Depressive symptoms predict change in glycemic control in adolescents with type 1 diabetes: rates, magnitude, and moderators of change

Hood KK, Rausch JR, Dolan LM. Depressive symptoms predict change in glycemic control in adolescents with type 1 diabetes: rates, magnitude, and moderators of change. Objective: To determine whether depressive symptoms in adolescents with type 1 diabetes predict change in glycemic control over time. Research design and methods: A total of 145 adolescents (aged 13–18 yr) participated in two study visits (baseline and 6 months). They completed a measure of depressive symptoms (Children's Depression Inventory; CDI) and had their A1c values and adherence to blood glucose monitoring (BGM) documented. Results: Three variables predicted A1c change over 6 months: CDI change score (B = 0.11; p < 0.001), BGM frequency at baseline (B = ?0.21; p = 0.03), and A1c at baseline (B = ?0.23; p = 0.002). A three‐way interaction among these variables was significant (p < 0.01) and showed that adolescents with high adherence to BGM who were achieving optimal glycemic control (≤7.5%) at baseline were resistant to increasing A1c values, even if depressive symptoms worsened. However, as adherence to BGM declines, there is a synergistic effect with depressive symptoms to accelerate the increase of A1c values over time, making it more difficult to bring A1c back to optimal levels. Conclusions: Results suggest that depressive symptoms are important predictors of A1c change by themselves as well as when considered with adherence to BGM. There is a need to screen for depressive symptoms and expand and develop prevention and intervention strategies in order to put adolescents with type 1 diabetes in the best position for optimal glycemic control.     

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13‐year‐old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller‐Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (?0.18 to ?0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller‐Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes‐related quality of life and reduced care giver burden, were reported. Further high‐quality randomised controlled trials and long‐term data are required to assess the benefits of CSII over MDI and the longevity of these methods.     

Correlates of depressive symptoms in adolescents with type 1 diabetes

Abstract: Purpose:  To determine correlates of depression in adolescents with type 1 diabetes.
Methods:  Data on 117 adolescents participating in a longitudinal study (72 F, 45 M; 95 W; age = 14.3 ± 2.0 yr; duration = 6.3 ± 3.7) were collected with the Children's Depression Inventory (CDI), Diabetes Family Behavior Scale (DFBS), Family Adaptability and Cohesion Scale (FACES), and chart review at study entry and 2-year follow-up.
Results:  Fifteen per cent of adolescents in this sample demonstrated depressive symptoms (CDI > 13) at study entry and 10% at 2 yr follow-up. Adolescents aged 14.1–16 yr and those with diabetes > 10 yr demonstrated the highest rates. When demographic/clinical variables were controlled, the DFBS warmth-caring subscale (p = 0.001) and the FACES adaptability subscale (p = 0.005), but not DFBS guidance-control (p = 0.635), contributed significantly to the explained variance in depressive symptoms ( R ² = 0.27) at study entry. At 2 yr follow-up, study entry CDI scores were the only significant predictor of depressive symptoms ( R ² = 0.40). By 2 yr, adolescents with depressive symptoms had significantly higher HbA1c than those without (p = 0.03).
Conclusion:  The prevalence of depressive symptoms in adolescents with type 1 diabetes coupled with the potential impact of depressive symptoms on metabolic control suggest the need for early diagnosis and treatment. Greater attention to psychosocial outcomes of youth, family functioning, and the potential burden of diabetes over time to youth/families is indicated.     

Insulin pump use in young children in the T1D Exchange clinic registry is associated with lower hemoglobin A1c levels than injection therapy

Insulin delivery via injection and continuous subcutaneous insulin infusion (CSII) via insulin pump were compared in a cross‐sectional study (n = 669) and retrospective longitudinal study (n = 1904) of young children (<6 yr) with type 1 diabetes (T1D) participating in the T1D Exchange clinic registry. Use of CSII correlated with longer T1D duration (p < 0.001), higher parental education (p < 0.001), and annual household income (p < 0.006) but not with race/ethnicity. Wide variation in pump use was observed among T1D Exchange centers even after adjusting for these factors, suggesting that prescriber preference is a substantial determinant of CSII use. Hemoglobin A1c (HbA1c) was lower in pump vs. injection users (7.9 vs. 8.5%, adjusted p < 0.001) in the cross‐sectional study. In the longitudinal study, HbA1c decreased after initiation of CSII by 0.2%, on average (p < 0.001). Frequency of a severe hypoglycemia (SH) event did not differ in pump vs. injection users (p = 0.2). Frequency of ≥1 parent‐reported diabetic ketoacidosis (DKA) event in the prior year was greater in pump users than injection users (10 vs. 8%, p = 0.04). No differences between pump and injection users were observed for clinic‐reported DKA events. Children below 6 yr have many unique metabolic characteristics, feeding behaviors, and care needs compared with older children and adolescents. These data support the use of insulin pumps in this youngest age group, and suggest that metabolic control may be improved without increasing the frequency of SH, but care should be taken as to the possibly increased risk of DKA.     

Application of novel dual wave meal bolus and its impact on glycated hemoglobin A1c level in children with type 1 diabetes

Background: An insulin pump is an advanced technology offering new options of bolus – normal (N), dual wave (D-W) or square wave (S-W) bolus to deliver mealtime insulin.
Objectives: To assess the impact of D-W/S-W boluses on metabolic control (glycated haemoglobin A1c, HbA1c) and to estimate the paediatric patients compliance with implementation of this system in daily practice.
Methods: The cross-sectional study included 499 records of patients aged 0–18 yr. Data from the insulin pump memory provided information on the number of D-W/S-W boluses during a 2-wk period, the insulin requirement (U/kg/d) and the percentage of basal insulin. The HbA1c value (%) and the patient's weight were determined during medical examinations. Mealtime dose of insulin in D-W/S-W bolus was calculated based on the amount of carbohydrate and fat/protein products.
Results: The number of applied D-W/S-W boluses was 16.6 ± 0.77/14 d (ranged 0–95), while 18.8% of patients did not program D-W/S-W boluses. The lowest HbA1c value was found in the group using two and/or more D-W/S-W boluses per day (p = 0.001) compared with the group administrating less than one D-W/S-W bolus/d. Patients with HbA1c level <7.5% had a statistically higher relevant number of D-W/S-W boluses, 19.55 (95% CI: 17.44–21.65) vs. 12.42 (95% CI: 10.22–14.61) (p < 0.001), while there was no correlation between the number of boluses and HbA1c in patients in the remission phase (<0.5 IU/kg/d) (r = 0.012, p = 0.930).
Conclusions: Patients using at least one D-W/S-W bolus per day achieved a recommended level of HbA1c. Paediatric patients with type 1 diabetes mellitus were found to be able to apply D-W/S-W boluses in daily self-treatment process based on food counting.     

Intensive vs. conventional insulin management initiated at diagnosis in children with diabetes: Should payer source influence the choice of therapy?

Intensive insulin management (IIM) in type 1 diabetes facilitates improved glycemic control and a reduction in long-term diabetes complications. We hypothesized that IIM can be started at diagnosis without deleterious effects on hemoglobin A1c (A1c), body mass index (BMI), and severe hypoglycemia regardless of payer source. Type 1 diabetes patients aged 0–18 yrs, in an academic endocrinology practice were identified for a retrospective chart review. Fifty-four patients on conventional insulin management (CIM) were compared to 51 on IIM. Insulin regimens, payer, and A1c values were compared at baseline, 12, 15, and 18 months. Secondary analyses included BMI changes and hypoglycemia frequency. Overall mean A1c values for the IIM group (8.15 ± 1.41) were lower across all time periods compared to the CIM group (8.57 ± 1.52). Repeated measures anova revealed a significant treatment group effect ( p = 0.01) with no time effect ( p = 0.87) or interaction (group by time) effect ( p = 0.65). Private insurance patients had lower mean A1C values than Medicaid patients (χ² = 4.5186, p < 0.05), regardless of regimen. A1c values between IIM and CIM were not statistically different within the Medicaid group. BMI changes between groups were not different. Chi-square analysis for severe hypoglycemia revealed no group differences. In conclusion, IIM had improved glycemic control. Private insurance vs. Medicaid patients had lower mean A1c values regardless of treatment group. Considering Medicaid patients only, IIM was not inferior, and for those with private insurance, IIM was superior. IIM, initiated at diagnosis, is a reasonable approach for newly diagnosed children with diabetes regardless of payer source.     

Discontinuation of insulin pump treatment in children,adolescents, and young adults. A multicenter analysis based on the DPV database in Germany and Austria

Hofer SE, Heidtmann B, Raile K, Fröhlich‐Reiterer E, Lilienthal E, Berghaeuser MA, Holl RW for the DPV‐Science‐Initiative and the German working group for insulin pump treatment in pediatric patients. Discontinuation of insulin pump treatment in children, adolescents, and young adults. A multicenter analysis based on the DPV database in Germany and Austria. Background: Insulin pump therapy is well established in the treatment of children and adolescents with type 1 diabetes. Most studies focus on outcome parameters like hemoglobin A1c (HbA1c), hypoglycemia, and quality of life, whereas few reports address patients who discontinue pump therapy. Objective: This survey focuses on the discontinuation rate of insulin pump treatment in the pediatric and young adult age group. Subjects and methods: The prospective multicenter Diabetes Patienten Verlausdokumentation (DPV) (electronic diabetes patient documentation system) database has been established since 1990 and is broadly used in Germany and Austria. All pump users among the participating centers documented since 1995 were included in this analysis. Results: In total, 11 710 patients with type 1 diabetes were recorded as treated with insulin pumps. In total, 463 patients (4%) switched from insulin pump treatment to multiple daily injections (MDI). In the group of patients who stopped with pump treatment, the mean duration of pump therapy was 1.7 yr (SE ± 0.06 yr), 60.5% of patients were female. Subdivided into age groups, the discontinuation rate was lowest in the age group < 5 yr (0.1%), followed by the groups aged 5–10 yr (0.3%) and 15–20 yr (0.8%). The group aged 10–15 yr showed the highest rate of discontinuation (2%). Conclusions: The discontinuation rate of insulin pump therapy is, in general, low (4%). The younger the patients at the time of initiating insulin pump treatment, the lower is the discontinuation rate. The highest rate was seen in adolescents aged 10–15 yr. Girls stopped insulin pump treatment more often than boys (60.5% vs. 39.5%).     

The effect of socioeconomic deprivation on efficacy of continuous subcutaneous insulin infusion: a retrospective paediatric case-controlled survey

We aimed to retrospectively evaluate the efficacy of continuous subcutaneous insulin infusion (CSII) therapy in relation to social deprivation in an urban paediatric type 1 diabetic population. Data were compared between 51 children on CSII therapy (mean age 11.2?years and duration of follow-up 1.9?years) and matched controls on multiple daily injection (MDI) therapy. Social deprivation was measured using the UK Office of National Statistics 2007 Index of Multiple Deprivation. Using linear mixed modelling analysis, lower HbA1c levels at 24?months were associated with CSII not MDI therapy (P?=?0.02), after adjustment for known variables. Children with the least educated parents showed a rise in HbA1c levels from baseline on MDI therapy (least versus most educated tertile; HbA1c change +0.5% [95% confidence interval ?0.1 to 1.1] versus 0% [?0.8 to 0.8]), whereas this was not observed in CSII therapy (least versus most educated tertile; HbA1c change ?0.3% [?0.7 to +0.1] versus ?0.2% [?0.7 to +0.3], P value for ANCOVA?=?0.02, after adjusting for income and employment). Conclusion: Parental educational deprivation was associated with a failure of MDI but not CSII therapy. These outcomes need confirmation by larger studies.     

