Lora Kleis

Real-time continuous glucose monitoring among participants in the T1D Exchange clinic registry.

OBJECTIVE To assess the frequency of continuous glucose monitoring (CGM) device use, factors associated with its use, and the relationship of CGM with diabetes outcomes (HbA1c, severe hypoglycemia [SH], and diabetic ketoacidosis [DKA]). RESEARCH DESIGN AND METHODS Survey questions related to CGM device use 1 year after enrollment in the T1D Exchange clinic registry were completed by 17,317 participants. Participants were defined as CGM users if they indicated using real-time CGM during the prior 30 days. RESULTS Nine percent of participants used CGM (6% of children <13 years old, 4% of adolescents 13 to <18 years, 6% of young adults 18 to <26 years, and 21% of adults ≥26 years). CGM use was more likely with higher education, higher household income, private health insurance, longer duration of diabetes, and use of insulin pump (P < 0.01 all factors). CGM use was associated with lower HbA1c in children (8.3% vs. 8.6%, P < 0.001) and adults (7.7% vs. 7.9%, P < 0.001). In adults, more frequent use of CGM (≥6 days/week) was associated with lower mean HbA1c. Only 27% of users downloaded data from their device at least once per month, and ≤15% of users reported downloading their device at least weekly. Among participants who used CGM at baseline, 41% had discontinued within 1 year. CONCLUSIONS CGM use is uncommon but associated with lower HbA1c in some age-groups, especially when used more frequently. Factors associated with discontinuation and infrequent use of retrospective analysis of CGM data should be considered in developing next-generation devices and education on CGM use.

Basal and bolus insulin requirements in children, adolescents, and young adults with type 1 diabetes mellitus on continuous subcutaneous insulin infusion (csii): Effects of age and puberty

OBJECTIVE Guidelines for insulin dosing, including the insulin to carbohydrate ratio (I/C), insulin sensitivity factor (ISF), and basal/bolus ratio guidelines, have been well established for adults with type 1 diabetes mellitus (T1DM). However, clinical experience suggests that these guidelines are not appropriate for children. The purpose of this study was to determine the continuous subcutaneous insulin infusion (CSII) settings in children with T1DM at different ages and stages of puberty. METHODS A total of 154 patients data between the ages of 3 and 21 years with well-controlled T1DM according to American Diabetes Association guidelines were reviewed. Only patients on CSII who were not in the honeymoon period were included. RESULTS Patients were divided into 8 groups according to age, gender, and/or pubertal stage. Insulin requirements increased with puberty in both sexes (0.69, 0.97, and 0.90 U/kg/day in children <7 years of age, midpubertal girls, and late-pubertal boys, respectively). Basal insulin requirement was lowest in the youngest group (34%; P<.01). The youngest group had the lowest I/C prediction factor (PF) (mean, 315.7 ± 79.4; P<.01 with all groups), and the ISF-PF was higher than that of the oldest group (mean, 2,588.3 ± 1,101.8; P<.01). CONCLUSION CSII dose calculations vary with age and pubertal status in children with T1DM. These differences must be considered when calculating CSII dosing, especially for younger children.

Spectrum of clinical presentations and endocrinological findings of patients with septo-optic dysplasia: a retrospective study.

Abstract Background: Septo-optic dysplasia (SOD) is a rare condition with variable clinical pictures and spectrum of findings. Objective: To analyze the spectrum of findings, frequency and age of onset of hypothalamic-pituitary dysfunctions in children with SOD. Method: A retrospective electronic medical record (EMR) chart review was done for patients with SOD seen in a tertiary care center’s pediatric endocrinology clinic between January 1, 2012, and March 31, 2014. The diagnostic criteria for SOD included presence of ≥2 of the following: (i) optic nerve hypoplasia, (ii) agenesis/hypoplasia of septum pellucidum and/or corpus callosum and (iii) hypothalamic-pituitary dysfunction. Results: Eighty patients fitting the diagnostic criteria of SOD were included in this study. The majority of patients (96%) had optic nerve hypoplasia on magnetic resonance imaging and were diagnosed due to visual issues including nystagmus (36%) or strabismus (13.8%). Hypothalamic-pituitary dysfunction was most common (51%) when optic nerve hypoplasia was present with (36%) or without (15%) dysgenesis of septum pellucidum and/or corpus callosum compared to dysgenesis of septum pellucidum and/or corpus callosum alone (4%). Hypothalamic-pituitary dysfunction was noted in 55% of patients, and most (86%) were diagnosed ≤2 years of age. Central hypothyroidism and growth hormone deficiency were most common followed by secondary/tertiary adrenal insufficiency and diabetes insipidus. Conclusions: The risk of hypothalamic-pituitary dysfunction in SOD is highest ≤2 years of age and when both optic nerve hypoplasia and dysgenesis of septum pellucidum/corpus callosum are present, suggesting a need for more frequent follow-up and screening tests for hypothalamic-pituitary dysfunction in these patients.

