Has covid-19 delayed the diagnosis and worsened the presentation of type 1 diabetes in children?

OBJECTIVE To evaluate whether the diagnosis of pediatric type 1 diabetes or its acute complications changed during the early phase of the coronavirus disease 2019 (COVID-19) pandemic in Italy. RESEARCH DESIGN AND METHODS This was a cross-sectional, web-based survey of all Italian pediatric diabetes centers to collect diabetes, diabetic ketoacidosis (DKA), and COVID-19 data in patients presenting with new-onset or established type 1 diabetes between 20 February and 14 April in 2019 and 2020. RESULTS Fifty-three of 68 centers (77.9%) responded. There was a 23% reduction in new diabetes cases in 2020 compared with 2019. Among those newly diagnosed patients who presented in a state of DKA, the proportion with severe DKA was 44.3% in 2020 vs. 36.1% in 2019 (P 5 0.03). There were no differences in acute complications. Eight patients with asymptomatic or mild COVID-19 had laboratory-confirmed severe acute respiratory syndrome coronavirus 2. CONCLUSIONS The COVID-19 pandemic might have altered diabetes presentation and DKA severity. Preparing for any “second wave” requires strategies to educate and reassure parents about timely emergency department attendance for non–COVID-19 symptoms

HERITABILITY OF TYPE 1 DIABETES MELLITUS IN A COHORT OF ITALIAN TWINS

We identified a population-based cohort of Italian twin pairs with at least one diagnosed with type 1 diabetes mellitus (T1DM) to estimate concordance in monozygotic (MZ) and dizygotic (DZ) twins, co-twin recurrence risk and disease discordance time, genetic and environmental components of susceptibility variance to T1DM. Twins were identified linking the Italian Twin Registry with 13,354 T1DM patients records, provided by diabetologists of 35 centers from all over Italy (Sardinia excluded). Out of the 148 pairs/triplets identified, 77 pairs and 1 unlike sex triplet have been enrolled so far. DNA has been collected from saliva of 61 pairs. Zygosity in same sex pairs was assigned by genotyping nine microsatellites or by standardized questionnaire on physical resemblance when DNA was not available: 29 are MZ (17 males) and 48 are DZ (12 and 18 same sex males and females, respectively, and 18 unlike sex). Mean age at diagnosis was 8 yrs (1.1–2.5) in first affected twins and 1.7 yrs (1.4– 19.9) in concordant co-twins. Proband-wise concordances were significantly different (p = .007) between MZ (43.2% [95% CI 23.3– 63.2]) and DZ pairs (11.3% [0–23]). Five years after the diagnosis in the index twins’ cumulative incidences were 35% in MZ co-twins and 6% in DZ co-twins. In concordant pairs, MZ co-twins developed T1DM within 34 days — 5.2 years (median 1.1 yrs) and DZ cotwins within 0 days — 7 yrs (median 4.7 yrs) from diagnoses of the index twins. In discordant pairs, median follow-up times are 4.45 yrs (range: .4–19.0) for MZ and 6.8 yrs (.2–31.8) for DZ unaffected cotwins. Under an ACE model, heritability (A) was estimated at .633 (.159–.893), while contributions of familial (C) and individual-specific (E) environmental effects were .154 (0–.546) and .213 (.107–.366), respectively. This study confirms the substantial contribution of genetics in T1DM susceptibility, with a significant role of individual specific factors. These results are in line with those observed in Finnish and Danish populations. Final results on a larger sample will be shown at the congress

Diabetes and Prediabetes in Children With Cystic Fibrosis: A Systematic Review of the Literature and Recommendations of the Italian Society for Pediatric Endocrinology and Diabetes (ISPED)

Cystic fibrosis related diabetes (CFRD) is a comorbidity of cystic fibrosis (CF) that negatively impacts on its clinical course. Prediabetes is an important predictor of either CFRD development and unfavorable prognosis of CF in both pediatric and adult patients. International guidelines recommend insulin only in case of CFRD diagnosis. Whether early detection and treatment of prediabetes may contribute to improve the clinical course of CF is still debated. A subgroup of pediatric diabetologists of the Italian Society for Pediatric Endocrinology and Diabetology (ISPED) performed a systematic review of the literature based on predefined outcomes: impact of pre-diabetes on clinical outcomes and on the risk of developing CFRD; diagnosis of diabetes and pre-diabetes under 10 years of age; effectiveness of therapy on glycemic control, impact of therapy on pulmonary function and nutritional status. Thirty-one papers were selected for the analysis data presented in these papers were reported in tables sorted by outcomes, including comprehensive evidence grading according to the GRADE approach. Following the grading of the quality of the evidence, the entire ISPED diabetes study group achieved consensus for the Italian recommendations based on both evidence and clinical experience. We concluded that in patients with CF, prediabetes should be carefully considered as it can evolve into CFRD. In patients with CF and prediabetic conditions, after complete evaluation of the OGTT trend, glucometrics, glycemic values measured during pulmonary exacerbations and/or steroid therapy, early initiation of insulin therapy could have beneficial effects on clinical outcomes of patients with CF and prediabetes

A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes

We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0–18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n=2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n=1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05–0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers