Fear of hypoglycemia in parents of children with type 1 diabetes

Humanistic burden of pediatric type 1 diabetes on children and informal caregivers: systematic literature reviews

BACKGROUND

Diagnosis of children with type 1 diabetes (T1D) imposes an unprecedented burden on children and their caregivers.

OBJECTIVE

To assess the burden of T1D on children and their informal caregivers, both after a recent diagnosis or after a longer duration of disease.

METHODS

A series of systematic literature reviews were performed to explore the burden of T1D on children with the disease and their primary informal caregivers, based on the time of diagnosis. After the extraction of the qualitative and quantitative data from the included studies, two literature-based conceptual frameworks were developed: on the burden of pediatric T1D on children, and on informal caregivers. A third conceptual framework on the shared burden of pediatric T1D on both children and informal caregivers as part of the same family unit was also developed.

RESULTS

The review of literature has identified a series of factors that affect the quality of life of children with T1D and their informal caregivers, with a direct impact on physical, emotional, and social outcomes. Generally, female patients and older adolescents experience more worry and stress that affects their quality of life. Other categories of factors affecting the child's and caregiver's burden include social, emotional, and physical factors, treatment-related and disease-related factors, as well as their coping abilities. Anxiety, depression, stress, and worry were commonly found among children and caregivers, starting with the diagnosis of T1D and continuing over time in relation to new challenges pertaining to aging or the disease duration.

CONCLUSION

T1D causes a significant burden to affected children and their caregivers, both independently and through transactional interaction within the family unit. Disease burden can be reduced by strengthening individuals for the benefit of the whole family.

Glucagon fill rates and cost among children and adolescents with type 1 diabetes in the United States, 2011-2021

AIMS

To characterize glucagon fill rates and costs among youth with type 1 diabetes mellitus (T1DM).

METHODS

Claims-based analysis of commercially-insured youth with T1DM included in OptumLabs® Data Warehouse between 2011 and 2021. Glucagon fill rates and costs were calculated overall and by formulation (injectable, intranasal, autoinjector, and pre-filled syringe). Sociodemographic and clinical factors associated with glucagon fills were examined using Cox regression.

RESULTS

We identified 13,267 children with T1DM (76.4% non-Hispanic White). Over mean follow-up of 2.81 years (SD 2.62), 70.0% filled glucagon, with stable fill rates from 2011 to 2021. Intranasal glucagon had rapid uptake following initial approval, and it accounted for almost half (46.6%) of all glucagon fills by 2021. Family income was positively associated with glucagon fills in a stepwise fashion (HR 1.39 [95% CI 1.27-1.52] for annual household income ≥$200,000 vs. <$40,000), while Black race was negatively associated with fills (HR 0.83 [95% CI 0.76-0.91]) compared to White race). Annual mean out-of-pocket costs ranged from $21-$68 (IQR $29-$44).

CONCLUSION

Roughly 30% of commercially-insured youth with T1DM may lack access to unexpired glucagon, with significant disparities among Black and low-income patients. Health systems, clinicians, schools, and caregivers should work together to ensure children have reliable access to this critical medication.

The impact of fear of hypoglycaemia on sleep in adolescents with type 1 diabetes

AIMS

Fear of hypoglycaemia (FOH) can contribute to impaired sleep for adults with type 1 diabetes (T1D) and parents of children with T1D, although it is unknown how FOH may affect sleep for adolescents with T1D. This study examines the relationship between adolescent FOH and sleep and assessed the influences of continuous glucose monitor (CGM) and insulin pump use.

METHODS

Adolescents ages 14-18 years with T1D completed questionnaires evaluating FOH (Child Hypoglycemia Fear Survey) and sleep (Pittsburgh Sleep Quality Index, PSQI). Analyses included linear and logistic regression, t-tests and Fisher's exact tests.

RESULTS

Participants included 95 adolescents (52 female) with a median (IQR) age of 16.5 (15.3-17.7) years and a T1D duration of 5.7 (2.5-9.6) years. Analyses showed increased FOH-Worry subscale scores were associated with reduced sleep duration (β = -0.03, p = 0.042, adjusting for BMI z-score, race and ethnicity) and increased sleep disturbances (OR = 1.1, p = 0.038, adjusting for race and ethnicity). Frequent CGM users had longer sleep duration (average 7.5 h) compared with infrequent or non-CGM users (average = 6.8 h; p = 0.029), and pump users had overall improved sleep health as determined by PSQI score (p = 0.019). Technology use did not have significant interactions in the relationships between FOH and sleep duration or sleep disturbances.

