Comparison of Initial Presentation of Pediatric Diabetes Before and During the Coronavirus Disease 2019 Pandemic Era

The impact of COVID-19 pandemic on the incidence, presentation, and management of type 1 diabetes in children and adolescents: a narrative review

Type 1 diabetes (T1D) is an autoimmune condition affecting approximately 1.5 million children and adolescents worldwide, with an incidence of approximately 2-3% each year and rising. During the recent COVID-19 pandemic, a significant increase in incidence of T1D in children and adolescents was observed in numerous countries worldwide, with an increased number of newly-diagnosed cases presenting with diabetic ketoacidosis. The increased frequency of T1D presenting with diabetic ketoacidosis has been attributed not only to the SARS-CoV-2 virus itself but also to the restrictions imposed by the pandemic. The shift to telemedicine and unwillingness to seek medical care due to fear of infection contributed to delayed diagnosis and more severe disease presentation. Furthermore, the periods of lockdown that were implemented during the pandemic presented multiple challenges for children and adolescents living with T1D and disrupted the management of their condition. Changes in physical activity and diet as well as shortage of medical supplies during that period have been linked to worsening of glycemic control, which were at least partly offset by increased parental involvement and use of telemedicine.

New-Onset Type 1 and Type 2 Diabetes Among Korean Youths During the COVID-19 Pandemic

Importance

Whether COVID-19 contributes to youth-onset diabetes is controversial, and research in Asia is lacking.

Objective

To explore the incidence and severity of diabetes among youths during the COVID-19 pandemic in South Korea.

Design, Setting, and Participants

This cohort study used claims data for January 1, 2017, through February 28, 2022, from the National Health Insurance Service database in South Korea. The incidence of type 1 diabetes (T1D) and type 2 diabetes (T2D) in patients younger than 20 years during the pandemic was analyzed and compared with that during the prepandemic period. The study included incident cases of T1D identified by at least 2 diagnosis codes with at least 2 insulin prescriptions within 1 year and T2D identified by at least 2 diagnosis codes with at least 2 prescriptions of diabetes medication within 1 year. Analyses were performed between January 29 and September 2, 2024.

Exposures

COVID-19 pandemic and SARS-CoV-2 infection.

Main Outcomes and Measures

The primary outcome was incidence of T1D and T2D, and secondary outcomes included the rate of diabetic ketoacidosis (DKA) and association of new-onset diabetes with SARS-CoV-2 positivity.

Results

The study included 2599 patients with T1D (mean [SD] age, 12.0 [4.8] years; 1235 [47.5%] male) and 11 040 patients with T2D (mean [SD] age, 16.0 [2.8] years; 6861 [62.1%] male). During the pandemic, the incidence rate ratios were 1.19 (95% CI, 1.10-1.29) for T1D and 1.41 (95% CI, 1.36-1.46) for T2D. The incidence rate of DKA at diagnosis increased during the first pandemic year compared with the prepandemic period (T1D, 42.8% [95% CI, 38.5%-47.0%] vs 31.3% [95% CI, 29.0%-33.7%], respectively; T2D, 6.0% [95% CI, 5.0%-7.1%] vs 2.9% [95% CI, 2.5%-3.3%], respectively) but returned to prepandemic levels in the second pandemic year (T1D, 34.5% [95% CI, 30.6%-38.5%]; T2D, 3.2% [95% CI, 2.6%-3.9%]). The hazard ratio for new-onset diabetes associated with SARS-CoV-2 positivity was 0.44 (95% CI, 0.17-1.13) for T1D and 1.08 (95% CI, 0.74-1.57) for T2D.

Conclusions and Relevance

These findings suggest that the incidence and severity of T1D and T2D among South Korean youths increased during the COVID-19 pandemic. The cohort analysis does not support SARS-CoV-2 infection itself as being directly associated with incident diabetes.

Changes in metrics of continuous glucose monitoring during COVID-19 in Korean children and adolescents with type 1 diabetes mellitus

PURPOSE

There are limited data regarding changes in glucose control in pediatric patients with type 1 diabetes (T1D) affected by coronavirus disease 2019 (COVID-19). This study aimed to evaluate changes in the metrics of a continuous glucose monitoring (CGM) system during COVID-19 infection in children and adolescents with T1D.

METHODS

Eighteen patients with T1D (<18 years of age) were included in this retrospective study. The effects of COVID-19 on CGM metrics were assessed at 5 time points (2 weeks before COVID-19 [time 1], 1 week before COVID-19 [time 2], during COVID-19 [time 3], 1 week after COVID-19 [time 4], and 2 weeks after COVID-19 [time 5]).

RESULTS

All participants had at least 1 symptom of COVID-19 and did not need to be hospitalized. The glucose management indicator (GMI) was higher at time 3 (7.7%±1.4%) compared to time 1 (7.1%±1.1%; P=0.016) and time 5 (7.0%±1.2%; P=0.008). According to the insulin delivery method, the GMI at time 3 was significantly higher than that at time 5 in patients treated with multiple daily injections (MDI) (median and interquartile range, 8.0% [6.1%-8.5%] vs. 7.1% [5.8%-7.9%]; P=0.020) but not in those treated with continuous subcutaneous insulin infusion (CSII).

CONCLUSION

Pediatric patients with T1D and mild COVID-19 showed worsening glycemic control during COVID-19 infection, but it returned to preinfection levels within 2 weeks of infection. CSII is more effective in maintaining stable glycemic control during COVID-19 infection than is MDI therapy.

Healthcare professionals' knowledge and perceptions of post-stroke rehabilitation in the peripandemic period: an online cross-sectional survey

The COVID-19 pandemic has profoundly affected healthcare systems, particularly post-stroke rehabilitation centers. The elevated severity of strokes and delayed hospital admissions caused numerous hurdles to rehabilitation administration during the peri-pandemic period. This study surveyed healthcare professionals' knowledge and perceptions of post-stroke rehabilitation during this period. An online cross-sectional survey was administered from September 17, 2023 to February 23, 2024, utilizing the SurveyMonkey platform. The questionnaire included 30 questions addressing participant baseline characteristics, knowledge of definitions and experiences, post-stroke rehabilitation procedures, obstacles encountered during the peri-pandemic period, and the utilization of telerehabilitation. Only complete responses from health professionals were considered. This report utilized convenience sampling. Data were analyzed via descriptive statistics and chi-square tests, with a significance threshold of p < 0.05. A total of 79 health professionals, predominantly physiatrists, neurologists, and physiotherapists, from eight countries participated in the study. Over half of the participants (64.6%) indicated the existence of a dedicated department for post-stroke rehabilitation. Significant obstacles comprised an absence of advanced rehabilitative treatments (60.8%), inadequately skilled workers (50.6%), and restricted space for rehabilitation (46.8%). Telerehabilitation was regarded as a feasible option by 45.6% of participants; nonetheless, obstacles, including patients' telecommunication proficiency and the possibility of diagnostic inaccuracies, were acknowledged. Complementary therapies, such as music and dance therapy, received favorable evaluations from 67.1% to 63.3% of respondents, respectively. The pandemic reduced rehabilitation admissions due to infection concerns (75.9%) and increased multimorbidity cases among patients (48.1%). The study underscores the pandemic's negative effect on post-stroke rehabilitation, emphasizing the necessity for multidisciplinary, customized therapy and enhanced integration of telerehabilitation to overcome access barriers. Addressing obstacles regarding infrastructure, training, and access to advanced approaches, particularly in a post-pandemic context, is essential to improving rehabilitation outcomes.

Clinical characteristics and outcomes of COVID-19 in children and adolescents with diabetes in Daegu, South Korea

PURPOSE

Children with comorbidities have a higher risk of severe, coronavirus disease 2019 (COVID-19). This study investigated the clinical features and outcomes of COVID-19 in children and adolescents with diabetes between January and March 2022.

METHODS

We retrospectively reviewed the medical records of 123 children and adolescents (73 with type 1 diabetes and 50 with type 2 diabetes, 59 males and 64 females) aged <18 years who had been diagnosed with diabetes. Data were collected from 7 academic medical centers in Daegu, South Korea.

