Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Jessica Schmitt. She's a pediatric endocrinologist at UAB Medicine and she's here to highlight treating pediatric type 1 diabetes. Dr. Schmitt, thank you so much for joining us today. I'd like you to start by telling us a little bit about the prevalence of type 1 diabetes. We hear a lot about type 2 and how that has really evolved over the years, but speak about type 1 in pediatric patients and what you've seen in the trends.

Dr Jessica Schmitt: Absolutely. Thank you so much for having me today. And the prevalence of type 1 diabetes we know is increasing. Like many types of autoimmune conditions, we're seeing a steady increase in the incidence and prevalence year over year. Classically, type 1 diabetes was thought of as juvenile diabetes and that is really an inaccurate nomenclature. We see type 2 diabetes in kids and type 1 diabetes can affect adults as well. Overall, about 1 in 300 children in the United States are affected by type 1 diabetes. But for people who have a family history of type 1, that risk can actually get up as high as 1 in 20, so definitely something that we are seeing.

And as I mentioned, type 1 diabetes can affect adults as well. So, for any adult with a new diagnosis of diabetes, it is important to test diabetes pancreatic autoantibodies to make sure that you're not missing a diagnosis of type 1. Especially in the setting of the increasing obesity epidemic, we can no longer rely on body habitus and body weight to distinguish type 1 and type 2 in either children or adults.

Melanie Cole, MS: I'm glad you made that point, Dr. Schmitt, because certainly when we're talking about the pancreas and beta cells and type 1 versus type 2, and as you said, it used to be juvenile onset, but we're not really calling it that anymore. And so, it's important to notice the difference between an insulin-resistant type and something that really is an organ damage. So, I'm glad that you made that point and thank you. What are some of the most telling symptoms? of type 1 diabetes in pediatric patients, because we're talking to primary care and pediatricians. What are they looking out for?

Dr Jessica Schmitt: Yes, absolutely. So in children, one of the most telling symptoms can be decrease in weight gain. So in Pediatrics and in Family Medicine, those growth charts are absolutely essential. And it is not uncommon for children with new type 1 diabetes to either lose actual weight or lose weight percentile. So even if they don't lose pounds, they might drift from the 20th percentile for weight down to the 15th percentile.

Other symptoms that occur, the classic symptoms are polyuria, polydipsia, so children who are suddenly much more thirsty than normal. And specifically to be on the lookout for younger kids who start bedwetting after they have been potty trained, that can be a very, very classic symptom. When the diabetes progresses and develops towards diabetic ketoacidosis, children can start to have higher respiratory rates as well. So, I did take care of one patient where they had been thought to have pneumonia, because they were tachypneic. And then, once the blood work came back, they saw the glucose of 400. So, just having that higher threshold and remembering to ask about those polyuria and polydipsia symptoms.

Melanie Cole, MS: Then, let's talk about some care strategies that you've seen to be most effective for pediatric patients with the help of their caregivers. I'd like you to speak about some of the latest development in diabetes technology and what's exciting in your field right now.

Dr Jessica Schmitt: So, we are huge fans of technology to help make diabetes a little bit easier to manage. As we've developed new medicines and new technologies for type 1 diabetes, we ask a lot out of our families, but we expect better outcomes as well.

At the University of Michigan, they've developed and identified six steps to success, which are associated with lower hemoglobin A1Cs and higher time and range for patients. And these six steps are making sure that patients with type 1 check their blood sugar four times a day or more, or use a continuous glucose monitor, that they give short-acting insulin three or more times per day, that they that they use an insulin pump, that they take their short-acting insulin before eating, that they check sugars for patterns in between clinic visits, and that they adjust insulin in between clinic visits. People who do all six of those steps are significantly more likely to have glycemic control and hemoglobin A1Cs in range than people who do not.

What I have also seen in my practice is that patients who have a routine tend to do much better than patients who do not. And so having more structure in the day, regular mealtimes, regular snack times, regular bedtimes, and good communication between the child and the parent or the caregiver are essential. We know that it can be really hard for parents to allow children to become more independent as they get older. And with a disease like type 1 diabetes, making sure that we're doing that in a way that the child still has the support and the supervision that they need. Emerging adolescence is a really tough time for people with diabetes, and balancing the child's independence with the safe oversight from the caregiver is really important.

Melanie Cole, MS: What a great point that you just made. And so, I'd like you to speak a little bit more about some of the technology. How much do you rely on patient-provided data when it comes to managing diabetes, as far as the parents keeping track of the CGM, the role of that professional versus personal? Speak a little bit about how that works together with your patients and their caregivers and that communication between the two.

Dr Jessica Schmitt: So, in order to make safe decisions for people with diabetes, we have to have accurate blood sugar data. My least favorite form of information is a handwritten logbook, because I just don't know where those numbers are coming from. And our patients, they want to do what they know they need to. And so, it is not uncommon to sometimes have handwritten blood sugars that do not line up with the labs that I'm measuring in clinic. And so, we know that it can be hard to keep up with blood sugars themselves. And so, using different tools that allow that to be done without the patient doing anything extra is really important. So, all of the continuous glucose monitors on the market have essentially a cloud-based sharing platform where once the patient authorizes us to view their data, that we can do so without any extra effort on the family. So, that's really my favorite way to get information that I need in clinic because it's not adding any extra burden to my families.

So, as I mentioned, all of the continuous glucose monitors have that capacity. Lots of the glucometers, so not the wearable CGMs, but the kind of traditional fingerstick blood sugars, if the families bring that into clinic, we can generally download the data from the glucometer in clinic. And if we can't, at the very least, we can review the blood sugars that are actually in that meter itself. Anything to add to the reported trends with objective data is very helpful.