CONCLUSIONS

Worrying about hypoglycaemia was associated with impaired sleep for adolescents with T1D. Diabetes technology users have some sleep improvements, but CGM and pump use do little to alter the relationship between FOH and sleep outcomes.

Parental Resilience and Physical Health in Parents of Children With Type 1 Diabetes in Northern Greece

BACKGROUND

Type 1 diabetes mellitus (T1DM) is the most common endocrine and metabolic disorder in children. On the other hand, little is known regarding the health of parents whose children suffer from T1DM.

AIM

The study aims to investigate the mental resilience and physical health of parents of children with type 1 diabetes.

METHODS

The sample consisted of 80 parents of children and adolescents with T1DM.The study was conducted with the contribution of associations of parents of children with type 1 diabetes in a large hospital in Northern Greece between April 2021 and September 2021. A demographic and clinical questionnaire, the Wagnild and Young Resilience Scale-14 (RS-14), and the General Health 28 Physical Health Measurement Questionnaire (GHQ-28) were used to collect the research data.

RESULTS

Of the parents, 18.8% were male while 65% were female. The mean age of the parents was 44.02±6.71 years while the age of their children with diabetes was 13.13±6.05 years. Almost half of the children followed intensive insulin treatment (47.5%) whereas 22,5% reported that their children received insulin via a pump. A higher percentage of parents reported measuring their children's blood sugar more than six times a day (46,3%) and having their glycated hemoglobin (HbA1c) levels checked four times a year (51.2%). Finally, statistically significant effects on the physical symptoms and severe depression of parents of children with type 1 diabetes were observed.

CONCLUSIONS

Additional research is needed to assess the Greek parent population's resilience and physical health. This study will help healthcare providers to expand their knowledge and meet parents' needs.

Prevalence of hypoglycemic conditions in adolescents with type 1 diabetes mellitus in real clinical practice

BACKGROUND. Hypoglycemia and fear of hypoglycemia remain critical problems in the treatment of adolescents with type 1 diabetes mellitus (DM1) and are factors limiting proper control of glycemia and preventing the achievement of metabolic compensation of the disease. The use of pump insulin therapy involves the prevention of hypoglycemic conditions.

AIM. To analyze the frequency and duration of hypoglycemia episodes, their effect on the metabolic compensation of the disease in adolescents with type 1 diabetes mellitus (DM1) in real clinical practice, depending on the mode/method of insulin administration.

MATERIALS AND METHODS. The study involved 117 adolescents with DM1 aged 12 to 19 years (average age 15.5 years). 37 adolescents received therapy by continuous subcutaneous insulin infusion (CSII); 80 adolescents received therapy by multiple insulin injections (MII). The level of glycated hemoglobin (HbA1c) was determined for all adolescents, and its main indicators were evaluated using a 6 days continuous glucose monitoring (CGM) by the «blind» method of a professional system with an iPro 2 sensor (Medtronic MiniMed, USA).

RESULTS. Episodes of a decrease in glucose levels <3,9 mmol/l were recorded in 87% of patients (n=102), 63% (n=74) showed a decrease in glucose levels <3,0 mmol/l. Episodes decrease in glucose levels <3,9 mmol/l at night were recorded in 68% of patients (n=80), and with glucose levels <3,9 mmol/l in 46% (n=54). The frequency of episodes of glucose lowering <3,9 mmol/l had no statistically significant differences depending on the methods of insulin administration (by continuous subcutaneous insulin infusion or multiple insulin injections), however, they are more common in adolescents with HbA1c <7,0% (p=0,03). The median time spent by patients in the range of <3,9 mmol/l was 5% per day, and a longer time in this range was observed in patients with HbA1c <7,0% (p=0,006). The median time in the range of <3,0 mmol/l was 1% per day and had no significant differences depending on the level of HbA1c (p=0,559). There were also no significant differences depending on the groups using CSII and MII (p=0,640 and p=0,250).

CONCLUSION. Episodes of glucose reduction in the range of <3,9 mmol/l according to CGM data are more common in adolescents with HbA1c target values, regardless of the method of insulin administration. Significantly more time in range of <3,9 mmol/l is spent by adolescents with target values of HbA1c i.е. <7,0% compared with HbA1c ≥7,0%, however, in both groups, a large number of patients had time in the range below the target level was higher than recommended values.

Potential mechanisms for poor glycaemic control in patients with type two diabetes and fear of hypoglycaemia

Purpose

The current study aimed to explore the potential effect of diabetes-related distress on the association between fear of hypoglycaemia and poor glycaemic control. We evaluated the specific aspects of fear of hypoglycaemia that affect glycaemic control among Saudi patients with type 2 diabetes (T2D).