RESULTS

Thirty-five children with diabetes were diagnosed with COVID-19 (18 with type 1 and 17 with type 2 diabetes). Eighteen of the 35 children with diabetes and COVID-19 and 50 of the 88 children with diabetes alone received a COVID-19 vaccination. No significant differences were observed between patients with diabetes and COVID-19 and patients with diabetes alone in the type of diabetes diagnosed, sex, age, body mass index, hemoglobin A1c, or vaccination status. All children with diabetes and COVID-19 had mild clinical features and were safely managed in their homes. Fourteen children had a fever of 38℃ or higher that lasted for more than 2 days, 11 of whom were not vaccinated (p=0.004). None experienced post-COVID-19 conditions.

CONCLUSION

All children and adolescents with pre-existing diabetes had mild symptoms of COVID-19 due to low disease severity, high vaccination rates, uninterrupted access to medical care, and continuous glucose monitoring. Unvaccinated children with diabetes who experienced COVID-19 presented with higher and more frequent fevers compared to vaccinated children.

The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review

The COVID-19 pandemic triggered disruptions to health care and lifestyles that could conceivably impact diabetes management. We set out to identify the impact of disruptions caused by COVID-19 on clinical outcomes in people with diabetes. We performed a systematic review of the available literature in the MEDLINE and OVID databases from Jan 1, 2020, to June 7, 2023, and included 138 studies (n>1 000 000 people). All but five studies were judged to be at some risk of bias. All studies compared prepandemic with pandemic periods. All-cause mortality (six studies) and diabetes-related mortality (13 studies) showed consistent increases, and most studies indicated increases in sight loss (six studies). In adult and mixed samples, data generally suggested no difference in diabetic ketoacidosis frequency or severity, whereas in children and adolescents most studies showed increases with some due to new-onset diabetes (69 studies). Data suggested decreases in hospital admissions in adults but increases in diabetes-related admissions to paediatric intensive care units (35 studies). Data were equivocal on diabetic foot ulcer presentations (nine studies), emergency department admissions (nine studies), and overall amputation rates (20 studies). No studies investigated renal failure. Where reported, the impact was most pronounced for females, younger people, and racial and ethnic minority groups. Further studies are needed to investigate the longer-term impact of the pandemic and the on potential differential impacts, which risk further exacerbating existing inequalities within people with diabetes.

Endocrinological Involvement in Children and Adolescents Affected by COVID-19: A Narrative Review

Since the advent of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increased incidence of several endocrinological anomalies in acute-phase and/or long-term complications has been described. The aim of this review is to provide a broad overview of the available literature regarding changes in the worldwide epidemiology of endocrinological involvement in children since December 2019 and to report the evidence supporting its association with coronavirus disease 2019 (COVID-19). Although little is known regarding the involvement of endocrine organs during COVID-19 in children, the current evidence in adults and epidemiological studies on the pediatric population suggest the presence of a causal association between the virus and endocrinopathies. Untreated transient thyroid dysfunction, sick euthyroid syndrome, nonthyroidal illness syndrome, and hypothalamic-pituitary-adrenal (HPA) axis and central precocious puberty have been observed in children in acute infection and/or during multisystem inflammatory syndrome development. Furthermore, a higher frequency of ketoacidosis at onset in children with a new diagnosis of type 1 diabetes is reported in the literature. Although the direct association between COVID-19 and endocrinological involvement has not been confirmed yet, data on the development of different endocrinopathies in children, both during acute infection and as a result of its long-term complications, have been reported. This information is of primary importance to guide the management of patients with previous or current COVID-19.

Impact of the COVID-19 pandemic on the incidence and clinical outcomes of diabetic ketoacidosis among male and female children with type 1 diabetes: systematic review and meta-analysis