Melanie Cole, MS: One of the things I find most interesting. And Dr. Schmitt, we know that our kids are so much more technologically savvy than we maybe are or ever were. As we're speaking about the technology, as the child grows, what is transitioning to their own care look like? As they become a teenager and this technology is coming directly to you, they may understand it even more than their caregivers.

Dr Jessica Schmitt: Yes. I think they definitely understand how to access the information very, very well. Where things can be difficult is when the caregivers are able to view information that prior to this age of technology, they would not have had access to. So if you think back to even as short as 10 years ago, when continuous glucose monitors were less common, the only information a caregiver would get is the fingerstick before breakfast at home and then when the kid came home from school. Now, they have access to see real time blood sugars throughout the entire day. And that can really shift the dynamic, particularly with our adolescent patients.

And so, strategizing with families to decide how much information is the right amount of information to keep the child safe, but not make every moment of every day focused around glucose in these kids who have so much else going on in their lives.

Melanie Cole, MS: Well, they certainly do and I'd like you to speak about clinical interventions for pediatric patients that really excite you. But before you do that, I'd like you to speak about the family. And as you're talking to other providers, and the medical home is where a lot of their visits come and go, and we think of exercise with its insulin-like effect, but a type A personality when we're exercising, what our children are eating, when they do live with type 1 diabetes. So, can you speak a little bit about how you work with the families as far as all of those lifestyles that come into play as well?

Dr Jessica Schmitt: Trying to teach families to build managing type 1 into their lives rather than letting type 1 rule their life. And so, we can work with people of all different energy levels and activity levels. So, some strategies that we will have particularly related to activity are trying to prevent hypoglycemia. And so, when patients have hypoglycemia, it feels awful. It can take a while to get the blood sugar back in the normal range. And even once that happens, it can ruin your whole day, just really disrupt your routine. So for activity, for people who are using an insulin pump, we talk a lot about reducing the insulin delivery the hour or two before activity to try to prevent any lows.

With some of the newer pumps on the market, they are what we call hybrid loop systems or automatic insulin delivery systems where they communicate to the glucose monitor, the CGM, and adjust insulin in response to the glucose trends. So, those can be very helpful in reducing hypoglycemia, particularly during activity. Ensuring that patients are doing a sport or an activity where they have access to both food and rapid-acting sugars to alleviate symptoms of hypoglycemia, and then obviously having access to a glucagon medication. There's lots of different types that can be delivered in different manners, but ensuring that they or the adult with them have that available during activity is essential. And as I mentioned before, routine is really helpful. The more predictable one's day is, the more one can kind of plan ahead and see how their body responds to different types of activities.

Melanie Cole, MS: This is such an informative conversation that we're having here, Dr. Schmitt. And as we wrap up, speak about things that excite you in the field, developing type 1 diabetes treatment options, what's most promising, giving us a little blueprint for further research, anything you'd like other providers to take away from this discussion today.

Dr Jessica Schmitt: So, one thing that is really different than it was in the past is that in 2023, an anti-CD3 medication was approved for people who are in what we call stage 2 type 1 diabetes. So, these are people who have positive, pancreatic autoantibodies, but have not yet developed overt diabetes. So when you do testing, they might be in what we call the pre diabetes range.

This medicine is an infusion given once a day for 14 days, and in clinical trials has been shown to delay the onset of insulin requirements by 2 years. So that is the difference. remarkable and, has really shifted things. In terms of other treatment options, there are lots of people trying to see other ways to delay progression of diabetes or prevent diabetes in the first place, most of which are related to trying to modify the immune system for those with type 1.

What I think is more likely to impact my patients' lives in the more immediate term is all of the diabetes-related technologies. Every year, there are new developments with insulin pumps, and every year they get better, particularly the ones that communicate to the continuous glucose monitors. They help the patients get tighter blood sugar control with less effort. And as I alluded to before, we ask a lot out of our patients. We ask them to count carbohydrates. We ask them to give insulin 15 minutes before eating. And so any little thing that technology can help them with and make them work not quite so hard to get just as much benefit. I'm all for.

As we enter the era of AI, what I would love to see is if we could develop gamification of those continuous glucose monitors. It's a boring graph and I think some of our patients would respond well if it turned into a video game where they had to keep the line from going up or down as much as they could. So, lots of ways that technology will continue to impact our families.

In the last 10 years, there's been some developments with the insulins themselves as well. We're getting insulins that last longer to be used not in insulin pumps, but as injections for the once a day basal insulin. And we're also getting insulins that have a more rapid onset of action, which is really helpful in kids like toddlers where You don't really know how much they're going to eat. And so often you do have to give their mealtime insulin after eating. The faster that insulin can take effect, the better for those patients.

So overall, while I think there is a lot of interesting and exciting work going on in the prevention of developing type 1 diabetes, what I think we are seeing the effects of right now is the impact of diabetes technologies and new insulins that have been developed. varying durations of actions and onsets of action.

With the newer anti CD3 medicine that can delay progression of type 1 diabetes, identifying those patients who are at risk is becoming more necessary and more important. In the past, we could identify people at risk, but we didn't have any FDA-approved treatment options for them. So, now, we do. And so providers who have families that have a history of type 1 diabetes, they can go to trialnet.org or askhealth.org to get information that their families can request for at-home screening tests to identify those who have positive pancreatic autoantibodies.

Melanie Cole, MS: Thank you so much. Dr. Schmitt, this has been very enlightening, and thank you for sharing your incredible expertise. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole.