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Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only [...]

Aims To evaluate the association between neighbourhood-level inequity and glycaemic control in paediatric participants with Type 1 diabetes using the Neighbourhood Equity Index ( NEI). Methods The NEI was linked to the clinical data of 519 children with diabetes followed at the Hospital for Sick Children (Toronto, Canada). The NEI is a composite measure of inequity developed using the World Health Organization's Urban Health Equity Assessment and Response Tool ( HEART), which encompasses 15 weighted indicators evaluating economic, social, environmental and lifestyle factors. The geographic distribution of participants was determined using postal codes, and the relationship between HbA1c and NEI was evaluated using regression and spatial analysis techniques. Results Participants' mean HbA1c was significantly correlated with NEI ( R = −0.24, P < 0.0001). Regression analysis demonstrated that NEI was a strong predictor of mean HbA1c ( P < 0.0001), accounting for differences in HbA1c as large as 1.0% (11 mmol/mol) when controlled for age, sex, diabetes duration, insulin pump therapy and number of annual clinic visits. Geo-mapping using spatial scan testing revealed the presence of two clusters of low-equity neighbourhoods containing 3.22 ( P = 0.001) and 2.83 ( P = 0.02) times more participants with HbA1c ≥ 9.5% (80 mmol/mol) than expected. Conclusions Our findings demonstrated that NEI was a significant predictor of HbA1c in our clinic population and a useful tool for investigating spatial trends related to inequities in health, providing evidence that a composite, area-based measure of overall inequity is well suited to the study of glycaemic control in urban paediatric Type 1 diabetes populations. [ABSTRACT FROM AUTHOR]

The emergence of Type 2 diabetes (T2D) in children and adolescents parallels the rising rates of childhood obesity. As a condition of impaired insulin sensitivity and relative insulin deficiency resulting in hyperglycemia, T2D has a complex underlying physiology that is reflected by the multiple approaches used to optimize medical care and prevent the myriad of diabetes-related complications. T2D diagnosed in children and adolescents represents a distinct and challenging condition to evaluate and treat. Here, we highlight the epidemiology, pathophysiology, risk factors, clinical presentation and diagnosis, treatment and public health impact of T2D in children and adolescents. [ABSTRACT FROM AUTHOR]

Objective. To assess the impact of exercise consultation on physical activity (PA) levels, anthropometric measures, and metabolic markers in obese adolescents. Methods. Obese adolescents (14-18 years) were randomized to either an exercise consultation (intervention group) or to review "Canada's Physical Activity Guide for Youth" (control group).Outcomes, including accelerometry, anthropometrics, blood pressure, stage of exercise behavior change, fasting glucose, insulin, and lipids, were measured at baseline and 3 months later. Results. Thirty adolescents (mean BMI = 36.1kg/m2; SD = 6.9) completed the study. At follow-up, the intervention group had significantly greater PA compared with controls (P < .05). Similarly, the intervention group weighed an average 2.6 kg less than the control group (P < .05), with a mean BMI z-score of 2.15 compared to 2.21 for controls (P = .054). No other differences were noted. Conclusion. Exercise consultation may be a simple approach to increase PA levels, reduce weight, and lower BMI in obese adolescents. [ABSTRACT FROM AUTHOR]

As one considers the near future of diabetes in children, some very sobering thoughts are in order. First, with respect to the magnitude of the problem, the worst is yet to come! The emergence of new economic giants such as China and India will bring with it potential massive increases in type 1 diabetes (2-5% per annum increases in incidence in the world's most populous countries) and childhood obesity (with its associated insulin resistance and type 2 diabetes). This will demand the training of enormous numbers of health care professionals and delivery of insulin and testing equipment that is of high quality and reasonable cost. Second, the majority of children with diabetes presently do not and, likely in the foreseeable future, will not achieve and maintain levels of metabolic control that provide protection from microvascular and macrovascular complications. In fact, an analysis by the Centers for Disease Control in the USA suggested that a child of 10 yr of age developing diabetes in the year 2000 would live a further approximately 50-55 yr, losing about 18-20 yr of life, this in the world's richest nation!Finally, Edwin Gale in 2005 issued the following warning: 'The individual and communal legacy of poor glucose control will remain with us for the next 30 years, EVEN if an effective means of preventing new cases of the disease were to be introduced tomorrow'.There is much work to be done and little room for complacency. Only when every single child with diabetes has ready access to experienced health care professionals, insulin, and other supplies, food water and protection will the first part of the job be done. [ABSTRACT FROM AUTHOR]

