Has COVID-19 lockdown improved glycaemic control in pediatric patients with type 1 diabetes? An analysis of continuous glucose monitoring metrics

Discordance between Glucose Management Indicator and Glycated Hemoglobin in a Pediatric Cohort with Type 1 Diabetes: A Real-World Study

The introduction of continuous glucose monitoring (CGM) systems in clinical practice has allowed a more detailed picture of the intra- and interdaily glycemic fluctuations of individuals with type 1 diabetes (T1D). However, CGM-measured glucose control indicators may be occasionally inaccurate. This study aims to assess the discrepancy between the glucose management indicator (GMI) and glycated hemoglobin (HbA1c) (ΔGMI-HbA1c) within a cohort of children and adolescents with T1D, exploring its correlation with other CGM metrics and blood count parameters. In this single-center, cross-sectional study, we gathered demographic and clinical data, including blood count parameters, HbA1c values, and CGM metrics, from 128 pediatric subjects with T1D (43% female; mean age, 13.4 ± 3.6 years). Our findings revealed higher levels of the coefficient of variation (CV) (p < 0.001) and time above range > 250 mg/dL (p = 0.033) among subjects with ΔGMI-HbA1c > 0.3%. No association was observed between blood count parameters and ΔGMI-HbA1c. In conclusion, despite the advancements and the widespread adoption of CGM systems, HbA1c remains an essential parameter for the assessment of glycemic control, especially in individuals with suboptimal metabolic control and extreme glycemic variability.

Real-World Performance of First- Versus Second-Generation Automated Insulin Delivery Systems on a Pediatric Population With Type 1 Diabetes: A One-Year Observational Study

BACKGROUND

The aim of this single-center observational study was to assess the real-world performance of first- and second-generation automated insulin delivery (AID) systems in a cohort of children and adolescents with type 1 diabetes over a one-year follow-up.

METHODS

Demographic, anamnestic, and clinical data of the study cohort were collected at the start of automatic mode. Data on continuous glucose monitoring metrics, system settings, insulin requirements, and anthropometric parameters at three different time points (start period, six months, 12 months) were retrospectively gathered and statistically analyzed.

RESULTS

Fifty-four individuals (55.6% of females) aged 7 to 18 years switching to AID therapy were included in the analysis. Two weeks after starting automatic mode, subjects using advanced hybrid closed-loop (AHCL) showed a better response than hybrid closed-loop (HCL) users in terms of time in range (P = .016), time above range 180 to 250 mg/dl (P = .022), sensor mean glucose (P = .047), and glycemia risk index (P = .012). After 12 months, AHCL group maintained better mean sensor glucose (P = .021) and glucose management indicator (P = .027). Noteworthy, both HCL and AHCL users achieved the recommended clinical targets over the entire study period. The second-generation AID system registered longer time spent with automatic mode activated and fewer shifts to manual mode at every time point (P < .001).

CONCLUSIONS

Both systems showed sustained and successful glycemic outcomes in the first year of use. However, AHCL users achieved tighter glycemic targets, without an increase of hypoglycemia risk. Improved usability of the device may also have contributed to optimal glycemic outcomes by ensuring better continuity of the automatic mode activation.

Endocrine manifestations of COVID-19 in children: A scoping review

In this review, we explore associations between SARS CoV-2 infection and the endocrine system and metabolism in children and adolescents. PubMed, Scopus and Google scholar databases were searched to identify published data on endocrine manifestations of COVID-19 in children up to 31 March 2023, including diabetes, obesity, puberty, thyroid disorders, adrenal disorders and pituitary disorders. Data on changes in disease pattern/ incidence, disease control, and other effects due to the COVID-19 pandemic, as well as effects of pre-existing endocrine conditions on severity of COVID-19 infection are presented, and practice points and research needs provided under each section.

Metabolic control during the first two years of the COVID-19 pandemic in pediatric patients with type 1 diabetes: results from the German DPV initiative

AIM

To assess effects of the SARS-CoV2 pandemic on metabolic control in youth with type 1 diabetes (T1D) in Germany in a population-based analysis.

METHODS

Data from 33,372 pediatric T1D patients from the Diabetes Prospective Follow-up (DPV) registry, with face-to-face visits or telemedicine contacts in the years 2019-2021, were available. Datasets from eight time periods between March 15, 2020, and December 31, 2021, according to SARS-CoV2 incidence waves, were compared to those from five control time periods. Parameters of metabolic control were assessed with adjustment for sex, age, diabetes duration, and repeated measurements. Laboratory-measured HbA1c values and those estimated from CGM were aggregated into a combined glucose indicator (CGI).

RESULTS

There was no clinically relevant difference in metabolic control between pandemic and control time periods with adjusted CGI values ranging from 7.61% [7.60-7.63] (mean [95% confidence interval (CI)]) in the third quarter of 2019 to 7.83% [7.82-7.85] in the time period from January 1 to March 15 2020, in the other control periods, and during the pandemic, CGI values lay between these values. BMI-SDS rose during the pandemic from 0.29 [0.28-0.30] (mean [95% CI]) in the third quarter of 2019 to 0.40 [0.39-0.41] during the fourth wave. Adjusted insulin dose rose during the pandemic. Event rates for hypoglycemic coma and diabetic ketoacidosis remained unchanged.

CONCLUSIONS

We found no clinically relevant change of glycemic control or incidence of acute diabetes complications during the pandemic. The observed BMI increase may represent an important health risk for youth with T1D.

An exploratory analysis of the impact of the COVID-19 pandemic on pediatric type 1 diabetes mellitus patient outcomes: A single-center study

Background

The COVID-19 pandemic led to substantial shifts in pediatric diabetes care delivery to virtual and hybrid models. It is unclear if these changes in care delivery impacted short-term patient outcomes.

Objectives

We aimed to explore glycemic control and other diabetes-related outcomes in children living with Type 1 Diabetes Mellitus (T1DM) during the first year of the COVID-19 pandemic at a tertiary pediatric academic center in Canada.

Subjects

Patients <18 years of age with a confirmed diagnosis of T1DM for at least one year were included.

Methods

This was a retrospective chart review. We compared data from two years pre-pandemic (March 15, 2018-March 14, 2020) to the first year of the pandemic (March 15, 2020-March 14, 2021). The data assessed included glycemic control [Hemoglobin A1c (HbA1c)], diabetic ketoacidosis (DKA), hospital attendance and hospitalizations, hypoglycemia, and hyperglycemia. The generalized estimating equation (GEE) analysis was used to model potential factors affecting the HbA1c and diabetes-related morbidities. Multiple imputations were conducted as a sensitivity analysis.

Results

There were 346 eligible patients included in the study. The HbA1c remained stable during the pandemic compared to the pre-pandemic phase (MD-0.14, 95% CI, -0.28, 0.01; p = 0.058). The pandemic saw an increase in the number of newly diagnosed patients (X2 = 16.52, p < 0.001) and a higher number of newly diagnosed patients presenting in DKA (X2 = 12.94, p < 0.001). In patients with established diabetes, there was an increase in hyperglycemia (OR1.38, 95% CI, 1.12,1.71; p = 0.003) and reduced DKA (OR 0.30, 95% CI, 0.12,0.73; p = 0.009) during the pandemic compared to the pre-pandemic phase. Stable rates of hospitalization (OR0.57, 95% CI, 0.31,1.04, p = 0.068) and hypoglycemia (OR1.11, 95% CI, 0.83,1.49; p = 0.484) were noted. These results were retained in the sensitivity analysis.

Conclusions

Glycemic control in children with T1DM remained stable during the first year of the pandemic. There were more newly diagnosed patients during the pandemic compared to the pre-pandemic phase, and more of these new patients presented in DKA. The latter presentation was reduced in those with established diabetes during the same period.Further studies are needed to assess the ongoing impact of the COVID-19 pandemic on T1DM care pathways and outcomes to allow children, families, and diabetes teams to personalize choices of care models.

The Impact of COVID-19 Lockdown on the Incidence of Type 1 DM and the Glycemic Control of Diabetic Children: Findings from a Teaching Hospital, Saudi Arabia