Methods

Descriptive cross-sectional survey of patients with T2D attending a specialist diabetes clinic in Taif, Saudi Arabia. We used the Hypoglycaemia Attitudes and Behaviour Scale (HABS) for assessing fear of hypoglycaemia among our sample. We used Structural Equation Modelling to evaluate the moderators and correlates of fear of hypoglycaemia.

Results

We surveyed 365 patients with T2D. Cronbach's alpha for the HABS assessment was 0.84, an indication of excellent internal consistency. The composite reliability for hypoglycaemic anxiety was 86.8%; hypoglycaemic avoidance was 85.2%; and hypoglycaemic confidence was 92.6%. The mean HABS score was 32.7 points (out of 70 points; SD = 9.8 points). Fear of hypoglycaemia was associated with increased levels of glycated haemoglobin (HbA1c), presence of eye disease, heart disease, and stroke. Fear of hypoglycaemia was associated with poor glycaemic control. No significant moderating effect of diabetes-related distress was observed. However, only hypoglycaemic anxiety and avoidance were associated with poor glycaemic control. Confidence in the ability to control low glucose levels was not associated with elevated HbA1c levels.

Conclusion

A significant finding of this study highlighted the considerable and direct effect of fear of hypoglycaemia on poor glycaemic control among patients with T2D. However, only fear-related anxiety and avoidance-and not confidence in the ability to control low glucose levels-had an effect on poor glycaemic control.

Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review

PROBLEM

Fear of hypoglycemia is a significant concern for parents of children/ adolescents with type 1 diabetes. Although some studies have explained the parental fear of hypoglycemia, the related factors were yet to be determined. This systematic review aims to identify the related factors of fear of hypoglycemia in the parents of children and adolescents with type 1 diabetes and provide a theoretical basis for further intervention.

ELIGIBILITY CRITERIA

PubMed, MEDLINE, EMBASE, Scopus, CINAHL, EBSCO, Web of Science, and Cochrane Library were systematically searched from 2010 to 2021. Studies evaluating the fear of hypoglycemia of parents and its associated factors were included.

SAMPLE

Twenty-three observational articles met the criteria.

RESULTS

Significant associations were found between fear of hypoglycemia and specific factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.

CONCLUSIONS

Understanding parental fear of hypoglycemia can help parents prevent potential problems in diabetes management, thus promoting children's growth. According to current evidence, effective targeted interventions based on modifiable relevant factors can be developed to reduce the fear of hypoglycemia in parents while maintaining optimal blood glucose control in children/ adolescents.

IMPLICATIONS

Health professionals should pay more attention to the mental health of parents, and parents should be involved in the care plan and have the opportunity to discuss their fear of hypoglycemia in the most appropriate way to manage type 1 diabetes.

Fear of hypoglycemia in children with type 1 diabetes and their parents: Validation of the Italian version of the Hypoglycemia Fear Survey for Children and for Parents

BACKGROUND

Currently, Italian versions of the Hypoglycemia Fear Survey for Children (CHFS) and for Parents (PHFS) quantifying Fear of Hypoglycemia (FoH) in pediatric diabetes are not available.

OBJECTIVE

To validate the Italian version of the CHFS and PHFS.

SUBJECTS AND METHODS

One hundred and seventy-four children with type 1 diabetes aged 6-18 and 178 parents completed the CHFS and PHFS, the PedsQL 3.0 Diabetes module and the KIDSCREEN-10. Internal consistency was good (α = 0.85 for CHFS, α = 0.88 for PHFS); validity was supported by correlations of CHFS total score (CHFS-T r = -0.50; p < 0.001, CI = -0.62 to -0.35) and Worry subscale (CHFS-W r = -0.49; p < 0.001, CI = -0.62 to -0.32) with measures of health-related quality of life (QoL), which were not related to PHFS scores. Factor analyses justified the structure and the separate scoring of Behavior and Worry subscales. Children's age was negatively correlated with CHFS-T (r = -0.16; p = 0.03, CI = -0.36 to 0.00), CHFS-W (r = -0.29; p = 0.02, CI = -0.39 to -0.07), PHFS-T (r = -0.20; p = 0.006, CI = -0.35 to -0.04), PHFS-B (r = -0.30; p = 0.001, CI = -0.43 to -0.17). Mean (SD) item scores of CHFS-T (1.47 ± 0.56 vs. 1.27 ± 0.57; p < 0.05) and CHFS-W (1.20 ± 0.73 vs. 0.96 ± 0.68; p < 0.05) were higher in children with HbA1c ≥7.5%. Higher levels of distress for upsetting hypoglycemia were associated with lower child's QoL scores as perceived by children (Peds-QL: 72.6 ± 12.8 vs. 80.4 ± 11.9; p < 0.001) and parents (Peds-QL: 70.6 ± 13.8 vs. 75.8 ± 12.9; p < 0.05).