We report in this study the death in bed of a 14-yr-old girl with type 1 diabetes and a review of the existing literature on this topic. Diagnosed at 5 yr of age, the patient followed a relatively benign disease course. Hemoglobin A1c was 6.6-8.4%, and there were no hospital admissions apart from the one at diagnosis. Hypoglycemic episodes were not excessive or severe. At age 14 yr, the patient was found dead in bed after having been well the night before. No apparent explanation could be provided. The 'dead-in-bed' syndrome accounts for 5-6% of mortality cases in patients with type 1 diabetes, amounting to two to six cases per 10 000 patient years. Theories attempting to explain the mechanism for this syndrome include hypoglycemia or cardiac autonomic dysfunction. This case emphasizes several problems faced by clinicians: the risk for sudden death in youth with diabetes, which may compromise good glycemic control, the question of early detection of autonomic dysfunction, and the need to understand this phenomenon better and search for preventive measures. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to identify predictors of the onset of disturbed eating behavior (DEB) in adolescent girls with type 1 diabetes.Research Design and Methods: In this prospective study, participants completed the Children's Eating Disorder Examination interview and self-report measures at baseline and at four follow-up assessments over 5 years. Participants were 126 girls with type 1 diabetes, aged 9-13 years at baseline. Of the 101 girls who did not have DEB at baseline, 45 developed DEB during the follow-up period; the 38 for whom data were available for the assessment before onset of DEB were compared with 38 age-matched girls who did not develop DEB. DEB was defined as dieting for weight control, binge eating, self-induced vomiting, or the use of diuretics, laxatives, insulin omission, or intense exercise for weight control.Results: Logistic regression indicated that a model including BMI percentile, weight and shape concern, global and physical appearance-based self-worth, and depression was significantly associated with DEB onset (chi(2) = 46.0, 5 d.f., P < 0.0001) and accounted for 48.2% of the variance.Conclusions: Even though scores on the measures were within the published normal range, the onset of DEB was predicted by higher depression and weight and shape concerns and lower global and physical appearance-based self-worth as well as higher BMI percentile 1-2 years earlier compared with those not developing DEB. Early interventions focused on helping girls with diabetes develop positive feelings about themselves, their weight and shape, and their physical appearance may have protective value. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To reevaluate the persistence and stability of previously observed differences between pediatric diabetes centers and to investigate the influence of demography, language communication problems, and changes in insulin regimens on metabolic outcome, hypoglycemia, and ketoacidosis. RESEARCH DESIGN AND METHODS: This was an observational cross-sectional international study in 21 centers, with clinical data obtained from all participants and A1C levels assayed in one central laboratory. All individuals with diabetes aged 11-18 years (49.4% female), with duration of diabetes of at least 1 year, were invited to participate. Fourteen of the centers participated in previous Hvidoere Studies, allowing direct comparison of glycemic control across centers between 1998 and 2005. RESULTS: Mean A1C was 8.2 +/- 1.4%, with substantial variation between centers (mean A1C range 7.4-9.2%; P < 0.001). There were no significant differences between centers in rates of severe hypoglycemia or diabetic ketoacidosis. Language difficulties had a significant negative impact on metabolic outcome (A1C 8.5 +/- 2.0% vs. 8.2 +/- 1.4% for those with language difficulties vs. those without, respectively; P < 0.05). After adjustement for significant confounders of age, sex, duration of diabetes, insulin regimen, insulin dose, BMI, and language difficulties, the center differences persisted, and the effect size for center was not reduced. Relative center ranking since 1998 has remained stable, with no significant change in A1C. CONCLUSIONS: Despite many changes in diabetes management, major differences in metabolic outcome between 21 international pediatric diabetes centers persist. Different application between centers in the implementation of insulin treatment appears to be of more importance and needs further exploration. [ABSTRACT FROM AUTHOR]

AIMS: To evaluate the glucose control [(as measured by hemoglobin A1c (HbA1c)], the factors associated with glycemic control, and possible explanations for these associations in a sample of children and adolescents with type 1 diabetes. METHODS: Data were collected on 155 children and adolescents, with type 1 diabetes mellitus, attending a multidisciplinary diabetes clinic in Portland, OR. Patients' hospital charts were reviewed to determine demographic factors, disease-related characteristics, and HbA1c level. RESULTS: Mean percent HbA1c was 9.3. Adolescents between the ages of 14 and 18 yr were in poorer metabolic control (adjusted mean percent HbA1c 0.56 higher than children 2-8 yr). Children who attended the clinic three to four times in the previous year were in better control (adjusted mean percent HbA1c 0.46 lower than those who visited two or fewer times and 1.11 lower than those who attended five or more times). Children with married parents were in better glycemic control than those of single, separated, or divorced parents (adjusted mean percent HbA1c 0.47 lower for children of married parents). This effect appeared to be mediated, in part, by the number of glucose checks performed per day. CONCLUSIONS: This study suggests that adolescents should be targeted for improved metabolic control. Diabetes team members need to be aware of changing family situations and provide extra support during stressful times. Regular clinic attendance is an important component of intensive diabetes management. Strategies must be developed to improve accessibility to the clinic and to identify patients who frequently miss appointments. [ABSTRACT FROM AUTHOR]

Improved metabolic control has unequivocally been demonstrated to delay the onset and slow the progression of microvascular complications in adolescents and adults with diabetes mellitus. Growing evidence also supports the association of tighter glucose control and more frequent blood glucose monitoring. Therefore, self-monitoring of blood glucose (SMBG) has become a fundamental part of diabetes care in children. Here, we review recent advances and ongoing trends in glucose monitoring in children with diabetes. Technologies have been developed to improve patient compliance with recommended monitoring, requiring less blood, involving less pain, and providing results more quickly. Alternate-site testing (AST) is also a potential means of improving patient compliance with SMBG by avoiding the sensitive fingertip area. The Continuous Glucose Monitoring System (CGMS) and the GlucoWatch Biographer are two recent tools that can track glucose levels continuously. However, inconsistency in their accuracy and precision remain challenges when using these technologies to guide management. [ABSTRACT FROM AUTHOR]

Objective: To compare the prevalence of eating disturbances in preteen and early teenage girls with type 1 diabetes to their nondiabetic peers.Research Design and Methods: A cross-sectional, case-controlled study of 101 girls with type 1 diabetes, ages 9-14 years, and 303 age-matched, female nondiabetic control subjects was conducted. Participants completed a Children's Eating Disorder Examination interview. Socioeconomic status, BMI, and diabetes-related variables were assessed. Groups were compared using chi(2) analyses.Results: Binge eating; the use of intense, excessive exercise for weight control; the combination of two disturbed eating-related behaviors; and subthreshold eating disorders were all more common in girls with type 1 diabetes. Metabolic control was not related to eating behavior in this study population.Conclusions: Eating disturbances, though mostly mild, were significantly more common in preteen and early teenage girls with type 1 diabetes. Screening and prevention programs for this high-risk group should begin in the preteen years. [ABSTRACT FROM AUTHOR]

Objective: This study investigated whether intimacy and autonomy in mother-daughter interactions and relational aspects of the self are associated with metabolic control in adolescent girls with type 1 diabetes.Research Design and Methods: This cross-sectional study included 88 girls with diabetes (mean age 14.9 +/- 2.2 years, diabetes duration 7.1 +/- 3.9 years, and HbA1c 8.9 +/- 1.6%) from the Diabetes Clinic at the Hospital for Sick Children in Toronto and their mothers. Teens completed a self-report measure assessing self-concept in eight domain-specific areas. Mothers and daughters engaged in a 7-min, videotaped, problem-solving task involving a diabetes-related conflict issue. Interactions were rated using a macroanalytic rating system to assess intimacy and autonomy in parent-teen relationships. Metabolic control was measured using HbA1c.Results: Self-concept in domains of perceived behavioral conduct (P=0.003), social acceptance (P=0.03), romantic appeal (P=0.03), and close friendships (P=0.04) independently predicted HbA1c levels, together accounting for 30% of the variance. Also, the experience of emotional closeness (i.e., intimacy) rather than separateness (i.e., autonomy) in mother-daughter relationships was associated with lower HbA1c (P=0.03).Conclusions: Relational aspects of the self and the experience of emotional closeness in relationships are associated with metabolic control in adolescent girls. Efforts to improve metabolic control in girls should include enhancing the self-concept and the experience of relatedness in familial, peer, and patient-caregiver relationships. [ABSTRACT FROM AUTHOR]

Because thyroid hormone is essential for normal brain development, children born with congenital hypothyroidism who lack thyroid hormone during a circumscribed period of early development are at risk of brain damage and mental retardation. Since the advent of newborn screening programs in the 1980s, the diagnosis and treatment of this condition are now provided in the first 2-3 weeks of birth in most regions. While this is usually sufficient to prevent mental retardation, the children so identified attain mildly reduced IQs from expectation, and may still experience subtle and specific neurocognitive deficits. Their particular deficits are related to the brief period of thyroid hormone insufficiency they undergo, especially factors reflecting the severity of hypothyroidism at the time of diagnosis, the duration of hypothyroidism in infancy, and thyroid hormones at time of testing. In this article, we review the specific kinds of deficits demonstrated by children with congenital hypothyroidism who were diagnosed by screening and treated early, as well as the factors associated with their disease and its management that contribute to these deficits. The disease-related factors that will be reviewed will include the etiology of hypothyroidism and severity of disease at the time of diagnosis, while the treatment-related factors will include age at onset of therapy, starting and subsequent dose levels, compliance, and treatment-adequacy issues. Also examined will be the effects of hormone levels at the time of testing. In addition, the role of moderating variables such as social, genetic, and environmental influences, as well as the child's gender, will be discussed. Furthermore, several new issues including the quality of subsequent management, ultimate outcome, and pregnancy will be additionally reviewed. In conclusion, while outcome in congenital hypothyroidism is substantially improved by screening, affected children do still experience mild neuropsychologic deficits. To reduce the impact of persisting deficits, further research is needed to determine the optimal starting dose for the different etiologies, guidelines for subsequent management, and alternative therapies. Moreover, now that the original samples are reaching adulthood and, in females, childbearing age, further research is also needed regarding treatment during pregnancy in women with congenital hypothyroidism, as is research to determine how this population ultimately fares in adulthood. [ABSTRACT FROM AUTHOR]

To determine the effects of hypothyroidism and hormonal patterns on outcome, we tested 65 7- to 12-year-old children with congenital hypothyroidism using standardized tests of intelligence, neuropsychological functioning, memory, and achievement. Results were analyzed by etiology, time to thyrotropin normalization, and hormone levels at testing. Children with athyreosis scored below other etiologies on visuospatial, attention, and arithmetic indices. Children whose thyroid-stimulating hormone levels normalized by 1 to 2 months of age scored higher than later normalizers on indices of visual memory, attention, and arithmetic. Normalization of thyroid-stimulating hormone by 3 months of age was associated with better memory and learning abilities than later normalization. Thyroid hormone levels at testing were correlated with indices of sensorimotor, spatial, and language abilities. Two children with persistently elevated thyrotropin levels were not adversely affected. Present findings signify the need to establish etiology, normalize thyrotropin early, and maintain hormone levels in the normal range throughout childhood in children with congenital hypothyroidism. [ABSTRACT FROM AUTHOR]

SUMMARY Aims To examine the relationship between dietary protein intake and possible early markers of diabetic nephropathy (creatinine clearance (CrCl), kidney volume and albumin excretion rate (AER)). Methods One hundred and forty-five subjects with diabetes for 5–10 years, divided into three pubertal groups, participated. Kidney volume was measured by ultrasound, and serum creatinine and HbA1c were assayed. Two or three 24-h urine collections were obtained for albumin, creatinine and urea excretion rates. Dietary protein intake was estimated from urinary urea nitrogen excretion rate. Glomerular filtration rate was estimated by creatinine clearance. Results Mean protein intake was 1.22 ± 0.48 g.kg-1.day-1 Protein intake was significantly higher in males than females (P < 0.0001) and highest in pre-pubertal compared to mid-pubertal and post-pubertal subjects (P < 0.001). In multiple regression analysis, protein intake was positively associated with CrCl (P < 0.0001), and male sex (P < 0.0001) and negatively associated with body surface area (P = 0.0013) and age (P = 0.01). Kidney volume and AER were not related to dietary protein intake. Conclusions This cross-sectional study failed to show a significant relationship between dietary protein intake and markers of early nephropathy, other than CrCl. However, a longitudinal, prospective study is required to definitively assess the role of protein intake in the evolution of diabetic nephropathy. [ABSTRACT FROM AUTHOR]

Recent years have seen an increase in awareness of the need to improve the quality of diabetes care for children and adolescents, as detailed in the Declaration of Kos, for example. This paper addresses some quality-of-care principles and evaluates specific examples of current management. The meaning of the terms quality of care, evidence-based medicine and cost-containment are examined, and the features central to the development and evaluation of quality health care (structure, process and outcome) are explored. The practical aspects of diabetes care are reviewed in terms of the causes and prevention of early mortality, ambulatory vs inpatient care, the value of measuring HbA[sub 1c], other metabolic control criteria (including the effect of patient selection, cultural, socioeconomic and biological differences) and clinical practice guidelines. It is concluded that a multidisciplinary team provides the optimum context for diabetes management and that care must be family centred and multidimensional (i.e. not focusing on HbA[sub 1c] levels alone). The task of improving diabetes care is massive and operates at all levels (individual, family, health-care providers, national and international bodies), but offers significant improvements in quality and cost-effectiveness. [ABSTRACT FROM AUTHOR]