Assessment of glycemic control by continuous glucose monitoring system in 50 children with type 1 diabetes starting on insulin pump therapy

OBJECTIVE: To report experience with a continuous glucose monitoring system (CGMS) and to identify factors influencing glycemic control in a large cohort of children and adolescents with type 1 diabetes and change to insulin pump therapy via continuous subcutaneous insulin infusion (CSII). RESEARCH DESIGN and METHODS: In 50 patients [21 boys, 29 girls; median age 12.6 yr (range: 1.3-16.4 yr); diabetes duration 5.0 yr (0.2-13.3)], hemoglobin A1c (HbA1c) and ambulatory CGMS were performed before and 6 wk after starting CSII. Average glucose concentration per 24 h, during day and night time as well as number of excursions, duration, and area under the curve (AUC) of glucose values above 180 mg/dL and below 60 mg/dL were calculated from CGMS data. Simultaneously, metabolic control was documented by standardized self-monitoring of blood glucose (SMBG). RESULTS: In the total cohort, HbA1c improved from 8.1 +/- 1.2% at baseline to 7.7 +/- 0.9% after 6 wk of CSII (p <0.001). This effect was more distinct in boys (8.0 +/- 1.4 vs. 7.5 +/- 1.1%, p=0.007) than in girls (8.1 +/- 1.1 vs. 7.8 +/- 0.7%, p=0.039) as well as in patients with poor glycemic control (HbA1c >8.0%) at baseline (8.9 +/- 0.6 vs. 8.1 +/- 0.8%, p <0.001) and in those older than 12 yr (8.2 +/- 1.2 vs. 7.7 +/- 1.0%, p <0.001). At 6 wk of CSII, the values of glucose average per 24 h, AUC and time above 180 mg/dL, particularly during the day, improved. HbA1c was correlated with AUC above 180 mg/dL (r=0.742, p <0.001) and CGMS average glucose per 24 h (r=0.628, p=0.002), but to a lesser extent with SMBG values (r=0.418, p=0.054). CONCLUSION: With the change to CSII, HbA1c improved significantly after 6 wk of therapy. CGMS usage provided additional information about glycemic control in these patients.     

Insulin pumps in pediatric routine care improve long-term metabolic control without increasing the risk of hypoglycemia

Although continuous subcutaneous insulin infusion (CSII) has been used in pediatric practice for >20 yr, the technique is not widely used in many countries. The aim of this non-randomized population-based study was to evaluate CSII in routine pediatric care. In a 1-yr cross-sectional evaluation, 27/89 patients (30.3%, age 7-21 yr) used pumps (two during the night only), the others 4-6 injections/day. In patients with >2 yr of diabetes, pump users had higher HbA1c (8.9+/-1.0 vs. 8.2+/-1.6%, p=0.04), less insulin/24 h (0.9+/-0.1 vs. 1.0+/-0.2 U/kg, p=0.002), and longer diabetes duration (p=0.02). The higher HbA1c is explained by 67% of pump patients having high HbA1c (>8.5%) as the major indication for CSII. The overall incidence of severe hypoglycemia was 31.5/100 patient years, 40.3 for injection therapy, and 11.1 for pump therapy (p=not significant). The incidence of severe hypoglycemia with unconsciousness was 12.9/100 patient years and with seizures 9.7 for injection therapy, whereas no children on pumps experienced these complications during the cross-sectional study year. We had no admissions for ketoacidosis in either group during this year. The pump patients were followed for 5 yr after pump start. Two stopped using the pump after 2 and 3 yr. For the patients with high HbA1c as indication, mean HbA1c the year before pump was 9.5%. Mean HbA1c during the first year with pump was lowered to 8.9% (p=0.019), the second year 8.6% (p=0.017), the third year 8.6 (p=0.012), the fourth year 8.7 (p=0.062), and the fifth year 8.9% (p=0.28). We found six cases of ketoacidosis corresponding to 4.7/100 patient years. In conclusion, we found a long-term lowering of HbA1c after starting CSII in a pediatric population, decreased frequency of severe hypoglycemia, and a low risk of ketoacidosis.     

Effectiveness of sensor-augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study

Slover RH, Welsh JB, Criego A, Weinzimer SA, Willi SM, Wood MA, Tamborlane WV. Effectiveness of sensor‐augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study. Objective: Maintenance of appropriate A1C values and minimization of hyperglycemic excursions are difficult for many pediatric patients with type 1 diabetes. Continuous glucose monitoring (CGM) sensor‐augmented pump (SAP) therapy is an alternative to multiple daily injection (MDI) therapy in this population. Research design and methods: Sensor‐augmented pump therapy for A1C reduction (STAR 3) was a 1‐yr trial that included 82 children (aged 7–12) and 74 adolescents (aged 13–18) with A1C values ranging from 7.4 to 9.5% who were randomized to either SAP or MDI therapy. Quarterly A1C values were obtained from all subjects. CGM studies were carried out at baseline, 6 months, and 12 months to quantify glycemic excursions [calculated as area under the glucose concentration‐time curve (AUC)] and variability. In the SAP group, sensor compliance was recorded. Results: Baseline A1C values were similar in subjects randomized to the SAP (8.26 ± 0.55%) and MDI groups (8.30 ± 0.53%). All subsequent A1C values showed significant (p < 0.05) treatment group differences favoring SAP therapy. Compared with the MDI group, subjects in the SAP group were more likely to meet age‐specific A1C targets and had lower AUC values for hyperglycemia with no increased risk of hypoglycemia. Glucose variability improved in the SAP group compared to the MDI group. Children wore CGM sensors more often and were more likely to reach age‐specific A1C targets than adolescents. Conclusions: SAP therapy allows both children and adolescents with marginally or inadequately controlled type 1 diabetes to reduce A1C values, hyperglycemic excursions, and glycemic variability in a rapid, sustainable, and safe manner.     

Re-hospitalization after diagnosis of diabetes varies by gender and socioeconomic status in urban African-American and Latino young people

Abstract: Purpose: To examine risk factors for re‐hospitalization after diagnosis of diabetes mellitus amongst urban minority children. Methods: Families of insulin‐treated African‐American and Latino patients aged < 18 yr at diagnosis (n = 216) were interviewed about sociodemographics and other characteristics, on average 5.9 yr after diagnosis. Results and conclusions: About 60% of respondents were re‐hospitalized at least once for diabetes‐related reasons (n = 128). Half of those questioned had Medicaid or no health insurance at all; 23% fit criteria for a non‐autoimmune, type 2 diabetic phenotype. Those who avoided re‐hospitalization were more likely to have been seen initially at a tertiary care facility, to have private health insurance, and to be males. They had, on average, 2 yr shorter duration of diabetes at the time of interview. Risk for re‐hospitalization was not associated with age at diagnosis, ethnicity, diabetic phenotype, or source of care during the past year. In multivariate analysis, predictors of re‐hospitalization were gender [odds ratio (OR) 1.98 for females vs. males (95% confidence interval (CI) = 1.05–3.72)], duration of diabetes [OR = 1.46 per yr (95% CI = 1.36–1.57)], initial ascertainment at a community hospital [OR = 5.44 vs. tertiary care facility (95% CI = 2.61–11.29)] and having Medicaid or no insurance [OR = 2.73 (95% CI = 1.42–5.24)], compared with those with another type of health insurance. There is a high risk of re‐hospitalization after the initial diagnosis of diabetes among insulin‐treated minority children, particularly the uninsured and those on Medicaid, in part related to duration of disease and where the initial treatment occurred.     

Changes in Glycemic Control and Quality of Life in Pediatric Type 1 Diabetics with Continuous Subcutaneous Insulin Infusion of Insulin Aspart Following Multiple Daily Injection Therapy

The efficacy of continuous subcutaneous insulin infusion (CSII) of the rapid-acting insulin analogue, insulin aspart, was evaluated in 26 patients with childhood-onset type 1 diabetes aged between 6 and 18 yr who had been on basal-bolus therapy (multiple daily injection (MDI) of regular human insulin or rapid-acting insulin and intermediate/long-acting insulin). The glycemic control in the patients was evaluated based on changes in the clinical parameters and the patient quality of life (QOL) was evaluated by using the insulin therapy-related QOL questionnaire. Twenty two patients continued CSII during the 6-mo study period. The mean HbA1c was 7.8 ± 1.8% at baseline and it decreased to 7.4 ± 0.8% at 6 mo after the start of the CSII. Overall, no decrease of the QOL post-CSII initiation was noted. The possible superiority of CSII as compared to MDI was suggested for patients who “eat out” or “have to look for an appropriate place for insulin injection.” Aside from an inadequate indwelling needle placement detected after the initiation of CSII in several patients, no adverse event associated with NovoRapid^® was seen. In conclusion, CSII of rapid-acting insulin appears to be a useful therapy for patients with childhood-onset type 1 diabetes.     

Insulin requirement in preschoolers treated with insulin pumps at the onset of type 1 diabetes mellitus

The aim: The aim of this study is to analyze changes in the basal insulin requirement in preschoolers treated with insulin pump at the onset of T1DM, using system to calculate meal time insulin.
Methods: 58 children (31 girls) under 6 years (mean age 3.3 ± 1.5 years) initiated on insulin pump therapy within 2 months after recognition of T1DM and treated at least for 1 year were analyzed during a follow-up period of 165 patient-years. Data was collected every 6 months: HbA1c, BMI SDS, diabetic ketoacidosis, severe hypoglycaemia, total daily insulin dose (TDD) and basal insulin.
Results: Basal insulin rose from 10% in the third month and did not exceed 30% of TDD after 12 months (p<0.0001). In the third month, 46% of children were without basal insulin; this group included significantly older children (3.7 ± 1.4 vs. 2.8 ± 1.4 years; p = 0.01), which had lower TDD (0.33 ± 0.18 vs. 0.54 ± 0.23u/kg/d; p = 0.0007) than children with basal insulin. HbA1c persisted ≤7.3%.
Conclusion: In preschool children initiated on CSII therapy at the time of T1DM diagnosis the first year of treatment is critical for altering the basal insulin dose. Preschoolers with TDD lower than 0.5U/kg/d may not require basal insulin. Moreover, basal insulin did not exceed 30% of TDD in the first years after T1DM onset.     

The effects of weight status on treatment outcomes in a randomized clinical trial of multisystemic therapy for adolescents with type 1 diabetes and chronically poor metabolic control

OBJECTIVE: The purpose of the study was to determine if being overweight attenuated the effect of multisystemic therapy (MST), an intensive, home-based psychotherapy, on metabolic outcomes among adolescents with type 1 diabetes and chronically poor metabolic control. As overweight is a marker of insulin resistance, it was hypothesized that weight status would limit the impact of behavioral changes in traditional aspects of adherence to the type 1 diabetes regimen on metabolic control. METHODS: A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and hemoglobin A1c (HbA1c) > or = 8% for the past year. Participants were randomly assigned to MST plus standard care (SC) or SC alone. Data were collected at baseline and 7 months post-test (i.e., treatment termination). Overweight was defined as body mass index > 85%. RESULTS: Forty-one percent of the sample was overweight. Intent-to-treat analysis showed that adolescents in the MST group had a significant increase in frequency of blood glucose testing (BGT) [F(1,113) = 15.43, p = 0.0001] and a trend to significant improvement in HbA1c [F(1,123) = 2.99, p = 0.086] irrespective of weight. However, HbA1c decreased 0.91% (p = 0.002) for normal weight adolescents in the MST group compared with 0.20% (p = 0.570) for overweight adolescents in the MST group. DISCUSSION: Despite improvements in adherence to BGT, overweight adolescents receiving an intensive behavioral intervention did not have a significant improvement in metabolic control compared with their normal weight peers. Overweight, an accepted marker of insulin resistance and a major public health issue, warrants increased consideration in intervention trials to improve the metabolic control of adolescents with type 1 diabetes.     

Treatment of Danish adolescent diabetic patients with CSII – a matched study to MDI