CONCLUSION

The Italian version of CHFS and PHFS appears to be a valid measure to assess FoH in clinical practice and factor analysis supports separate scoring for the Worry and Behavior subscales.

The Quality of Life and Satisfaction with Continuous Glucose Monitoring Therapy in Children under 7 Years of Age with T1D Using the rtCGM System Integrated with Insulin Pump-A Caregivers Point of View

Quality of life (QoL) is an important parameter that affects the choice of therapy. Assessment of QoL and satisfaction with therapy using the rtCGM in children with T1D aged < 7 years was conducted. The study group consisted of 38 children with T1D aged < 7 years (34% aged 2–4, 66% aged 5–7 years), HbA1c: 6.53 ± 0.63%, duration of diabetes: 2.6 ± 1.6 years, treated with an rtCGM-augmented insulin pump for 1.92 ± 1.15 years. Two anonymous surveys were conducted: a. PedsQL3.0 diabetes standardized questionnaire—QoL assessment among age groups: 2–4/5–7 years. b. An original survey assessing the CGM use satisfaction. The mean scores in PedsQL3.0: communication 75%, worries 30%, treatment 70%, and problems associated with diabetes 65%. The QoL scale is: 0–19% very low, 20–39% low, 40–59% moderate, 60–79% high, 80–100% very high. The most frequently reported concerns were long-term diabetes complications and prick pain. Satisfaction with CGM use was high (68% in group aged 5–7 and 92% 2–4 years). Twenty-seven (71%) caregivers confirmed the positive effect of CGM on sleep. During the use of rtCGM a high quality of life was reported, and the quality of sleep in their caregivers was increased.

Severe Hypoglycemia: Is It Still a Threat for Children and Adolescents With Type 1 Diabetes?

Severe hypoglycemia is defined as a condition with serious cognitive dysfunction, such as a convulsion and coma, requiring external help from other persons. This condition is still lethal and is reported to be the cause of death in 4-10% in children and adolescents with type 1 diabetes. The incidence of severe hypoglycemia in the pediatric population was previously reported as high as more than 50-100 patient-years; however, there was a decline in the frequency of severe hypoglycemia during the past decades, and relationship with glycemic control became weaker than previously reported. A lot of studies have shown the neurological sequelae with severe hypoglycemia as cognitive dysfunction and abnormalities in brain structure. This serious condition also provides negative psychosocial outcomes and undesirable compensatory behaviors. Various possible factors, such as younger age, recurrent hypoglycemia, nocturnal hypoglycemia, and impaired awareness of hypoglycemia, are possible risk factors for developing severe hypoglycemia. A low HbA_1c level is not a predictable value for severe hypoglycemia. Prevention of severe hypoglycemia remains one of the most critical issues in the management of pediatric patients with type 1 diabetes. Advanced technologies, such as continuous glucose monitoring (CGM), intermittently scanned CGM, and sensor-augmented pump therapy with low-glucose suspend system, potentially minimize the occurrence of severe hypoglycemia without worsening overall glycemic control. Hybrid closed-loop system must be the most promising tool for achieving optimal glycemic control with preventing the occurrence of severe hypoglycemia in pediatric patients with type 1 diabetes.

Evaluation of flash glucose monitoring after long-term use: A pediatric survey

AIMS

To understand the opinions of children with type 1 diabetes about their everyday use of flash glucose monitoring. (FGM).

METHODS

Children with type 1 diabetes using the FreeStyle Libre® FGM system and/or their parents were surveyed in several French medical centers between December 2016 and June 2017, regardless of their treatment regimen and metabolic control.

RESULTS

Of the 347 patients recruited, 79.5% had been using the sensor for more than three months (average usage time: 285 days). The main reported motivations for initiating this type of monitoring were to avoid finger prick pain (for 85.9% of patients) and to allow parents to check nocturnal glucose levels (60.8%). Two-thirds of respondents experienced difficulties, mainly the sensor falling off (47.6%), measurement discrepancies (25.1%) and cutaneous reactions (22.2%); 89.5% changed their habits: 70.6% took more scans, 37.2% corrected their hyperglycemia more promptly, and 37.5% used trends to adjust their insulin dosage. About one-third of the study group (35.1%) experienced lower HbA1c levels, and two thirds (67.1%) were satisfied with the device.

CONCLUSIONS

Our results show that FGM is a widely accepted option for self-monitoring diabetes, but that specific training is required to improve its use for insulin dosage adjustment and metabolic results.

