Adrenal insufficiency in pediatric kidney transplantation recipients.

BACKGROUND: Immunosuppression of pediatric kidney transplant (PKT) recipients often includes corticosteroids. Prolonged corticosteroid exposure has been associated with secondary adrenal insufficiency (AI); however, little is known about its impact on PKT recipients. METHODS: This was a retrospective cohort review of PKT recipients to evaluate AI prevalence, risk factors, and adverse effects. AI risk was assessed using morning cortisol (MC) and diagnosis confirmed by an ACTH stimulation test. Potential risk factors and adverse effects were tested for associations with MC levels and AI diagnosis. RESULTS: Fifty-one patients (60.8% male, age 7.4 (IQR 3.8, 13.1) years; 1 patient counted twice for repeat transplant) were included. Patients at risk for AI (MC < 240 nmol/L) underwent definitive ACTH stimulation testing, confirming AI in 13/51 (25.5%) patients. Identified risk factors for AI included current prednisone dosage (p = .001), 6-month prednisone exposure (p = .02), daily prednisone administration (p = .002), and rejection episodes since transplant (p = .001). MC level (2.5 years (IQR 1.1, 5.1) post-transplant) was associated with current prednisone dosage (p < .001), 6-month prednisone exposure (p = .001), daily prednisone administration (p = .006), rejection episodes since transplant (p = .003), greater number of medications (ß = -16.3, p < .001), 6-month hospitalization days (ß = -3.3, p = .013), creatinine variability (ß = -2.4, p = .025), and occurrence of acute kidney injury (ß = -70.6, p = .01). CONCLUSION: Greater corticosteroid exposure was associated with a lower MC level and confirmatory diagnosis of AI noted with an ACTH stimulation test. Adverse clinical findings with AI included greater medical complexity and kidney function lability. These data support systematic clinical surveillance for AI in PKT recipients treated with corticosteroids.

Defining a Childhood Type 1 Diabetes Cohort, Clinical Practice Measures, and Outcomes Within Administrative Data in British Columbia.

OBJECTIVE: We used administrative data to 1) establish a cohort of individuals with childhood-onset type 1 diabetes (T1D) in British Columbia (BC), and 2) define T1D-related clinical practice measures. METHODS: We applied a validated diabetes case-finding definition and differentiating algorithm to linked administrative data (1992-1993 to 2019-2020). Cases were removed when they did not meet inclusion criteria for childhood-onset T1D. Clinical practice measures were defined based on clinical practice guidelines. RESULTS: We developed an administrative cohort that included 5,901 individuals with childhood-diagnosed T1D between April 1, 1996, and March 31, 2020. The mean age was 22.31 (standard deviation 8.21) years. Clinical practice measures derived included diabetes outpatient visits (N=4,935) and glycated hemoglobin tests (N=4,935), and screening for thyroid function (N=4,457), retinopathy (N=1,602), and nephropathy (N=2,369). CONCLUSIONS: We established an administrative cohort of ∼6,000 individuals with childhood-onset T1D with 20+ years of follow-up data that can be used to describe the association between clinical practice measures and clinical outcomes.

Designing a Collaborative Patient-Centered Digital Health Platform for Pediatric Diabetes Care in British Columbia: Formative Needs Assessment by Caregivers of Children and Youths Living With Type 1 Diabetes and Health Care Providers.

BACKGROUND: Digital health apps are becoming increasingly available for people living with diabetes, yet data silos continue to exist. This requires health care providers (HCPs) and patients to use multiple digital platforms to access health data. OBJECTIVE: In this study, we gathered the perspectives of caregivers of children and youths living with type 1 diabetes (T1D) and pediatric diabetes HCPs in the user-centered design of TrustSphere, a secure, single-point-of-access, integrative digital health platform. METHODS: We distributed web-based surveys to caregivers of children and youths living with T1D and pediatric diabetes HCPs in British Columbia, Canada. Surveys were designed using ordinal scales and had free-text questions. Survey items assessed key challenges, perceptions about digital trust and security, and potential desirable features for a digital diabetes platform. RESULTS: Similar challenges were identified between caregivers of children and youths living with T1D (n=99) and HCPs (n=49), including access to mental health support, integration of diabetes technology and device data, and the ability to collaborate on care plans with their diabetes team. Caregivers and HCPs identified potential features that directly addressed their challenges, such as more accessible diabetes data and diabetes care plans. Caregivers had more trust in sharing their child's data digitally than HCPs. Most caregivers and HCPs stated that an integrative platform for T1D would support collaborative patient care. CONCLUSIONS: Caregiver and HCP perspectives gathered in this study will inform the early prototype of an integrative digital health platform. This prototype will be presented and iterated upon through a series of usability testing sessions with caregivers and HCPs to ensure the platform meets end users' needs.

Systematic review of technology-mediated peer support interventions in paediatric type 1 diabetes care.

AIMS: There is increasing interest in the role of peer support in diabetes care. However, technology-mediated peer support in paediatric type 1 diabetes remains understudied.We aimed todescribe technology-mediated peer support interventions for children living with type 1 diabetes, their caregivers and healthcare providers. METHODS: CINAHL, Embase and MEDLINE (Ovid) were searched from Jan 2007 to June 2022. We included randomised and non-randomised trials with peer support interventions for children living with diabetes, their caregivers and/or healthcare providers. Studies examining clinical, behavioural or psychosocial outcomes were included. Quality was assessed with the Cochrane risk of bias tool. RESULTS: Twelve of 308 retrieved studies were included, with a study duration range of 3 weeks to 24 months and most were randomised trials (n = 8, 66.67%). Four technology-based interventions were identified: phone-based text messages, video, web portal and social media, or a hybrid peer support model. Most (58.6%, n = 7) studies exclusively targeted children with diabetes. No significant improvement was observed in psychosocial outcomes (quality of life, n = 4; stress and coping, n = 4; social support, n = 2). Mixed findings were observed in HbA1c (n = 7) and 28.5% studies (n = 2/7) reported reduced incidence of hypoglycaemia. CONCLUSIONS: Technology-mediated peer support interventions may have the potential to improve diabetes care and outcomes. However, further well-designed studies are necessary that address the needs of diverse populations and settings, and the sustainability of intervention effects.

Patient Perceptions of Telehealth for Pediatric Type 1 Diabetes During the COVID-19 Pandemic: A Follow-up Study.

OBJECTIVES: There was rapid uptake of pediatric diabetes telehealth at the onset of the COVID-19 pandemic and initial studies demonstrated good usability and satisfaction. As exposure to telehealth continued to increase during the pandemic, we aimed to determine changes in telehealth usability and changes in future preferences for telehealth care. METHODS: A telehealth questionnaire was administered early in the pandemic and again more than 1 year later. Survey data were linked with a clinical data registry. A multivariable proportional odds logistic mixed-effects model was used to assess the association between exposure to telehealth and outcome of future preference for telehealth. Multivariable linear mixed-effects models were used to examine associations between exposure to early and later pandemic periods and the outcome of usability scores. RESULTS: Survey response rate was 40%, with 87 early and 168 later period participants. Virtual visits increased from 46% to 92% of all telehealth visits. Virtual visits improved in "ease of use" (p=0.0013) and "satisfaction" (p=0.045); there were no improvements in telephone visits. The odds of indicating higher preference for more future telehealth visits was 5.1-fold higher in the later pandemic group (p=0.0298). Eighty percent of participants would like their future care to include telehealth visits. CONCLUSIONS: At our tertiary diabetes centre, families' desire for future telehealth care has increased during this 1-year period of additional telehealth exposure, and virtual care has now become the preferred option. This study provides important family perspectives that can help guide development of future diabetes clinical care.

Using Human-Centered Design and Cocreation to Create the Live 5-2-1-0 Mobile App to Promote Healthy Behaviors in Children: App Design and Development.