Background: Some studies suggest that the SARS-CoV-2 pandemic increased the incidence of type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA). However, the impact of this pandemic on pediatric T1DM is still mostly unknown. Therefore, we aimed to assess the effect of the COVID-19 pandemic on clinical outcomes in children with T1DM. Methods: We systematically searched for six databases up to 31 August 2022. We included 46 observational studies, 159,505 children of both sexes with T1DM, and 17,547 DKA events. Results: The COVID-19 pandemic significantly increased, in both sexes, the incidence of 1) DKA (OR 1.68; 95% CI 1.44-1.96), 2) severe DKA (OR 1.84; 95% CI 1.59-2.12), 3) DKA in newly diagnosed T1DM (OR 1.75; 95% CI 1.51-2.03), and 4) ICU admissions (OR 1.90; 95% CI 1.60-2.26). However, we did not find a significant association between this pandemic and 1) the incidence of T1DM, 2) the incidence of DKA in established T1DM, 3) the incidence of KDA complications, 4) the length of hospitalization stay, and 5) mortality. Subgroup analysis showed that the study design and the continent of origin accounted for the heterogeneity. Conclusions: The pandemic SARS-CoV-2 raised, in both sexes, the risk of DKA, severe DKA, DKA de novo, and ICU admissions.

Pediatric COVID-19 and Diabetes: An Investigation into the Intersection of Two Pandemics

Coronavirus disease 2019 (COVID-19) is a complex infectious disease caused by the SARS-CoV-2 virus, and it currently represents a worldwide public health emergency. The pediatric population is less prone to develop severe COVID-19 infection, but children presenting underlying medical conditions, such as diabetes mellitus, are thought to be at increased risk of developing more severe forms of COVID-19. Diabetic children face new challenges when infected with SARS-CoV-2. On one hand, the glycemic values become substantially more difficult to manage as COVID-19 is a predisposing factor for hyperglycemia. On the other hand, alongside other risk factors, high glycemic values are incriminated in modulating immune and inflammatory responses, leading to potentially severe COVID-19 cases in the pediatric population. Also, there are hypotheses of SARS-CoV-2 being diabetogenic itself, but this information is still to be confirmed. Furthermore, it is reported that there was a noticeable increase in the number of cases of new-onset type 2 diabetes among the pediatric population, and the complications in these patients with COVID-19 include the risk of developing autoimmune diseases under the influence of stress. Additionally, children with diabetes mellitus are confronted with lifestyle changes dictated by the pandemic, which can potentially lead to the onset or exacerbation of a potential underlying anxiety disorder or depression. Since the literature contains a series of unknowns related to the impact of COVID-19 in both types of diabetes in children, the purpose of our work is to bring together the data obtained so far and to identify potential knowledge gaps and areas for future investigation regarding COVID-19 and the onset of diabetes type 1 or type 2 among the pediatric population.

The Impact of Entry Restrictions on the Spread of Severe Acute Respiratory Syndrome Coronavirus Variants Between 2021 and 2022

To contain the surge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the South Korean government has implemented non-pharmacological interventions as well as border restrictions. The efficacy of entry restrictions should be evaluated to facilitate their preparation for new variants of SARS-CoV-2. This study explored the impact of border policy changes on overseas entrants and local cases of SARS-CoV-2 variants. Data from the Korea Disease Control and Prevention Agency randomly collected between April 11, 2021 and August 20, 2022 were evaluated using the Granger causality model. The results showed that the outbreak gap of delta variants between international and domestic cases was 10 weeks, while that of omicron variants was approximately 2 weeks, meaning that the quarantine policy helped contain delta variants rather than more transmissible variants. It is recommended that countries implement quarantine policies based on particular purposes accounting for the specific features of different variants to avoid potential negative impacts on the economy.

Impact of the COVID-19 Pandemic on Children and Adolescents with New-Onset Type 1 Diabetes

Background

The COVID-19 pandemic has an impact on the incidence of type 1 diabetes and frequency of diabetic ketoacidosis. However, the exact relationships are unclear. It is also not known whether this is a short-term phenomenon or whether the effects have long-term relevance. Furthermore, it is not known whether these changes during the pandemic are due to direct effects of SARS-CoV-2 or to changes in the patient's environment during the pandemic.

Methods

We conducted an extensive literature search on PubMed. For the estimation of relative risks of new-onset type 1 diabetes, we applied a Poisson regression model and for the comparison of incidences and we included the logarithm of person-years. Furthermore, we performed a meta-analysis using the logarithm of the relative risk for new-onset type 1 diabetes as effect size.

Results

Pooling the relative risk estimates in a random-effects meta-analysis revealed that the type 1 diabetes incidence rate increased by 20% (relative risk 1.200 (95% CI 1.125, 1.281)), and that the risk of new-onset type 1 diabetes after a SARS-CoV-2 infection increased by 62% (relative risk 1.622 (95% CI 1.347, 1.953)) compared with the prepandemic period.