Objective:  To compare two intensified insulin therapy regimens – continuous subcutaneous insulin infusion (CSII) against multiple daily insulin injection (MDI) – in Danish adolescents examined in a prospective, matched controlled study design.
Research design and methods:  Thirty type 1 diabetic adolescents at CSII and 26 matched MDI controls were included in this open intention-to-treat study. Actrapid was used in both groups. Before study entry, all participants followed a brush-up course in order to minimize study effect. At each visit, the following parameters were recorded: hemoglobin A1c (HbA1c), insulin dose, weight, number of hypoglycemic and diabetic ketoacidosis (DKA) events, and the time resources used. At entry and exit of the study, diet registration and validated quality-of-life (QoL) questionnaires were filled by the participants.
Results:  A non-significant decline in HbA1c was seen in both groups (p = 0.468); HbA1c decreased from 9.5 to 8.9% and from 9.7 to 9.5% in the CSII and MDI group, respectively. The insulin dose and the number of severe hypoglycemic events per patient were lower (non-significant) in the CSII group. Both groups showed increased body mass index – highest in the CSII group – and mild to moderate DKA episodes were only seen among CSII users. No differences could be demonstrated within the QoL or diet registrations.
Conclusions:  CSII treatment is beneficial as an intensified insulin therapy for selected type 1 diabetic patients and both MDI and CSII can be offered by the professional diabetes team to better tailor therapy. In future, there is a strong need to identify the characteristics of responders to CSII treatment in order to increase the efficacy and safety of CSII treatment.     

Feeding problems reported by parents of young children with type 1 diabetes on insulin pump therapy and their associations with children's glycemic control

Objective: Previous research demonstrated high rates of perceived mealtime behavior problems in families of young children with type 1 diabetes who were managed with conventional therapy. Because of new insulin regimens that offer greater flexibility, reexamination of mealtime behaviors is required. We assessed parent-reported mealtime behaviors in a sample of young children using an insulin pump. An additional aim was to evaluate the associations of two measures of parental feeding behavior with children's glycemic control.
Methods: Primary caregivers of 31 young children (mean age = 5.0 ± 1.3 yr) completed the Child Feeding Questionnaire (CFQ) and the Behavioral Pediatric Feeding Assessment Scale (BPFAS). Hemoglobin A1c (HbA1c) was used as a surrogate marker for children's glycemic control.
Results: Children had a mean HbA1c of 7.8 ± 0.64%. Mean CFQ – Restriction and Pressure to Eat scores were 3.1 ± 0.94 and 2.0 ± 0.88, respectively (range = 1–5). Mean BPFAS – Parent and Child scores were 16.0 ± 4.3 (range = 10–50) and 44.9 ± 9.3 (range = 25–125), respectively. Positive correlations were found between children's HbA1c levels and caregivers' reporting of frequency of child mealtime behavior problems.
Conclusions: Caregivers of young children on pump therapy report relatively low rates of mealtime behavior problems. However, correlations with children's HbA1c suggest that parent–child mealtime behaviors continue to relate to children's health outcomes. Research is needed to determine if changing mealtime interactions can improve children's glycemic control; items from the BPFAS and CFQ can offer targets to guide interventions.     

Insulin detemir improves glycemic control and reduces hypoglycemia in children with type 1 diabetes: findings from the Turkish cohort of the PREDICTIVE™ observational study

Background: Insulin detemir is a basal insulin analog designed to produce a superior pharmacokinetic profile to basal formulations of human insulin. It has shown consistently improved tolerability in comparison to neutral protamine Hagedorn (NPH) insulin in adult cohorts, but there are relatively few publications involving pediatric cohorts. Methods: The efficacy and safety of insulin detemir in children with type 1 diabetes was assessed using data from the Turkish cohort of PREDICTIVE? (a large, multinational, observational) study. The children investigated were using basal–bolus therapy involving NPH insulin or insulin glargine at baseline but were switched to insulin detemir as part of routine clinical care by their physicians. Results: Twelve weeks of treatment with insulin detemir significantly reduced mean hemoglobin A1c (9.7–8.9%, p < 0.001) and mean fasting glucose [185–162 mg/dL (10.3–9 mmol/L), p < 0.01]. Fasting glucose variability was also lower after treatment with insulin detemir than previously (on either NPH or glargine, p < 0.05). The frequencies of total, major and nocturnal hypoglycemic events were significantly reduced with insulin detemir relative to baseline, with an estimated mean of 6.89 fewer events/patient/yr overall (p < 0.001) and 2.6 fewer nocturnal events/patient/yr (p < 0.01). Weight and insulin dose remained relatively unchanged. Conclusions: Twelve weeks of treatment with insulin detemir improved glycemic control and reduced hypoglycemia in children with type 1 diabetes. This improved tolerability might allow further dose titration and therefore additional improvements in glucose control.     

Continuous subcutaneous insulin infusion benefits quality of life in preschool-age children with type 1 diabetes mellitus

OBJECTIVE: To compare medical, nutritional, and psychosocial outcomes of continuous subcutaneous insulin infusion (CSII) therapy and multiple daily insulin injections (MDI) in preschoolers with type 1 diabetes mellitus (T1DM) in a randomized controlled trial. STUDY DESIGN: Sixteen children (mean age 4.4 +/- 0.7 yr, range 3.1-5.3 yr) with T1DM were randomly assigned to CSII or MDI. Hemoglobin A1c (HbA1c) was measured monthly for 6 months. Glucose variability was measured at baseline and at 6 months using continuous blood glucose sensing. Quality of life, adverse events, and nutrition information were assessed. RESULTS: Parents of the CSII group reported a significant decrease in diabetes-related worry, while parents of the MDI group reported an increased frequency of stress associated with their child's medical care. Mean HbA1c levels from baseline (CSII 8.3 +/- 1.4%, MDI 8.0 +/- 0.8%) to 6 months (CSII 8.4 +/- 0.8%, MDI 8.2 +/- 0.4%) remained stable, and group differences were not significant. There were no significant group differences in duration of hypo- or hyperglycemic events or frequency of adverse events. CONCLUSION(S): For young children with T1DM, CSII therapy is comparable to MDI therapy with regard to glucose control but is associated with higher treatment satisfaction and improved quality of life.     

Insulin degludec in combination with bolus insulin aspart is safe and effective in children and adolescents with type 1 diabetes

Insulin degludec (IDeg) once‐daily was compared with insulin detemir (IDet) once‐ or twice‐daily, with prandial insulin aspart in a treat‐to‐target, randomized controlled trial in children 1–17 yr with type 1 diabetes, for 26 wk (n = 350), followed by a 26‐wk extension (n = 280). Participants were randomized to receive either IDeg once daily at the same time each day or IDet given once or twice daily according to local labeling. Aspart was titrated according to a sliding scale or in accordance with an insulin:carbohydrate ratio and a plasma glucose correction factor. Randomization was age‐stratified: 85 subjects 1–5 yr. (IDeg: 43), 138 6–11 yr (IDeg: 70) and 127 12–17 yr (IDeg: 61) were included. Baseline characteristics were generally similar between groups overall and within each stratification. Non‐inferiority of IDeg vs. IDet was confirmed for HbA1c at 26 wk; estimated treatment difference (ETD) 0.15% [?0.03; 0.32]_95%CI. At 52 wk, HbA1c was 7.9% (IDeg) vs. 7.8% (IDet), NS; change in mean FPG was ?1.29 mmol/L (IDeg) vs. +1.10 mmol/L (IDet) (ETD ?1.62 mmol/L [?2.84; ?0.41]_95%CI, p = 0.0090) and mean basal insulin dose was 0.38 U/kg (IDeg) vs. 0.55 U/kg (IDet). The majority of IDet treated patients (64%) required twice‐daily administration to achieve glycemic targets. Hypoglycemia rates did not differ significantly between IDeg and IDet, but confirmed and severe hypoglycemia rates were numerically higher with IDeg (57.7 vs. 54.1 patient‐years of exposure (PYE) [NS] and 0.51 vs. 0.33, PYE [NS], respectively) although nocturnal hypoglycemia rates were numerically lower (6.0 vs. 7.6 PYE, NS). Rates of hyperglycemia with ketosis were significantly lower for IDeg vs. IDet [0.7 vs. 1.1 PYE, treatment ratio 0.41 (0.22; 0.78)_95%CI, p = 0.0066]. Both treatments were well tolerated with comparable rates of adverse events. IDeg achieved equivalent long‐term glycemic control, as measured by HbA1c with a significant FPG reduction at a 30% lower basal insulin dose when compared with IDet. Rates of hypoglycemia did not differ significantly between the two treatment groups; however, hyperglycemia with ketosis was significantly reduced in those treated with IDeg.