BACKGROUND: The prevalence of obesity among Canadian children is rising, partly because of increasingly obesogenic environments that limit opportunities for physical activity and healthy nutrition. Live 5-2-1-0 is a community-based multisectoral childhood obesity prevention initiative that engages stakeholders to promote and support the message of consuming ≥5 servings of vegetables and fruits, having <2 hours of recreational screen time, participating in ≥1 hour of active play, and consuming 0 sugary drinks every day. A Live 5-2-1-0 Toolkit for health care providers (HCPs) was previously developed and piloted in 2 pediatric clinics at British Columbia Children's Hospital. OBJECTIVE: This study aimed to co-create, in partnership with children, parents, and HCPs, a Live 5-2-1-0 mobile app that supports healthy behavior change and could be used as part of the Live 5-2-1-0 Toolkit for HCPs. METHODS: Three focus groups (FGs) were conducted using human-centered design and participatory approaches. In FG 1, children (separately) and parents and HCPs (together) participated in sessions on app conceptualization and design. Researchers and app developers analyzed and interpreted qualitative data from FG 1 in an ideation session, and key themes were subsequently presented separately to parents, children, and HCPs in FG-2 (co-creation) sessions to identify desired app features. Parents and children tested a prototype in FG 3, provided feedback on usability and content, and completed questionnaires. Thematic analysis and descriptive statistics were used for the qualitative and quantitative data, respectively. RESULTS: In total, 14 children (mean age 10.2, SD 1.3 years; 5/14, 36% male; 5/14, 36% White), 12 parents (9/12, 75% aged 40-49 years; 2/12, 17% male; 7/12, 58% White), and 18 HCPs participated; most parents and children (20/26, 77%) participated in ≥2 FGs. Parents wanted an app that empowered children to adopt healthy behaviors using internal motivation and accountability, whereas children described challenge-oriented goals and family-based activities as motivating. Parents and children identified gamification, goal setting, daily steps, family-based rewards, and daily notifications as desired features; HCPs wanted baseline behavior assessments and to track users' behavior change progress. Following prototype testing, parents and children reported ease in completing tasks, with a median score of 7 (IQR 6-7) on a 7-point Likert scale (1=very difficult; 7=very easy). Children liked most suggested rewards (28/37, 76%) and found 79% (76/96) of suggested daily challenges (healthy behavior activities that users complete to achieve their goal) realistic to achieve. Participant suggestions included strategies to maintain users' interest and content that further motivates healthy behavior change. CONCLUSIONS: Co-creating a mobile health app with children, parents, and HCPs was feasible. Stakeholders desired an app that facilitated shared decision-making with children as active agents in behavior change. Future research will involve clinical implementation and assessment of the usability and effectiveness of the Live 5-2-1-0 app.

RAISE (Raising Infants to Be Smart Eaters) Pilot Study.

Background: Many of the complex determinants of obesity originate during infancy when small changes in the environment can permanently influence appetite, behavior, and energy metabolism. Parent feeding style ("how" rather than "what" to feed) has emerged as a potentially important factor in early obesity prevention. Objectives: (1) To assess the feasibility of conducting a brief responsive feeding education intervention by public health nurses during routine well-baby visits. (2) To assess whether this intervention affects parents' attitudes and behavior related to responsive feeding. Methods: Prospective, nonrandomized, comparative pilot study conducted in two communities. Intervention participants were exposed to enhanced responsive feeding education by public health nurses at routine well-baby visits from 0 to 18 months along with wall posters, handouts, automated text messages and tangible takeaways. Parent knowledge and behavior were measured using the Infant Feeding Style Questionnaire and the Toddler Development Index. Feasibility and acceptability were assessed by patients and nurses through open text feedback forms and mid-point and exit interviews. Results: Recruitment (18 intervention; 9 control) and retention fell below targets. Average adherence to protocol by nurses from 0 to 12 months was 89%. Delivery of the intervention was feasible and acceptable, but the additional research-related tasks were challenging in a busy clinical setting. Parents found the different formats and information new and helpful. There was a trend toward less nonresponsive (pressuring, restrictive, laissez-faire) feeding practices in the intervention group. Conclusions: This pilot study demonstrated encouraging results related to overall feasibility and effect on parent feeding style.

Insulin pump complications among children with diabetes.

