Fasting during the holy month of Ramadan among older children and adolescents with type 1 diabetes in Kuwait.

Background To evaluate the safety of fasting during the holy month of Ramadan among children and adolescent with type 1 diabetes (T1D). Methods A retrospective cohort study of 50 children and adolescents with T1D whose mean age was 12.7 ± 2.1 years was conducted. Twenty-seven patients (54%) were on multiple daily injections (MDI) insulin regimen and 23 (46%) were on insulin pump therapy. Before fasting for Ramadan, children and their families were evaluated and educated about diabetes management during Ramadan. Hemoglobin A1c (HbA1c), weight, number of days fasted, hypoglycemia and hyperglycemia episodes, and emergency hospital visits were collected and analyzed after completing the month. Participants were compared according to the insulin treatment regimen and their glycemic control level before Ramadan. Results The children were able to fast 20 ± 9.9 days of Ramadan, and the most common cause for breaking the fast was mild hypoglycemia (7.8% among all cases). There was no significant difference between the two insulin regimen groups in breaking fast days, frequency of hypo- or hyperglycemia, weight and HbA1c changes post Ramadan. Patients with HbA1c ≤ 8.5% were able to fast more days during Ramadan with significantly less-frequent hypoglycemic attacks as compared to patients with HbA1c > 8.5 (1.2 ± 1.5 vs. 3.3 ± 2.9 days of hypoglycemia, p = 0.01, respectively). Conclusions Fasting for children with T1D above the age of 10 years is feasible and safe in both pump and non-pump users, and well-controlled patients are less likely to develop complications. Education of the families and their children before Ramadan, along with intensive monitoring of fasting children during the month are crucial.

A cross-cultural study on perceived health-related quality of life in children and adolescents with type 1 diabetes mellitus.

OBJECTIVE: This study investigated whether culture can affect self- and proxy-reports of perceived diabetes-specific health-related quality of life of children and adolescents with type 1 diabetes when taking into account glycemic control, gender and age. METHODS: A total of 416 patients aged between 8 and 18 years--84 (Greece), 135 (Hungary) and 197 (Kuwait)--and their parents completed the Pediatric Quality of Life Inventory 3.0. Diabetes Module. RESULTS: Gender and age did not have any effect on perceived diabetes-specific health-related quality of life. Significant differences were detected among countries in self- and proxy-reports of diabetes-specific health-related quality of life when controlling for glycemic control. More specifically, Greek patients with type 1 diabetes and their parents reported significantly worse disease-specific health-related quality of life than their peers from Kuwait and Hungary. Moreover, culture affected the level of agreement between self- and proxy-reports with parents from Kuwait underestimating their children's diabetes-specific health-related quality of life. CONCLUSION: The impact of culture on self- and proxy-reports of diabetes-specific health-related quality of life warrants further investigation, since it might suggest the need for differential psychosocial treatment.

Analysis of transcription factors key for mouse pancreatic development establishes NKX2-2 and MNX1 mutations as causes of neonatal diabetes in man.

Understanding transcriptional regulation of pancreatic development is required to advance current efforts in developing beta cell replacement therapies for patients with diabetes. Current knowledge of key transcriptional regulators has predominantly come from mouse studies, with rare, naturally occurring mutations establishing their relevance in man. This study used a combination of homozygosity analysis and Sanger sequencing in 37 consanguineous patients with permanent neonatal diabetes to search for homozygous mutations in 29 transcription factor genes important for murine pancreatic development. We identified homozygous mutations in 7 different genes in 11 unrelated patients and show that NKX2-2 and MNX1 are etiological genes for neonatal diabetes, thus confirming their key role in development of the human pancreas. The similar phenotype of the patients with recessive mutations and mice with inactivation of a transcription factor gene support there being common steps critical for pancreatic development and validate the use of rodent models for beta cell development.

Growth hormone therapy and treatment outcomes: current clinical practice of the Gulf Cooperation Council.

Over the last 20 years, recombinant human growth hormone (somatropin) has been the cornerstone of managing children with growth hormone deficiency (GHD). Although both international and national guidelines for growth hormone (GH) therapy exist, there is currently no consensus on the optimal use of GH therapy in Gulf Cooperation Council (GCC) countries. The goals of GH therapy are to normalize height during childhood, attain normal adult height and correct metabolic abnormalities related to GHD. However, extended use of GH >50 µg/kg/day may increase frequency of adverse events. Here, we report the proceedings from a meeting of nine GCC pediatric endocrinology experts, which took place in Beirut in November 2011. The meeting was also attended by three European counterparts and aimed to provide consensus on best practice in the management of children with GHD in the GCC based on current local medical and regulatory environments.

Early-onset, coexisting autoimmunity and decreased HLA-mediated susceptibility are the characteristics of diabetes in Down syndrome.

OBJECTIVE: Down syndrome (DS) is associated with an increased risk of diabetes, particularly in young children. HLA-mediated risk is however decreased in children with DS and diabetes (DSD). We hypothesized that early-onset diabetes in children with DS is etiologically different from autoimmune diabetes. RESEARCH DESIGN AND METHODS: Clinical and immunogenetic markers of autoimmune diabetes were studied in 136 individuals with DSD and compared with 194 age- and sex-matched individuals with type 1 diabetes, 222 with DS, and 671 healthy controls. HLA class II was analyzed by sequence-specific primed PCR. Islet autoantibodies were measured by radioimmunoassay. RESULTS: Age at onset of diabetes was biphasic, with 22% of DS children diagnosed before 2 years of age, compared with only 4% in this age-group with type 1 diabetes in the general population (P < 0.0001). The frequency of the highest-risk type 1 diabetes-associated HLA genotype, DR3-DQ2/DR4-DQ8, was decreased in both early- and later-onset DSD compared with age-matched children with type 1 diabetes (P < 0.0001), although HLA DR3-DQ2 genotypes were increased (P = 0.004). Antibodies to GAD were observed in all five samples tested from children diagnosed at ≤2 years of age, and persistent islet autoantibodies were detected in 72% of DSD cases. Thyroid and celiac disease were diagnosed in 74 and 14%, respectively, of the DSD cohort. CONCLUSIONS: Early-onset diabetes in children with DS is unlikely to be etiologically different from autoimmune diabetes occurring in older DS children. Overall, these studies demonstrate more extreme autoimmunity in DSD typified by early-onset diabetes with multiple autoimmunity, persistent islet autoantibodies, and decreased HLA-mediated susceptibility.

Periodontal health of children with type 1 diabetes mellitus in Kuwait: a case-control study.

OBJECTIVE: The aim of this study was to evaluate periodontal health in children diagnosed with type 1 diabetes mellitus. SUBJECTS AND METHODS: Periodontal health was clinically examined and compared in 95 children diagnosed with type 1 diabetes and 61 healthy control subjects (4-14 years old). Plaque index, gingival index, clinical attachment loss and bleeding on probing were assessed on the 6 Ramfjord index teeth. Diabetes history was recorded based on information provided by the physician from the medical record of each diabetic child. Diabetes history included date of diagnosis, diabetes duration, age at diagnosis, latest reading for glycosylated hemoglobin and any existing diabetes complications. Data were analyzed using the Statistical Package for Social Science software, version 18. 'Periodontitis' was defined as at least one site with clinical attachment loss >2 mm on at least 2 teeth. RESULTS: Sixty-two of the diabetic children (65%) had poor compliance with dental care, and 42 of them (44%) had never visited the dentist before. The children with type 1 diabetes mellitus had a significantly higher plaque index and gingival index and more bleeding on probing than control subjects (p < 0.001). In the diabetic group, periodontitis was significantly associated with longer duration of diabetes (odds ratio 2.230, confidence interval 1.308-3.801; p = 0.003) and older age at diagnosis of diabetes (odds ratio 1.838, confidence interval 1.091-3.096; p = 0.022). CONCLUSIONS: Periodontal disease in young patients with type 1 diabetes was more evident than in those without diabetes. These data showed that diabetes duration may play a significant role in the progression of periodontal disease in diabetic children.

Obesity in children and adolescents in Gulf countries: Facts and solutions / Obesidad en niños y adolescentes en países del Golfo: hechos y soluciones

The rapid pace of socioeconomic development in the Arabian Gulf nations and the rapidly changing environment are probably determining the altering scenario of child and adolescent nutrition in the developed societies. The rapid urbanization in everyday life, accompanied by decreased levels of physical activity and increased caloric intake of non-traditional food has become responsible for the emerging of obesity in children and adolescents as a major public health issue in these countries. The six Arabian Gulf nations are a good example for this developmental transition and its consequences. Prevalence is high among Kuwaiti and Saudi pre-school children (8-9%), and among the highest in the world among Kuwaiti adolescents (40-46%), taking into account that different standard of assessment of obesity are used. Although data on the prevalence of type 2 diabetes (T2DM) and metabolic syndrome (MS) in children in the region are sparse, both morbidities are expected to rise, knowing the strong association between obesity and T2DM in the adult population. Prevention strategies need the collaborative efforts of governmental and community-led agencies to establish long-term programs to improve health education, targeting young children and their families. Healthy eating and physical activity should be promoted and encouraged in schools, nurseries, and child care settings. This article gives an overview of overweight and obesity among children and adolescents in the 6-Arabian Gulf countries. It will also address possible strategies for the prevention and management of this major health epidemic

El frenético ritmo de los avances socioeconómicos en los países del Golfo Pérsico y el rápidamente cambiante entorno está probablemente definiendo el perturbador panorama de la nutrición de niños y adolescentes en las sociedades desarrolladas. La fugaz urbanización de la vida diaria, acompañada por unos niveles reducidos de actividad física y un aumento de la ingesta calórica en forma de alimentos no tradicionales, ha convertido la obesidad en los niños y adolescentes en un tema de salud pública de gran importancia en estos países. Los seis países del Golfo Pérsico son un buen ejemplo de esta transición en el desarrollo y de sus consecuencias. La prevalencia es elevada entre los niños preescolares kuwaitíes y saudíes (8%-9%), y entre los adolescentes kuwaitíes cuenta con una de las más elevadas en el mundo (40%-46%), de acuerdo con diferentes estándares para valorar la obesidad. Aunque los datos sobre la prevalencia de la diabetes tipo 2 (DMT2) y el síndrome metabólico (SM) en los niños de la región son escasos, se esperan que ambas morbilidades aumenten, debido a la existencia de una importante asociación entre la obesidad y la DMT2 en la población adulta. Las estrategias de prevención exigen una fuerte colaboración entre el gobierno y las agencias dirigidas por la comunidad para establecer programas a largo plazo para mejorar la educación sanitaria, centrada en los niños pequeños y sus familias. Es necesaria la promoción de una dieta saludable y de la actividad física tanto en colegios, como en guarderías y centros de puericultura. Este artículo aporta una visión general del sobrepeso y la obesidad en niños y adolescentes en los seis países que conforman el Golfo Pérsico. También se contemplan posibles estrategias para la prevención y la gestión de esta importante epidemia sanitaria

'The honeymoon phase' in children with type 1 diabetes mellitus: frequency, duration, and influential factors.

BACKGROUND: The honeymoon period (i.e., partial remission) of type 1 diabetes mellitus is characterized by reduced insulin requirements while good glycemic control is maintained. The clinical significance is the potential possibility for pharmacological intervention during this period to either slow down or arrest the ongoing destruction of the remaining beta-cells. METHODS: A group of 103 diabetic children, younger than 12 yr of age, were prospectively studied to assess the frequency, duration, and factors that may affect partial remission. At the time of admission, patients were characterized by age, gender, symptom duration, diabetic ketoacidosis (DKA), and blood sugar level at admission. The honeymoon period was defined as a period with insulin requirements of less than 0.5 U/kg/day and hemoglobin A1c (HbA1c) level of less or equal to 6%. RESULTS: Partial remission occurred in 71, being complete in three. The length of time until remission was 28.6 +/- 12.3 (mean +/- SD) days. The duration of remission was 7.2 +/- 4.8 months. Remission rates were higher in those patients older than 5 yr compared with those between 3 and 5 yr of age. DKA at presentation and long duration of symptoms were associated with lower duration of remission (p < 0.001 and p < 0.001, respectively). Children in whom remission occurred had significantly lower blood glucose levels and higher pH at presentation (p < 0.001 and p < 0.001, respectively). CONCLUSIONS: Young age and severe disease at presentation are associated with decreased residual beta-cells function that is reflected by a lower incidence of partial remission. These observations are important to consider in the research regarding therapies that will have the potential goal to induce prolonged and/or complete remission at disease onset or shortly thereafter.

Leigh's disease in 3 sibs of a Kuwaiti family.

OBJECTIVE AND IMPORTANCE: To describe Leigh's disease in 3 sibs of a Kuwaiti family. CASE PRESENTATION: Two brothers presented in early infancy with progressive neurological symptoms of hypotonia, delayed milestones and brisk reflexes. Investigations revealed metabolic acidosis, high serum and cerebrospinal fluid lactate. Magnetic resonance imaging (MRI) showed characteristic changes of Leigh's disease. The 3rd brother, who was asymptomatic initially, was investigated because of his family history and was found to have similar changes. INTERVENTION: All children developed progressive neurological deterioration and persistent metabolic lactic acidosis, which was treated with sodium bicarbonate, and the 1st patient needed renal dialysis to control the acidosis. The 2nd child was placed on vitamins and carnitine. CONCLUSION: The neurological deterioration was progressive in all 3 sibs, and they eventually died of respiratory failure despite ventilatory support. Since MRI changes are characteristic, MRI should be done to confirm the diagnosis.