Effects of probiotic administration on immune responses of children and adolescents with type 1 diabetes to a quadrivalent inactivated influenza vaccine.

This study was planned to evaluate whether a 3-month treatment with Lactobacillus rhamnosus GG (LGG) can modify immune system functions in children and adolescents with type 1 diabetes (T1D), leading to an increased immune response to an injectable quadrivalent inactivated influenza vaccine (QIV). A total of 87 pediatric patients with T1D were screened, although 34 patients in the Probiotic group and 30 in the Control group accepted to be vaccinated with QIV and completed the study. Vaccine immunogenicity and safety and the inflammatory cytokine response were studied. Results showed that QIV was immunogenic and safe in T1D pediatric patients and pre-administration of LGG for three months did not substantially modify the QIV humoral immunity. The combination of QIV and LGG reduced inflammatory responses (i.e., IFN-γ, IL17A, IL-17F, IL-6, and TNF-α) from activated PBMCs of pediatric patients with T1D, without dampening the production of seroprotective antibodies. In conclusion, QIV is associated with an adequate immunogenicity in children and adolescents with T1D in presence of a good safety profile. Although a systematic administration of LGG did not result in an improvement of humoral responses to an influenza vaccine, the probiotic did induce important anti-inflammatory effects.

Linear Growth in Children and Adolescents with Type 1 Diabetes Mellitus.

Ensuring normal linear growth is one of the major therapeutic aims in the management of type one diabetes mellitus (T1DM) in children and adolescents. Many studies in the literature have shown that pediatric patients with T1DM frequently present some abnormalities in their growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis compared to their healthy peers. Data on the growth of T1DM children and adolescents are still discordant: Some studies have reported that T1DM populations, especially those whose diabetes began in early childhood, are taller than healthy pediatric populations at diagnosis, while other studies have not found any difference. Moreover, many reports have highlighted a growth impairment in T1DM patients of prepubertal and pubertal age, and this impairment seems to be influenced by suboptimal glycemic control and disease duration. However, the most recent data showed that children treated with modern intensive insulin therapies reach a normal final adult height. This narrative review aims to provide current knowledge regarding linear growth in children and adolescents with T1DM. Currently, the choice of the most appropriate therapeutic regimen to achieve a good insulin level and the best metabolic control for each patient, together with the regular measurement of growth parameters, remains the most important available tool for a pediatric diabetologist. Nevertheless, since new technologies are the therapy of choice in young children, especially those of pre-school age, it would be of great interest to evaluate their effects on the growth pattern of children with T1DM.

Environmental Factors Associated With Type 1 Diabetes.

Type 1 diabetes (T1D) is a chronic autoimmune disorder that leads to progressive pancreatic ß-cell destruction and culminates in absolute insulin deficiency and stable hyperglycaemia. It is very likely that environmental factors play a role in triggering islet autoimmunity. Knowing whether they have true relevance in favoring T1D development is essential for the effective prevention of the disease. Moreover, prevention could be obtained directly interfering with the development of autoimmunity through autoantigen-based immunotherapy. In this narrative review, the present possibilities for the prevention of T1D are discussed. Presently, interventions to prevent T1D are generally made in subjects in whom autoimmunity is already activated and autoantibodies against pancreatic cell components have been detected. Practically, the goal is to slow down the immune process by preserving the normal structure of the pancreatic islets for as long as possible. Unfortunately, presently methods able to avoid the risk of autoimmune activation are not available. Elimination of environmental factors associated with T1D development, reverse of epigenetic modifications that favor initiation of autoimmunity in subjects exposed to environmental factors and use of autoantigen-based immunotherapy are possible approaches, although for all these measures definitive conclusions cannot be drawn. However, the road is traced and it is possible that in a not so distant future an effective prevention of the disease to all the subjects at risk can be offered.

Flash Glucose Monitoring: A Review of the Literature with a Special Focus on Type 1 Diabetes.

In people with type 1 diabetes mellitus (T1DM), obtaining good glycemic control is essential to reduce the risk of acute and chronic complications. Frequent glucose monitoring allows the adjustment of insulin therapy to improve metabolic control with near-normal blood glucose concentrations. The recent development of innovative technological devices for the management of T1DM provides new opportunities for patients and health care professionals to improve glycemic control and quality of life. Currently, in addition to traditional self-monitoring of blood glucose (SMBG) through a glucometer, there are new strategies to measure glucose levels, including the detection of interstitial glucose through Continuous Glucose Monitoring (iCGM) or Flash Glucose Monitoring (FGM). In this review, we analyze current evidence on the efficacy and safety of FGM, with a special focus on T1DM. FGM is an effective tool with great potential for the management of T1DM both in the pediatric and adult population that can help patients to improve metabolic control and quality of life. Although FGM might not be included in the development of an artificial pancreas and some models of iCGM are more accurate than FGM and preferable in some specific situations, FGM represents a cheaper and valid alternative for selected patients. In fact, FGM provides significantly more data than the intermittent results obtained by SMBG, which may not capture intervals of extreme variability or nocturnal events. With the help of a log related to insulin doses, meal intake, physical activity and stress factors, people can achieve the full benefits of FGM and work together with health care professionals to act upon the information provided by the sensor. The graphs and trends available with FGM better allow an understanding of how different factors (e.g., physical activity, diet) impact glycemic control, consequently motivating patients to take charge of their health.

