Managing type 1 diabetes in children and young people: challenges and solutions
Intended for healthcare professionals
CPD    

Managing type 1 diabetes in children and young people: challenges and solutions

Val Wilson Independent diabetes author and researcher,

Why you should read this article:
  • To recognise that effective self-management is crucial for children and young people with type 1 diabetes

  • To enhance your awareness of the challenges of managing type 1 diabetes during school hours

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Type 1 diabetes is the most common form of diabetes in school-age children. Effective management and self-management at home and during school hours are essential to improve the quality of life of children and young people and reduce their risk of developing complications such as cardiovascular disease and kidney disease. There are, however, multiple barriers to effective management and self-management, notably in adolescence. Interventions, education and support based on clear psychoeducational principles improve the outcomes of children and young people. This article explores type 1 diabetes including its causes and risk factors, presentation and diagnosis, complications and comorbidities, and treatment and management. It focuses in particular on the role of nurses in supporting self-management and on the challenges of type 1 diabetes care in school.

Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1465

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

Correspondence

drvwilson@gmail.com

Conflict of interest

None declared

Wilson V (2023) Managing type 1 diabetes in children and young people: challenges and solutions. Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1465

Published online: 05 June 2023

Aims and intended learning outcomes

The aim of this article is to assist nurses to support children and young people with type 1 diabetes management. After reading this article and completing the time out activities you should be able to:

  • Describe the main symptoms and clinical presentation of type 1 diabetes.

  • Identify children and young people with type 1 diabetes who may be at increased risk of developing diabetes complications.

  • Explain the challenges of type 1 diabetes management and self-management for children and young people and their families and carers.

  • Outline the crucial elements of effective self-management of type 1 diabetes.

Introduction

Type 1 diabetes is an autoimmune disease caused by continuous destruction of insulin-producing pancreatic beta cells. It is a chronic, irreversible condition requiring the regular administration of insulin to control blood glucose levels (NHS 2021). Type 1 diabetes is the most common form of diabetes in school-age children and it is estimated that 29,000 children and young people in the UK live with the condition (Juvenile Diabetes Research Foundation (JDRF) 2022). To minimise the risk of long-term complications and improve quality of life, it is crucial that every child and young person with type 1 diabetes receives appropriate care and support from diagnosis onwards.

Causes and risk factors

In type 1 diabetes, antibodies attack the insulin-producing islet beta cells in the pancreas. Once a certain number of cells have been destroyed, the lack of insulin leads to a failure of the body to regulate blood glucose levels and exogenous insulin administration is warranted (Toren et al 2021, Diabetes UK 2023).

Risk factors for type 1 diabetes include:

  • Genetic factors – Type 1 diabetes is a heritable polygenic disease. The child of a parent with type 1 diabetes has a 1-9% risk of developing it. For siblings, the risk is 6-7%, increasing to 30-70% in identical twins (National Institute for Health and Care Excellence (NICE) 2023).

  • Environmental factors – In genetically susceptible people, certain environmental factors can trigger the development of an autoimmune reaction to pancreatic beta cells. These factors include diet, vitamin D exposure, obesity, decreased gut-microbiome diversity and early-life exposure to viruses associated with islet inflammation (NICE 2023). Several viruses have been associated with type 1 diabetes, the strongest evidence being for human enteroviruses (Morse and Horwitz 2021), which enter the human body via the gut and spread because of suboptimal hygiene or sanitation.

  • Ethnicity – Type 1 diabetes is more common among white children than among children from non-white ethnic backgrounds (Centers for Disease Control and Prevention 2021).

