injection times (breakfast, lunch, afternoon, dinner, bedtime) and insulin types (short, long and premixed; human or analog), 786 different therapeutic combinations were classified in six main types of regimens. The distribution of the different regimens and their correlation with HbA1c were evaluated as a function of year and age.

RESULTS

Over 10 yr, basal bolus increased from 13 to 52% and the pump from <1 to 13%, regimens with two to three injections per day decreased from 50 to 25%, those with only premixed insulins from 33 to 7%, and diverse regimens from 9 to 1%. HbA1c was significantly higher with premixed insulin only, but there were no differences between the other regimens throughout the follow-up. Mean yearly HbA1c (8.21-8.45%) did not show any significant decrease, but the percentage of patients with HbA1c > 9 and 10% decreased significantly, in those treated with two to three injections and the pump, not with basal bolus or premixed only regimens.

CONCLUSION

A major trend in intensifying insulin treatment in children and adolescents with type 1 diabetes was accompanied by modest improvements in HbA1c. No insulin regimen has shown any better results, except over premixed insulins.

Efficacy and safety of switching to insulin glulisine from other rapid-acting insulin analogs in children with type 1 diabetes

We investigated the efficacy and safety of switching to insulin glulisine (GLU) from other rapid-acting insulin analogs (Ra) in children with type 1 diabetes treated with multiple daily injections of insulin or continuous subcutaneous insulin infusion. A total of 26 children with type 1 diabetes were included. Ra in all of these patients was changed to GLU, and they were observed for a 6-month period after having previously finished treatment with other Ra. The mean glycated hemoglobin value decreased from 7.6 ± 1.0 to 7.4 ± 0.9% (P = 0.0034), and mean plasma glucose values after breakfast and supper also improved from 183 ± 50 to 153 ± 32 mg/dL (P = 0.0035), and from 203 ± 29 to 164 ± 23 mg/dL (P < 0.0001), respectively. Furthermore, the mean frequency of hypoglycemia was reduced from 7 ± 6 to 4 ± 4/month (P = 0.0004), while insulin doses and obesity degree were stable with statistically non-significant differences. In conclusion, switching to GLU might be a good treatment option for improving glycemic control in children with type 1 diabetes.

Toddlers' diabetes: the lost insulin drop and SemiPens vs. DeciPen

Background: While childhood diabetes incidence is rising, especially in toddlers, once or twice-daily toddler-friendly insulin mixtures were withdrawn, imposing four to five miniscule injections, on needle-phobic toddlers. Although more injections may mean more needle-dribbling, such potential dose-loss is unstudied.Objective: Study insulin loss in toddlers' dose range if one-drop dribbled during injection from half-unit pens (SemiPens). Drop-loss is assessed relative to current insulin dose adjustment, and if significant, propose solutions.Methods: The SemiPens, New HumaPen Luxura HD® (HumaPen) and NovoPen Junior® (NovoPen), with 31G-5mm BD-MicroFine needles were used to study drop size or dose-fraction lost if one drop dribbled in dose range 0.5-10 units.Results: HumaPen and NovoPen produced sizable drops mean standard deviation (SD) 0.30 (0.05) and 0.36 (0.06) units/drop (p<0.001). This constituted progressively increasing proportion of the toddlers' doses, 10-fold higher percentage from 6 to 60% or 7.2 to 72%, as the dose gets smaller from 5 to 0.5 units.Discussion: Insulin dose-adjustments are usually done therapeutically within 5-20% dose-changes, while one-step reduction by >20% is hardly required.Therefore, the unintentional dosing change if a drop dribbles is clinically important particularly on using multiple doses below 6 units, compared with fewer larger daily injections. We propose using U20 insulin in disposable SemiPens to make DeciPen, with fivefold-reduction in insulin loss if a drop is lost through dribbling or skin-leak.Conclusion: The one-drop insulin loss is statistically significant, clinically important, and potentiates glycemic variability. Disposable DeciPen may minimize insulin dribbling and leaking and fivefold improve dose accuracy and precision; and ensure reproducibility without prolonging injection time.

Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden

BACKGROUND

Several studies show that good metabolic control is important for children and adolescents with type 1 diabetes. In Sweden, there are large differences in mean haemoglobin A1c (HbA1c) in different hospitals and difficulties implementing national guidelines in everyday practice. This study shows how the participation in an improvement collaborative could facilitate improvements in the quality of care by paediatric diabetes teams. The Swedish paediatric diabetes quality registry, SWEDIABKIDS was used as a tool and resource for feedback and outcome measures.

METHODS

Twelve teams at paediatric diabetes centres, caring for 30% (2302/7660) of patients in Sweden, participated in an 18-month quality improvement program. Each team defined treatment targets, areas needing improvement, and action plans. The main outcome was the centre patients' mean HbA1c levels, but other clinical variables and change concepts were also studied. Data from the previous six months were compared with the first six months after starting the program, and the long-term follow up after another eleven months.

RESULTS

All centres reduced mean HbA1c during the second and third periods compared with the first. The mean reduction for all was 3·7 mmol/mol (p<0.001), compared with non-participating centres who improved their mean HbA1c with 1·7 mmol/mol during the same period. Many of the participating centres reduced the frequency of severe hypoglycaemia and/or ketoacidosis, and five centres reached their goal of ensuring that all patients had some sort of physical activity at least once weekly. Change concepts were, for example, improved guidelines, appointment planning, informing the patients, improving teamwork and active use of the registry, and health promotion activities.

CONCLUSIONS

By involving paediatric diabetes teams in a quality improvement collaborative together with access to a quality register, the quality of paediatric diabetes care can improve, thereby contributing to a reduced risk of late complications for children and adolescents with diabetes.

Consensus statement on diabetes in children

While T1DM has been traditionally seen as a minor concern in the larger picture of pediatric ailments, new data reveals that the incidence of T1DM has assumed alarming proportions. It has long been clear that while the disease may be diagnosed at an early age, its impact is not isolated to afflicted children. The direct impact of the disease on the patient is debilitating due to the nature of the disease and lack of proper access to treatment in India. But this impact is further compounded by the utter apathy and often times antipathy, which patients withT1DM have to face. Lack of awareness of the issue in all stakeholders, low access to quality healthcare, patient, physician, and system level barriers to the delivery of optimal diabetes care are some of the factors which hinder successful management of T1DM. The first international consensus meet on diabetes in children was convened with the aim of providing a common platform to all the stakeholders in the management of T1DM, to discuss the academic, administrative and healthcare system related issues. The ultimate aim was to articulate the problems faced by children with diabetes in a way that centralized their position and focused on creating modalities of management sensitive to their needs and aspirations. It was conceptualized to raise a strong voice of advocacy for improving the management of T1DM and ensuring that "No child should die of diabetes". The unique clinical presentations of T1DM coupled with ignorance on the part of the medical community and society in general results in outcomes that are far worse than that seen with T2DM. So there is a need to substantially improve training of HCPs at all levels on this neglected aspect of healthcare.

Insulin pump therapy in youth with type 1 diabetes: toward closed-loop systems

INTRODUCTION

Insulin pump technology has advanced considerably over the past three decades, leading to more favorable metabolic control and less hypoglycemic events when compared with multiple daily injection therapy. The use of insulin pumps is increasing, particularly in children and adolescents with type 1 diabetes.

AREAS COVERED

This review outlines recent developments in insulin pump therapy from a pediatric perspective. 'Smart' pumps, sensor-augmented pump therapy and threshold-suspend feature of insulin pumps are reviewed in terms of efficacy, safety and psychosocial impact. The current status of closed-loop systems focusing on clinical outcomes is highlighted.

EXPERT OPINION

Closed-loop insulin delivery is gradually progressing from bench to the clinical practice. Longer and larger studies in home settings are needed to expand on short- to medium-term outpatient evaluations. Predictive low glucose management and overnight closed-loop delivery may be the next applications to be implemented in daily routine. Further challenges include improvements of control algorithms, sensor accuracy, duration of insulin action, integration and size of devices and connectivity and usability. Gradual improvements and increasing sophistication of closed-loop components lie on the path toward unsupervised hands-off fully closed-loop system.