QUESTION: Several children with diabetes in our clinic use continuous subcutaneous insulin infusion therapy. Recently a 5-year-old presented with a dysfunctional pump, and it took 2 days to identify the problem and resolve it. What are the potential pitfalls of insulin pumps in children and how can these be prevented? ANSWER: The use of continuous subcutaneous insulin infusion pumps has increased considerably during the past decade. Adverse events can range from mild events that can be resolved by troubleshooting at home, to severe incidents that necessitate admission to the hospital. Adverse events include technical issues, skin complications that can lead to infection, and metabolic imbalances that can lead to hospitalization. Long-term monitoring and targeted education are needed for children and their families to ensure early identification of problems with the pump and to avoid diabetic ketoacidosis or hypoglycemia.

Evaluation of two social norms nudge interventions to promote healthier food choices in a Canadian grocery store.

The objective of this study was to determine the impact of two nudge interventions on customers' produce purchases at a rural Canadian grocery store. A pre- and post-intervention observational study design was used. Sales data were gathered before and after the staggered implementation of two nudge-based interventions to encourage produce purchases: grocery cart dividers to encourage shoppers to fill one-third of their cart with produce and grocery cart plaques with information about how many fruits and vegetables were typically purchased in the store. The proportion of total sales accounted for by produce was compared between baseline and implementation of the first intervention (Phase 1), between implementation of the first intervention and the addition of the second intervention (Phase 2), and between baseline and post-implementation of both interventions together. There was a 5% relative increase (0.5% absolute increase) in produce spending between baseline and post-implementation of both interventions (10.3% to 10.8%, p < 0.001, 95% CI 0.2%, 0.7%). Intervention phase-specific produce spending showed no significant change in the percentage of produce spending from baseline to Phase 1 of the intervention, and an 8% relative increase (0.8% absolute increase) in the percentage of produce spending from Phase 1 to Phase 2 of the intervention (10.3% to 11.1%, p < 0.001, 95% CI 0.5, 1.1%). Simple, low-cost nudge interventions were effective at increasing the proportion of total grocery spend on produce. This study also demonstrated that partnerships with local businesses can promote healthier food choices in rural communities in Canada.

Anthropometric Measurements and Laboratory Investigations in Children and Youth With Type 1 Diabetes Before and During the COVID-19 Pandemic.

OBJECTIVES: Our aim in this study was to compare rates of anthropometric, blood pressure (BP) and glycated hemoglobin (A1C) measurements and laboratory screening for hypothyroidism, nephropathy and dyslipidemia in children and youth with type 1 diabetes (T1D), 1 year before and after the onset of COVID-19. METHODS: Clinical data were analyzed from a voluntary registry of children and youth with T1D followed at the BC Children's Hospital between March 2019 and 2021. Logistic and Poisson mixed-effect models were used. RESULTS: Four hundred forty patients, with median (interquartile range) age and time since diagnosis 12.7 (9.5 to 15.4) and 4.7 (2.6 to 7.9) years, respectively, were included. Clinic visits were all in-person before March 2020, and 99% via telemedicine afterward. The number of visits per patient was 2 (2 to 3), with a 6% increase during the pandemic (relative risk [RR], 1.06; 95% confidence interval [CI], 1.01 to 1.10). There was a substantial decrease in height, weight and BP measurements (RR, 0.32; 95% CI, 0.28 to 0.36; RR, 0.34, 95% CI, 0.31 to 0.38; RR, 0.005, 95% CI, 0.002 to 0.014, respectively); only 49% of patients had anthropometric and 1% BP data during the pandemic year, compared with >97% before the pandemic. A1C measurements dropped from 3 (2 to 4) to 1 (1 to 2) per patient per year (RR, 0.53; 95% CI, 0.48 to 0.57). Rates of screening investigations were suboptimal before the pandemic, and these rates continued to decline. CONCLUSIONS: Shifting to telemedicine allowed ongoing care during the pandemic, but the frequency of anthropometric, BP and A1C measurements decreased dramatically. A combined telemedicine/in-person model may be needed to ensure adequate care for this population.

