Sociodemographic and psychosocial factors associated with continuous subcutaneous insulin infusion in adolescents with type 1 diabetes

Cortina S, Repaske DR, Hood KK. Sociodemographic and psychosocial factors associated with continuous subcutaneous insulin infusion in adolescents with type 1 diabetes. Objective: To examine the role of sociodemographic factors and psychosocial adjustment in continuous subcutaneous insulin infusion (CSII) use among adolescents with type 1 diabetes. Methods: A total of 150 adolescents with type 1 diabetes and their caregivers completed measures of general psychological functioning, diabetes functioning, and stressful life events. Blood glucose monitoring (BGM) frequency and glycemic control were also assessed. Logistic regression was used to determine associations between CSII use and sociodemograpic and psychosocial factors. Results: All logistic regression models were significant, indicating a large proportion of the variance in CSII use was associated with sociodemographic, diabetes‐specific and psychosocial variables. Final models showed higher frequency of BGM and having private insurance as significant correlates of CSII use. CSII use was also associated with adolescent and caregiver reports of sharing of responsibilities around diabetes management and negative affect regarding BGM. Conclusions: Adolescents currently prescribed CSII therapy evidenced key differences from their counterparts using multiple daily injections (MDI) in insurance status, diabetes management behavior, and family functioning related to diabetes. Efforts to understand the role of family factors in the maintenance of CSII therapy with clinical indicators of CSII use may inform treatment effectiveness.     

Measuring self-reported, health-related, quality of life in adolescents with type 1 diabetes using both generic and disease-specific instruments

AIMS: To describe perceived functional health and well-being and diabetes-related impact, worry and satisfaction with life in relation to demographic and clinical variables in a population of adolescents with type 1 diabetes. To compare perceived functional health and well-being between adolescents with diabetes and a group of healthy controls and to analyse the relationship between generic functional health and well-being and diabetes-related impact, worry and satisfaction with life. METHODS: A total of 130 adolescents were invited to complete the Child Health Questionnaire (CHQ-CF87) and the Diabetes Quality of Life (DQOL) questionnaire modified for youths. A total of 115 (88.5%) subjects participated in the study; mean age 14.5 y (SD 1.86), mean duration of diabetes 6.99 y (SD 3.77, range 1-16 y), mean HbA1c 9.3% (SD 1.62, range 6.2-14.0%). Forty-eight percent of the subjects were girls. RESULTS: When compared with healthy adolescents, subjects with diabetes reported a significantly lower degree of general health. The CHQ-CF87 scales showed that higher age in adolescents with diabetes was associated with lower scores for mental health (p < 0.001), self-esteem (p < 0.001), behaviour (p = 0.004) and general health (p < 0.001). Findings from the DQOL questionnaire showed that older adolescents were more worried (p < 0.001), perceived a greater impact of diabetes on daily life (p = 0.008) and lower diabetes-related life satisfaction (p < 0.001). The scores for girls were lower than those for boys in assessment of mental health (p < 0.001), self-esteem (p = 0.004) and family cohesion (p = 0.002). Girls also reported a greater impact of diabetes (p = 0.028), more worries (p = 0.001) and less satisfaction with life (p = 0.006) than boys. Neither HbA1c, nor other clinical variables could sufficiently explain the variations in DQOL or CHQ-CF87. CONCLUSIONS: Health-related quality of life varied significantly by age and gender, but less so by HbA1c and other clinical variables. Adolescents with diabetes reported a significantly lower degree of general health than that reported by healthy controls. The CHQ-CF87 is a valuable supplement to DQOL, allowing for comparisons with the general population.     

应用胰岛素泵治疗儿童及青少年1型糖尿病对糖代谢的影响

为观察应用胰岛素泵治疗儿童及青少年1型糖尿病(T1DM)对糖代谢的影响 ,随访10例胰岛素泵治疗的T1DM患儿 ,分别观察胰岛素泵治疗前、后6个月的糖化血红蛋白值(HbA1c)、胰岛素用量、严重低血糖及酮症酸中毒发生次数的变化情况。结果显示 ,胰岛素泵治疗6个月后HbA1c 显著下降 ,治疗前为8.97 %±1.69 %,治疗后为7.51 %±1.17 % (t=2.52 ,P<0.05) ;胰岛素用量无显著下降 ;未发生严重低血糖和酮症酸中毒。表明胰岛素泵治疗可有效控制血糖 ,明显降低HbA1c,减少低血糖及酮症酸中毒的发生 ,是儿童及青少年T1DM常规治疗的较好选择。     

The selection of children and adolescents for treatment with continuous subcutaneous insulin infusion (CSII)

Abstract:  Continuous subcutaneous insulin infusion (CSII) was first introduced as a mode of treatment for persons with type 1 diabetes mellitus (T1DM) in the late 1970s. Since that time, there have been many reports and reviews of this modality of treatment in adults and adolescents with diabetes and several reports of the use of this technology in the treatment of children with T1DM. Conflicting data have accumulated on the consistency of improvement in hemoglobin A1c (HbA1c) and in the frequency of complications, most significantly that of hypoglycemia. Some studies report the findings of controlled randomized studies, but many of these studies were conducted on small numbers of highly selected patients. Some studies are prospective but not randomized, where subjects pre-CSII serve as their own controls. Yet other studies are retrospective reviews of children and adolescents who have been treated with CSII. This paper reviews what has been learned about patient selection and outcomes of CSII treatment, with the goal of outlining steps in the selection and preparation of patients for CSII that will facilitate optimum outcome.     

常规注射胰岛素和胰岛素泵治疗的1型糖尿病儿童主观生活质量及影响因素研究

目的调查常规注射和使用胰岛素泵输注胰岛素两种治疗方式下1型糖尿病患儿的生活质量并探讨影响患儿生活质量的相关因素。方法采用儿少主观生活质量问卷和父母养育方式评价量表,对42例1型糖尿病患儿、26例健康儿童进行评测,并对影响患儿生活质量的相关指标进行多因素回归分析。结果糖尿病患儿生活质量低于健康儿童,采用胰岛素泵治疗患儿在学校生活、抑郁体验、焦虑体验、情感成分以及总体满意度上优于常规注射治疗患儿(P均<0.05)。糖尿病患儿较正常儿童更容易得到父母的关心理解和情感温暖,更容易受到父母的过度保护,其生活质量与父亲的情感温暖、关心理解以及采用的治疗方式密切相关。结论1型糖尿病患儿生活质量下降客观存在,父亲多给予患儿情感温暖和采用胰岛素泵有助提高患儿生活质量。     

A cross-sectional international survey of continuous subcutaneous insulin infusion in 377 children and adolescents with type 1 diabetes mellitus from 10 countries

OBJECTIVE: To document current practices using continuous subcutaneous insulin infusion (CSII) by downloading electronically the 90-d pump data held within the pump memory and relating that to clinical data from children and adolescents in different pediatric diabetes centers from Europe and Israel. METHODS: Data of patients (1-18 yr) treated with CSII in 23 centers from nine European countries and Israel were recorded with the encapture software (PEC International, Frankfurt, Germany). The number of patients who participated was 377 (48% female; mean diabetes duration +/- SD: 6.8 +/- 3.7 yr; age: 12.9 +/- 3.8 yr, preschool n = 33; prepubertal n = 95; adolescent n = 249; CSII duration: 1.6 +/- 1.2 yr; local HbA1c: 8.1 +/- 1.2%). RESULTS: The total insulin dose was lower than previously reported for injection therapy (0.79 +/- 0.20 U/kg/d). Covariance coefficient of daily total insulin was high in all age groups (adolescents 19 +/- 9%, prepubertal 18 +/- 8 and preschool 17 +/- 8). The distribution of basal insulin infusion rates over 24 hr (48 +/- 12% of total dose) varied significantly between centers and age groups. The number of boluses per day (7 +/- 3) was not significantly different between the age groups (average daily bolus amount: 0.42 +/- 0.16 U/kg). The rate of severe hypoglycemia (coma/convulsions) was 12.4 episodes per 100 patient-years and the number of diabetes-related hospital days was 124 per 100 patient-years. DISCUSSION: Pediatric CSII patients show a high variability in their insulin therapy. This relates both to age-dependent differences in the distribution of basal insulin as to the age-independent day-to-day variation in prandial insulin.     