The design and development of a computer game on insulin injection

BACKGROUND

Insulin therapy is of high importance in glycemic control and prevention of complications in type 1 diabetes in children. However, this treatment is unpleasant and stressful for many children, and it is difficult for them to accept. The purpose of the study was to design and develop an educational computer game for diabetic children to familiarize them with insulin injections.

METHODS

After a review of the literature and the collection of basic information, we discussed the purpose of this research with some diabetic children, their parents, and nurses. The findings that we acquired from the discussion were considered in designing and developing the game. Then, following the principles associated with the development of computer games, we developed seven different games that related to insulin injections, and the games were evaluated in a pilot study.

RESULTS

The games developed through the design and programming environment of Adobe Flash Player and stored on a computer disk (CD). The seven games were a pairs game, a puzzle game, a question and answer game, an insulin kit game, a drawing room game, a story game, and an insulin injection-room game). The idea was that diabetic children could become acquainted with insulin injections and the injection toolkit by playing a variety of entertaining and fun games. They also learned about some of the issues associated with insulin and experienced insulin injection in a simulated environment.

CONCLUSIONS

It seems that the use of new technologies, such as computer games, can influence diabetic children's acquaintance with the correct method of insulin injection, psychological readiness to initiate insulin therapy, reduction in stress, anxiety, and fear of insulin injection.

The levels of circulating TRAIL at the onset of type 1 diabetes are markedly decreased in patients with ketoacidosis and with the highest insulin requirement

Experimental evidence in animal models suggests that TNF-related apoptosis-inducing ligand (TRAIL), a member of the TNF superfamily, might play an important role in type 1 diabetes (T1D). We have performed a retrospective study by analyzing the sera of a cohort of pediatric subjects (age ≤18 years; n = 507) consisting of (1) patients diagnosed with T1D (n = 387), (2) healthy individuals (n = 98, considered as controls), and (3) healthy autoantibody-positive subjects (n = 22). Patients with T1D exhibited significantly decreased levels of circulating TRAIL with respect to the control healthy subjects, as well as to the healthy autoantibody-positive subjects. Within the T1D group, no differences in the levels of circulating TRAIL were observed between patients with or without other concomitant autoimmune pathologies. Of note, the levels of TRAIL were significantly lower in the T1D patients analyzed at onset, although reduction in TRAIL levels persisted also in patients analyzed after disease onset (>1 year from diagnosis). In particular, T1D patients who exhibited ketoacidosis at onset showed significantly lower levels of circulating TRAIL with respect to patients without ketoacidosis at onset. Moreover, the levels of TRAIL at diagnosis correlated inversely with the insulin requirement up to 21 months of follow-up. This is the first study demonstrating that the levels of circulating TRAIL are significantly decreased in T1D, with the lowest levels of TRAIL being observed in patients with ketoacidosis at the onset and with the highest insulin requirement.

Insulin therapy in children and adolescents with type 1 diabetes

Treatment of type 1 diabetes mellitus (T1DM) requires lifelong administration of exogenous insulin. The primary goal of treatment of T1DM in children and adolescents is to maintain near-normoglycemia through intensive insulin therapy, avoid acute complications, and prevent long-term microvascular and macrovascular complications, while facilitating as close to a normal life as possible. Effective insulin therapy must, therefore, be provided on the basis of the needs, preferences, and resources of the individual and the family for optimal management of T1DM. To achieve target glycemic control, the best therapeutic option for patients with T1DM is basal-bolus therapy either with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Many formulations of insulin are available to help simulate endogenous insulin secretion as closely as possible in an effort to eliminate the symptoms and complications of hyperglycemia, while minimizing the risk of hypoglycemia secondary to therapy. When using MDI, basal insulin requirements are given as an injection of long- or intermediate-acting insulin analogs, while meal-related glucose excursions are controlled with bolus injections of rapid-acting insulin analogs. Alternatively, CSII can be used, which provides a 24-h preselected but adjustable basal rate of rapid-acting insulin, along with patient-activated mealtime bolus doses, eliminating the need for periodic injections. Both MDI treatment and CSII therapy must be supported by comprehensive education that is appropriate for the individual needs of the patient and family before and after initiation. Current therapies still do not match the endogenous insulin profile of pancreatic β-cells, and all still pose risks of suboptimal control, hypoglycemia, and ketosis in children and adolescents. The safety and success of a prescribed insulin regimen is, therefore, dependent on self-monitoring of blood glucose and/or a continuous glucose monitoring system to avoid critical hypoglycemia and glucose variability. Regardless of the mode of insulin therapy, doses should be adapted on the basis of the daily pattern of blood glucose, through regular review and reassessment, and patient factors such as exercise and pubertal status. New therapy options such as sensor-augmented insulin pump therapy, which integrates CSII with a continuous glucose sensor, along with emerging therapies such as the artificial pancreas, will likely continue to improve safe insulin therapy in the near future.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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.