Toward Building a Provincial Diabetes Registry of Children and Youth Living With Diabetes in British Columbia, Canada.

OBJECTIVES: Pediatric diabetes health-care providers and decision-makers in British Columbia (BC) have prioritized the creation of a provincial pediatric diabetes clinical registry to improve care quality. Our objective is to build the first BC Pediatrics Diabetes Registry (BC-PDR) for quality improvement and coordination of pediatric diabetes care across the province. METHODS: Patients <19 years of age and diagnosed with diabetes were invited to participate in our study. Recruitment began in 2017 at the BC Children's Hospital (BCCH) and expanded to 6 community-based pediatric diabetes clinics in the Interior Health Authority (HA) in 2019. In response to COVID-19, recruitment shifted from in-person to virtual using an electronic consent system. Patient-level (e.g. age at diabetes onset, ethnicity) and visit-level (e.g. glycated hemoglobin [A1C], blood pressure, diabetes regimen, technology use, medications) data were collected in addition to screening for and presence of diabetes complications. RESULTS: As of January 2021, 635 patients from the BCCH and Interior HA were included in the BC-PDR. From the BCCH, 94% of 590 patients were diagnosed with type 1 diabetes and the median A1C was 7.8% and increased with age. Just under half of the BCCH patients were using insulin pump technology and/or a continuous glucose monitoring system. CONCLUSIONS: Over the last 3 years, we have worked to adapt and operationalize the BC-PDR. The next steps for the BC-PDR include engaging diabetes stakeholders in the development of an electronic benchmarking dashboard along with linkage of the data to patient-reported outcome and experience measures and provincial administrative databases.

Peer Support Interventions on Digital Platforms for Children With Type 1 Diabetes and Their Caregivers.

Peer support for children with type 1 diabetes and their caregivers has been recognized as a key component in diabetes management and mental health. In this era of digitization, support programs delivered via technology are growing rapidly, particularly with increased access to technology and social media. Although the development of different digital modalities for this purpose is in its early stages, five different types of digital platforms have been recognized: voice, text, website, video, and social media. This article discusses the significance of peer support and explores various digital peer support interventions in pediatric patients with type 1 diabetes (0-18 years of age) and their caregivers.

Effectiveness of Mobile Apps in Promoting Healthy Behavior Changes and Preventing Obesity in Children: Systematic Review.

BACKGROUND: Mobile apps have been increasingly incorporated into healthy behavior promotion interventions targeting childhood obesity. However, their effectiveness remains unclear. OBJECTIVE: This paper aims to conduct a systematic review examining the effectiveness of mobile apps aimed at preventing childhood obesity by promoting health behavior changes in diet, physical activity, or sedentary behavior in children aged 8 to 12 years. METHODS: MEDLINE, Embase, PsycINFO, CINAHL, and ERIC were systematically searched for peer-reviewed primary studies from January 2008 to July 2021, which included children aged 8 to 12 years; involved mobile app use; and targeted at least one obesity-related factor, including diet, physical activity, or sedentary behavior. Data extraction and risk of bias assessments were conducted by 2 authors. RESULTS: Of the 13 studies identified, most used a quasi-experimental design (n=8, 62%). Significant improvements in physical activity (4/8, 50% studies), dietary outcomes (5/6, 83% studies), and BMI (2/6, 33% studies) were reported. All 6 multicomponent interventions and 57% (4/7) of standalone interventions reported significant outcomes in ≥1 behavioral change outcome measured (anthropometric, physical activity, dietary, and screen time outcomes). Gamification, behavioral monitoring, and goal setting were common features of the mobile apps used in these studies. CONCLUSIONS: Apps for health behavior promotion interventions have the potential to increase the adoption of healthy behaviors among children; however, their effectiveness in improving anthropometric measures remains unclear. Further investigation of studies that use more rigorous study designs, as well as mobile apps as a standalone intervention, is needed.

Drawing on Cultural Traditions to Improve Cardiorespiratory Fitness with South Asian Children: A Feasibility Study.

Background: South Asian children have a higher prevalence of cardiovascular disease risk factors compared with children of other ethnic backgrounds. Our objective was to explore the feasibility, acceptability, and potential fitness-related impact of a 7-month afterschool Bhangra dance intervention for South Asian children. Methods: We recruited 172 children grades 3 through 6 across 4 elementary schools for an intervention involving twice weekly Bhangra sessions in the school setting. Feasibility and acceptability were defined by recruitment, attendance, and retention metrics. The primary fitness outcome was cardiorespiratory fitness (CRF), measured via shuttle run laps and VO2 max. Secondary fitness outcomes included musculoskeletal (vertical jump height) and morphological fitness (waist circumference and BMI). Results: Sample size ranged from 28 to 54 participants per school (n = 172); mean attendance rate was 74%; and retention rate was 87%. VO2 max and shuttle laps increased by 1.4 mL·kg/min [95% confidence interval (CI): 0.93 to 1.84] and by 7.6 (95% CI: 6.11 to 9.08), respectively. Both these improvements remained significant after controlling for sex and age (VO2 max) and sex and baseline weight (shuttle laps). Musculoskeletal and morphological fitness indices also improved. Conclusions: Findings suggest that an afterschool Bhangra dance intervention is feasible, acceptable, and associated with CRF improvements as well as other indices of physical fitness.

Hyperthyroidism With Atrial Fibrillation in Children: A Case Report and Review of the Literature.

Atrial fibrillation is exceedingly rare in children with structurally and functionally normal hearts. We present a novel case of a 15-year-old female with known hyperthyroidism who subsequently developed atrial fibrillation. She had been suffering from fatigue, heat intolerance and myalgias for 6 months. Her initial TSH was 0.01mU/L, and free T4 was 75.4 pmol/L, with a free T3 of >30.8 pmol/L. An electrocardiogram showed atrial fibrillation with a ventricular rate of 141 beats per minute. An echocardiogram demonstrated an enlarged left atrium and ventricle, with mild mitral regurgitation. She was treated with methimazole and underwent synchronized cardioversion. She subsequently returned to a euthyroid state and remained in normal sinus rhythm. In this case, we discuss the physiologic and arrhythmogenic properties of thyroid hormone, with a summary of the existing literature on atrial fibrillation in hyperthyroidism in children. Current guidelines for treatment of atrial fibrillation are also outlined.

Risk Factors for Developing Posttransplant Diabetes After Pediatric Kidney Transplant in a Canadian Tertiary Care Children's Hospital Between 1995 and 2016.

BACKGROUND: Posttransplant diabetes mellitus (PTDM) is a serious complication in kidney transplant recipients (KTRs) due to its negative impact on graft and patient survival. Although reported in 3% to 20% of pediatric KTRs, it has not been as well characterized in adults. In this study we describe incidence and risk factors associated with development of PTDM in pediatric KTRs. METHODS: This work is a retrospective cohort study of nondiabetic pediatric patients, aged 6 months to 19 years, who underwent a first kidney transplant during 1995 to 2016. We estimated the cumulative incidence rate and used multivariable logistic regression to identify the diabetogenic risk factors for PTDM. RESULTS: A total of 142 KTRs were included in this study. The cumulative incidence of PTDM was 31% and 14.1% in the first and second year posttransplant, respectively. Significant risk factors for PTDM in the first year after transplant included: dysglycemia in the first 8 to 30 days posttransplant (adjusted odds ratio [aOR], 3.02; 95% confidence interval [CI], 1.21 to 7.53; p=0.018) and use of sirolimus in the first 30 days posttransplant (aOR, 5.33; 95% CI, 1.16 to 24.35; p=0.031). No significant association was found with typical diabetogenic factors. CONCLUSIONS: The incidence of PTDM is high among pediatric KTRs. Independent risk factors associated with PTDM included meeting the criteria for dysglycemia or diabetes and sirolimus use in the first month posttransplant. Typical diabetogenic risk factors for type 2 diabetes were not associated with increased risk. This study provides valuable information for posttransplant medical care and future research.

An Analysis of Self-Reported Barriers to Type 1 Diabetes Care in a Pediatric Population in British Columbia, Canada.