Time Out 1

Before reading on, list as many signs, symptoms and chronic complications of type 1 diabetes in children and young possible as you can think of. Then read the next two sections of the article and compare your list with what the article says

Key points

  • Type 1 diabetes is a chronic, irreversible condition and the most common form of diabetes in school-age children

  • Effective management and self-management of type 1 diabetes are essential to prevent complications

  • In adolescence, management and self-management of type 1 diabetes may be impaired by hormonal variations and lack of adherence to treatment

  • Supportive relationships with healthcare professionals assist children and young people to self-manage type 1 diabetes

  • Schools need to recognise the needs of pupils with type 1 diabetes and work in partnership with families and diabetes specialist nurses

Presentation and diagnosis

The peak incidence of type 1 diabetes is between the ages of four years and six years and between the ages of ten years and 14 years; 45% of children with type 1 diabetes present with the condition before the age of ten years (Shah and Nadeau 2020).

Signs and symptoms of type 1 diabetes in children and young people include (NICE 2022):

  • Increased thirst or dehydration.

  • Frequent or increased urination.

  • Excessive tiredness or fatigue.

  • Blurred vision.

  • Cuts and scratches taking longer than usual to heal.

  • Unexplained weight loss.

  • Vomiting.

  • Abdominal pain.

  • Reduced level of consciousness.

If type 1 diabetes is suspected, the child or young person must be immediately referred, that same day, to a multidisciplinary children’s diabetes team for confirmation of the diagnosis and initiation of treatment (NICE 2022). Type 1 diabetes should be confirmed using the World Health Organization (2019) guidance on the diagnosis and classification of diabetes mellitus. It should be assumed that the child or young person has type 1 diabetes unless there are indicators suggesting the presence of type 2 diabetes, monogenic diabetes or mitochondrial diabetes. NICE (2015) recommends that capillary blood glucose should be measured at presentation with the classic symptoms of type 1 diabetes.

Being overweight is increasingly common in children and young people with type 1 diabetes, as well as those with type 2 diabetes. In overweight children and young people, the clinical presentation of type 1 or type 2 diabetes may overlap (Minges et al 2013). In the past, children and young people with type 1 diabetes would present with dramatic weight loss due to cell starvation. Today, if the child or young person is overweight when they contract a virus that triggers type 1 diabetes, the suspicion may be, at first, that they have type 2 diabetes. The distinction between type 1 diabetes and type 2 diabetes is ultimately made through antibody testing. In type 1 diabetes, autoantibodies are markers of beta cell autoimmunity (Minges et al 2013).

NICE (2015) advises not to measure C-peptide levels to distinguish between type 1 and type 2 diabetes. However, measuring C-peptide levels should be considered to distinguish between type 1 diabetes and other diabetes types. Genetic testing to investigate the possibility of monogenic diabetes should be undertaken when presentation or clinical characteristics are atypical and when there is a family history.

Complications and comorbidities

Having type 1 diabetes (or type 2 diabetes) from an early age reduces quality of life and life expectancy due to changes in metabolic parameters affecting glycaemic control and the development of chronic complications (Rawshani et al 2017). Like type 2 diabetes, type 1 diabetes is associated with complications and comorbidities including cardiovascular disease, diabetic retinopathy leading to blindness, end-stage kidney disease and limb amputations. It is often accompanied by the onset of other autoimmune conditions, such as thyroid and/or coeliac disease, Addison’s disease and hypertension (NICE 2022).

Among young people with a similar body mass index, those with type 1 diabetes (or type 2 diabetes) have been shown to have cardiovascular deficiencies that are not present in those who do not have diabetes. These deficiencies include increased ventricular mass, impaired filling of the heart during diastole, reduced cardiopulmonary fitness, decreased blood flow to the limbs and increased kidney filtration (Bjornstad et al 2015, Koren et al 2015, Bacha et al 2016, Cree-Green et al 2019).

NICE (2015) advises that children and young people with type 1 diabetes should receive:

  • Ongoing monitoring until adulthood for thyroid disease.

  • Annual monitoring from the age of 12 years for moderately increased albuminuria to detect diabetic kidney disease.

  • Annual monitoring from the age of 12 years for hypertension.

Undiagnosed type 1 diabetes – or omitted insulin administration – can prompt acute and life-threatening complications such as diabetic ketoacidosis and hyperosmolar hyperglycaemic state, which have a distinctly different pathophysiology but fundamentally the same management protocol (Muneer and Akbar 2020).

