A two-week summer program promoting physical activity: quality of life assessment in Italian children

Physical activity (PA) can be associated with better health-related quality of life (HRQoL). This study aimed to assess HRQoL before and after a two-week summer program promoting PA in Italian school-aged children. Participants were recruited during the Giocampus summer2017 (Parma, Italy), from June to July. Before (T0) and after (T1) the program, children and one of their parents answered the Kindl questionnaire. For each domain, least-square mean changes (LSmc) at T1 were derived from linear regression models stratified by responder and adjusted for child gender, age group, time spent in PAs and HRQoL score of the responder at T0. 350 children (7-13 years, 52% males) and 342 parents answered the questionnaire at both T0 and T1. At T1, the HRQoL score of the children significantly improved in the emotional (LSmc 2.9, p<0.001), self-esteem (LSmc 3.3, p<0.001), family (LSmc 4.2, p<0.001) and friend (LSmc 3.1, p<0.001) domains. Parents reported significantly more improvement in self-esteem than children (LSmc 6.7 vs 3.3, p=0.012). Children spending more time in PA reported significantly more improvement in self-esteem than those doing less PA (LSmc 4.4 [p<0.001] vs 2.2 [p=0.181]). A short summer program promoting PA may improve HRQoL in the general population of school-aged children.

Foreword: Research in times of pandemic COVID-19

Editorial.

WHO Declares COVID-19 a Pandemic

The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing , WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is "deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction," and he called on countries to take action now to contain the virus. "We should double down," he said. "We should be more aggressive." [...].

WHO Declares COVID-19 a Pandemic

The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing , WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is "deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction," and he called on countries to take action now to contain the virus. "We should double down," he said. "We should be more aggressive." [...].

WHO Declares COVID-19 a Pandemic

The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing , WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is "deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction," and he called on countries to take action now to contain the virus. "We should double down," he said. "We should be more aggressive." [...].

Clinical utility of beta-hydroxybutyrate measurement in the management of physiological ketosis at home in children under 5

AIM

To verify the possible advantages of 3- β-hydroxybutyrate (3HB) measurement compared to urinary assay of ketones during an intercurrent disease managed at home.

METHODS

Twelve Pediatricians were asked to enroll at least 4 patients aged 3 to 5 years, affected by an intercurrent illness and showing at least one of symptoms reliable to ketosis. Recruited patients were submitted to the simultaneous assay of 3HB in capillary blood and ketones in urine at 3 (T3) and 6 hours (T6) from the first measurement (T0). For urinary and blood ketone detection commercial tests were used.

RESULTS

Thirty-eight children (4.36±2.60 years old; 25 boys) were enrolled into the study. At T0 all children showed 3HB levels (1.2-3.2 mmol/L), but only 10 of them (26.3%) associated also urinary ketone bodies (2 to 4+). In response to 3 hour treatment (T3) with a glucose solution, 3HB values decreased in 19 (0,8-1,8 mmol/L) and normalized in 13 children (<0.2 mmol/L); while ketonuria disappeared in only 2 patients, it was confirmed in 8 and appeared (4+) the first time in the remaining 28 children. At T6 3HB levels fell definitively within the normal range in all children, while ketonuria was still present (2+) in 9 patients (23%). The pediatricians reported two limitations about blood 3HB dosage compared to the urinary test: the invasiveness of capillary blood collection, and the cost of supplies for finger pricking, reagent strips and reflectance meter.

CONCLUSIONS

3HB monitor in capillary blood is more effective and clinically more useful in diagnosing and managing of an ongoing ketosis in children with a mild infective disease than ketones detection in the urine. These advantages are mitigated by the cost of 3HB measurement.

Disturbed eating behavior in pre-teen and teenage girls and boys with type 1 diabetes

AIM

To investigate Disturbed Eating Behavior (DEB) and eating patterns in the context of a teenage population with T1D.

METHODS

DEB was investigated using Eating Disorder Examination (EDE) test by a psychologist. Questions regarding insulin dosage manipulation or omission to obtain decrease in weight were added. Specific behavioral items from the EDE were used to define DEB: Objective Binge-eating, Self-induced Vomiting for weight control; the use of Diuretics, Laxatives or Insulin Omission for weight loss. Some EDE items provided information about four composite subscales which assesse Restraint, Eating concern, Shape concern and Weight concern.

RESULTS

Shape and Weight concern showed significantly higher scores than those observed in the other two subscales (p=0.021). Average scores of each subscale resulted significantly higher in girls than in boys as well as in teen than in pre-teen participants. Objective binge eating (20%) and insulin dosage omission or reduction (17.6%) were the most common DEB (p<0.03). Forty-one percent of participants reported to consume three, 25% four and 34% five meals daily. A significantly lower proportion of females than males resulted to consume breakfast and mid-afternoon snacks.

CONCLUSIONS

Findings from this study suggest that caregivers working in pediatric diabetes units should be alert in order to discover some DEB such as medication omission and binge-eating, all indicative symptoms of dissatisfaction of the body and psychological distress in diabetes management.

Could infantile interactive drawing technique be useful to promote the communication between children with Type-1 diabetes and pediatric team?

Aim: to finding what young patients with type-1 diabetes (T1D) knows about their body and also on their illness in perspective to tailor educational interventions to their real ability to understand. Methods: the present study involved 68 children with T1D , 5 to 14 years old with a duration of diabetes ranging from 2 to 6 years and a total HbA1c mean value of 7.96±0.87%. The sample was divided into two age Groups: 28 children 5 to 10 years old were gathered in the Group 1 and 40 teenagers aged from 11 to 14 years in the Group 2. These patients were invited to draw over a white paper using a black pencil “The human body as it is made inside”. Subsequently they were asked to explain: “what is diabetes?” and “where does insulin go?”. According to the methodology of the “interactive drawing”, the interviewer interacted with the children while drawing, forcing them to verbalize the reasons for their choices, to justify their proceeding, to explain their plan and then to explicit their theories. Drawings and replies were classified as Correct, Correct-but-Incomplete and Incorrect. Results: the overall production of correct/correct-but-incomplete drawings was 83.82% vs 16.20% of the incorrect ones. One-hundred of the children who have produced a correct drawing supplied also a correct verbal reply, whereas 100% of the children who have produced an incorrect drawing was unable to supply any information on diabetes or about insulin. Both younger and older subjects who produced a complete-but-incorrect drawing appeared to have misunderstood the action of insulin therapy (only 23% and 17% of correct replies). Children who produced incomplete drawings and provided incorrect replies to the questions about their disease showed also a HbA1c mean value higher (8.36±0.97%) compared to the children who drew and answered correctly (p=0.0023). Conclusions: the operative epistemic approach could represent a promising tool for a health professional team to verify the real understanding acquired by a child about T1D, and to provide pediatrician a guideline to directly communicate with his patient. (www.actabiomedica.it)

Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities

Aim:

To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D).

