ISPAD Clinical Practice Consensus Guidelines 2022: Insulin treatment in children and adolescents with diabetes

9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025

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

Understanding the parental journey: Exploring experiences, needs, and perceptions during hospitalization for children newly diagnosed with type 1 diabetes

OBJECTIVE

The onset of childhood diabetes necessitates that the child and family quickly must learn numerous self-management tasks. Diabetes education is key to successful self-management, and established diabetes-related habits are known to be difficult to change. Hence, the initial hospital-based diabetes education and support is a distinct opportunity to optimize habits and disease management. The aim of this study is to investigate parents' experiences with the education and support provided at the hospital when a child has been newly diagnosed with type 1 diabetes.

METHODS

Twenty semi-structured interviews were conducted with parents of children (0-18 years) newly diagnosed with type 1 diabetes. Inductive thematic analysis was used for data analysis.

RESULTS

Four overarching themes, each with its own implications were identified: 1) From a feeling of uncertainty toward a sense of perceived security 2) Certainty induces calmness 3) A balanced approach to diabetes 4) Trying to learn all about diabetes in just one week. The four themes stress the families' need of immediate reassurance from the health professionals.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The study sheds light on families' challenges during initial hospital-based diabetes education, offering insights for healthcare professionals to tailor support strategies and improve diabetes management.

An Evidence-Based Measure to Assess Self-Efficacy Among Adolescents With Type 1 Diabetes Mellitus in Jordan

PURPOSE

The purpose of the study was to assess self-efficacy among adolescents with type 1 diabetes mellitus and to identify its contributing factors using a new measure based on the International Society for Pediatric and Adolescent Diabetes Guidelines: the Type 1 Diabetes Mellitus Self-Efficacy Scale (T1DM-SES).

METHOD

A descriptive, cross-sectional design was used to collect data from 161 adolescents ages between 12 and 18 via an online questionnaire survey, including demographic and management-related variables and the 21 items of T1DM-SES.

RESULTS

Results demonstrated that adolescents had high self-efficacy levels regarding the basic needs to manage their diabetes and relatively moderate and low levels regarding more sophisticated needs, such as adjusting insulin dose to correct fluctuated glucose levels, covering carbohydrates, and managing ketoacidosis at home. Adolescent females and adolescents who have working mothers or caregivers demonstrated higher levels of self-efficacy, whereas adolescents who have another family member with T1DM reported lower levels.

CONCLUSION

Assessing adolescents' self-efficacy using evidence-based measures is crucial for informing health education plans. There should be a greater focus on acquiring the advanced knowledge and skills necessary for adolescents to manage the constantly evolving challenges of diabetes management. Access to health care and sufficient health insurance coverage that encompasses modern technology are fundamental for the effective management of T1DM.

Expecting factors for inadequate glycemic control in children and adolescents with type 1 diabetes mellitus: a single center experience

Objectives

Achieving an ideal glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM) is both a difficult and challenging process. We aim to highlight the expected factors contributing to inadequate glycemic control in children and adolescents with T1DM in a sample of Iraqi children and adolescents.

Methods

This was a descriptive cross-sectional study that recruited 247 T1DM patients aged < 18 years & disease duration ≥ 1 year. Data collected included socio-demographic & clinical characteristics with recent HbA1c value. Each patient was examined for signs of puberty and any lipodystrophy at insulin injection sites. Factors studied using Independent-Samples T-Test, One way ANOVA & Multivariable logistic regression.

Results

Of the 247 patients, 108 (43.7%) were males, and 139 (56.3%) were females. The mean & SD of the age of patients was 10.13 ± 3.85 years. The Mean & SD of the recent HbA1c level was 9.43 ± 2.56. HbA1c ≤ 7.5 was achieved in 27.1% of patients. Using Multivariable logistic regression to study the association between variable factors and inadequate glycemic control, showed a significant association with higher odds in terms of the older age of the patient, maternal illiteracy, presence of recurrent diabetic ketoacidosis (DKA) episodes, absence of carb counting, and presence of lipodystrophy. Higher HbA1c was also associated significantly with puberty, rural residency, poor socioeconomic status, DKA presentation, and using regular + NPH insulin regimen.

Conclusions

In the current study, inadequate glycemic control was induced by many factors, Strategies should be applied to control these factors to minimize the prospective risks of macro-vascular complications linked to T1DM in children & adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01442-2.

Teachers' knowledge about the principles of dealing with a student with type 1 diabetes mellitus

INTRODUCTION

A proper self-management and therapy process, and the involvement of patients and their carers in this process, influences the effectiveness of T1DM therapy. The responsibility for the self-management process lies with children and adolescents with T1DM, as well as their parents and other carers.

AIMS

The aim of this study was to assess the level of teachers' knowledge of the principles of the treatment and self-management of T1DM in children and to demonstrate the influence of various factors influencing teachers' knowledge.

MATERIALS AND METHODS

A cross-sectional survey was conducted among the teachers in the Pomeranian Voivodeship. The first part of the survey contained questions on sociodemographic data, the second part contained questions on personal attitudes towards a student with T1DM, and the third part contained twenty-nine questions assessing the basic knowledge of the self-management and treatment principles of T1DM.

RESULTS

Tests were conducted with 698 (86.4%) female teachers and 110 (13.6%) male teachers. The median (25thQ ÷ 75thQ) score of the test on the teachers' knowledge was 20 (18 ÷ 21) points, with a maximum of 29 and a minimum of 0 points. Male teachers, aged between 26-40 years, with 6-10 years of seniority, working in rural areas, having a person with T1DM in their immediate environment or having a student with T1DM in their class had a higher knowledge level. Teachers who worked in schools where no nurse was employed and those who had not completed specific training on the principles of caring for a child with T1DM at school had a lower level of knowledge.

CONCLUSIONS

1. Knowledge of teachers is insufficient to ensure safe stay at school for a child with T1DM. 2. The ongoing training of teachers on the principles of the self-management and treatment of T1DM is necessary to improve and increase the safety of children and adolescents with T1DM in school units. 3. There is a need to improve the quality of health care for children with T1DM in the learning environment by increasing the number of school nurses and improving their knowledge, and by the ongoing training of teachers and other staff in school units. 4. Detailed care plans should be developed for children with T1DM, adapted to the school conditions.

Revisiting the Pattern of Loss of β-Cell Function in Preclinical Type 1 Diabetes

Type 1 diabetes (T1D) results from β-cell destruction due to autoimmunity. It has been proposed that β-cell loss is relatively quiescent in the early years after seroconversion to islet antibody positivity (stage 1), with accelerated β-cell loss only developing around 6-18 months prior to clinical diagnosis. This construct implies that immunointervention in this early stage will be of little benefit, since there is little disease activity to modulate. Here, we argue that the apparent lack of progression in early-stage disease may be an artifact of the modality of assessment used. When substantial β-cell function remains, the standard assessment, the oral glucose tolerance test, represents a submaximal stimulus and underestimates the residual function. In contrast, around the time of diagnosis, glucotoxicity exerts a deleterious effect on insulin secretion, giving the impression of disease acceleration. Once glucotoxicity is relieved by insulin therapy, β-cell function partially recovers (the honeymoon effect). However, evidence from recent trials suggests that glucose control has little effect on the underlying disease process. We therefore hypothesize that the autoimmune destruction of β-cells actually progresses at a more or less constant rate through all phases of T1D and that early-stage immunointervention will be both beneficial and desirable.

ARTICLE HIGHLIGHTS

Automated Insulin Delivery Systems in Pediatric Type 1 Diabetes: A Narrative Review

This narrative review assesses the use of automated insulin delivery (AID) systems in managing persons with type 1 diabetes (PWD) in the pediatric population. It outlines current research, the differences between various AID systems currently on the market and the challenges faced, and discusses potential opportunities for further advancements within this field. Furthermore, the narrative review includes various expert opinions on how different AID systems can be used in the event of challenges with rapidly changing insulin requirements. These include examples, such as during illness with increased or decreased insulin requirements and during physical activity of different intensities or durations. Case descriptions give examples of scenarios with added user-initiated actions depending on the type of AID system used. The authors also discuss how another AID system could have been used in these situations.

Using Quality Improvement to Design and Evaluate an Outpatient Day Treatment Pathway for Pediatric Patients with Diabetes Mellitus Requiring Insulin Initiation

Introduction

Education and management of children with new-onset or established diabetes mellitus (DM) requiring insulin initiation do not always require hospitalization. We developed a pathway for outpatient day treatment of select patients after initial evaluation in the emergency department (ED) at a pediatric, tertiary care academic medical center.

Methods

A multidisciplinary team identified key initial eligibility criteria for outpatient day treatment for insulin initiation, including absence of diabetic ketoacidosis, age ≥3 years, and plasma beta-hydroxybutyrate (BOHB) <1 mmol/L. Electronic medical record reviews and surveys administered to endocrine providers determined exclusions or reasons for nonparticipation. Refinement of the pathway occurred through iterative plan-do-study-act cycles. Statistical process control evaluated the uptake among eligible patients.

Results

We launched the pathway in September 2020. Of 534 patients presenting to the ED with new-onset or established DM requiring insulin initiation in the first 2.5 years, 198 were potentially eligible for day treatment. Of these, 65 children (33%) completed the pathway. One additional patient was hospitalized following Day 1 of education due to newly identified psychosocial stressors. The increase of BOHB cutoff to 1.5 mmol/L and the option of rapid-acting insulin bolus for borderline BOHB resulted in a significant shift in utilization from a mean of 24.4% to 41.1%. Persistent barriers to participation include limited appointment availability, weekend presentation, and patient/family concerns.

Conclusions

Outpatient day treatment was successful for select pediatric patients with new-onset or established DM requiring insulin initiation. However, this approach necessitates flexible resources and supportive patient messaging.

Clinical practice recommendations for management of Diabetes Mellitus in Arab region: An expert consensus statement from Arab Diabetes Forum (ADF)

Prevalence of diabetes in Arab region has significantly increased, resulting in a significant economic burden on healthcare systems. This surge can be attributed to obesity, rapid urbanization, changing dietary habits, and sedentary lifestyles. The Arab Diabetes Forum (ADF) has established localized recommendations to tackle the region's rising diabetes prevalence. The recommendations, which incorporate worldwide best practices, seek to enhance the quality of treatment for people with diabetes by raising knowledge and adherence among healthcare providers. The guidelines include comprehensive recommendations for screening, diagnosing, and treating type 1 and type 2 diabetes in children and adults for better overall health results.

Questionnaire survey on severe hypoglycemia in pediatric patients with diabetes-English version

A questionnaire survey on severe hypoglycemia (SH) in pediatric patients with diabetes was distributed to pediatric diabetes specialists and members of the Committee of Pediatric Diabetes in the Japan Diabetes Society. Thirty-three hospitals answered the questionnaire survey, and 17 had treated the eligible patients under 15 years of age, including 506 with type 1 diabetes and 302 with type 2 diabetes. Of these patients, 25 experienced SH from January 2017 to December 2021. SH occurred in 3 patients at 0-5 years, 5 at 5-10 years, and 15 at 10-15 years, and it most frequently occurred between the times of 0:00 and 08:00 a.m. The majority of the patients had SH at home during the nighttime. Only 4 patients experienced SH during school time. Eleven patients took glucose orally, while 5 used glucagon nasal powder. Fifteen patients were transferred to hospital emergency units for the management of SH. From these results, the frequency of SH was estimated to be 0.01/patient/year, and the treatment for SH seemed insufficient.

Barriers to Type 1 Diabetes Adherence in Adolescents

Background: Adolescence is a particularly crucial period of physical, emotional, and social development and adaptation, rendering these formative years rather challenging for individuals with chronic conditions like type 1 diabetes (T1D). Despite rapid improvement in diabetes therapies, adolescents with T1D are characterized by poorer adherence to treatment regimens compared with other pediatric age groups. Insufficient adherence is strongly related to low diabetes control, increasing morbidity, and risk for premature mortality. This study aimed to provide a comprehensive overview of adolescents' most common barriers to T1D adherence, stressing the need for a deep and comprehensive understanding of these barriers. The complexity of these barriers is underscored by the diverse factors contributing to poor T1D adherence in adolescents. Methods: A narrative review was conducted, surveying four databases (PubMed, Scopus, EMBASE, and Web of Science) for full-text articles in the English language published up to June 2024. All studies related to barriers to T1D adherence in adolescents were considered. The literature was selected using selection and exclusion criteria and extracted and organized using Mendeley. Exclusion criteria included studies with insufficient data and non-peer-reviewed articles. This review revealed that adolescents face numerous obstacles to T1D adherence related to psychological factors, flux in family dynamics, perceived social pressures, therapy-related factors, transitioning responsibility, risk-taking behaviors, and pubertal changes. Conclusions: Navigating the adaptations to the different aspects of T1D, from treatment to complications and adolescents' personal growth, effectively requires a thorough understanding of the barriers of a treatment regimen that patients at this critical age face.