Comparison of the effect of insulin glulisine to insulin aspart on breakfast postprandial blood glucose levels in children with type 1 diabetes mellitus on multiple daily injections

OBJECTIVE Rapid-acting insulins, including insulin aspart (NovoLog) and lispro (Humalog), do not seem to effectively control postprandial glycemic excursions in children with type 1 diabetes mellitus (T1DM). The objective of this study was to determine if insulin glulisine (Apidra), another rapid-acting insulin analog, would be superior in controlling postprandial hyperglycemia in children with T1DM. METHODS Thirteen prepubertal children ages 4 to 11 years completed this study. Inclusion criteria included T1DM ≥6 months, glycosylated hemoglobin (HbA1C) 6.9 to 10%, blood glucose (BG) levels in adequate control for 1 week prior to study start, multiple daily injections (MDI) with insulin glargine or determir once daily and aspart or lispro premeal. If fasting BG was 70 to 180 mg/dL, subjects received insulin glulisine alternating with aspart prior to a prescribed breakfast with a fixed amount of carbohydrate (45, 60, or 75 g) for 20 days. Postprandial BG values were obtained at 2 and 4 hours. RESULTS Mean baseline BG values for insulin glulisine (136.4 ± 15.7 mg/dL; mean ± SD) and aspart (133.4 ± 14.7 mg/dL) were similar (P = .34). Mean increase in 2-hour postprandial BG was higher in glulisine (+113.5 ± 65.2 mg/dL) than aspart (+98.6 ± 66.9 mg/dL), (P = .01). BG remained higher at 4 hours (glulisine: 141.9 ± 36.5 mg/dL, aspart: 129.0 ± 37.0 mg/dL) (P = .04). Although statistically insignificant, more hypoglycemic events occurred at 2- and 4-hours postprandial with insulin aspart. CONCLUSION Insulin aspart appears to be more effective than insulin glulisine in controlling 2- and 4-hour postprandial BG excursions in prepubertal children with T1DM.

Atypical neurologic presentations of new onset type 1 diabetes mellitus in pediatric age group: a report of five unusual cases and review of the literature.

Abstract Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in childhood and is caused by insulin deficiency resulting from the autoimmune destruction of insulin producing beta cells of the pancreas. Most children in the US with new onset T1DM present with the classic signs and symptoms of hyperglycemia and 30% with diabetic ketoacidosis (DKA). Neurologic manifestations are relatively rare and mostly include lethargy, decreased level of consciousness, and coma as a result of DKA. In this article, five cases of new onset T1DM with exceedingly rare or unreported neurologic manifestations in the pediatric age group are presented, along with a review of the literature.

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation syndrome and celiac disease in a 13-year-old girl: further evidence for autoimmunity?

Abstract Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is a rare and potentially lethal disorder. The etiology is unclear but paraneoplastic syndrome and autoimmunity secondary to neural crest tumors have been considered, even in patients without any detectable tumor due to their tendency for spontaneous remission. We are presenting a 13-year-old girl with ROHHAD syndrome and celiac disease, which may suggest further evidence for immune-mediated etiology in the pathogenesis of ROHHAD syndrome.

Response to comment on Wong et al. Real-time continuous glucose monitoring among participants in the T1D exchange clinic registry. Diabetes Care 2014;37:2702-2709.

We thank Price et al. (1) for their comments on our recent article exploring use of continuous glucose monitoring (CGM) in the T1D Exchange Clinic Network registry (2). We acknowledge, as we did in the original article, that the experience of participants included in our study was based on older generations of CGM devices and agree with Price et al. that newer generations …

Comparison of the expectations of caregivers and children with type 1 diabetes mellitus for independence in diabetes care-related tasks.