Methods:

Children <10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management.

Results:

From 1^st January 2014 to December 31^st 2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program.

Conclusions:

1The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members. (www.actabiomedica.it)

Diabetic ketoacidosis at the onset of Type 1 diabetes in young children Is it time to launch a tailored campaign for DKA prevention in children <5 years?

AIM

To analyze clinical characteristics associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes (T1D) in children aged <5 years in order to identify early signs or symptoms useful to prevent DKA appearance.

METHODS

Data of patients  with newly diagnosed TID aged <5 years (Group 1) and 6-10 years old  (Group 2) coming from the province of Parma were collected in the period 2012-2016.

RESULTS

Mild/moderate ketoacidosis at diabetes diagnosis occurred more frequently in Group 1 than in Group 2 patients (p<0.0015). Severe DKA incidence was higher in children below 5 (21.8%) than in those over 5 years of age (3.75%; p=0.021). Latent period before overt T1D diagnosis was longer in Group 1 than in Group 2 patients (p=0.0081). During this latent period similar indicators were recorded among parents of children <3 years old: frequent use of disposable baby diapers (87%), wet baby diapers because of a large amount of urine (86%), body weight loss (79%).  In children aged 3-4 years reported symptoms consisted of polyuria (89%), polydipsia (79%), fatigue (72%). In Group 2 patients predominant signs concern unusual episodes of  enuresis.

CONCLUSIONS

We believe that it is time to launch a DKA prevention campaign tailored for children under 5 years old and focused just on the above-mentioned three warning signs. Information program must involves pediatricians, pediatric nurses, new moms and nursery school teachers.

A new Journal section on Health System's Research: purpose and rationale

N/A.

Spontaneous Dissemination in Neighboring Provinces of DKA Prevention Campaign Successfully Launched in Nineties in Parma's Province

Aim: to investigate how much effectiveness of the historical campaign of DKA prevention at T1D diagnosis has survived in Parma’s province where this was launched in Nineties, and how much it has spontaneously spread in the neighboring provinces. Method: children aged 6-14 years with newly diagnosed TID coming from province of Parma (Group 1) and from two other nearby provinces (Group 2) were investigated. Clinical and laboratory data were retrospectively collected from medical files of each patient and included age, gender, capillary pH, serum bicarbonate, 3-beta-hydroxybutyrate (3HB), glycated hemoglobin (HbAlc) at the time of admittance from 1st January 2012 and 31 December 2016. Results: no DKA condition was globally found in 25/36 patients (69.4%): 16/17 and 9/19 patients belonged to Group 1 and 2 respectively (p=0.002). Mild or moderate DKA was reported in 5.9% patients of Group 1 and in 47.31% (p=0.005) patients from Group 2. Severe DKA was observed in only 1 child from Group 2. Normal 3-beta-hydroxybutyrate (3HB) serum levels was reported in the 25 patients without DKA at diabetes diagnosis. Duration of hyperglycemia-related symptoms before overt T1D diagnosis was shorter (4.6±2.5 days) in patients with 3HB levels <1 mmol/dl than in those with 3HB levels exceeding 1 mmol/dl (9.6±4.2 days, p<0.0001). HbA1c values were on overage lower in patients without DKA (9.9±1.2%) than in patients with DKA at diabetes diagnosis (13.60±1.3%; p<0,001). Conclusion: 1) the campaign for DKA prevention, launched in Nineties and renewed at beginning of Twenties in Parma’s province, continues to be effective in the same province after several years; 2) in the two control provinces despite no information campaign being officially promoted in loco, an unexpected decrease in severe DKA incidence as well a shorter latency before overt T1D diagnosis were observed in the same period. (www.actabiomedica.it)

Letter from the Editor

N/A.

A new Journal section on Health System's Research: purpose and rationale

N/A.

Giocampus school: a "learning through playing" approach to deliver nutritional education to children

To improve nutritional knowledge of children, single-group educational interventions with pre/post knowledge assessment were performed in primary schools in Parma, Italy, participating to the Giocampus Program. A total of 8165 children (8-11 years old) of 3rd, 4th and 5th grades of primary school were involved in 3 hours per class nutritional lessons, with specifically designed games and activities for each school grade. To evaluate children learning, a questionnaire was administered before and after three months of educational intervention. A total of 16330 questionnaires were analysed. Children nutritional knowledge significantly increased (p< 0.001) in all school grades. The integrated "learning through playing" approach, including the educational figures, tools and games, was successful in improving children's nutritional knowledge. A stable integration of this method in primary school settings could prepare a new generation of citizens, better educated on health-promotion lifestyles.

A hand-made supplementary food for malnourished children

We tested the possibility to prepare a hyperproteic and hyperenergetic supplementary food for malnutrition rehabilitation in children starting from available ingredients in popular markets in Sierra Leone. Twelve residents in Paediatrics from University of Parma, Italy, prepared in a hospital near the capital Freetown with modest technology a mixture of peanut flour, palm oil, milk powder, sugar and vitamins to which they gave the name of "Parma pap". Three hundred and thirty-two malnourished children (mean age 14±6.3 months) who were receiving Feeding Program Supplementations (FPS), were enrolled in the study: 177 participants received randomly FSP portions only (Group 1), and 159 participants were treated with FSP regimen plus a supplement of "Parma pap" (Group 2). Outcomes of the study were computed as WHZ-score increment (Δ value) by subtracting the discharge WHZ-score from the admission WHZ-score. The best Δ-WHZ-scores (&gt;+4) were recorded among participants of Group 2 (64%) rather than in Group 1 (21%; p=0.040). The children receiving FSP portions plus "Parma pap" recovered faster (5.54 week on average) than those treated with FSP regimen only (8.16 on average). The percentage of children who did not recover was higher in Group 1 (25.3%) than in Group 2 (; 13%; p=0.05). A slight positive correlation has been found between WHZ-scores at admission and at the end of the study (r=0.19; p=0.045). During the experience in Sierra Leone we have had the chance to give "Parma pap" to twenty one malnourished children admitted to Xaverian Mission in Makeni, northern Sierra Leone, not taking other supplementary food. Sixteen of these children recovered in 4.9 week on average and five in 6 to 8 weeks. Mean Δ-WHZ-scores ranged between + 1 and + 5. The data from the present study suggest that "Parma pap" could be an effective additional food to FPS regimen in malnutrition recovering. Further researches are needed on the contrary to prove if "Parma pap" could be defined as a veritable ready to use therapeutic food, although this characteristic seems already to result from the experience in Makeni Mission.

"GIOCAMPUS" - An effective school-based intervention for breakfast promotion and overweight risk reduction

The aim of this study was to evaluate the efficacy of a campaign promoting breakfast in primary school-children from the city of Parma, Italy, where 22 % of peer school-children had reported in 2005 to  skip breakfast. Two groups of children were interviewed by a multiple choice questionnaire on their breakfast habits. Group 1 counted only the children who  underwent the intensive campaign (n. 341), and  Group 2 a number of matched peers who did not attend any breakfast-promoting program (n. 291). Children who did not eat breakfast were found to be more numerous in Group 2 (17.5 %) than in  Group 1 (8.0 %; p=0.0001). In the Group 2 the percentage of  overweight (18.4 %) was higher compared to Group 1 patients (11.7 %; p=0.022). No significant difference in obesity percentage (8.9 vs 5.0 %; p=0.071).  Seventy five percent of children in Group I and the 25% of children in Group 2 (p=0.031) had one or two parents who had reported to skip routinely breakfast. Children with one or both parents used to skip breakfast had a greater odds ratio of 3.04  and  3 respectively of skipping breakfast compared to the children  with parents who had regularly  breakfast (p=0.0002). Compared to the children tested in 2005,  children admitted to   the Giocampus program showed: a significant decrease in breakfasting (22 vs 8 %; p=0.0001), a significant decrease in overweight (18.5 vs 11.7 %; p=0.003) but not in obesity (7.5 vs 5.0 %; p=0.138) status; a significant increase in consumption of cereals (p=0.0001) and fruit (p=0.0001). In conclusion, an intensive breakfast-centred strategy seems to be effective in breakfast promotion and in overweight risk decrease.

Metabolic outcomes in young children with type 1 diabetes differ between treatment centers: the Hvidoere Study in Young Children 2009

OBJECTIVE

To investigate whether center differences in glycemic control are present in prepubertal children <11 yr with type 1 diabetes mellitus.

RESEARCH DESIGN AND METHODS

This cross-sectional study involved 18 pediatric centers worldwide. All children, <11 y with a diabetes duration ≥12 months were invited to participate. Case Record Forms included information on clinical characteristics, insulin regimens, diabetic ketoacidosis (DKA), severe hypoglycemia, language difficulties, and comorbidities. Hemoglobin A1c (HbA1c) was measured centrally by liquid chromatography (DCCT aligned, range: 4.4-6.3%; IFFC: 25-45 mmol/mol).

RESULTS

A total of 1133 children participated (mean age: 8.0 ± 2.1 y; females: 47.5%, mean diabetes duration: 3.8 ± 2.1 y). HbA1c (overall mean: 8.0 ± 1.0%; range: 7.3-8.9%) and severe hypoglycemia frequency (mean 21.7 events per 100 patient-years), but not DKA, differed significantly between centers (p < 0.001 resp. p = 0.179). Language difficulties showed a negative relationship with HbA1c (8.3 ± 1.2% vs. 8.0 ± 1.0%; p = 0.036). Frequency of blood glucose monitoring demonstrated a significant but weak association with HbA1c (r = -0.17; p < 0.0001). Although significant different HbA1c levels were obtained with diverse insulin regimens (range: 7.3-8.5%; p < 0.001), center differences remained after adjusting for insulin regimen (p < 0.001). Differences between insulin regimens were no longer significant after adjusting for center effect (p = 0.199).

CONCLUSIONS

Center differences in metabolic outcomes are present in children <11 yr, irrespective of diabetes duration, age, or gender. The incidence of severe hypoglycemia is lower than in adolescents despite achieving better glycemic control. Insulin regimens show a significant relationship with HbA1c but do not explain center differences. Each center's effectiveness in using specific treatment strategies remains the key factor for outcome.

Children with type 1-diabetes from ethnic minorities: vulnerable patients needing a tailored medical support

BACKGROUND AND AIM

Newly diagnosed children with type 1 diabetes from ethnic minorities are a growing presence in outpatient pediatric clinics, and are reported as a group at risk of poor metabolic control. In the present study we investigated the barriers affecting chances of minority diabetic children to achieve the same metabolic targets of native peers with type 1 diabetes.

MATERIALS AND METHODS

The study investigated 35 children from ethnic minorities (group 1) admitted to the Children University Hospital of Parma, Italy, from 1st January 2000 to December 31st, 2011, and data concerning current age, gender, ethnicity, age at diabetes onset, HbA1c, DKA severity degree at diagnosis, insulin therapy, annual number of out patient clinic visits, number of admissions for acute decompensation, and treatment cost. A short questionnaire on background, family situation, difficulties in diabetes monitoring, and outpatient clinic procedures completed the study. The results were compared with data collected from 30 matched native peers (group 2).

RESULTS

Mean HbA1c level at admittance was higher in Group 1 (11.8 +/- 1.0%) than in Group 2 (9.0 +/- 2.2%; p=0.000). The differences were confirmed when HbAlc mean cumulative values (8.6 +/- 2.1 vs 7.6 +/- 1.1; p=0.022) were calculated. Group 1 children at admission showed poorer metabolic conditions and longer stay at hospital (16 +/- 3 days) than Group 2 patients (8 +/- 2 days; p=0.000). The total costs for DKA treatment and family education resulted higher in group 1 (+54%) than in group 2 patients. Discontinuous capillary blood glucose monitoring and outpatient clinic visits missed were more frequent in Group 1 than in group 2 patients. Thirteen patients in group 1 needed a re-admittance to hospital because of a hypoglycemia (5 cases) or a hyperglycemia (8 cases). The same episodes were not recorded in group 2 patients. Most of parents expressed the wish to be supported with educational material in their own language.

CONCLUSIONS

Children with TDM belonging to an ethnic minority had poorer metabolic control compared with native patients. This results from several cultural, educational, economic deficiencies which influence their family life and probably reduced their chances to obtain a better control.

Sulfonylurea-responsive neonatal diabetes mellitus diagnosed through molecular genetics in two children and in one adult after a long period of insulin treatment

A permanent neonatal diabetes mellitus has finally been diagnosed through molecular genetics in two children and one adult after 9 to 35 years of uninterrupted insulin treatment. These patients developed diabetes before 6 months of age and were autoantibody negative. In one boy, a mutation in the KCNJ11 gene was identified at 9 years of age. In the other two patients (daughter and father, 12.6 and 25 years old respectively) the new gene variant (ABCC8/L213P) was found. Switching from insulin to sulfonylurea treatment leads to the definitive discontinuance of insulin therapy, improving metabolic control as well as the amelioration of the associated neurodevelopmental disabilities in the young girl in which an intermediate Development Delay, Epilepsy, Neonatal Diabetes syndrome was diagnosed.