Mindfulness and fear of hypoglycaemia in parents of children with Type 1 diabetes: results from Diabetes MILES Youth - The Netherlands

AIMS

To identify the sociodemographic and clinical correlates of fear of hypoglycaemia among parents of children (aged 4-18 years) with Type 1 diabetes and to examine the relationships between parental fear of hypoglycaemia, mindfulness and mindful parenting.

METHODS

Sociodemographic, self-reported clinical and psychological data were extracted from the cross-sectional Diabetes MILES Youth - The Netherlands dataset. Questionnaires included the Hypoglycaemia Fear Survey - Parent Worry (parental fear of hypoglycaemia), the Freiburg Mindfulness Inventory - Short version (mindfulness) and the Interpersonal Mindfulness in Parenting Scale (mindful parenting).

RESULTS

A total of 421 parents (359 mothers) participated. Hierarchical linear regression analyses showed that greater parental fear of hypoglycaemia was related to younger parental age, low educational level, non-Dutch nationality, more frequent blood glucose monitoring, and less general mindfulness. Adding mindful parenting to the model negated the previous contribution of general mindfulness. In this model, lower mindful parenting was related to greater parental fear of hypoglycaemia. In particular, parents with an increased ability to be less judgemental of themselves as parents and less reactive to emotions within parenting interactions reported less fear of hypoglycaemia. In total, 21% of the variance in parental fear of hypoglycaemia was explained.

CONCLUSION

Parental fear of hypoglycaemia was associated largely with parental characteristics, including non-modifiable sociodemographics (i.e. age, education, nationality) and modifiable psychological factors (i.e. mindful parenting). These findings suggest that it is important to further explore mindfulness-based interventions for parents to reduce fear of hypoglycaemia next to interventions to reduce hypoglycaemia.

Fear of Hypoglycemia, Parenting Stress, and Metabolic Control for Children with Type 1 Diabetes and Their Parents

This study sets out to extend current knowledge of parenting stress and fear of hypoglycemia (FoH) in parents of children with type 1 diabetes mellitus (T1DM). We examined if the relationship between parental and children's FoH and metabolic control, as reflected by HbA1c, is mediated by parenting stress. A total of 63 parents and children with T1DM were recruited during their routine physician's appointment. Parents completed questionnaires on parenting stress and FoH. Children eight years and older also completed a questionnaire on FoH. HbA1c values were obtained from all children. Mediation analysis revealed an indirect association between parental FoH and HbA1c values through parenting stress (Sobel's z = 2.42, p = .02), but no indirect association between children's FoH and HbA1c. We concluded that parental FOH has an indirect association with the child's metabolic control that is mediated by parenting stress. More simply, fear of hypoglycemia predicts parent stress, which in turn, predicts metabolic control.

PREP-T1 (Preteen Re-Education With Parents-Type 1 Diabetes) Feasibility Intervention Results

There has been a 2% to 3% increase in Type 1 diabetes (T1D) in children below 11 years old. Preteens (9-12 years old) with T1D are often overlooked regarding future diabetes self-management (DSM) expectations because parents are still in the "driver's seat." The study purpose was to explore feasibility/ability to recruit and conduct a two-arm trial on reeducation, collaboration, and social support. One component of DSM was reviewed (hypoglycemia) with preteens (n = 22) and parents (n = 22). The experimental preteens discussed hypoglycemia management with a teen mentor and nurse educator using a human patient simulator for practice, and working collaboratively with parents. Concurrently, mothers met with a parent mentor and psychologist to discuss growth and development, and collaborative shared management. Comparison dyads discussed hypoglycemia management with a nurse. Preteens slightly improved in diabetes knowledge; the experimental arm had higher problem-solving scores. Parents in the experimental arm had higher self-efficacy scores. Findings will inform future research.

Anxiety in children and adolescents with type 1 diabetes

Although anxiety is a normal and developmentally appropriate experience of childhood and anxiety disorders are among the most commonly diagnosed disorders, the prevalence of anxiety symptomatology and anxiety disorders in children with type 1 diabetes (T1D) is not well documented. Most studies have focused on anxiety-related syndromes associated with T1D including fear of hypoglycemia, specific phobia of needles (i.e., needle anxiety), and anxiety related to uptake of new and sophisticated diabetes technology (e.g., continuous glucose monitors, continuous subcutaneous infusion therapy), but the extant literature is sparse, and more research is greatly needed. Identification, prevention, and treatment of anxiety are critical to providing comprehensive diabetes care and management. This review provides a summary of the literature focused on anxiety in children and adolescents with T1D with suggestions for future research and clinical implications.