Efficacy and safety of the artificial pancreas in the paediatric population with type 1 diabetes.

BACKGROUND: Type 1 diabetes (DM1) is one of the most common chronic diseases in childhood and requires life-long insulin therapy and continuous health care support. An artificial pancreas (AP) or closed-loop system (CLS) have been developed with the aim of improving metabolic control without increasing the risk of hypoglycaemia in patients with DM1. As the impact of APs have been studied mainly in adults, the aim of this review is to evaluate the efficacy and safety of the AP in the paediatric population with DM1. MAIN BODY: The real advantage of a CLS compared to last-generation sensor-augmented pumps is the gradual modulation of basal insulin infusion in response to glycaemic variations (towards both hyperglycaemia and hypoglycaemia), which has the aim of improving the proportion of time spent in the target glucose range and reducing the mean glucose level without increasing the risk of hypoglycaemia. Some recent studies demonstrated that also in children and adolescents an AP is able to reduce the frequency of hypoglycaemic events, an important limiting factor in reaching good metabolic control, particularly overnight. However, the advantages of the AP in reducing hyperglycaemia, increasing the time spent in the target glycaemic range and thus reducing glycated haemoglobin are less clear and require more clinical trials in the paediatric population, in particular in younger children. CONCLUSIONS: Although the first results from bi-hormonal CLS are promising, long-term, head-to-head studies will have to prove their superiority over insulin-only approaches. More technological progress, the availability of more fast-acting insulin, further developments of algorithms that could improve glycaemic control after meals and physical activity are the most important challenges in reaching an optimal metabolic control with the use of the AP in children and adolescents.

Carbohydrate Counting in Children and Adolescents with Type 1 Diabetes.

Carbohydrate counting (CC) is a meal-planning tool for patients with type 1 diabetes (T1D) treated with a basal bolus insulin regimen by means of multiple daily injections or continuous subcutaneous insulin infusion. It is based on an awareness of foods that contain carbohydrates and their effect on blood glucose. The bolus insulin dose needed is obtained from the total amount of carbohydrates consumed at each meal and the insulin-to-carbohydrate ratio. Evidence suggests that CC may have positive effects on metabolic control and on reducing glycosylated haemoglobin concentration (HbA1c). Moreover, CC might reduce the frequency of hypoglycaemia. In addition, with CC the flexibility of meals and snacks allows children and teenagers to manage their T1D more effectively within their own lifestyles. CC and the bolus calculator can have possible beneficial effects in improving post-meal glucose, with a higher percentage of values within the target. Moreover, CC might be integrated with the counting of fat and protein to more accurately calculate the insulin bolus. In conclusion, in children and adolescents with T1D, CC may have a positive effect on metabolic control, might reduce hypoglycaemia events, improves quality of life, and seems to do so without influencing body mass index; however, more high-quality clinical trials are needed to confirm this positive impact.

Eating Disorders and Disordered Eating Symptoms in Adolescents with Type 1 Diabetes.

Eating problems in adolescents with type 1 diabetes (T1D) can be divided into two groups. The first includes the diagnosed eating disorders (EDs), i.e., diseases specifically identified by defined signs and symptoms for which a degree of severity has been established, such as anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, and rumination. The second is the group of disordered eating symptoms (DES), which include behaviors such as dieting for weight loss, binge eating, self-induced vomiting, excessive exercise, and laxative or diuretic use; these behaviors cannot be categorized as complete diseases, and, although apparently mild, they must be closely evaluated because they can evolve into true EDs. In this review, present knowledge about the clinical relevance of EDs and DES and the possible preventive and therapeutic measures used to reduce their impact on the course of T1D will be discussed. As adolescents with diabetes are at higher risk of eating disturbances and consequently for higher rates of disease complications, care providers should pay attention to clinical warning signs that raise suspicion of disturbed eating to refer these patients early to an expert in nutrition and mental health disorders. To ensure the best care for adolescents with T1D, diabetes teams should be multidisciplinary and include a pediatric diabetologist, a skilled nurse, a dietician, and a psychologist.