Physical activity and sedentary lifestyle in children with type 1 diabetes: a multicentre Italian study

BACKGROUND

Regular Physical Activity (RPA) is one of the cornerstones of Type 1 Diabetes (T1D) therapy, but conflicting results are reported in the literature.

AIM

To compare (RPA) and Sedentary Lifestyle (SL) among children with type 1 diabetes (T1D) and healthy peers.

SUBJECTS AND METHODS

Seven Italian paediatric diabetes centres enrolled 129 children with T1D and 214 healthy peers who were interviewed by a telephone questionnaire on physical activity level, sedentary lifestyle and clinical data.

RESULTS

Compared to healthy peers, children with T1D: performed the same amount of RPA, were more frequently engaged in team sports (p = 0.018), described RPA as an enjoyable activity (p = 0.033), not boring (p = 0.035), a chance to spend time with peers (p = 0.033) and to meet new friends (p = 0.016). Children with T1D were finally used to consume less snacks during watching TV (p < 0.001) or after physical activity (p < 0.001 ). HbA1c values were not related with time spent in physical activity, in watching TV or in playing video-games.

CONCLUSIONS

Most interviewed children with T1D are physically active and perform the same amount of exercise as their healthy peers. They demonstrate to consider RPA a source of enjoyment and sociality and not a therapeutic imposition. (www.actabiomedica.it)

The ALBA project: an evaluation of needs, management, fears of Italian young patients with type 1 diabetes in a school setting and an evaluation of parents' and teachers' perceptions

OBJECTIVE

To determine how Italian parents and school personnel of 6-13-year-old children with type 1 diabetes (T1D) manage during school hours, including insulin administration, management of hypoglycemia, and glucagon use. A further aim was an investigation into the responsibilities and training of school personnel regarding diabetes.

RESEARCH DESIGN AND METHODS

After an initial qualitative phase, semi-structured questionnaires were completed by a sample of parents and teachers.

RESULTS

220 parent and 52 teacher questionnaires were completed. 43.6% of parents said diabetes had negatively influenced school activities. Children either self-administer insulin, or have help from a parent, since there is very rarely a nurse present (3.6%) or a teacher who will take responsibility for the treatment (2.9%). Most parents (55.9%) stated either that the school had no refrigerator to store glucagon or that they did not know if the school was so equipped. A small percentage of teachers considered their schools to be equipped to manage an emergency (23%) and said they would use glucagon directly in an emergency (14.9%). Only 40.4% of teachers said that they had received any specific training.

CONCLUSIONS

The study shows that people who are not directly involved have superficial knowledge of the different aspects of diabetes, even though no parents reported episodes of neglect/incorrect management. There is no legislation which clearly defines the role of the school in the care of children with T1D, and teachers are not trained to help them. Training sessions for school personnel and greater legislative clarity about the 'insulin and glucagon question' are key factors that may improve the full integration of the child with diabetes.

Differences between ethnic minority and native children in breakfast habits

Aim of this study was to investigate the breakfast habits in a cohort of school ethnic minority (EM) children admitted to a summer sport school (SSS) in order to evaluate the possible differences with their Italian peers (IP). One hundred-seventy-nine children aged 6-14 years were interviewed through a questionnaire about breakfast behaviors and nutrition habits. The results were compared with those obtained in a randomized sample of 179 Italian peers (IP) attending the same SSS. EM children skip breakfast more frequently than IP (15% vs 7%; p = 0.029). The omissions are attributed to the lack of time (45% vs 54%) and not being hungry upon waking (44% vs 38%). During weekends the percentage of breakfast skippers decreased of about 3 percentage points but persisted a significant difference between the two groups (p = 0.024). EM children who did not have breakfast show a mean BMI higher than breakfast consumers (p = 0.05). Bakery products and milk were the most frequently consumed food and drink in EM and IP children (68% vs 70% and 71% vs 76% respectively). EM children chose and prepared personally breakfast at home more frequently than IP (54% vs 22%). These EM children were more inclined to skip breakfast (p = 0.025) and to have an elevated BMI (p = 0.006) than IP. An educational program, for ethnic minority families, in different languages and according to their cultural, religious and socio-economic influences could be a possible means for changing their lifestyle and reducing their risk to become overweight.

Permanent diabetes during the first year of life: multiple gene screening in 54 patients

AIMS/HYPOTHESIS

The aim of this study was to investigate the genetic aetiology of permanent diabetes mellitus with onset in the first 12 months of age.

METHODS

We studied 46 probands with permanent, insulin-requiring diabetes with onset within the first 6 months of life (permanent neonatal diabetes mellitus [PNDM]/monogenic diabetes of infancy [MDI]) (group 1) and eight participants with diabetes diagnosed between 7 and 12 months of age (group 2). KCNJ11, INS and ABCC8 genes were sequentially sequenced in all patients. For those who were negative in the initial screening, we examined ERN1, CHGA, CHGB and NKX6-1 genes and, in selected probands, CACNA1C, GCK, FOXP3, NEUROG3 and CDK4. The incidence rate for PNDM/MDI was calculated using a database of Italian patients collected from 1995 to 2009.

RESULTS

In group 1 we found mutations in KCNJ11, INS and ABCC8 genes in 23 (50%), 9 (19.5%) and 4 (8.6%) patients respectively, and a single homozygous mutation in GCK (2.1%). In group 2, we identified one incidence of a KCNJ11 mutation. No genetic defects were detected in other loci. The incidence rate of PNDM/MDI in Italy is estimated to be 1:210,287.

CONCLUSIONS/INTERPRETATION

Genetic mutations were identified in ~75% of non-consanguineous probands with PNDM/MDI, using sequential screening of KCNJ11, INS and ABCC8 genes in infants diagnosed within the first 6 months of age. This percentage decreased to 12% in those with diabetes diagnosed between 7 and 12 months. Patients belonging to the latter group may either carry mutations in genes different from those commonly found in PNDM/MDI or have developed an early-onset form of autoimmune diabetes.

The PTPN22 C1858T gene variant is associated with proinsulin in new-onset type 1 diabetes

Background

The protein tyrosine phosphatase nonreceptor type 2 (PTPN22) has been established as a type 1 diabetes susceptibility gene. A recent study found the C1858T variant of this gene to be associated with lower residual fasting C-peptide levels and poorer glycemic control in patients with type 1 diabetes. We investigated the association of the C1858T variant with residual beta-cell function (as assessed by stimulated C-peptide, proinsulin and insulin dose-adjusted HbA_1c), glycemic control, daily insulin requirements, diabetic ketoacidosis (DKA) and diabetes-related autoantibodies (IA-2A, GADA, ICA, ZnT8Ab) in children during the first year after diagnosis of type 1 diabetes.

