Growth Trajectory in Children with Type 1 Diabetes Mellitus: The Impact of Insulin Treatment and Metabolic Control

Background: Linear growth was reported to be negatively affected by type 1 diabetes mellitus (T1DM), in relation to disease duration and poor metabolic control. It is unclear whether a subtle growth failure still persists despite the optimization of therapy. Our aim was to analyse pubertal growth, adult height, and metabolic profile in a cohort of children with T1DM undergoing intensive insulin treatment by multiple daily injections or continuous subcutaneous insulin infusion (CSII). Methods: One-hundred and four children (51 males) with prepubertal onset of T1DM were prospectively followed up to final height attainment. Results: Age at puberty onset was 11.7 ± 1.1 years in males and 10.9 ± 1.3 in females. Age at adult height attainment was 16.4 ± 1.6 years in males and 14.1 ± 1.8 years in females. Pubertal height gain was 24.4 ± 4.9 cm in males and 19.0 ± 3.8 cm in females. HbA1c, HDL cholesterol, and triglyceride levels increased during puberty. HDL cholesterol levels were higher in patients treated with CSII. Height standard deviation score (SDS) at diagnosis (0.52 ± 1.04) was higher than target height SDS (0.01 ± 1.07), but declined afterwards, and both height SDS at puberty onset (0.22 ± 1.1) and adult height SDS (-0.1 ± 1.02) were not significantly different from target height SDS. BMI SDS showed a positive trend from diagnosis to puberty onset and stabilized later (-0.04 ± 1.4 at T1DM onset, 0.55 ± 2.1 at puberty onset, and 0.53 ± 2.1 at adult height attainment). Conclusions: Although subtle abnormalities of growth still persist, the modern advancements of insulin therapy are able to normalize puberty and final height of children with T1DM

Diabetic ketoacidosis (DKA) in children with type 1 diabetes mellitus (T1DM): an Italian multicentre survey

Background and aims: Italian children with T1DM are usually followed by pediatric diabetologists. Since recent data on epidemiology and management of primary diabetic ketoacidosis in children with T1DM are lacking a questionnaire was sent to the 77 centres belonging to the study group of diabetology of the Italian Society for Pediatric Diabetology and Endocrinology (ISPED) enquiring on epidemiology (2012-2013) and present management of DKA. Materials and methods: From 1/1/2012 to 31/12/2013 a survey on DKA was conducted in all pediatric Centres belonging to the ISPED. Presence DKA was defined according to the IDF/ISPAD criteria. The following data were collected: treatment according IDF/ISPAD protocol yes or not, type of rehydrating solution used, bicarbonates use yes or not and amount of insulin infused. Results: Data were returned from 68/77 Centres (87%) for a total of 14.493 patients with T1D. We recorded 2453 children with T1DM onset, with DKA in 945 (38.5%) (severe in 10.3%). Considering only preschool children DKA was observed in 72% (severe in 16.6%). Cerebral oedema following DKA treatment was observed in 5 cases (0.5%). DKA treatment according ISPAD guidelines was adopted in 67% of the Centres, while 11% did not follow any specific guidelines. In the first 1-2 hours, rehydration was started with normal saline, at different rates: 5-10 ml/kg/h in 71%, 10-20 ml/kg/h in 16%, <5 ml/kg/h in 4%. After the first hours, differences among Centres were observed regarding the type of solutions used: saline 0.9-0.45% in 75%, 5-10% glucose solution in 19%, irrespective of glycemic values. Potassium supplementation was performed at the rate of 20-40 mEq/l in 63% of Centres. Bicarbonates were never used in 17% of Centres, while in 68% were exceptionally used according to pH and clinical conditions. Insulin was infused starting form 2nd-3rd hour at the rate of 0.05-0.1 U/kg/h in 63% of Centres, while others used infusion rate lowest as 0.025 U/kg/h. Conclusion: Notwithstanding prevention campaign, DKA is still observed at clinical diabetes onset in Italian children. Despite international guidelines significant variability in DKA treatment still exists, underlying the need to share them among Centres. In Italy cerebral edema is a rare complication of DKA

Severe hypoglycemia and ketoacidosis over one year in Italian pediatric population with type 1 diabetes mellitus: A multi center retrospective observational study

BACKGROUND AND AIMS:Evaluation of incidence and correlates of severe hypoglycemia (SH) and diabetes ketoacidosis (DKA) in children and adolescents with T1DM. METHODS AND RESULTS:Retrospective study conducted in 29 diabetes centers from November 2011 to April 2012. The incidence of SH and DKA episodes and their correlates were assessed through a questionnaire administered to parents of patients aged 0-18 years. Incidence rates and incident rate ratios (IRRs) were estimated through multivariate Poisson regression analysis and multilevel analysis. Overall, 2025 patients were included (age 12.4 \ub1 3.8 years; 53% males; diabetes duration 5.6 \ub1 3.5 years; HbA1c 7.9 \ub1 1.1%). The incidence of SH and DKA were of 7.7 and 2.4 events/100 py, respectively. The risk of SH was higher in females (IRR = 1.44; 95%CI 1.04-1.99), in patients using rapid acting analogues as compared to regular insulin (IRR = 1.48; 95%CI 0.97-2.26) and lower for patients using long acting analogues as compared to NPH insulin (IRR = 0.40; 95%CI 0.19-0.85). No correlations were found between SH and HbA1c levels. The risk of DKA was higher in patients using rapid acting analogues (IRR = 4.25; 95%CI 1.01-17.86) and increased with insulin units needed (IRR = 7.66; 95%CI 2.83-20.74) and HbA1c levels (IRR = 1.63; 95%CI 1.36-1.95). Mother's age was inversely associated with the risk of both SH (IRR = 0.95; 95%CI 0.92-0.98) and DKA (IRR = 0.94; 95%CI 0.88-0.99). When accounting for center effect, the risk of SH associated with the use of rapid acting insulin analogues was attenuated (IRR = 1.48; 95%CI 0.97-2.26); 33% and 16% of the residual variance in SH and DKA risk was explained by center effect.CONCLUSION:The risk of SH and DKA is mainly associated with treatment modalities and strongly depends on the practice of specialist centers