Kids in Lockdown: How COVID-19 Affected Children with Type 1 Diabetes

ENDO 2021 presented a plethora of research detailing how COVID-19 impacted a number of endocrine comorbidities. However, two studies in particular took a closer look at how the virus impacted pediatric patients with type 1 diabetes.

Each year, ENDO is something of an “embarrassment of riches” because it consists of four days packed with the latest cutting-edge research that presents groundbreaking new ideas that not only advance the science and practice of endocrinology but serves to advance human health worldwide. This year’s first all-virtual conference was certainly no different as ENDO 2021 saw new studies that delved into particular facets of type 1 diabetes previously not studied.

Not surprisingly, two of these studies were impacted by the COVID-19 pandemic as they examined how the virus (the social implications as well as the disease itself) affected pediatric patients with type 1 diabetes. In each of these areas, the research represents important gains in our collective understanding of this complex and elusive disease.

As one of the researchers put it, “due to the difference in epidemiologic and comorbidity profiles between type 1 diabetes and other types of diabetes, it is important to investigate factors affecting this unique group.”

Glycemic Control During Lockdown

While studying children and teenagers with type 1 diabetes at Doncaster and Bassetlaw Teaching Hospitals, Neil Lawrence, MBChB, of Sheffield Children’s Hospital NHS Foundation Trust in Sheffield, United Kingdom, and team found a silver lining of the nationwide lockdown in the UK last year.

They compared diabetic glycemic control for a three-month period before the lockdown, from December 2019 to March 2020, with the kids’ glycemic control for a three-month period during the UK’s first lockdown, from April 2020 through June 2020. Their study group was 80 patients under age 19 (median age 13.6) years who had either continuous glucose monitors (CGMs) with the Dexcom system or the FreeStyle Libre 14-day Flash Glucose Monitoring System as well as those with regular blood sugar monitoring with intermittent measures. From the data uploaded automatically into their online systems, they saw significant differences before and during lockdown. “The average blood sugar decreased from 9.7 to 9.5 mmol/L in those with CGMs, and the variability of their blood sugars decreased as well. The average standard deviation of went down from 4. 4 to 4.1 after the lockdown,” Lawrence explains.

“There is some data available that shows both type 1 and type 2 diabetes can be associated with increased risk of complications with COVID-19 in adults as well as independently associated with a higher risk of in hospital death from COVID-19, but there is very limited data available for pediatric type 1 diabetes and COVID-19 infections.” –  Manish Raisingani, MD, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Ark.

The team also took a look at the hemoglobin A1c (HbA1c), this time in a larger cohort of 120 patients, before and after lockdown and found significant decreases there as well, from 67.4 mmol/L to 61.3 mmol/L. “It’s important to mention that these are children and so you have to consider the honeymoon period after diagnosis, but we did exclude all children that had been diagnosed in the 12 months prior to the beginning of the first period we looked at, so that is not including any honeymoon effects; we’re truly seeing a significant lowering of the HbA1c,” Lawrence says. He further explained that results were not skewed by increased time in hypoglycemia because they looked at the percentage time in range in those with CGMs on. “Again, we saw that the time below range in hypoglycemia didn’t actually change, but we did see a significant increase in the time spent in range from 55% all the way through to 58% following lockdown, so this change in HbA1c was driven by higher time in range.”

What struck Lawrence and team was that the service adaptations they were forced to make because of the lockdown did not pose a detriment to glycemic control. Although they had to cancel in-person appointments with the exception of extenuating circumstances, they increased telehealth appointments. “There was a significant difference in how we were interacting with the patients. Face-to-face consultations decreased from 245 in the period before to 151 afterward, but in replacement for this, we increased contacts via either video or phone consultations from 1,700 to 2,200 between the periods,” Lawrence says. “At the time, we worried that these sorts of changes to the service would have detrimental effects on glycemic control, but as we’ve seen from the data, this wasn’t the case. Control got better.”