Time Out 2

Find out more about the sources of support for children and young people newly diagnosed with type 1 diabetes and their parents by visiting https://jdrf.org.uk/information-support/newly-diagnosed/support-newly-diagnosed-children. What do you think are the main areas of information that need to be discussed with newly diagnosed patients and their families?

Treatment and management

The essential treatment for type 1 diabetes is insulin administration. Intensive administration via multiple daily injections or an insulin pump provides basal and meal bolus insulin, thereby improving glycaemic control (Karges et al 2017). However, exogenous insulin does not quite mimic physiologic insulin, despite advances in insulin pump and glucose sensor technologies. Research is therefore under way to produce super-fast insulins that will instantly respond to a rise in plasma glucose levels but stop acting when glucose levels fall too low (De Ridder et al 2019).

The management of type 1 diabetes in childhood – similarly to that of type 2 diabetes – involves achieving the best possible glycaemic and weight control through a healthy diet and regular exercise. However, few studies have shown that there is value in lifestyle modifications in children and young people with diabetes and many, if not most, young patients do not meet blood glucose targets (Wood et al 2013, Hamman et al 2014). A level of glycated haemoglobin (HbA1c) above 6.5% increases the risk of chronic complications, but with hormonal instability in puberty, HbA1c targets are often challenging to achieve. Furthermore, strict glycaemic control increases the incidence of hypoglycaemia, but hyperglycaemia triggers microvascular and macrovascular complications of diabetes. In type 1 diabetes, hypoglycaemia is correlated with cellular resistance to insulin and failure of the pancreatic islet beta cells (Chan et al 2017), as well as with weight gain. A steady and balanced glycaemic control is needed to reduce low blood glucose levels and minimise or prevent weight increase.

Blood glucose monitoring is essential in the management of type 1 diabetes. Children and young people as well as their parents and carers need to understand the optimal target ranges for short-term plasma glucose. According to NICE (2015), blood glucose levels should ideally be:

  • Between 4 to 7mmol/L on waking, before a meal and at any other time of day (fasting glucose).

  • Between 5 to 9mmol/L after meals.

Children and young people and their parents and carers should be supported to develop a practical understanding of an optimal diet for diabetes management that includes low-glycaemic-index foods, fruit and vegetables and healthy types of fats; encouraged to make healthy food choices; and prompted to regularly discuss diet with healthcare professionals (NICE 2015). While children and young people with type 1 diabetes can eat the same as their peers with dose adjustment for normal eating, there may be social and cultural considerations that need to be discussed when giving dietary advice.

For children and young people who experience frequent and unpredictable hypoglycaemia and/or emotional distress while trying to reach blood glucose and HbA1c targets, real-time continuous glucose monitoring should be considered. Continuous glucose monitoring was licensed for use in children aged four years and over in March 2022 (NICE 2022). Patients and their families and carers will need education and support to use the technology.

Time Out 3

List five psychosocial issues related to type 1 diabetes in children and young people that tend to increase anxiety and stress for their parents and carers. How can nurses help ease these anxieties and stress?

Psychosocial issues

There are multiple barriers to effective management and self-management of type 1 diabetes (Wilson 2019), notably in adolescence, when management and self-management may be impaired by hormonal variations and a lack of adherence to treatment or lifestyle modifications. Type 1 diabetes often negatively affects body image, especially in adolescents, who will feel different from their peers. Disordered eating and unhealthy methods of weight control such as insulin omission can become habitual, and lifetime dependence on insulin can be experienced as reducing self-worth and the sense of belonging. Anxiety and depression can contribute to behavioural issues such as rebellion against, and problems with, glycaemic control (Wilson 2022a).

The management of type 1 diabetes in children and young people places a considerable burden on parents and carers, potentially causing high levels of anxiety and stress (Moghadam et al 2022). However, the involvement of parents and carers is important for (Copeland et al 2013):

  • Ensuring the child or young person’s normal development and growth.

  • Initiating and maintaining healthy eating and exercise routines.

  • Ensuring the child or young person undergoes regular blood glucose testing.

  • Ensuring the child or young person receives their insulin treatment if and when needed.

  • Providing coping strategies to manage the fear of hypoglycaemia if diabetes is treated with insulin.

  • Ensuring the diabetes management needs of the child or young person are addressed in school.

Parents and carers supporting adolescents with type 1 diabetes will also be responsible for managing:

  • Physiological factors linked with hormonal changes, which make diabetes management more difficult.

  • Psychological issues arising in young people due to the changes they undergo in adolescence.

  • Young people’s dependence on adults at a time in their life when they are striving for independence.

Time Out 4

Use an RCN online learning resource (https://www.rcn.org.uk/clinical-topics/Diabetes/Diabetes-essentials#healthcareprofessionals-rolesandresponsibilities) to find out more about the role of the nursing team in treating people with diabetes. How would you describe your role in the care of children and young people with diabetes?

Role of nurses and self-management

Beyond detecting diabetes and enabling prompt diagnosis and initiation of treatment, nurses provide essential support to patients and their families and carers in managing type 1 diabetes and navigating its challenges. The chronic complications of the condition contribute to excess morbidity and mortality, but education on effective self-management can prevent or delay their onset. Patients need a self-management strategy to live a long and healthy life. The children’s diabetes specialist nurse has a crucial role in engaging patients, families and carers in self-management and in encouraging them to take ownership of the condition.

Glucose and HbA1c targets can be challenging for a young person with type 1 diabetes to meet and the role of nurses may include agreeing on a compromise with the patient. If efforts to control blood glucose levels lead to increased hypoglycaemia and/or distress, more achievable targets need to be agreed. The role of nurses includes explaining to young people and their families and carers the benefits of keeping HbA1c within acceptable limits without increasing hypoglycaemic episodes, and how to reduce and treat hypoglycaemia.

Enhancing type 1 diabetes self-management involves other parties, including school nurses and social care teams. Currie et al (2013) suggested that adherence to an effective self-management routine can be determined by contacting the patient’s GP to determine how often prescription requests are made. However, if the patient and their family feel that they are not believed and that they are being ‘checked up on’, this can lead to suboptimal relationships with healthcare professionals and non-adherence (Wilson 2022a).

Supportive relationships with healthcare professionals and carers have been described as the most beneficial elements in assisting young people to self-manage their condition. In a study by Ayala et al (2014), parents of children with type 1 diabetes described a partnership with healthcare professionals as crucial and reported that the partnership was enhanced when healthcare professionals were able to:

  • Understand what it means to live with type 1 diabetes.

  • Connect with the family and invite open communication on all aspects of family life related to diabetes and diabetes care.

  • Interact with empathy and respond therapeutically to the family’s emotional needs.

  • Recognise when they needed to assume a leading role in management.

The Royal College of Nursing (2022) has laid out the roles and responsibilities of healthcare professionals in diabetes management. In England and Wales, TREND-UK (Training, Research and Education for Nurses in Diabetes), Diabetes UK, WAND (Welsh Academy for Nursing in Diabetes) and representatives of diabetes specialist nurses and higher education institutions have developed a competency framework that incorporates diabetes-specific nursing outcomes in a clear pathway for career development (Royal College of Nursing 2022).

Time Out 5

There are several areas of concern for parents about their child’s diabetes care during school hours. Identify three actions you could take in clinical practice to explore these concerns and help parents address them

Type 1 diabetes care in schools

Optimal management of type 1 diabetes is needed in schools (Department of Health 2007, Royal College of Nursing 2013, NICE 2022). Type 1 diabetes is a ‘hidden disability’, meaning that the condition must be known to the school to ensure the child’s needs are met. Children should be able to participate safely in all school activities, undertake glucose testing, eat appropriately and administer insulin – or be supported to do so – as necessary. School staff need to understand the care requirements of children with type 1 diabetes and support them to self-manage their condition. Children aged between four years and 11 years may require the assistance of a designated adult for diabetes care during school hours.

In its guidance on managing medicines in schools and early years settings, the Department for Education and Skills (2005) stated: ‘If a child’s medical needs are inadequately supported this may have a significant impact on a child’s experiences and the way they function in or out of school or a setting’. However, since this guidance was issued little appears to have changed to improve support for type 1 diabetes self-management in schools. Wilson (2019) identified several areas of concern for parents of children with type 1 diabetes regarding diabetes care at school:

  • Making the school and its staff aware of the child’s condition.

  • Ensuring the child’s diabetes care is provided while they are at school.

  • Developing a school diabetes care plan and raising awareness of that plan among staff.

  • Involving the child/young person’s diabetes specialist nurse.

  • Accessing a named member of staff for assistance.

  • Blood glucose monitoring at school.

  • Injecting insulin at school.

  • Correct use of insulin pump therapy at school.

  • Administering insulin pump boluses at school.

  • Participation in extracurricular activities.

  • Bullying because of diabetes.

It is imperative that schools recognise the needs of children with type 1 diabetes and work in partnership with the children, their parents and carers, and diabetes specialist nurses (Wilson 2022a, 2022b).

Time Out 6

How would you explain diabetes management to school staff? For inspiration, you can access the National Education Union’s guidance for school staff to support the uninterrupted education of children with diabetes (https://neu.org.uk/advice/diabetes-schools).

School care plan

Several studies have focused on the self-management of type 1 diabetes in schools. In a systematic review, Edwards et al (2014) explored barriers to, and facilitators of, optimal self-management of type 1 diabetes in UK schoolchildren. In 55 of the included studies, less than half of children had a written care plan, while diabetes self-management activities during school hours had been overlooked in school policies. However, school nurses felt that it was important to facilitate for type 1 diabetes emergency events (Edwards et al 2014).

Dietary management

The timing and availability of school meals are the most common concerns among children with type 1 diabetes and their parents and carers regarding diabetes care in schools. Children with type 1 diabetes need to eat at certain times to match insulin peak working times, although this is more manageable with basal/bolus insulin regimens. Edwards et al (2014) found that 75% of primary school and almost 65% of secondary school teaching staff did not understand why children taking insulin needed to eat on time. Healthy snacks and meals from vending machines, the school canteen and nearby shops were somewhat limited (Edwards et al 2014). Furthermore, while at school, children with type 1 diabetes need to know what the food on offer contains so that they can assess its carbohydrate content and take the correct amount of insulin. This involves prominent and consistent food labelling.

Blood glucose monitoring

Children aged between five years and 11 years can be supported to self-monitor their blood glucose levels during school hours. Edwards et al (2014) noted that children younger than ten years had reported needing assistance with blood glucose monitoring while at school. This was usually the role of the school nurse, but there are fewer and fewer school nurses. Edwards et al (2014) noted that, in some instances, a designated staff member would offer guidance and that in other cases parents had to come to the school to ensure blood glucose testing was carried out. In secondary school, children generally required less assistance with blood glucose monitoring (Edwards et al 2014).

Insulin administration

Injecting insulin or administrating a bolus of insulin via an insulin pump can prove problematic in schools. Teaching staff may not be aware of what to do in a supervisory or guidance capacity, or they may not feel that it is within their remit to assist pupils with type 1 diabetes care. Furthermore, the school nurse may not have been trained in that area. Children and young people are often responsible for their own diabetes care and insulin administration, especially those aged 11 years and over. Edwards et al (2014) noted that older children would independently administer insulin wherever convenient – in the school toilets, for example – but that children up to the age of five years required supervision to do so. In many cases, parents had to come to the school to bring an injection kit and oversee insulin administration (Edwards et al 2014).