OBJECTIVE: We evaluated glycemic control among T1DM pediatric patients attending the endocrinology pediatrics clinics at King Fahd Hospital of the University (KFHU) prior to and during COVID-19 restraining regulations. In addition, we assessed the trends and variations in the incidence of T1DM during 2017-2021, including the COVID-19 years by identifying newly diagnosed patients presenting to pediatrics emergency department (ED) in KFHU. METHODS: To estimate the effect of COVID-19 on the incidence of T1DM, we identified newly diagnosed cases of T1DM among pediatric patients attending the ED during the years 2017- 2021. The participants' data were collected through electronic medical records. Information collected included patient age, sex, and HbA1c readings. Three HbA1c readings of interest that were defined and collected are pre-COVID reading, in-COVID reading, and post-COVID reading. RESULTS: The difference of female participants' readings was statistically non-significant (Z= -0.416, p = 0.678), with a pre- and post-COVID median of 10.70 (Q1= 9.00, Q3= 12.15), and 10.50 (Q1= 8.80, Q3= 12.35), respectively. In contrast, the difference was statistically significant among male participants (Z= -2.334, p = 0.02), with a pre- and post-COVID median of 10.20 (Q1= 8.70, Q3= 11.80), and 10.65 (Q1= 9.00, Q3= 12.70), respectively. There was a statistically significant increase in HbA1c of persons > 11 years old (Z= -2.471, p= 0.013), with a pre- and post-COVID median of 10.40 (Q1= 9.00, Q3= 12.10), and 10.90 (Q1= 9.00, Q3= 12.60), respectively. Conversely, persons ≤ 11 years old showed no statistically significant change in HbA1c (Z= -.457, p= 0.648), with a pre- and post-COVID median of 10.45 (Q1= 8.70, Q3= 11.85), and 10.20 (Q1= 8.40, Q3= 12.075), respectively. Disregarding any influence of time, the effect of sex showed no statistically significant difference in HbA1c between males and females [F (1,125) = 0.008, p = 0.930]. Meanwhile, the age effect on HbA1c, regardless of time influence, was statistically significant [F (1,125) = 4.993, p = 0.027]. There was no statistically significant interaction between time and sex on HbA1c levels [F (1.74, 217) = 0.096, p = 0.883] and between age and time [F (3.92,289.57) = 1.693, p = 0.190]. CONCLUSIONS: The number of visits to healthcare facilities dropped significantly during the COVID-19 pandemic, but the rate of newly diagnosed T1DM increased. There was a variable effect on HbA1c levels of those patients, which suggests that each demographic group in the population might have been affected differently by the pandemic. Future research should determine factors associated with better glycemic control and measures to sustain these changes the pandemic might have created.

The impact of COVID lockdown on glycaemic control in paediatric patients with type 1 diabetes: A systematic review and meta-analysis of 22 observational studies

INTRODUCTION

The COVID lockdown has posted a great challenge to paediatric patients with type 1 diabetes (T1D) and their caregivers on the disease management. This systematic review and meta-analysis sought to compare the glycaemic control among paediatric patients with T1D (aged under 18 years) pre- during, and post-lockdown period.

METHODS AND MATERIALS

We did a systematic search of three databases (PubMed, Embase, and the WHO COVID-19 Global literature) for the literature published between 1 Jan 2019 to 10 Sep 2022. Studies meeting the following inclusion criteria were eligible for this study: (1) a COVID-19 related study; (2) inclusion of children aged 18 years old or under with established T1D; (3) comparing the outcomes of interest during or after the COVID lockdown with that before the lockdown. Study endpoints included mean difference (MD) in HbA1c, blood glucose, time in range (TIR, 70-180 mg/dl), time above range (TAR, >180mg/dl), time below range (TBR,<70mg/dl) and glucose variability (coefficient of variation [CV]) between pre-lockdown and during lockdown and/or between pre- and post-lockdown period. The MD and its corresponding 95% CI of each endpoint were pooled using random-effect model considering the potential between-study heterogeneity in COVID restrictions and T1D management.

RESULTS

Initial search identified 4488 records and 22 studies with 2106 paediatric patients with T1D were included in the final analysis. Compared with pre-lockdown period, blood glucose was significantly decreased by 0.11 mmol/L (95%CI: -0.18, -0.04) during lockdown period and by 0.42 mmol/L (95%CI: -0.73, -0.11) after lockdown. The improvement was also found for TIR, TAR, TBR, and CV during and post-lockdown (all p values<0.05) except for the post-lockdown TBR (p =0.35). No significant change in HbA1c was observed during and post- lockdown period when compared with the pre-lockdown value. There was moderate to high between-study heterogeneity for most of the analyses.

CONCLUSION

Compared with pre-lockdown period, there was significant improvement in T1D paediatric patients' glucose metrics during and post-lockdown. The underlying reasons for this positive impact warrant further investigation to inform future paediatric diabetes management.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022359213.