Other service adaptations included a drive-thru clinic where patients could get their HbA1c measured using the point-of-care analysis they used in in-person clinic as well as upload data from their monitors there for those who lacked the appropriate equipment to do so at home.

While the study outcome is certainly a beneficial one, that study underscores a difficult truth about type 1 diabetes: how challenging it is to manage the disease out in the world. “This is a behavioral disease,” Lawrence says, “and the increased time at home and perhaps the increased anxiety about health during the first lockdown improved control.”

Lawrence and team believe that continuing to connect with patients via telehealth and other methods of convenient service provision in the future is our best hope to sustain the trend of improved glycemic control in young people.

Poor Diabetes Control in Children Associated with Worse COVID-19 Outcomes

Manish Raisingani, MD, of the University of Arkansas for Medical Sciences and Arkansas Children’s in Little Rock, Ark., presented his team’s findings on the risk of complications in children with type 1 diabetes and COVID-19. “There is some data available that shows both type 1 and type 2 diabetes can be associated with increased risk of complications with COVID-19 in adults as well as independently associated with a higher risk of in hospital death from COVID-19, but there is very limited data available for pediatric type 1 diabetes and COVID-19 infections,” Raisingani says.

Using the international TriNet X database that collects real-time information from the electronic health records of COVID-19 patients from over 31 countries, the researchers zeroed in on children ages 0 to 18 years diagnosed with COVID-19 infection with and without type 1 diabetes, looking for complications of mortality, sepsis, and intubation.

Of the 500,000 kids with COVID-19 but no type 1 diabetes, 235 died, a 0.047% mortality rate. Of the 3,000 kids with COVID-19 infection and type 1 diabetes, 10 died, giving a much higher mortality rate of 0.328% and a seven times higher relative risk of dying. Extracting the children whose HbA1c was ≥9% (poorly controlled), the relative risk of dying from COVID-19 infection jumps to about 15 times higher. “The higher the HbA1c, the higher the risk of dying with COVID-19 infection,” Raisingani says. The 482 kids with well-controlled type 1 diabetes, defined as HbA1c ≤7%, had 0 deaths from COVID-19 infection, which is similar to mortality rates in the general population.

Regarding sepsis, 575 children without type 1 diabetes developed this complication, a 0.114% risk, relative risk of 1.0. In those with type 1 diabetes, the risk of developing sepsis was 0.492%, with a relative risk of 4.3, a significantly higher risk. Once more, of those whose type 1 diabetes is well controlled, 0 developed sepsis.

“It’s important to mention that these are children and so you have to consider the honeymoon period after diagnosis, but we did exclude all children that had been diagnosed in the 12 months prior to the beginning of the first period we looked at, so that is not including any honeymoon effects; we’re truly seeing a significant lowering of the HbA1c.” – Neil Lawrence, MBChB, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, United Kingdom

“Our data shows that kids with well-controlled type 1 diabetes have outcomes not much different from kids who don’t have type 1 diabetes,” Raisingani says. Similar results were found with intubation: 142 kids without type 1 diabetes required endotracheal intubation, a 0.028% risk, while in kids with type 1 diabetes, this risk went up to 0.328% and a relative risk of 11 times higher. Once more, none of the kids with HbA1c ≤7% required intubation.

Concluded Raisingani: “It is all the more important that during these times that children with type 1 diabetes keep their blood sugars under control to prevent hospitalizations, death, and other complications. A question we get asked in the clinic frequently is, ‘when can my child with type 1 diabetes return to school?’. If the HbA1c is ≤7% and appropriate precautious like wearing masks and social distancing are observed, then it should be safe to go back to school. If that HbA1c exceeds 9%, it’s wise to get it under control before returning.”

Horvath is a freelance writer based in Baltimore, Md. She wrote about COVID-19’s impact on a variety of endocrine comorbidities in the June issue.