Effects of insulin pump vs. injection treatment on quality of life and impact of disease in children with type 1 diabetes mellitus in a randomized, prospective comparison

Objective:  Effects of pump treatment vs. four times daily injections were explored in children with diabetes with regard to quality of life and impact of disease as well as adverse effects and parameters of metabolic control.
Methods:  An open, parallel, randomized controlled prospective comparative study lasting 14 months was completed by 38 type 1 children with diabetes (age 4–16 yr) following a 3.5-months run-in phase. Standardized quality-of-life Pediatric Quality of life Inventory (PedsQL) and impact of disease scores were obtained every 3.5 months as well as regular medical parameters. Parallel treatment group data and longitudinal within-patient data were analysed for each treatment modality.
Results:  Within-patient comparisons of the two treatment modalities showed significant improvement in PedsQL and impact scores after pump treatment. Treatment group comparisons did not show significant improvement. Pump treatment resulted in decreased symptomatic hypoglycaemia and lowered haemoglobin A1c by 0.22% after run in.
Conclusions:  Within-patient comparison suggests that metabolic control, frequency of severe hypoglycaemia (a threefold decrease), quality of life and impact of disease scores are improved by pump treatment in comparison to regular treatment with four daily insulin injections.     

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.     

Improved treatment satisfaction but no difference in metabolic control when using continuous subcutaneous insulin infusion vs. multiple daily injections in children at onset of type 1 diabetes mellitus

Objective: The aim of this study was to compare safety, metabolic control, and treatment satisfaction in children/adolescents at onset of type 1 diabetes mellitus who were treated with either continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI). Research design and methods: Seventy‐two children/adolescents (7–17 yr of age) were enrolled in this open, randomized, parallel, multicenter study. Approximately half of the patients were treated with MDI (natural protamine hagedorn [NPH] insulin twice daily and rapid‐acting insulin three to –four times daily, n = 38) by pen, and the other half received CSII (n = 34). The patients were followed for 24 months with clinical visits at the entry of the study and after 1, 6, 12, and 24 months. During these visits, hemoglobin A1c, insulin doses, weight, and height were registered. Severe episodes of hypoglycemia and ketoacidosis as well as technical problems were recorded. In addition, the patients/parents answered the Diabetes Treatment Satisfaction Questionnaire. Results: There was no significant difference in metabolic control between the treatment groups. Treatment satisfaction was significantly higher in the group treated with CSII compared with the MDI group (p ≤ 0.01 at all screening visits). There were no episodes of ketoacidosis and there was no significant difference regarding severe hypoglycemia between the treatment groups. Conclusions: CSII treatment proved to be a safe therapy in children/adolescents followed for 24 months after onset of their diabetes. Treatment satisfaction was higher in the CSII group, although there was no difference in metabolic control compared with the MDI group.     

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.     

Age,metabolic control and type of insulin regime influences health-related quality of life in children and adolescents with type 1 diabetes mellitus

The effects of illness and treatment of diabetes mellitus extend beyond medical outcomes. We therefore evaluated health-related quality of life (HRQOL) in children (aged 8–12 years) and adolescents (aged 13–16 years) with type 1 diabetes to compare their results with healthy peers and to identify HRQOL determinants. A total of 68 children and adolescents from a tertiary care clinic which specialises in the management of diabetes, completed the generic KINDL-R questionnaire. This instrument for children and adolescents has six dimensions and an additional module assessing condition-related HRQOL. Overall, the HRQOL was not different between patients with type 1 diabetes and healthy controls. In some areas, children and adolescents with diabetes reported a better HRQOL compared to healthy peers: adolescents reported better psychological well-being ( P <0.05) and children higher levels of well-being in the school domain ( P <0.05). In general, children reported a better HRQOL ( P <0.05) than adolescents with type 1 diabetes confirming age-related differences in HRQOL in the general population. Lower HbA1c (<8%) and intensified insulin therapy (>3 injections/day) were associated with a better HRQOL in different domains ( P <0.05). The subscale chronic illness showed a better HRQOL ( P <0.001) in children and adolescents with diabetes compared to age-matched controls with other chronic conditions. Conclusion:Children and adolescents from a paediatric department specialising in diabetes management report good health-related quality of life. Younger age, good metabolic control and intensified insulin therapy are associated with a better health-related quality of life. Dimensions of health-related quality of life appear to play different roles at different ages, emphasising the importance of the multidimensional health-related quality of life concept and the value of age-appropriate self-reports.     