Health-related quality of life and treatment preferences in adolescents with type 1 diabetes. The VIPKIDS study

A multi-centre, observational, cross-sectional study was carried out to determine whether the health-related quality of life (HRQOL) of adolescents with type 1 diabetes is affected by different insulin treatment systems, and which features of HRQOL are impacted by the respective insulin treatment. The study regarded 577 adolescents, aged 10-17 years, with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) (n = 306) or multiple daily injections (MDI) (n = 271). The Insulin Delivery System Rating Questionnaire was validated in Italian and was self-completed by the subjects during a routine visit to the centres. Subjects were compared following the domains of the questionnaire. Good HRQOL was seen in subjects treated with either MDI or CSII. Significant differences were not found in the domains for general diabetes, including diabetes worries, social burden and psychological well-being. Multiple quantile regression analysis showed that CSII confers significant advantages in terms of HRQOL with improvements in treatment satisfaction, perceived clinical efficacy and reduction in treatment interference with daily activities. This favourable impact was more evident in subjects reporting lower HRQOL scores, suggesting that CSII may be especially useful for individuals perceiving a poor HRQOL. Analysis of the domains indicated that CSII was associated with a higher HRQOL than MDI. Life-course HRQOL evaluation using a standardised questionnaire can ensure better chronic disease management. This is particularly important when providing individualised care for adolescents, as they become increasingly responsible for managing their diabetes.

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

Basal insulin requirement of youth with type 1 diabetes differs according to age

We investigated the percentage of total basal insulin dose to total daily insulin dose (%TBD) among Japanese youth of different ages with type 1 diabetes. The study enrolled 69 patients with type 1 diabetes who were treated with multiple daily injections of insulin. The participants were divided into the following age groups: group A, 0 to <10 years (n = 18); group B, 10 to <20 years (n = 31) and group C, 20 to <25 years (n = 20). We found no difference in the sex ratio, body mass index, and glycated hemoglobin and 2-h postprandial C-peptide levels among the three groups. Participants assigned to group B had a significantly higher percentage of total daily insulin dose than those in group A and group C (49.7 ± 10.4% vs 38.5 ± 13.7% and 38.3 ± 8.2%, P = 0.0005). In conclusion, the basal insulin requirements of Japanese youth with type 1 diabetes might have an age effect that is associated with puberty.

A randomized trial comparing the rate of hypoglycemia--assessed using continuous glucose monitoring--in 125 preschool children with type 1 diabetes treated with insulin glargine or NPH insulin (the PRESCHOOL study)

BACKGROUND

Avoidance of hypoglycemia is a key consideration in treating young children with type 1 diabetes (T1DM).

KEY OBJECTIVE

To evaluate hypoglycemia with insulin glargine vs. neutral protamine Hagedorn (NPH) insulin in young children, using continuous glucose monitoring (CGM).

SUBJECTS

Children of 1 to <6 yr treated with once-daily glargine vs. once- or twice-daily NPH, with bolus insulin lispro/regular human insulin provided to all.

METHODS

Twenty-four week, multicenter, randomized, open-label study. Primary endpoint was event rate of composite hypoglycemia [symptomatic hypoglycemia, low CGM excursions (<3.9 mmol/L) or low fingerstick blood glucose (FSBG; <3.9 mmol/L)]. Noninferiority of glargine vs. NPH was assessed for the primary endpoint.

RESULTS

One hundred and twenty-five patients (mean age, 4.2 yr) were randomized to treatment (glargine, n = 61; NPH, n = 64). At baseline, mean HbA1c was 8.0 and 8.2% with glargine and NPH, respectively. Composite hypoglycemia episodes/100 patient-yr was 1.93 for glargine and 1.69 for NPH; glargine noninferiority was not met. Events/100 patient-yr of symptomatic hypoglycemia were 0.26 for glargine vs. 0.33 for NPH; low CGM excursions 0.75 vs. 0.72; and low FSBG 1.93 vs.1.68. There was a slight difference in between-group severe/nocturnal/severe nocturnal hypoglycemia and glycemic control. All glargine-treated patients received once-daily injections; on most study days NPH-treated patients received twice-daily injections.

CONCLUSIONS

While glargine noninferiority was not achieved, in young children with T1DM, there was a slight difference in hypoglycemia outcomes and glycemic control between glargine and NPH. Once-daily glargine may therefore be a feasible alternative basal insulin in young populations, in whom administering injections can be problematic.

Growth status of children and adolescents with type 1 diabetes mellitus

BACKGROUND AND OBJECTIVES

Growth parameters are important indicators of a child's overall health, and they are influenced by factors like blood glucose control in diabetic children. Data on growth parameters of Indian diabetic children is scarce. This retrospective, cross-sectional, case control study was conducted at diabetes clinic for children at a tertiary care center at Pune, to study growth parameters of diabetic children in comparison with age-gender matched healthy controls and evaluate effect of different insulin regimes and age at diagnosis of diabetes on growth.

MATERIALS AND METHODS

ONE TWENTY FIVE DIABETIC CHILDREN (BOYS: 50) and age gender matched healthy controls were enrolled. All subjects underwent anthropometric measurements (standing height and weight). Mean height (HAZ), weight (WAZ) and body mass index (BAZ) for age Z scores were calculated. Diabetes control was evaluated by measuring glycosylated hemoglobin (HbA1C). Statistical analysis was done by SPSS version 12.

RESULTS

Mean age of diabetic children and age gender matched controls was 9.7 ± 4.4 years. Diabetic children were shorter (128.3 ± 24.3 cm vs. 133.6 ± 24.7 cm) and lighter (29.2 kg ± 15.3 vs. 31.3 ± 15.4 kg). HAZ (-1.1 ± 1.2 vs. -0.2 ± 0.8) and WAZ (-1.2 ± 1.3 vs. -0.7 ± 1.3) were significantly lower in diabetic children (P < 0.05). Children on both insulin regimes (intensive and conventional) were shorter than controls (HAZ-intensive -1.0 ± 1.0, conventional -1.3 ± 1.3, control -0.2 ± 0.8, P < 0.05). HAZ of children who were diagnosed at <3 years of age was the least (-1.6 ± 1) amongst all diabetic children while those diagnosed after puberty (>14 years) were comparable to healthy controls.

CONCLUSIONS

Growth was compromised in diabetic children in comparison to controls. Children diagnosed at younger age need more attention to optimize growth.

A profile of self-care behaviors in emerging adults with type 1 diabetes

PURPOSE

The purpose of this study is to characterize daily diabetes self-care behaviors and to evaluate associations among self-care behaviors, psychosocial adjustment, and glycemic control in an understudied sample of emerging adults with type 1 diabetes.

METHODS

Forty-nine emerging adults (65% women; ages 18-26 years) completed 2 diabetes interviews to assess self-care behaviors and self-report measures of psychosocial adjustment. Glycemic control was assessed via hemoglobin A1C.

RESULTS

Diabetes self-care behaviors varied widely and were largely suboptimal; only a small percentage of participants demonstrated self-care behaviors consistent with national and international recommendations. Psychosocial adjustment was within normal limits and was unrelated to frequency of self-care behaviors in this sample. Mean glycemic control (8.3%) was higher than the recommended A1C level (< 7.0%) for this age group. Use of intensive (e.g., multiple daily injections or pump) insulin regimens was related to better glycemic control.

