Fran R. Cogen

Diagnosis and treatment of neonatal diabetes: an United States experience

Background/objective:  Mutations in KCNJ11, ABCC8, or INS are the cause of permanent neonatal diabetes mellitus in about 50% of patients diagnosed with diabetes before 6 months of age and in a small fraction of those diagnosed between 6 and 12 months. The aim of this study was to identify the genetic cause of diabetes in 77 consecutive patients referred to the University of Chicago with diabetes diagnosed before 1 yr of age.

Satisfaction and Quality of Life in Children with Type 1 Diabetes and Their Parents Following Transition to Insulin Pump Therapy

The purpose of this study was to describe satisfaction with the transition to insulin pump therapy and subsequent quality of life among 22 children with type 1 diabetes and their parents. Following the transition to pump therapy, children and parents completed a newly developed measure of insulin pump therapy satisfaction (Insulin Pump Therapy Satisfaction Questionnaire [IPTSQ]), and children completed a standardized measure of diabetes-related quality of life. IPTSQ results suggest that children and parents were overwhelmingly satisfied with insulin pump use. Parents and children reported greatest satisfaction with flexibility related to eating and sleeping afforded by pump therapy. Parent-child satisfaction were highly correlated (r = .53), and childrens pump satisfaction was significantly positively correlated with diabetes-related quality of life (r = .51). These pilot data are among the first to document specific areas of satisfaction and indicate an association between insulin pump therapy satisfaction and quality of life. Understanding specific aspects of insulin pump therapy that are related to quality of life is important for improving health outcomes among youngsters with type 1 diabetes using insulin pumps.

Characteristics of Children with Type 1 Diabetes and Persistent Suboptimal Glycemic Control

Objective: This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement. Methods: A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children’s National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39). Results: Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in >25% of patients. Conclusion This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention. Conflict of interest:None declared.

Authoritative parenting, parenting stress, and self-care in pre-adolescents with type 1 diabetes.

Parent involvement in type 1 diabetes (T1DM) care leads to improved adherence; however, the manner in which parents approach illness management interactions with children must also be considered. It was hypothesized that greater use of an authoritative parenting style and less parenting stress would be associated with greater behavioral adherence and better metabolic control. Ninety-five primary caregivers of preadolescents (ages 8–11) with T1DM completed questionnaires assessing parenting style, pediatric parenting stress, and child behavioral adherence. Caregivers primarily self-identified as using an authoritative parenting style. Greater authoritative parenting was associated with greater behavioral adherence and less difficulty with pediatric parenting stress; no differences in metabolic control were observed. Greater engagement in authoritative parenting behaviors may contribute to increased age-appropriate child behavioral adherence and less pediatric parenting stress. Interventions highlighting diabetes-specific authoritative parenting techniques may enhance health outcomes and improve overall family functioning.

Sleep Behaviors and Parent Functioning in Young Children With Type 1 Diabetes

This study evaluates sleep characteristics among young children with type 1 diabetes and associations with parent sleep and emotional functioning and diabetes care. Study participants included 24 parents of young children with type 1 diabetes (ages 2–5) enrolled in a pilot study of a randomized-controlled trial. Child sleep characteristics were within normal limits. However, increased child bedtime resistance and behavioral insomnia were related to greater parent stress, anxiety, and depression and use of an intensive insulin regimen. Type 1 diabetes management may impact child and parent sleep as well as parent emotional functioning. Implications for practice are presented.

Predictors of Diabetes-related Quality of Life after Transitioning to the Insulin Pump

OBJECTIVE To examine family and individual psychosocial, medical, and demographic factors associated with improved diabetes-related quality of life (QOL) after transitioning to the insulin pump among youth with type 1 diabetes. METHOD Fifty-three parent-child dyads completed questionnaires on four occasions prior to and following this medical regimen change, assessing QOL, family environment, depressive and anxiety symptoms, and medical and demographic information. Trajectories of change in QOL were analyzed using multilevel modeling. RESULT Psychosocial, medical, and demographic characteristics were associated with QOL prior to pump-start. Elements of childrens QOL significantly improved after the transition, and improvement was predicted by psychosocial, medical, and demographic characteristics. CONCLUSION Results indicate that individual and contextual factors may play a role in QOL as children transition to the insulin pump. Findings may guide efforts to support families through this challenging time and potentially inform candidacy for transition to the pump.

Using Qualitative Methods to Guide Clinical Trial Design: Parent Recommendations for Intervention Modification in Type 1 Diabetes

Parents of young children with Type 1 diabetes assume significant responsibility for a complex daily illness regimen, yet little research has evaluated supportive interventions for this population. This study presents mixed-methods program evaluation data from participants who completed a five-session intervention designed to promote parent mastery of diabetes-related tasks and increase social and emotional support. Twelve parents (75% female) of young children with Type 1 diabetes completed a satisfaction survey following intervention completion. Additionally, four parents were selected for completion of an in-depth interview designed to elicit specific recommendations for program improvement. Results suggested high levels of satisfaction with the intervention program. Thematic coding of interview data revealed two clear directions for future research, including offering the intervention program closer to the time of diagnosis and enhancing educational and supportive offerings for parents and other caregivers. Incorporation of in-depth interviews and subsequent qualitative data analyses in addition to a quantitative satisfaction survey provided richly detailed data related to program evaluation and improvement. Results highlighted critical components for intervention refinement and provided a unique window into the experiences of parents of young children with Type 1 diabetes and the need for additional support in the months following diagnosis, both for themselves and other caregivers.

Screening and Identification of Children and Adolescents at Risk for Depression During a Diabetes Clinic Visit

In Brief Among patients with type 1 or type 2 diabetes, depression is one of the most commonly occurring comorbid conditions. A dual diagnosis of depression and diabetes has been linked to poor adherence and decreased daily diabetes self-care and often leads to suboptimal metabolic control and increased diabetes-related complications. Pediatric diabetes clinicians are in a unique position to identify behavior changes over time and provide early identification and preventive intervention for children and adolescents at risk for depression. This article provides an overview of the differential diagnosis process that pediatric clinicians face and practical advice for providers when evaluating and addressing depressive symptoms during routine diabetes clinic visits.

A Learner-Centered Diabetes Management Curriculum Reducing resident errors on an inpatient diabetes pathway

OBJECTIVE Diabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children’s hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors. RESEARCH DESIGN AND METHODS The 8-week curricular intervention consisted of 1) an online tutorial addressing residents’ baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay. RESULTS Before the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%. CONCLUSIONS An interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children’s hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines.

Health attitudes, beliefs, and risk behaviors among adolescents and young adults with type 1 diabetes

Decision making about engaging in health-promoting and health-compromising behaviors among adolescents and young adults with type 1 diabetes is an important but understudied topic. The purpose of this study was to describe the health attitudes, beliefs, risk behaviors, and general psychological functioning of adolescents and young adults with diabetes and to compare these psychosocial aspects of health to those of adolescents and young adults without diabetes. Fifty-three adolescents and young adults with type 1 diabetes and 53 demographically matched controls were recruited from 2 pediatric teaching hospitals and administered a confidential self-report questionnaire consisting of individual survey items and standardized scales. Compared to healthy adolescents and young adults, adolescents and young adults with diabetes had more frequent thoughts about health and sickness, rated their health as poorer, viewed smoking as less addictive, reported greater symptoms of depression, and reported greater exposure to smoking in their households, but less smoking experimentation. Poorer metabolic control was associated with decreased physical activity. Additional research on the design and implementation of diabetes-specific cardiovascular disorder and tobacco control programs for adolescents and young adults is warranted.