Use of diabetes management technology

Some children manage type 1 diabetes with an insulin pump and/or a continuous glucose monitoring sensor placed under the skin. Although children and young people are proficient in using diabetes management technology, younger children may require support with mealtime insulin bolus administration. Insulin pump therapy and/or continuous glucose monitoring are prescribed to improve diabetes self-management and quality of life and it is imperative that they continue to be used during school hours (Wilson 2019).

Access to glucagon injection

Rapid access to a glucagon injection is critical in the event of severe hypoglycaemia to avoid severe acquired brain damage (The Royal Children’s Hospital Melbourne 2019). Edwards et al (2014) found that fewer than 50% of children in UK schools had access to a glucagon injection in the event of severe hypoglycaemia. Sixty per cent of children and parents felt that the availability of a glucagon injection, and of a person who would know how administer it – was a necessity. School staff thought that if a child developed severe hypoglycaemia emergency services should be called. Only 10% of children in Edwards et al’s (2014) systematic review had experienced a serious hypoglycaemic episode while at school. Edwards et al’s (2014) systematic review is the only available study mentioning access to glucagon in UK schools and it is possible that the situation has changed since it was published.

Access to blood glucose monitoring equipment and snacks

Access to blood glucose monitoring equipment and snacks is important for children with type 1 diabetes to address low glucose levels as soon as possible (Wilson 2019). This can be problematic if the child does not carry testing equipment, glucose tablets or snacks with them during the school day, or if these items are stored in a locker or the nurse’s room. Even if a child or young person is prepared for hypoglycaemia and parents have provided snacks in their school bag, children have reported not being permitted to eat in the classroom or finding it difficult to eat a snack before engaging in physical activity (Edwards et al 2014).

Flexibility over tests and exams

Older children and young adults with type 1 diabetes may experience unpredictable hypoglycaemia or hyperglycaemia before a test or exam, which may compound their anxiety and that of their parents. Edwards et al (2014) noted that 23-39% of children aged over 11 years had not been able to retake an exam if they had experienced hypoglycaemia before or during it. Special allowances for these situations were not documented.

Extracurricular activities

Type 1 diabetes can affect families’ decisions about participating in extracurricular activities. While parents may feel more reassured if they accompany their child on school trips and excursions, this should not be a prerequisite for children’s participation (American Diabetes Association 2012). Edwards et al (2014) noted that 15-20% of parents reported challenges concerning who was responsible for their child during school trips, especially in the case of children younger than ten years. In some instances, the issue of responsibility prevented participation in extracurricular activities.

Psychosocial considerations

Children and young people with type 1 diabetes experience challenges such as altered body image and reduced self-worth. Having type 1 diabetes can make them feel different from their peers and cause embarrassment, potentially leading to suboptimal self-management. Edwards et al (2014) reported that for children aged over 12 years, drawing attention to the need to inject insulin, carry out glucose testing or eat had resulted in them being picked on, bullied or teased. As a result, these children only told a few close and trusted friends about their condition and its management requirements. On one hand, this ‘safety net’ translated into improved HbA1c levels and an improved quality of life due to peace of mind (Edwards et al 2014). On the other hand, if a child feels discriminated against they may develop psychosocial issues leading to alienation.

Further Resources

Royal College of Nursing – Diabetes Essentials

www.rcn.org.uk/clinical-topics/diabetes/diabetes-essentials

Conclusion

There are many challenges to the effective management and self-management of type 1 diabetes in children and young people, including during the school day. Children and young people with type 1 diabetes require optimal diabetes care and support from healthcare professionals and school staff, including education and encouragement to self-manage. Self-management must be integrated into all aspects of patient education. This will support children and young people to maximise their potential, maintain an equal footing with their peers and access educational opportunities and extracurricular activities.