CONCLUSIONS

The majority of emerging adults in this sample did not engage in optimal daily diabetes self-care. Intensive insulin therapy was associated with better glycemic control without corresponding psychosocial distress. Diabetes care behaviors could be improved in this age group, and emerging adults may benefit from targeted education and behavioral support to enhance diabetes self-management and optimize health outcomes.

Current treatment options for type 2 diabetes mellitus in youth: today's realities and lessons from the TODAY study

The incidence of type 2 diabetes in children and adolescents has increased over the last 2 decades, paralleled by an increase in obesity over the same time period. Although the value of lifestyle modification in obese youth is unquestioned, scant evidence for optimal treatment of type 2 diabetes in this age group exists. Despite recent therapeutic drug trials, metformin and insulin are the only medicines currently approved by the U.S. Food and Drug Administration for the treatment of type 2 diabetes in youth. Because of recently amended pharmaceutical regulations, however, it is likely that more antidiabetic medications soon will be added to the armamentarium of therapeutic options for youth with type 2 diabetes. Additionally, the recently published TODAY study comparing safety and efficacy of three treatment regimens in maintaining glycemic control in youth with type 2 diabetes has shed new light on the problem.

Benefits of continuous subcutaneous insulin infusion on quality of life

PURPOSE

The aim of this study was to compare the general health-related quality of life (HRQoL), the metabolic control (HbA1c), the anthropometric measurement, and the cardiorespiratory fitness (expressed by VO2max) in youths with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) to those receiving multiple daily injections (MDI). We looked for factors influencing the HRQoL and metabolic control.

METHODS

A total of 239 patients treated with CSII (51 girls and 53 boys) or MDI (64 girls and 71 boys) between ages 8 and 18 years were assessed with the Pediatric Quality of Life Inventory, Generic Core Scales, and Diabetes Module. VO2max was evaluated using the 20-meter shuttle run test.

RESULTS

CSII group had significantly better HRQoL according to both child self-report and parent proxy-report. Youths with CSII reported better physical, emotional, and school-related functioning, and had less diabetes-related fear and symptoms than the MDI group. There were no significant differences in body mass index z-scores, insulin doses, HbA1c, and VO2max between the groups. HRQoL was predicted by the CSII therapy (β = -0.220; p = .000) and the VO2max (β = 0.386; p = .000), other clinical and anthropometric parameters had no effect; the HbA1c was predicted only by VO2max (β = -0.353; p = .000).

CONCLUSIONS

Diabetic youths treated with CSII therapy have better HRQoL than those treated with MDI. There are no differences between the investigated groups in anthropometric data, glycated hemoglobin, and physical fitness. Moreover, good physical fitness has an important role in achieving better metabolic control and HRQoL, which underlines the importance of regular aerobic exercise in the treatment and care of type 1 diabetes in childhood.

Reducing stress and supporting positive relations in families of young children with type 1 diabetes: a randomized controlled study for evaluating the effects of the DELFIN parenting program

BACKGROUND

To assess initial efficacy and feasibility of a structured behavioural group training (DELFIN) for parents of children with diabetes type 1, in order to reduce parenting stress and to improve parenting skills.

METHODS

A randomized controlled study was conducted between July 2008 and September 2010, at a children's hospital in Hannover with parents of children with type 1 diabetes (2-10 yrs) (intervention group n = 37; control group n = 28). Parenting skills, parents' psychological burden, children's behavioural difficulties and quality of metabolic control were assessed before, 3 months after and 12 months after participating in the training program.