OBJECTIVE Children who are given unsupervised responsibility for their diabetes care prior to developmental and/or emotional readiness may have poorer glycemic control. The purpose of this study was to assess the age-related expectations of children and caregivers for independence in diabetes care-related tasks. METHODS A total of 150 participants with type 1 diabetes mellitus (T1DM) receiving multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) were enrolled in this study. All caregivers and participants older than 10 years of age completed questionnaires evaluating the expected age of independence for different diabetes care-related tasks. RESULTS The participants expected independence with no direct supervision in most diabetes care-related tasks at a younger age than their caregivers (P<.05). The difference was more prominent for those on CSII compared to MDI (P<.01). There was a positive correlation between the age when caregivers expect independence for most of the diabetes-related tasks and the age at diagnosis, regardless of the use of MDI or CSII (P<.01). CONCLUSION Children with T1DM expect to assume independence at a younger age than their caregivers do. The younger the children are at diagnosis, the younger they are expected by their caregivers to be independent, especially those on CSII.

Metastatic Insulinoma in a 16-Year-Old Adolescent Male With Men-1: A Case Report and Review of the Literature

ABSTRACT Objective: Multiple endocrine neoplasia type 1 (MEN-1) is an autosomal dominant condition associated with various combinations of endocrine and nonendocrine tumors. Insulinomas are rare endocrine tumors in the pediatric age group and may be associated with MEN-1 in 10% of cases. Malignant insulinomas only constitute 5 to 10% of all the insulinomas and are exceedingly rare in children. There are only 11 cases of malignant insulinoma reported in the literature in the pediatric age group. Methods: We are reporting a 16-year-old adolescent male who presented with symptoms of hypoglycemia for the 4 months prior to referral. Results: He was diagnosed with malignant insulinoma with multiple metastases to liver and was treated with surgical resection followed by octreotide treatment. He had additional findings consistent with the diagnosis of MEN-1, including elevated prolactin levels combined with a 4 to 5 mm pituitary lesion possibly due to prolactinoma and mildly elevated calcium levels with a parathy...

Failure to Thrive: Overview of Diagnosis and Management

Failure to thrive (FTT) is a common and potentially serious growth problem identified in the first three years of life, affecting 5% to 10% of children seen in the primary care setting (Schwartz, 2000). It accounts for 5% to 10% of referrals to (Daniel et al., 2008) and 1% of hospital admissions in tertiary care centers (Berwick et al., 1982). Although FTT is relatively common, there seems to be no consensus regarding its definition (Raynor & Rudolf, 2000). The term is most often used to describe persistently inadequate linear growth and/or weight gain within the first three years of life (Schwartz, 2000). FTT is a sign or finding rather than a diagnosis since it simply represents an abnormal growth pattern in young children. The underlying condition causing FTT might be difficult to determine, requiring a thorough history and physical examination with special attention to dietary and psychosocial factors. It requires close monitoring by the primary physician. Poor growth or poor weight gain in children may be due to a variety of medical or psychosocial problems. Therefore, monitoring growth is an invaluable tool for primary care physicians and should be done vigilantly at every well-child visit. Growth charts are useful in comparing a child to appropriate standards for age, sex and ethnic background. If any abnormality in the growth pattern is detected, necessary measures should be undertaken to ensure appropriate evaluation for and treatment of any underlying condition. Long-term FTT without significant underlying organic etiology has been shown to negatively impact neurodevelopmental outcome (Hufton et al., 1977). Studies have shown that five to eight years after a FTT diagnosis these children show disorders of personality trait, have decreased educational attainment and demonstrate lower IQ’s despite having average anthropometric parameters at the time of evaluation (Hufton, et al., 1977). Therefore, early diagnosis and intervention are believed to be key factors in improving outcome in children with FTT (Casey et al., 1994). In the absence of effective treatment, children with FTT may develop irreversible cognitive and behavioral disorders that seem to correlate with the severity and duration of the FTT. However, other studies have reached the opposite conclusion. In a review and analysis of thirteen studies, there seemed to be no significant difference in the IQ of patients with failure to thrive compared to the general population (Wright et al., 1998). This discrepancy in outcome is probably due to the lack of large, randomized, controlled studies in children with FTT.