Time Out 7

Identify how improving the management and self-management type 1 diabetes in children and young people applies to your practice and the requirements of your regulatory body

Time Out 8

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

References

  1. American Diabetes Association (2012) Diabetes care in the school and day care setting. Diabetes Care. 35, Suppl 1, S76-S80. doi: 10.2337/dc12-s076
  2. Ayala J, Howe C, Dumser S et al (2014) Partnerships with providers: reflections from parents of children with type 1 diabetes. Western Journal of Nursing Research. 36, 9, 1238-1253. doi: 10.1177/0193945913518848
  3. Bacha F, Gidding SS, Pyle L et al (2016) Relationship of cardiac structure and function to cardiorespiratory fitness and lean body mass in adolescents and young adults with type 2 diabetes. Journal of Pediatrics. 177, 159-166.e1. doi: 10.1016/j.jpeds.2016.06.048
  4. Bjornstad P, Lanaspa MA, Ishimoto T et al (2015) Fructose and uric acid in diabetic nephropathy. Diabetologia. 58, 9, 1993-2002. doi: 10.1007/s00125-015-3650-4
  5. Centers for Disease Control and Prevention (2021) New Research Uncovers Concerning Increases in Youth Living with Diabetes in the U.S. http://www.cdc.gov/media/releases/2021/p0824-youth-diabetes.html#:∼:text=Type%201%20diabetes%20remains%20more,racial%20or%20ethnic%20minority%20groups (Last accessed: 15 March 2023.)
  6. Chan CL, Pyle L, Morehead R et al (2017) The role of glycemia in insulin resistance in youth with type 1 and type 2 diabetes. Pediatric Diabetes. 18, 6, 470-477. doi: 10.1111/pedi.12422
  7. Copeland KC, Silverstein J, Moore KR et al (2013) Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. American Academy of Pediatrics 131, 2, 364-382. doi: 10.1542/peds.2012-3494
  8. Cree-Green M, Bergman BC, Cengiz E et al (2019) Metformin improves peripheral insulin sensitivity in youth with type 1 diabetes. Journal of Clinical Endocrinology & Metabolism. 104, 8, 3265-3278. doi: 10.1210/jc.2019-00129
  9. Currie CJ, Peyrot M, Morgan CL et al (2013) The impact of treatment non-compliance on mortality in people with type 1 diabetes. Journal of Diabetes and its Complications. 27, 3, 219-223. doi: 10.1016/j.jdiacomp.2012.10.006
  10. De Ridder F, den Brinker M, De Block C (2019) The road from intermittently scanned glucose monitoring to hybrid closed-loop systems: part A. Keys to success: subject profiles, choice of systems, education. Therapeutic Advances in Endocrinology and Metabolism. 10, 2042018819865399. doi: 10.1177/2042018819865399
  11. Department for Education and Skills (2005) Managing Medicines in Schools and Early Years Settings. DfES, London.
  12. Department of Health (2007) Making Every Young Person with Diabetes Matter. DH, London.
  13. Diabetes UK (2023) Type 1 Diabetes. http://diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-1 (Last accessed: 15 March 2023.)
  14. Edwards D, Noyes J, Lowes L et al (2014) An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings. BMC Pediatrics. 14, 228. doi: 10.1186/1471-2431-14-228
  15. Hamman RF, Bell RA, Dabelea D et al (2014) The SEARCH for Diabetes in Youth study: rationale, findings, and future directions. Diabetes Care. 37, 12, 3336-3344. doi: 10.2337/dc14-0574
  16. Juvenile Diabetes Research Foundation (2022) Type 1 Diabetes Facts and Figures. http://jdrf.org.uk/information-support/about-type-1-diabetes/facts-and-figures (Last accessed: 15 March 2023.)
  17. Karges B, Schwandt A, Heidtmann B et al (2017) Association of insulin pump therapy vs insulin injection with severe hypoglycemia, ketoacidosis, and glycemic control among children, adolescents, and young adults with type 1 diabetes. JAMA. 318, 14, 1358-1366. doi: 10.1001/jama.2017.13994