Tear Proteomics in Children and Adolescents with Type 1 Diabetes: A Promising Approach to Biomarker Identification of Diabetes Pathogenesis and Complications

The aim of the current study was to investigate the tear proteome in children and adolescents with type 1 diabetes (T1D) compared to healthy controls, and to identify differences in the tear proteome of children with T1D depending on different characteristics of the disease. Fifty-six children with T1D at least one year after diagnosis, aged 6-17 years old, and fifty-six healthy age- and sex-matched controls were enrolled in this cross-sectional study. The proteomic analysis was based on liquid chromatography tandem mass spectrometry (LC-MS/MS) enabling the identification and quantification of the protein content via Data-Independent Acquisition by Neural Networks (DIA-NN). Data are available via ProteomeXchange with the identifier PXD052994. In total, 3302 proteins were identified from tear samples. Two hundred thirty-nine tear proteins were differentially expressed in children with T1D compared to healthy controls. Most of them were involved in the immune response, tissue homeostasis and inflammation. The presence of diabetic ketoacidosis at diagnosis and the level of glycemic control of children with T1D influenced the tear proteome. Tear proteomics analysis revealed a different proteome pattern in children with T1D compared to healthy controls offering insights on deregulated biological processes underlying the pathogenesis of T1D. Differences within the T1D group could unravel biomarkers for early detection of long-term complications of T1D.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Effectiveness of switching from first-generation basal insulin to Glargine 300 U/mL in children and adolescents with type 1 diabetes: results from the ISPED CARD database

AIMS

Glargine 300 U/mL (Gla-300) has been recently approved for use in children and adolescents with type 1 diabetes (T1D). However, real-world effectiveness data are scarce, and aim of this analysis was to assess clinical outcomes in young patients with T1D switching from 1st generation basal insulin (1BI) to Gla-300.

METHODS

ISPED CARD is a retrospective, multicenter study, based on data anonymously extracted from Electronic Medical Records. The study involved a network of 20 pediatric diabetes centers. Data on all patients aged < 18 years with T1D switching from 1BI to Gla-300 were analyzed to assess clinical characteristics at the switch and changes after 6 and 12 months in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and standardized body mass index (BMI/SDS). Titration of basal and short-acting insulin doses was also evaluated.

RESULTS

Overall, 200 patients were identified. The mean age at the switch to Gla-300 was 13 years, and mean duration of diabetes was 3.9 years. Average HbA1c levels at switch were 8.8%. After 6 months, HbA1c levels decreased by - 0.88% (95% CI - 1.28; - 0.48; p < 0.0001). The benefit was maintained after 12 months from the switch (mean reduction of HbA1c levels - 0.80%, 95% CI - 1.25; - 0.35, p = 0.0006). Trends of reduction in FBG levels were also evidenced both at 6 months and 12 months. No significant changes in short-acting and basal insulin doses were documented.

CONCLUSIONS

The study provides the first real-world evidence of the effectiveness of Gla-300 in children and adolescents with T1D previously treated with 1BI. The benefits in terms of HbA1c levels reduction were substantial, and sustained after 12 months. Additional benefits can be expected by improving the titration of insulin doses.

Comparison of Metabolic Control in Children and Adolescents Treated with Insulin Pumps

BACKGROUND

While insulin pumps remain the most common form of therapy for youths with type 1 diabetes (T1DM), they differ in the extent to which they utilize data from continuous glucose monitoring (CGM) and automate insulin delivery.

METHODS

The aim of the study was to compare metabolic control in patients using different models of insulin pumps. This retrospective single-center study randomly sampled 30 patients for each of the following treatments: Medtronic 720G without PLGS (predictive low glucose suspend), Medtronic 640G or 740G with PLGS and Medtronic 780G. In the whole study group, we used CGM systems to assess patients' metabolic control, and we collected lipid profiles. In three groups of patients, we utilized CGM sensors (Guardian 3, Guardian 4, Libre 2 and Dexcom G6) to measure the following glycemic variability proxy values: time in range (TIR), time below 70 mg/dL (TBR), time above 180 mg/dL (TAR), coefficient of variation (CV) and mean sensor glucose.

RESULTS

Medtronic 640G or 740G and 780G users were more likely to achieve a target time in the target range 70-180 mg/dL (≥80%) [Medtronic 720G = 4 users (13.3%) vs. Medtronic 640G/740G = 10 users (33.3%) vs. Medtronic 780G = 13 users (43.3%); p = 0.0357)] or low glucose variability [Medtronic 720G = 9 users (30%) vs. Medtronic 640G/740G = 18 users (60%) vs. Medtronic 780G = 19 users (63.3%); p = 0.0175)].

CONCLUSIONS

Any integration between the insulin pump and CGM was associated with better glycemic control. More advanced technologies and artificial intelligence in diabetes help patients maintain better glycemia by eliminating various factors affecting postprandial glycemia.

High prevalence of depression in parents of children with Type 1 diabetes in a meta-analysis of data from five continents

AIM

This meta-analysis identified the prevalence of depression in parents of children with Type 1 diabetes.

METHODS

MEDLINE, PsycINFO and CINAHL databases were searched for papers published in English from 1980 to May 2022, yielding 18 studies (N = 2044 participants). The prevalence of parental depression was pooled across the studies.

RESULTS

The prevalence of depression among parents of children with Type 1 diabetes was high. Random-effects meta-analyses estimated the prevalence of moderate depression and above in the total sample as 18.4% (95% CI 12.8-24.6; k = 17, N = 2044), with rates of 17.3% in mothers (95% CI 12.7-22.5; k = 12, N = 1106) and 9% in fathers (95% CI 4.3-15.1; k = 6, N = 199). The estimated prevalence of mild depression and above in the total sample was 32.7% (95% CI 20.3-46.6; k = 8, N = 797), with rates of 29.4% in mothers (95% CI 17.8-42.6; k = 4 N = 330) and 13.6% in fathers (95% CI 5.2-25.2; k = 2 N = 44). All results were characterised by high levels of heterogeneity. The risk of publication bias was low.

CONCLUSION

More than 1 in 6 parents of children with Type 1 diabetes had depression in the moderate plus category. The limitations and implications of these results are discussed.

Glucose sensor with predictive alarm for hypoglycaemia: Improved glycaemic control in adolescents with type 1 diabetes

AIM

Hypoglycaemic events are linked to microvascular and macrovascular complications in people with type 1 diabetes. We aimed to evaluate the efficacy of glucose sensor [real-time continuous glucose monitoring (RT-CGM)] with predictive alarm (PA) in reducing the time spent below the range (%TBR <70 mg/dl) in a group of adolescents with type 1 diabetes (AwD).

MATERIALS AND METHODS

This was a crossover, monocentric and randomized study. RT-CGM was set with Alarm on Threshold (AoT) at 70 mg/dl) or PA for hypoglycaemia (20 m before threshold). Twenty AwD were enrolled and randomized to either a PA/AoT or AoT/PA treatment sequence, in a 1:1 ratio. The two groups (PA vs. AoT) were compared using two-way repeated measures ANOVA taking account of the carryover effect.

RESULTS

AwD using PA for hypoglycaemia spent less time in severe hypoglycaemia (%TBR2 <54 mg/dl; 0.32 ± 0.31 vs. 0.91 ± 0.90; p < .02) and hypoglycaemia (%TBR <70 mg/dl; 1.68 ± 1.06 vs. 2.90 ± 2.05; p < .02), with better glycaemia risk index (51.3 ± 11.0 vs. 61.5 ± 12.6; p ≤ .01).

CONCLUSION

The use of RT-CGM with PA for hypoglycaemia technology in AwD using multiple daily insulin injection treatment could significantly reduce the risk of having hypoglycaemic events resulting in an improved quality of glucose control.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05574023.

Looking at Diabetes Through Different Lenses: Focus Groups Conducted With Somali Canadian Families and Their Health-care Providers

OBJECTIVES

In Toronto, many families with Somali backgrounds have children living with type 1 diabetes (T1D). At our clinic, children with African and Caribbean backgrounds have higher glycated hemoglobin than children from European backgrounds. In this study, we explored the experiences and perspectives of Somali Canadian families with children living with T1D, as well as health-care professionals (HCPs) who care for them, to better understand how T1D impacts these families.