Methods

The C1858T variant was genotyped in an international cohort of children (n = 257 patients) with newly diagnosed type 1 diabetes during 12 months after onset. We investigated the association of this variant with liquid-meal stimulated beta-cell function (proinsulin and C-peptide) and antibody status 1, 6 and 12 months after onset. In addition HbA_1c and daily insulin requirements were determined 1, 3, 6, 9 and 12 months after diagnosis. DKA was defined at disease onset.

Results

A repeated measurement model of all time points showed the stimulated proinsulin level is significantly higher (22%, p = 0.03) for the T allele carriers the first year after onset. We also found a significant positive association between proinsulin and IA levels (est.: 1.12, p = 0.002), which did not influence the association between PTPN22 and proinsulin (est.: 1.28, p = 0.03).

Conclusions

The T allele of the C1858T variant is positively associated with proinsulin levels during the first 12 months in newly diagnosed type 1 diabetes children.

Celiac disease in children with type 1 diabetes: impact of gluten free diet on diabetes management

Background and aim of the work the coexistence of Type 1 Diabetes (T1D) and celiac disease (CD) has been long established.

METHODS

Between January 2000 and December 2009, biopsy-proven CD was diagnosed in 12 children with T1D, giving a prevalence of 4.8 % in our out-patient clinic population. For each patient with coexisting T1D and CD, two control subjects with T1D and without CD who matched for age, sex and duration of diabetes were chosen. Prospective study follow up lasted 24 months. At the enrolment time, and at 2-month intervals, time from diagnosis of T1D to diagnosis of CD, presence of gastrointestinal symptoms, HbA1c value, body mass index (BMI), Height and Weight SDS were collected by a single observer. Daily insulin requirements were also retained.

RESULTS

In 3 children, CD predated the onset of T1D and these children were excluded from the analysis. The 9 children who subsequently developed CD became earlier diabetic than control group (p=0.002). Eight of these children had CD diagnosis within 1 year after T1D onset. Seven out of 9 children were positive for TTG antibodies and all were positive for EMA. A significant increase in insulin requirement was found in CD children after 1 year of GFD (p= 0.02). The mean HbAlc value in CD children was higher than in the control subjects (p<0.01).A significant increase in the insulin requirement after 1 year in the GFD compliant children was found. There was a significant improvement in height-SDS after institution of GFD in the GFD-compliant children. Families of children with both T1D and CD reported higher burden than those affected by T1D only (p=0.001). The health care providers perceived family burden to increase with CD appearance (p<0.05).

CONCLUSION

Our study supports the importance of screening for CD in children with T1D 1. The early treatment with GFD of biopsy-confirmed CD children promotes a significant catch-up growth and prevents a growth failure during the follow-up.

Target setting in intensive insulin management is associated with metabolic control: the Hvidoere childhood diabetes study group centre differences study 2005

OBJECTIVE

To evaluate glycaemic targets set by diabetes teams, their perception by adolescents and parents, and their influence on metabolic control.

METHODS

Clinical data and questionnaires were completed by adolescents, parents/carers and diabetes teams in 21 international centres. HbA1c was measured centrally.

RESULTS

A total of 2062 adolescents completed questionnaires (age 14.4 +/- 2.3 yr; diabetes duration 6.1 +/- 3.5 yr). Mean HbA 1c = 8.2 +/- 1.4% with significant differences between centres (F = 12.3; p < 0.001) range from 7.4 to 9.1%. There was a significant correlation between parent (r = 0.20) and adolescent (r = 0.21) reports of their perceived ideal HbA1c and their actual HbA1c result (p < 0.001), and a stronger association between parents' (r = 0.39) and adolescents' (r = 0.4) reports of the HbA1c they would be happy with and their actual HbA1c result. There were significant differences between centres on parent and adolescent reports of ideal and happy with HbA1c (8.1 < F > 17.4;p < 0.001). A lower target HbA1c and greater consistency between members of teams within centres were associated with lower centre HbA1c (F = 16.0; df = 15; p < 0.001).

CONCLUSIONS

Clear and consistent setting of glycaemic targets by diabetes teams is strongly associated with HbA1c outcome in adolescents. Target setting appears to play a significant role in explaining the differences in metabolic outcomes between centres.

Sedentary lifestyle in active children admitted to a summer sport school

Aim of this study was to investigate the sedentary patterns of school-aged active children admitted to a summer sport school. One hundred-twelve children aged 9-11 years were interviewed through a questionnaire about sedentary behaviours and nutrition habits. Seventy-one per cent of children reported they watch TV seven days a week, girls less than boys (84 +/- 45 minutes vs. 110 +/- 75 minutes) (t = 2.056; p = 0.042). The habit of TV viewing during meals was widespread (38% breakfast, 31% lunch, 62% dinner, 18% every meal). The prevalence of overweight or obesity (58.5%) was significantly higher among boys watching TV at dinner compared to the boys viewing TV only in the afternoon (35%) (chi2 = 4.976; p = 0.026). Fifty-seven per cent of children (65% boys) were accustomed to nibble snacks during TV viewing, and this habit was widespread in overweight or obese boys (chi2 = 4.546; p = 0.033). The dietary patterns of children watching TV include more snack foods and fewer fruits than the dietary patterns of the same children exercising (chi2 = 4.199 p = 0.040). Also in active children the habit to watch television is widespread and, in spite of the tendency to physical activity, 46% of them were overweight or obese; in fact the time spent looking at a TV may be associated to overweight/obesity and this relationship could be explained by the amount of high-density foods consumption during inactivity. Playing video games, read a book and listening to music are sedentary lifestyle patterns but these seem not to represent a risk factor for an increased BMI.

Insulin resistance and secretion indexes in healthy Italian children and adolescents: a multicentre study

BACKGROUND AND AIM

To establish normal values of insulin resistance, secretion and sensitivity using respectively HOMA-IR, HOMA-beta% and QUICKI indexes in healthy Italian children and adolescents, based on fasting samples.

METHODS

We determined HOMA-IR, HOMA-beta% and QUICKI at baseline in 142 healthy subjects from Pediatric Centres, aged 2.7 to 19 years (10.6 +/- 3.8, Mean +/- SD), with different Tanner's pubertal Stages (TS). None had hypo/hyperglycemia (fasting plasma glucose ranging from 3.6 to 5.6 mmol/l), obesity (BMI (kg/m2) 17.9 +/- 2.4, M +/- SD), or family history for diabetes mellitus.

RESULTS

The HOMA-IR index slightly increases with Tanner's stage. As regards HOMA-beta% and QUICKI, a weak variation throughout puberty was observed. No significant correlation was observed between HOMA-IR, HOM A-beta%, QUICKI and BMI-SDS or chronologic age.

CONCLUSIONS

Normal values of HOMA-IR, HOMA-beta% and QUICKI are useful tools in the clinical and epidemiological practice for baseline screening and follow-up of subjects at risk for type 2 diabetes mellitus.

Haemolysis during diabetic ketoacidosis treatment in two girls with incomplete glucose-6-phosphate dehydrogenase deficiency

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a typical X-linked enzymopathy causing severe haemolytic anaemia in males, and mild to moderate anaemia in homozygous females. Haemolysis due to G6PD deficiency in patients with type 1 diabetes mellitus (T1DM) has been principally reported in males, but is uncommon. During the last 10 years 2 girls with an unknown incomplete G-6-PD deficiency showed haemolysis during the treatment of DKA at the onset of T1DM. We speculate that the patients here described showed haemolytic anaemia as a phenotypic expression of the lyonization process and/or an uncommon penetrance of the defective gene. Haemolysis occurred when blood glucose levels were returning to normal values. In normal red blood cells, G6PD provides a source of reducing power for maintaining sulphydryl groups (SH) and facilitating the detoxification of free radicals and peroxides. During insulin i.v. infusion the copious glucose available due to the hyperglycaemia progressively decreased and affected the old red blood cells to generate nicotinamide adenine dinucleotide (NADPH), a crucial source for energy-dependent functions. This NADPH loss could have enhanced the rate of all factors such as methaemoglobin generation, Heinz body formation, and lipid peroxidation, which occur in G6PD deficient cells in response to both endogenous and exogenous oxidants. The direct consequence of this phenomenon is an increased erytrocyte oxidant sensitivity and a loss of sulphydryl group availability causing premature red blood cell destruction.

Serum Th1 (CXCL10) and Th2 (CCL2) chemokine levels in children with newly diagnosed Type 1 diabetes: a longitudinal study

AIMS

Cell-mediated immunity and pro-inflammatory cytokines are implicated in the pathogenesis of Type 1 diabetes. The aim of this study was to investigate whether circulating chemokines involved in T-helper 1 (CXCL10) and T-helper 2 (CCL2) autoimmunity are increased in children with Type 1 diabetes at onset and follow-up.

METHODS

Serum CXCL10 and CCL2 were measured in 96 children with newly diagnosed Type 1 diabetes, 59 age-matched first-degree relatives of diabetic children and 40 age-matched non-diabetic children with no family history of diabetes. In the diabetic children, an additional serum sample was obtained a median of 16 months after diagnosis.

RESULTS

Serum CXCL10 levels were significantly higher in Type 1 children than in relatives or control children (P < 0.001); 44.7% of patients had a serum CXCL10 level >or= 2 standard deviation above the mean value of the control group vs. 3.4% of relatives (P < 0.0001). In contrast, serum CCL2 levels were similar in patients, relatives and control subjects. In the Type 1 diabetic patients at follow-up, CXCL10 was significantly reduced vs. baseline (P = 0.01), while CCL2 did not change.

CONCLUSIONS

In children with newly diagnosed Type 1 diabetes, raised serum CXCL10 and normal CCL2 concentrations signal a predominant T-helper 1-driven autoimmune process, which shifts toward T-helper 2 immunity over the first 1-2 years from diagnosis.

Available tools for primary ketoacidosis prevention at diabetes diagnosis in children and adolescents. "The Parma campaign"

Diabetic Ketoacidosis (DKA) is a leading cause of death and disability in children with type 1 diabetes (T1D) and it is generally related to a long duration of misdiagnosed hyperglycaemia-related symptoms. Shortening this latency period could be a winning preventive strategy. It is intuitively easy to achieve this goal when other members with T1D in a family exist, as well as during the follow-up of the relatives of patients with T1D positive for genetic, immunological or metabolic markers. An incidental blood glucose level over 100 mg/dl found in children without history for T1D has been reported as indicative of a progressive beta-cell dysfunction and so it may be recommended for DKA prevention at diabetes diagnosis. More encouraging results have been obtained with a campaign of information promoted in schools and in paediatricians' offices, centred on the earliest symptom of diabetes (nocturnal enuresis in a dry child) as reported by 89% of parents. During 8 years of this campaign, the cumulative frequency of DKA dropped from 78% to 12.5% and its long effects were still observed several years after it was promoted. The Parma campaign obtained a reduction in DKA incidence at diabetes diagnosis never found before. The key-success of this campaign may be attributed to the communication of a valuable and reliable message easy to understand and follow; information toward a large population through school and paediatric consultation; involvement of family paediatricians and Parents' Association; free access to experienced health providers in diabetes diagnosis.

Are family factors universally related to metabolic outcomes in adolescents with Type 1 diabetes?

AIMS

To assess the importance of family factors in determining metabolic outcomes in adolescents with Type 1 diabetes in 19 countries.

METHODS

Adolescents with Type 1 diabetes aged 11-18 years, from 21 paediatric diabetes care centres, in 19 countries, and their parents were invited to participate. Questionnaires were administered recording demographic data, details of insulin regimens, severe hypoglycaemic events and number of episodes of diabetic ketoacidosis. Adolescents completed the parental involvement scale from the Diabetes Quality of Life for Youth--Short Form (DQOLY-SF) and the Diabetes Family Responsibility Questionnaire (DFRQ). Parents completed the DFRQ and a Parental Burden of Diabetes score. Glycated haemoglobin (HbA(1c)) was analysed centrally on capillary blood.

RESULTS

A total of 2062 adolescents completed a questionnaire, with 2036 providing a blood sample; 1994 parents also completed a questionnaire. Family demographic factors that were associated with metabolic outcomes included: parents living together (t = 4.1; P < 0.001), paternal employment status (F = 7.2; d.f. = 3; P < 0.001), parents perceived to be over-involved in diabetes care (r = 0.11; P < 0.001) and adolescent-parent disagreement on responsibility for diabetes care practices (F = 8.46; d.f. = 2; P < 0.001). Although these factors differed between centres, they did not account for centre differences in metabolic outcomes, but were stronger predictors of metabolic control than age, gender or insulin treatment regimen.

CONCLUSIONS

Family factors, particularly dynamic and communication factors such as parental over-involvement and adolescent-parent concordance on responsibility for diabetes care appear be important determinants of metabolic outcomes in adolescents with diabetes. However, family dynamic factors do not account for the substantial differences in metabolic outcomes between centres.

Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? The Hvidoere Study Group on Childhood Diabetes

OBJECTIVE

To reevaluate the persistence and stability of previously observed differences between pediatric diabetes centers and to investigate the influence of demography, language communication problems, and changes in insulin regimens on metabolic outcome, hypoglycemia, and ketoacidosis.

RESEARCH DESIGN AND METHODS

This was an observational cross-sectional international study in 21 centers, with clinical data obtained from all participants and A1C levels assayed in one central laboratory. All individuals with diabetes aged 11-18 years (49.4% female), with duration of diabetes of at least 1 year, were invited to participate. Fourteen of the centers participated in previous Hvidoere Studies, allowing direct comparison of glycemic control across centers between 1998 and 2005.

RESULTS

Mean A1C was 8.2 +/- 1.4%, with substantial variation between centers (mean A1C range 7.4-9.2%; P < 0.001). There were no significant differences between centers in rates of severe hypoglycemia or diabetic ketoacidosis. Language difficulties had a significant negative impact on metabolic outcome (A1C 8.5 +/- 2.0% vs. 8.2 +/- 1.4% for those with language difficulties vs. those without, respectively; P < 0.05). After adjustement for significant confounders of age, sex, duration of diabetes, insulin regimen, insulin dose, BMI, and language difficulties, the center differences persisted, and the effect size for center was not reduced. Relative center ranking since 1998 has remained stable, with no significant change in A1C.

CONCLUSIONS

Despite many changes in diabetes management, major differences in metabolic outcome between 21 international pediatric diabetes centers persist. Different application between centers in the implementation of insulin treatment appears to be of more importance and needs further exploration.

Outside-hospital assistance for children and adolescents with type 1 diabetes mellitus

Telephone care, Telemedicine, Home care and Diabetic Camps are the most useful ways for Paediatricians to transfer diabetic care outside the hospital. These provide children with diabetes and their parents with an effective and practical tool to solve directly arising therapeutic problems and improve their quality of care and life. The advantages for the National Health Care System could be macroscopic: according to some studies, the Telephone care service allows to save 85% of the hospitalisation costs for children with acute metabolic intercurrent illnesses-related derangements. Telemedicine service, based on telephone line relying on the Internet technology, is a complementary tool to follow children and adolescents with diabetes in out-patient clinic. The rare experiences in this field report a reduction in insulin doses and an improvement of metabolic control and quality of life. The Home care service has to be performed by a nurse and has to be useful for patients and parents to organize the management of diabetes at home and to improve therapeutic adherence. Diabetic camps give the opportunity to children and adolescents with diabetes to verify, outside the family and under health professionals' supervision, their ability to manage the disease, and to increase own self-esteem.

A case report of visceral leishmaniasis in the Tharaka District, Kenya

Leishmaniasis is a parasitic disease that is transmitted through a bite of some species of sandflies. It is caused by obliged intra-cellular protozoa of the genus Leishmania and is responsible for a broad spectrum of clinical syndromes: cutaneous leishmaniasis (CL), visceral leishmaniasis (VL) and mucocutaneous leishmaniasis (ML). The visceral disease (classically known as "kala azar") is the most aggressive form and if undervalued is fatal. Here we describe the first case of visceral leishmaniasis in the Tharaka District reported in literature.

Parent and health professional perspectives in the management of adolescents with diabetes: Development of assessment instruments for international studies

OBJECTIVE

Assessment of quality of life (QOL) in adolescents with diabetes requires patient, parent and health professional input. Psychometrically robust instruments to assess parent and professional perspectives are required.

RESEARCH DESIGN AND METHODS

Questionnaires concerning adolescent QOL were developed for completion by parents and health professionals. In an international study assessing QOL in 2,101 adolescents with diabetes (median age 14 years, range 10-18; from 17 countries including Europe, Japan and North America), parents and health professionals completed their respective questionnaires between March and August 1998.

RESULTS

Feasibility and acceptability of the new questionnaires were indicated by high questionnaire completion rates (adolescents 92%; parents 89%; health professionals 94%). Internal consistency was confirmed (Cronbach's alpha coefficients 0.80 parent; 0.86 health professional). Correlations of Diabetes Quality of Life Questionnaire for Youths (DQOLY) scores with parent and health professional global QOL ratings were generally low (r ranging from 0.12 to 0.36). Parent-rated burden decreased incrementally across adolescence, particularly for girls. Professional-rated burden followed a similar profile but only after age 15 years. Until then, burden was rated as uniformly high. Clinically relevant discrepancies in parent and professional burden scores were noted for one-parent families and families where adolescents had been referred for psychological help. In both cases, health professionals but not one-parent families perceived these as high burden situations. The clinical significance of this relates to the significantly poorer metabolic control recorded for adolescents in both situations.

CONCLUSIONS

Parent and health professional questionnaires were found to have adequate internal consistency, and convergent and discriminant validity in relation to key clinical and QOL outcomes. The questionnaires are brief, easy to administer and score. They may also enable comparisons across countries and languages to facilitate development of international health outcome parameters. The inclusion of the parent and health professional perspectives completes a comprehensive assessment of adolescent QOL relevant to diabetes.

A monosymptomatic Melkersson-Rosenthal syndrome in an 8-year old boy

Melkersson-Rosenthal Syndrome (MRS) is a systemic neuro-mucocutaneous granulomatous disease, characterized in its classical form by a triad of recurrent facial nerve paralysis, swelling of the lips and lingua plicata. However, this classical triad is rarely present, while the monosymptomatic or oligosymptomatic forms are more frequent. The presence of two or one of the manifestations mentioned above, with granulomatous cheilitis in the biopsy, is sufficient to make the diagnosis of monosymptomatic or oligosymptomatic form of MRS. This syndrome is very rare in childhood, instead, it is more frequent in young adults between the second and third decades of life. We present the case of an 8 years old boy who was brought to us because of a non painful swelling of the upper lip, associated with gingival hypertrophy, that had persisted for more than two months. Given the negative results of the hemato-chemical and instrumental assessments, we performed an upper lip biopsy whose histological study showed granulomatous cheilitis. We diagnosed this case as a monosymptomatic MRS and administered an intralesional steroid therapy using triamcinolone, with complete recovery.