RESULTS

In the intervention group parenting behaviour in conflict situations improved significantly after 3 months (Z = -3.28; p ≤ 0.001). It remained stable over 12 months (Z = -2.94; p ≤ 0.01). Depression and anxiety scores of parents decreased (Z = -1.93; p ≤ .05; Z = -2.02; p ≤ .05). Even though the outcome in the intervention group was more positive, the differences between both study arms failed to reach statistical significance. Unexpectedly parenting behaviour in the control group improved also (Z = -2.45; p ≤ .05). Anxiety as well as stress scores decreased in this group (Z = -2.02; p ≤ .05 and Z = -2.11; p ≤ .05). In both groups the initial metabolic control was good and without significant differences (A1c 7.2 ± 0.8% vs. 7.1 ± 0.4%; p > 0.5). It remained stable in the DELFIN group (A1c 7.1 ± 0.8%; p > 0.5), but it increased slightly in controls (A1c 7.3 ± 0.5%; Z = -2.79; p = .005).

CONCLUSIONS

This study has brought first evidence for the efficacy and feasibility of the program. A multicentre study with a larger sample is necessary to confirm these first results.

Continuous subcutaneous insulin infusion for managing diabetes: women's health implications

The use of continuous subcutaneous insulin infusion (CSII), also called insulin pump therapy, is increasing for management of type 1 diabetes. This article provides a comprehensive background on CSII, reviews recent studies comparing it to multiple daily insulin injections, offers strategies to troubleshoot potential problems, and discusses the implications of CSII for women's health across the lifespan.

The influence of structure, process, and policy on HbA(1c) levels in treatment of children and adolescents with type 1 diabetes

AIMS

To identify factors which improve glycaemic control measured as HbA(1c) in children and adolescents with diabetes treated at paediatric departments.

METHODS

Through data from the Swedish paediatric diabetes quality registry, SWEDIABKIDS, five centres respectively with the lowest, highest, and largest decrease in centre mean HbA(1c) (Low, High, Decrease HbA(1c) centres) were identified. Diabetes team members completed questionnaires (109 of 128 responded) and reported team structure, process and policy. Open-ended questions were analysed with summative content analysis.

RESULTS

Compared to the High HbA(1c) centres, the Low and Decrease HbA(1c) centres showed higher compliance with guidelines, although they had shorter professional experience and lower proportion of special diabetes-educated team members. A clear message was given and the centres aimed at a lower HbA(1c) target value. Team members were devoted, had a positive attitude and perception of a well-functioning team. Trends for higher mean insulin dose and larger centre size were found. High HbA(1c) centres gave a vague message and had a perception of lack of cooperation in the team.

CONCLUSIONS

Team members' policy and approaches affect glycaemic control in children and adolescents. Team members need to be aware of their approach and of the importance of using resources within the team.

Insulin therapy in children and adolescents

Insulin therapy is the mainstay of treatment in children and adolescents with type 1 diabetes (T1D) and is a key component in the treatment of type 2 diabetes (T2D) in this population as well. A major aim of current insulin replacement therapy is to simulate the normal pattern of insulin secretion as closely as possible. This aim can best be achieved with basal-bolus therapy using multiple daily injections (MDI) or continuous insulin infusion (CSII) pump therapy. Only a few years ago, options for insulin formulations were limited. There are now more than 10 varieties of biosynthetic human and analogue insulin.

Insulin administration: selecting the appropriate needle and individualizing the injection technique

INTRODUCTION

Patients with diabetes who receive insulin therapy often fail to meet their targets for metabolic control with insulin injections. Their inadequate glycemic control may be related to incorrect injection procedure.

AREAS COVERED

This review examines the latest data related to insulin injection and needle characteristics, which play an integral role in patient satisfaction. Searches of Medline and Cumulative Index to Nursing and Allied Health Literature databases were conducted. Results show that optimal insulin injection can facilitate glycemic control in pediatric and adult patients. In general, needles shorter than 8 mm are appropriate for normal weight, obese pediatric and adult patients. However, body mass index, gender, race, age and injection site can influence the depth of subcutaneous tissue and thus, the desired needle size and injection technique. Although the abdomen, thighs and buttocks are all recommended injection sites, abdominal injections disperse insulin slightly more rapidly than thigh injections.

EXPERT OPINION

Wider acceptance of needles shorter than 6 mm will occur with more evidence of their safety and efficacy, particularly in children. Development of shorter and thinner needles to make injections even easier and less burdensome may be expected in the future.