METHODS

We conducted 3 separate focus groups with Somali Canadian parents of children with T1D (n=11), Somali Canadian adolescents with T1D (n=5), and HCPs who treat patients with diabetes (n=9), respectively. A grounded theory approach to data analysis was applied to identify themes.

RESULTS

Four key themes emerged: 1) the general impact of living with diabetes, 2) the challenges of self-management, 3) uncertainty on whose job it is to manage the diabetes, and 4) how cultural differences between Canada and Somalia impact diabetes management. There was discordance in the perspectives of families and HCPs for all themes, but especially themes 1 and 3. Parents focussed on the social impact of diabetes and behavioural indicators of management success, whereas HCPs emphasized clinical measures. Families believed children should take charge of their diabetes self-management early on, whereas HCPs believed the children were not developmentally ready for this responsibility.

CONCLUSIONS

Differing perspectives of patients, families, and HCPs may lead to diverging expectations for treatment and management. Families and practitioners must work together to identify barriers to care and build strategies to promote competency and resilience in the self-management of T1D.

Selenium chemistry for spatio-selective peptide and protein functionalization

The ability to construct a peptide or protein in a spatio-specific manner is of great interest for therapeutic and biochemical research. However, the various functional groups present in peptide sequences and the need to perform chemistry under mild and aqueous conditions make selective protein functionalization one of the greatest synthetic challenges. The fascinating paradox of selenium (Se) - being found in both toxic compounds and also harnessed by nature for essential biochemical processes - has inspired the recent exploration of selenium chemistry for site-selective functionalization of peptides and proteins. In this Review, we discuss such approaches, including metal-free and metal-catalysed transformations, as well as traceless chemical modifications. We report their advantages, limitations and applications, as well as future research avenues.

Virtual reality's impact on children with type 1 diabetes: a proof-of-concept randomized cross-over trial on anxiety, pain, adherence, and glycemic control

AIMS

 Assess the effectiveness of virtual reality (VR) technology, in reducing pain and anxiety, and improving adherence and glycemic control among children with type 1 diabetes (T1D).

METHODS

Children with T1D, managed with continuous glucose monitoring and insulin pumps, were recruited for a randomized cross-over trial. Children were randomized to one of two interventions for diabetes management: group 1 used VR glasses first and group 2 listened to vocal-guided affective imagery first (audio). After 1 month, the interventions were crossed over. The outcome measures included pain and anxiety assessment, adherence, glycemic control, and patient-reported outcome measures (PROMs) of VR satisfaction and effectiveness.

RESULTS

 Forty children, mean age 11.4 ± 1.8 years, were participated. During the VR part, the monthly mean pain score compared to the baseline improved in both groups by 30% (p = 0.03). A 14% reduction in the state anxiety score was observed from baseline to 1 month in both groups (p = 0.009). Glycemic control measures including time in range, time above range, and glucose management indicator improved in both groups during VR part (p < 0.004 for all), compared to audio part. After one month, the patient-reported outcome measure (PROM) of satisfaction and effectiveness was sixfold higher after 1 month in group 1 compared to group 2 (p = 0.002). Adherence improved for both groups.

CONCLUSIONS

VR was shown to be effective in reducing pain and anxiety, improving adherence, PROM, and glycemic control among children with T1D. We suggest incorporating VR technology in pediatric diabetes clinics to facilitate and improve coping and management of diabetes.

TRIAL REGISTRATION

Trial registration number and date of registration for prospectively registered trials:ClinicalTrials.gov Identifier: NCT05883267, May 10th, 2023.

Error traps in the perioperative management of children with type 1 diabetes

Patients with type 1 diabetes mellitus (T1D) require insulin administration at all times to maintain euglycemia and metabolic stability. Insulin administration in the perioperative period is complicated by fasting requirements and perioperative stressors that can change the patient's insulin needs. In addition, many anesthesia providers are not familiar with insulin dosing strategies and technology, such as insulin pumps and continuous glucose monitors (CGMs), that are commonly used by patients with T1D. Errors in perioperative insulin administration can lead to hypoglycemia, hyperglycemia, and diabetic ketoacidosis. This article reviews common errors of associated with the perioperative management of patients with T1D, including failure to assess and coordinate patient care preoperatively; failure to understand diabetes management and technology; failure to monitor blood glucose and recognize dysglycemia; and failure to appropriately administer basal insulin.