KCNJ11 activating mutations in Italian patients with permanent neonatal diabetes

Permanent neonatal diabetes mellitus (PNDM) is a rare condition characterized by severe hyperglycemia constantly requiring insulin treatment from its onset. Complete deficiency of glucokinase (GCK) can cause PNDM; however, the genetic etiology is unknown in most PNDM patients. Recently, heterozygous activating mutations of KCNJ11, encoding Kir6.2, the pore forming subunit of the ATP-dependent potassium (K(ATP)) channel of the pancreatic beta-cell, were found in patients with PNDM. Closure of the K(ATP) channel exerts a pivotal role in insulin secretion by modifying the resting membrane potential that leads to insulin exocytosis. We screened the KCNJ11 gene in 12 Italian patients with PNDM (onset within 3 months from birth) and in six patients with non-autoimmune, insulin-requiring diabetes diagnosed during the first year of life. Five different heterozygous mutations were identified: c.149G>C (p.R50P), c.175G>A (p.V59M), c.509A>G (p.K170R), c.510G>C (p.K170N), and c.601C>T (p.R201C) in eight patients with diabetes diagnosed between day 3 and 182. Mutations at Arg50 and Lys170 residues are novel. Four patients also presented with motor and/or developmental delay as previously reported. We conclude that KCNJ11 mutations are a common cause of PNDM either in isolation or associated with developmental delay. Permanent diabetes of non autoimmune origin can present up to 6 months from birth in individuals with KCNJ11 and EIF2AK3 mutations. Therefore, we suggest that the acronym PNDM be replaced with the more comprehensive permanent diabetes mellitus of infancy (PDMI), linking it to the gene product (e.g., GCK-PDMI, KCNJ11-PDMI) to avoid confusion between patients with early-onset, autoimmune type 1 diabetes.

Self-monitoring adherence to physical activity in children and adolescents with type 1 diabetes

Monitoring blood glucose is essential for good diabetes control and even more important when participating in sports. Many variables can have an effect on blood sugar response to aerobic or anaerobic activities. A moderate exercise produces an average fall in plasma glucose of approximately 40% of baseline values. The majority of hypoglycaemia episodes occurs in children with pre-exercise plasma glucose concentrations < 120 mg/dl, therefore it is advisable to achieve a blood glucose level of at least 120 mg/dl if not higher before starting an exercise in order to prevent hypoglycaemia episodes. Since 15 g of oral glucose result in only about a 20-mg/dl rise in glucose concentrations, 30-45 g of oral glucose may be more appropriate to treat hypoglycaemia during exercise. A sufficient adherence to the physical activity prescribed by the health care professionals it easy to find in the children with Type 1 diabetes. According our experience, 60 per cent of the children report to spend on average 1 hour daily for exercise, proving so to consider physical activity beneficial in the treatment of diabetes mellitus. Glycate haemoglobin levels in these motivated patients were better than in children exercising sporadically and shortly either at school or in the spare time. Although the health care professionals effort, only half of the patients referred to monitor blood glucose levels before, after or before and after the exercise. Only one third of the patients reported to regularly adjust insulin dosage to own response to physical activity. Two third of the patients referred to consume added carbohydrate to avoid hypoglycaemia.

Anti-CD38 autoimmunity in children with newly diagnosed type 1 diabetes mellitus

AIMS

To test for anti-CD38 autoimmunity in children with newly-diagnosed type 1 diabetes mellitus (DM1).

METHODS

Serum anti-CD38 autoantibodies were detected by Western blot in 270 children (130 girls, 140 boys, mean age 8 +/- 4 years) with newly-diagnosed DM1 and 179 gender- and age-matched non-diabetic children. In 126 diabetic children, another blood sample was obtained 15 +/- 4 months after the diagnosis.

RESULTS

Anti-CD38 autoantibody titers at least 3 SD above the mean value for the control group were found in 4.4% of children with DM1 vs 0.6% of controls (chi2 = 5.8, p <0.016). No statistical differences were observed between anti-CD38 positive and negative patients in terms of phenotype. At follow-up, of six diabetic children who were positive for anti-CD38 antibodies, two were new cases. A positive correlation was found between the antibody titer of diabetic sera at diagnosis and follow up (r = 0.46, p <0.0001).

CONCLUSION

An autoimmune reaction against CD38, a protein expressed in human islets, is associated with newly-diagnosed DM1. In children with DM1, CD38 autoimmunity increases with time and persists.

Nationwide cross-sectional survey of 3560 children and adolescents with diabetes in Italy

Clinical characteristics and metabolic control in a large cohort of children with Type 1 diabetes (T1DM) were evaluated. Fifty-three Italian centers for childhood diabetes collected blood samples and clinical records from 3560 consecutive eligible patients aged 1.6-17.10 yr with disease duration >12 months. HbA1c determinations were centralized in a Diabetes Control and Complications Trial-controlled laboratory. HbA1c grand mean was 8.87 +/- 1.77%. Thirty-two percent of the patients had HbA1c values <8.0%. Puberty and disease duration were the main determinants of increase in HbA1c levels (<0.001). HbA1c values were inversely correlated to the frequency of blood glucose monitoring (p<0.001). Among the total population, 53.7% of the patients had 4 or more injections per day, 37.8% three injections, 7.4% < or =2 injections and only 1.1% was on pumps. Daily number of injections increased with age (p<0.001). Hypoglycemia episodes were reported in 17.6% patient-years and diabetic ketoacidosis (DKA) in 1.0% of children, more frequently in those with HbA1c >8.8% (p<0.02). Two thirds of Italian children with T1DM have HbA1c>8% despite regionalized centers, multidisciplinary team approach, free access to appropriate diabetes care, education, frequent blood glucose monitoring and multiple insulin injections.

Breakfast habits of 1,202 northern Italian children admitted to a summer sport school. Breakfast skipping is associated with overweight and obesity

Very little is known about the differences in breakfast of children performing physical activity in the morning. This paper analyzed the breakfast habits of 747 boys and 455 girls, distributed in 2 homogeneous age groups, 6-10 and 11-14 year-old, participating in a Summer Sport School. Children were asked whether, when, where, how and with whom they consumed breakfast; who prepared meals; what they ate and drank; what they did during breakfast. Weight, height and BMI were recorded. Seventy-eight percent of children usually had breakfast, but 22% reported skipping breakfast. In the non-breakfast consumer subjects, 27.5% were overweight and 9.6% obese vs 9.1 and 4.5% respectively in breakfast eaters. Bakery products (76%) and milk (71%) were the most frequently consumed foods. Only 15% of parents encouraged their children to consume additional foods at breakfast before exercising, and 42% of children believed that this extra nutrition was unnecessary. In 80% of cases, the chief decision-maker for breakfast was the mother, the father played little part (1%). During breakfast, 48% of children ate and drank in silence, 26% played with brothers and sisters, 18% watched television and only 8% talked with parents. A high prevalence of over-weight and obesity was found among non-breakfast consumer children. Breakfast omission in children exercising conflicts with their increased energy requirements and may be connected to the trend of parents and children to under-estimate the importance of breakfast for nutritional balance and for environment promotion of physical performance.