Conclusion

There is considerable evidence that there is an increase in type 1 diabetes in children during the COVID-19 pandemic. Many studies suggesting a direct effect of SARS-CoV-2 have methodological weaknesses. As no evidence of an increase in presymptomatic cases with isolated islet autoimmunity was found, this could also suggest an accelerated transition from presymptomatic patients to clinically overt type 1 diabetes. Furthermore, there was a marked exacerbation of the preexisting increase in the prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes during the pandemic. Both the increased incidence of paediatric type 1 diabetes and the higher prevalence of diabetic ketoacidosis at diagnosis led to a massive rise in the number of children with diabetic ketoacidosis during the pandemic.

The Effects of COVID-19 Pandemic and Lockdown on Pediatric Nutritional and Metabolic Diseases: A Narrative Review

SARS-CoV-2 was the first pathogen implied in a worldwide health emergency in the last decade. Containment measures have been adopted by various countries to try to stop infection spread. Children and adolescents have been less clinically involved by COVID-19, but the pandemic and consequent containment measures have had an important influence on the developmental ages. The COVID-19 pandemic and the subsequent lockdown periods have influenced the nutrition and lifestyles of children and adolescents, playing an epigenetic role in the development of nutrition and metabolic diseases in this delicate age group. The aim of our review is to investigate the effects of the COVID-19 pandemic on nutrition and metabolic diseases in the developmental ages. Moreover, we have analyzed the effect of different containment measures in children and adolescents. An increase in being overweight, obesity and type 2 diabetes mellitus has been detected. Concerning type 1 diabetes mellitus, although a validated mechanism possibly linking COVID-19 with new onset type 1 diabetes mellitus has not been yet demonstrated, barriers to the accessibility to healthcare services led to delayed diagnosis and more severe presentation of this disease. Further studies are needed to better investigate these relationships and to establish strategies to contain the nutritional and metabolic impact of new pandemics in the developmental ages.

Interplay of diabetes mellitus and rheumatic diseases amidst the COVID-19 pandemic: influence on the risk of infection, outcomes, and immune responses

Outcomes of COrona VIrus Disease-19 (COVID-19) in patients with rheumatic diseases (RDs) reported in various studies are heterogenous owing to the influence of age and comorbidities which have a significant bearing on the infection risk, severity, morbidity, and mortality. Diabetes mellitus (DM) and RDs are closely linked with underlying pathobiology and treatment of RDs affecting the risk for DM as well as the glycemic control. Hence, we undertook this narrative review to study the influence of DM on outcomes of COVID-19 in patients with RDs. Additionally, aspects of patient attitudes and immune response to COVID-19 vaccination were also studied. The databases of MEDLINE/PubMed, Scopus, and Directory of Open Access Journals (DOAJ) were searched for relevant articles. Studies from mixed cohorts revealed insufficient data to comment on the influence of DM on the risk of infection, while most studies showed twice the odds for hospitalization and mortality with DM. Specific cohorts of rheumatoid arthritis and systemic lupus erythematosus revealed a similar association. Poor health was noted in patients with spondyloarthritis and DM during the pandemic. The presence of DM did not affect patient attitudes towards vaccination and did not predispose to additional vaccine-related adverse effects. Immune response to inactivated vaccines was reduced but mRNA vaccines were maintained in patients with DM. Detailed assessment of DM with its duration, end-organ damage, and glycemic control along with a focused association of DM with various aspects of COVID-19 like risk, hospitalization, severity, mortality, post-COVID sequelae, immune response to infection, and vaccination are needed in the future. Key Points • Diabetes mellitus is associated with the severity of infection, COVID-19-related hospitalization, and mortality in rheumatic diseases across most studies but studies analyzing its specific role are lacking. • Poor outcomes of COVID-19 in RA and poor health in spondyloarthritis are strongly associated with diabetes mellitus. • Diabetes mellitus may negatively influence the humoral response to inactivated vaccines but does not seem to affect the immune responses to mRNA vaccines. • Diabetes mellitus does not influence the attitude towards vaccination or deviation from the prescribed medications during the pandemic.