Initial insulin therapy in children and adolescents with type 1 diabetes mellitus

Weitzel D, Pfeffer U, Dost A, Herbst A, Knerr I, Holl R. Initial insulin therapy in children and adolescents with type 1 diabetes mellitus. Objective: The aim of the study was to define parameters that influence the initial insulin dosage in young subjects with type 1 diabetes regarding the amount of daily insulin, the ratios of basal and prandial insulin, and the insulin/carbohydrate ratios. Study design: We used a computer‐based registry (with prospectively collected data) in Germany and Austria, a software for the management and data documentation of diabetic patients (DPV), to analyze the initial insulin therapy in 2247 children with newly diagnosed type 1 diabetes to identify factors that influence diabetes therapy within the first 10 d. Results: For both genders, glucosylated hemoglobin A1c (HbA1c), blood pH at diabetes onset, and pubertal status are the major factors determining the initial insulin dosage calculated as the amount of daily insulin per kilogram body weight (kg), the basal and prandial insulin dose per kilogram, and day and the insulin/carbohydrate ratios for meals. The frequency of hypoglycemia correlated with increasing quotient of applied to calculated insulin dosage. Conclusion: The predictive factors of insulin requirement may exert beneficial effects on the assessment and adjustment of insulin therapy in young diabetic subjects at disease onset. On the basis of a multiple, linear regression, we suggest a formula to calculate the initial insulin therapy.     

Prolonged use of continuous glucose monitors in children with type 1 diabetes on continuous subcutaneous insulin infusion or intensive multiple-daily injection therapy

Objective:  For continuous glucose sensors to improve the treatment of children with type 1 diabetes (T1D), they must be accurate, comfortable to wear, and easy to use. We conducted a pilot study of the FreeStyle Navigator™ Continuous Glucose Monitoring System (Abbott Diabetes Care) to examine the feasibility of daily use of a continuous glucose monitor (CGM) in an extended ambulatory setting.
Methods:  Following a 13-wk trial of daily Navigator use, 45 children with T1D [10.7 ± 3.7 yr, range 4.6–17.6, 24 using insulin pumps; continuous subcutaneous insulin infusion (CSII) and 21 using glargine-based multiple daily injections (MDI)] used the Navigator for an additional 13 wk.
Results:  Navigator use was initially slightly higher in the CSII users than in the MDI users but declined similarly in both groups by 22–26 wk. After 26 wk, 11 (46%) of 24 CSII users and 7 (33%) of 21 MDI users were using the CGM at least 5 d a week. No baseline demographic or clinical factors were predictive of the amount of sensor use at 26 wk. However, Navigator use during weeks 1–13 and scores on a CGM satisfaction survey at 13 wk were predictive of use in weeks 22–26.
Conclusions:  CGM was generally well-tolerated in children with T1D for more than 6 months, and early acceptance of CGM was predictive of extended use of the device. Although many subjects and parents found CGM valuable, the declining usage over time underscores the need to develop new technologies and strategies to increase acceptance, effectiveness, and long-term use of these devices in youth with T1D.     

A questionnaire survey on the use of quick-acting insulin analog in Japanese children and adolescents with type 1 diabetes

BACKGROUND: The aim of this study was to investigate the actual condition of quick-acting insulin analog (Q) in Japanese children and adolescents with type 1 diabetes. METHODS: Forty-seven physicians who managed 944 patients under 18 years of age with type 1 diabetes, were requested to complete questionnaires in May 2002 regarding the use of Q. RESULTS: Q was administered to 417 out of 944 (44%) patients. The details of the daily insulin regimens were as follows: three doses of Q with basal insulin in 116 of 403 (29%), three doses of Q with more than twice the basal insulin in 69 of 403 (17%), and other modifications using either Q or regular insulin (R) depending on the patients' lifestyles in 213 of 403 (53%). Q dose was equal to R after the change of insulin regimens in 232 of 290 (80%). After switching to Q from R, the basal insulin dosage increased in 113 of 341 (33%) and the number of basal insulin injections increased in 42 of 341 (12%). After the transfer to Q from R, glycemic control was judged to improve in 179 of 372 (48%), to have no significant change in 162 of 372 (44%), and to aggravate in 31 of 372 (8%). The majority of patients, (305/389; 78%), noted an improvement of quality of life (QOL) following the administration of Q. CONCLUSIONS: Q was considered to be useful in flexibility of daily insulin therapy and improvement of QOL in children and adolescents with type 1 diabetes. Insulin therapy for type 1 diabetes during childhood and adolescence should be tailored to meet individual needs.     

Basal rates and circadian profiles in continuous subcutaneous insulin infusion (CSII) differ for preschool children, prepubertal children, adolescents and young adults

Bachran R, Beyer P, Klinkert C, Heidtmann B, Rosenbauer J, Holl RW; for the German/Austrian DPV Initiative, the German Pediatric CSII Working Group and the BMBF Competence Network Diabetes. Basal rates and circadian profiles in continuous subcutaneous insulin infusion (CSII) differ for preschool children, prepubertal children, adolescents and young adults. Objective: Initiation of continuous subcutaneous insulin therapy (CSII) requires an appropriate basal rate profile. Different approaches exist; however, there is a lack of evidence‐based recommendations, especially in young children. Study design: In this large multicenter survey, 5941 CSII patients from the German/Austrian prospective documentation system (DPV) were analyzed. Patients were divided into four age groups: <6 yr (n = 837), 6 to <12 yr (n = 1739), 12 to <18 yr (n = 2985) and 18 to <25 yr (n = 380). Basal insulin requirement and diurnal distribution were evaluated based on the most recent documentation for each patient. Results: Basal insulin requirement differed significantly between the four age groups (<6: 0.25 ± 0.12; 6 to <12: 0.33 ± 0.12; 12 to <18: 0.43 ± 0.15; 18 to <25: 0.35 ± 0.13 U/kg; p < 0.001). Circadian insulin profiles were markedly different between the younger and older age groups. In addition to age, longer diabetes duration, female gender, higher HbA1c and lower body mass index standard deviation score (BMI‐SDS) were related to higher basal insulin requirement per kilogram of body weight. Conclusions: Age of the patient is the primary factor that influences both total daily requirement and circadian distribution of basal insulin in CSII. Experience from a large database may therefore facilitate the initiation of pump therapy in pediatric patients.     

Insulin allergy desensitization with simultaneous intravenous insulin and continuous subcutaneous insulin infusion

Abstract:  Persistent 'IgE-mediated' insulin allergy (type 1 allergy) (1) , unresponsive to changes in insulin type or the use of antihistamines, necessitates desensitization. A number of case reports (2–7) and recent reviews (8, 9) have demonstrated that desensitization can be achieved with continuous subcutaneous insulin infusion (CSII), but in type 1 diabetes mellitus, the need to slowly increase insulin dose from sub-therapeutic levels competes with the need for glycaemic control and suppression of ketogenesis. Tolerance to intravenous (IV) insulin despite persistent life-threatening allergic reactions to subcutaneous human insulin (bolus or CSII) has been recently described (10) . We present the cases of two unrelated 9-yr-old boys with persistent generalized urticarial reactions to subcutaneous injections of all available insulin types, despite treatment with oral antihistamines. After failed rapid desensitization to insulin delivered by either subcutaneous injection or CSII, the concurrent use of IV insulin allowed desensitization to CSII over 5–6 d.