9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024

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

Determinants and Characteristics of Insulin Dose Requirements in Children and Adolescents with New-Onset Type 1 Diabetes: Insights from the INSENODIAB Study

Aims

New-onset type 1 diabetes mellitus (T1D) in pediatric patients represents a clinical challenge for initial total daily insulin dosing (TIDD) due to substantial heterogeneity in practice and lack of consensus on the optimal starting dose. Our INSENODIAB (INsulin SEnsitivity in New Onset type 1 DIABetes) study is aimed at (1) exploring the influence of patient-specific characteristics on insulin requirements in pediatric patients with new-onset T1D; (2) constructing a predictive model for the recommended TIDD tailored to individual patient profiles; and (3) assessing potential associations between TIDD and patient outcomes at follow-up intervals of 3 and 12 months.

Methods

We conducted a comprehensive analysis of medical records for children aged 6 months to 18 years, hospitalized for new-onset T1D from 2013 to 2022. The study initially involved multivariable regression analysis on a retrospective cohort (rINSENODIAB), incorporating baseline variables. Subsequently, we validated the model robustness on a prospective cohort (pINSENODIAB) with a significance threshold of 5%. The model accuracy was assessed by Pearson's correlation.

Results

Our study encompassed 103 patients in the retrospective cohort and 80 in the prospective cohort, with median TIDD at diagnosis of 1.1 IU/kg BW/day (IQR 0.5). The predictive model for optimal TIDD was established using baseline characteristics, resulting in the following formula: TIDD (IU/d) = ([0.09 × Age2] + [0.68 × %Weight Loss] + [28.60 × Veinous pH] - [1.03 × Veinous bicarbonates] + [0.81 × Weight] - 194.63). Validation of the model using the pINSENODIAB cohort demonstrated a significant Pearson correlation coefficient of 0.74. Notably, no significant correlation was observed between TIDD at diagnosis and partial remission markers (IDAA1C, C-peptide) at 3- and 12-months postdiagnosis time points.

Conclusions

In the context of new-onset T1D in pediatric patients, we identified key influencing factors for determining optimal TIDD, including age, percentage of weight loss, weight, veinous pH, and bicarbonates. These findings have paved the way for the development of a dosing algorithm to potentially expedite glycemic control stabilization and facilitate a more individualized approach to treatment regimens.

The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus

Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.

Entwicklung der Insulintherapie in der pädiatrischen Diabetologie- Auswertung des DPV-Registers von 1995-2021

Der Einsatz von Insulin zur Therapie des Diabetes mellitus Typ 1 beim Menschen hat vor 100 Jahren erstmals zum Überleben betroffener Patienten nach Manifestation der Erkrankung geführt. War zuvor die Diagnose mit der Gewissheit verknüpft, dass es sich um eine unmittelbar lebensbedrohliche Erkrankung handelt, wurde mit dem Einsatz des Hormons Insulin ab 1922 die Perspektive eröffnet, den Verlauf der Erkrankung zu beeinflussen und die Prognose für die Patienten damit zu verbessern.

Ziel der vorliegenden Arbeit ist die Analyse von 92366 Patienten eines pädiatrischen Patientenkollektivs aus Deutschland, Österreich, Luxemburg und der Schweiz im Hinblick auf den Einsatz der verschiedenen Insulinarten im Zeitraum 1995–2021.

Der Anteil der Insulinanaloga stieg insbesondere seit dem Jahr 2000 stark an, auch da die Nutzung von Insulinpumpen mit Analoginsulin im Vergleich zur intensivierten Insulintherapie mit Pen für alle Altersgruppen deutlich anstieg. Bereits im Jahr 2010 betrug der Anteil der Insulinanaloga in der Diabetestherapie bei Kindern insgesamt > 60 %.

Im Jahr 2022 können Diabetologen auf mehr als zehn Insulinarten und mindestens fünf verschiedene Therapieformen zur Behandlung des Diabetes mellitus Typ 1 zurückgreifen.