OBJECTIVES: Our aim in this study was to identify patient-level barriers to attending pediatric type 1 diabetes mellitus (T1DM) clinic and to better understand the demographic and clinical characteristics of these reporting barriers. METHODS: Patients were recruited from pediatric T1DM clinics throughout British Columbia. Barriers to attending clinic were identified through a survey. Demographic and clinical characteristics of patients who reported difficulty attending clinic appointments were compared with those who did not. RESULTS: Of the 197 study participants, 31% reported difficulty attending appointments. Commonly reported barriers were distance to clinic and missing work. Younger child age and residing in northern regions increased the odds of reporting a barrier, whereas residing on Vancouver Island decreased odds of reporting a barrier. There were no differences in glycated hemoglobin levels between the 2 groups. CONCLUSIONS: Approximately 1 in 3 patients identified challenges in attending T1DM appointments in British Columbia. Further research is needed to determine whether similar challenges exist in other provinces.

The four I's of adolescent transition in type 1 diabetes care: A qualitative study.

AIMS: To explore adolescent perspectives on programme design in the transition to adult care. METHODS: We conducted five focus groups on adolescents with type 1 diabetes nearing the age of transition to adult care. Study participants also completed an embedded survey where they rated a wide range of potential transition interventions. Focus group transcripts were analysed with three iterations of line-by-line coding to triangulate themes and subthemes. RESULTS: Four themes were identified: Individualization-how to personalize the transition experience (having choices in the transition experience, meeting adult provider before transition and specific transition preparation); Identity-how the world relates to my diabetes (stigma of type 1 diabetes, confusion with type 2 diabetes, diagnosis disclosure and resilience); Interconnection-how my support system can help me with my diabetes (peer support, near peer support, parental support, loss of bond with paediatric team and fear of not having a bond with adult team); and Impediment-how my diabetes limits me (self-care takes work and time, unpredictability and restrictiveness, and emotional burden). Highly rated interventions from the survey included: good communication between the paediatric and adult teams, medical summary of past diabetes care, and having paediatric and adult teams in the same building. CONCLUSIONS: The design of future transition interventions for adolescents with type 1 diabetes should address the issues of Individualization, Identity, Interconnection and Impediment. Collaborative processes between paediatric and adult providers were also rated as important strategies to facilitate the transition to adult care.

Celiac disease in children with type 1 diabetes varies around the world: An international, cross-sectional study of 57 375 patients from the SWEET registry.

BACKGROUND: Children with type 1 diabetes (T1D) are at much higher risk of developing celiac disease (CD) than the general population. The aim of the study was to assess the prevalence and differences in clinical presentation of CD in T1D in different regions of the world. METHODS: This study is based on the Better control in Pediatric and Adolescent diabeteS: Working to crEate cEnTers of Reference (SWEET) database. There were 57 375 patients included in the study, aged ≤18 years from 54 SWEET centers. Only centers with screening for celiac disease were included. Regression models adjusted for age, diabetes duration, and gender and a fixed effect in the models for region was used. Diabetes duration, age at diabetes onset, and sex were presented as unadjusted results. RESULTS: CD was present in 2652 subjects (4.5%), with different prevalence among regions: from 1.9% in Asia/Middle East to 6.9% in Australia/New Zealand. CD was observed more often among females. Comparing children with and without CD, characteristics for those with CD were younger age at diabetes onset (6.3 [3.3; 9.8] vs 8.1 [4.6; 11.3], P < 0.001) and had longer diabetes duration (6.4 [3.6; 9.8] vs 4.8 [2.1; 8.2], P < 0.001). Further, they had lower glycosylated hemoglobin (HbA1c) in Europe and North America/Canada; lower body mass index (BMI)-SD score (BMI-SDS) in southern Europe, North America, and Canada; In most regions daily insulin dose was lower, height-SDS was lower, and the percentage of insulin pump users was higher in children with T1D and CD. CONCLUSIONS: The prevalence and the anthropometric and metabolic consequences of CD in children with T1D differ around the world.