  18. Koren D, Chirinos JA, Katz LE et al (2015) Interrelationships between obesity, obstructive sleep apnea syndrome and cardiovascular risk in obese adolescents. International Journal of Obesity. 39, 1086-1093. doi: 10.1038/ijo.2015.67
  19. Minges KE, Whittemore R, Grey M (2013) Overweight and obesity in youth with type 1 diabetes. Annual Review of Nursing Research. 31, 47-69. doi: 10.1891/0739-6686.31.47
  20. Moghadam YH, Zeinaly Z, Alhani F (2022) How mothers of a child with type 1 diabetes cope with the burden of care: a qualitative study. BMC Endocrine Disorders. 22, 1, 129. doi: 10.1186/s12902-022-01045-z
  21. Morse ZJ, Horwitz MS (2021) Virus infection is an instigator of intestinal dysbiosis leading to type 1 diabetes. Frontiers in Immunology. 12, 751337. doi: 10.3389/fimmu.2021.751337
  22. Muneer M, Akbar I (2020) Acute metabolic emergencies in diabetes: DKS, HHS and EDKA. In Islam MS (Ed) Diabetes: From Research to Clinical Practice. Springer, Cham, 85-114.
  23. NHS (2021) What is Type 1 Diabetes? http://www.nhs.uk/conditions/type-1-diabetes/about-type-1-diabetes/what-is-type-1-diabetes (Last accessed: 15 March 2023.)
  24. National Institute for Health and Care Excellence (2022) Diabetes (Type 1 and Type 2) in Children and Young People: Diagnosis and Management. NICE guideline No. 18. NICE, London.
  25. National Institute for Health and Care Excellence (2023) Diabetes Type 1: What Are the Causes and Risk Factors? http://cks.nice.org.uk/topics/diabetes-type-1/background-information/causes-risk-factors (Last accessed: 15 March 2023.)
  26. Rawshani A, Rawshani A, Franzén S et al (2017) Mortality and cardiovascular disease in type 1 and type 2 diabetes. NEJM. 376, 15, 1407-1418. doi: 10.1056/NEJMoa1608664
  27. The Royal Children’s Hospital Melbourne (2019) Clinical Practice Guidelines: Hypoglycaemia. http://www.rch.org.au/clinicalguide/guideline_index/Hypoglycaemia (Last accessed: 15 March 2023.)
  28. Royal College of Nursing (2013) Supporting Children and Young People with Diabetes. RCN Guidance for Nurses in Schools and Early Years Settings. RCN, London.
  29. Royal College of Nursing (2022) Diabetes Essentials: Healthcare Professionals – Roles and Responsibilities. http://rcn.org.uk/clinical-topics/diabetes/diabetes-essentials#healthcareprofessionals-rolesandresponsibilities (Last accessed: 15 March 2023.)
  30. Shah AS, Nadeau KJ (2020) The changing face of paediatric diabetes. Diabetologia. 63, 4, 683-691. doi: 10.1007/s00125-019-05075-6
  31. Toren L, Burnette KS, Banerjee RR et al (2021) Partners in crime: beta-cells and autoimmune responses complicit in type 1 diabetes pathogenesis. Frontiers in Immunology. 12, 756548. doi: 10.3389/fimmu.2021.756548
  32. Wilson VL (2019) How to Live Well with Diabetes: A Comprehensive Guide to Taking Control of Your Life with Diabetes. Robinson, London.
  33. Wilson VL (2022a) Psychology in Diabetes Care and Practice. Routledge, Abingdon.
  34. Wilson V (2022b) COVID-19 and diabetes: onset and challenges in management. Primary Health Care. doi: 10.7748/phc.2022.e1766
  35. Wood JR, Miller KM, Maahs DM et al (2013) Most youth with type 1 diabetes in the T1D Exchange Clinic Registry do not meet American Diabetes Association or International Society for Pediatric and Adolescent Diabetes clinical guidelines. Diabetes Care. 36, 7, 2035-2037. doi: 10.2337/dc12-1959
  36. World Health Organization (2019) Classification of Diabetes Mellitus. http://www.who.int/publications/i/item/classification-of-diabetes-mellitus (Last accessed: 15 March 2023.)

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