XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Importance More than one-third of adults and 17% of youth in the United States are obese, although the prevalence remained stable between 2003-2004 and 2009-2010. Objective To provide the most recent national estimates of childhood obesity, analyze trends in childhood obesity between 2003 and 2012, and provide detailed obesity trend analyses among adults. Design, Setting, and Participants Weight and height or recumbent length were measured in 9120 participants in the 2011-2012 nationally representative National Health and Nutrition Examination Survey. Main Outcomes and Measures In infants and toddlers from birth to 2 years, high weight for recumbent length was defined as weight for length at or above the 95th percentile of the sex-specific Centers for Disease Control and Prevention (CDC) growth charts. In children and adolescents aged 2 to 19 years, obesity was defined as a body mass index (BMI) at or above the 95th percentile of the sex-specific CDC BMI-for-age growth charts. In adults, obesity was defined as a BMI greater than or equal to 30. Analyses of trends in high weight for recumbent length or obesity prevalence were conducted overall and separately by age across 5 periods (2003-2004, 2005-2006, 2007-2008, 2009-2010, and 2011-2012). Results In 2011-2012, 8.1% (95% CI, 5.8%-11.1%) of infants and toddlers had high weight for recumbent length, and 16.9% (95% CI, 14.9%-19.2%) of 2- to 19-year-olds and 34.9% (95% CI, 32.0%-37.9%) of adults (age-adjusted) aged 20 years or older were obese. Overall, there was no significant change from 2003-2004 through 2011-2012 in high weight for recumbent length among infants and toddlers, obesity in 2- to 19-year-olds, or obesity in adults. Tests for an interaction between survey period and age found an interaction in children ( P  = .03) and women ( P  = .02). There was a significant decrease in obesity among 2- to 5-year-old children (from 13.9% to 8.4%; P  = .03) and a significant increase in obesity among women aged 60 years and older (from 31.5% to 38.1%; P  = .006). Conclusions and Relevance Overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012. Obesity prevalence remains high and thus it is important to continue surveillance.

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Prevalence of childhood and adult obesity in the United States, 2011-2012.

Prospective Cohort Study

The adolescent brain and age-related behavioral manifestations

The reference human genome sequence set the stage for studies of genetic variation and its association with human disease, but epigenomic studies lack a similar reference. To address this need, the NIH Roadmap Epigenomics Consortium generated the largest collection so far of human epigenomes for primary cells and tissues. Here we describe the integrative analysis of 111 reference human epigenomes generated as part of the programme, profiled for histone modification patterns, DNA accessibility, DNA methylation and RNA expression. We establish global maps of regulatory elements, define regulatory modules of coordinated activity, and their likely activators and repressors. We show that disease- and trait-associated genetic variants are enriched in tissue-specific epigenomic marks, revealing biologically relevant cell types for diverse human traits, and providing a resource for interpreting the molecular basis of human disease. Our results demonstrate the central role of epigenomic information for understanding gene regulation, cellular differentiation and human disease.

Integrative analysis of 111 reference human epigenomes

The COVID19 pandemic has had adverse effects on the wellbeing, health and behaviour of children and adolescents, probably due to social restrictions.1– 3 A lot of studies were conducted during the particularly challenging first year of the pandemic, when there were lockdowns and day care, schools and leisure facilities were closed. Our online survey in February 2022 investigated parents' perceptions of the longterm consequences of the pandemic on child development. We also explored associations between these consequences and the children's age and sex, the family's socioeconomic status (SES) and the children's fear of COVID19. The data were collected as part of the LIFE Child longitudinal cohort study in Leipzig, Germany, which has been investigating healthy child development from the prenatal period to young adulthood since 2011. Most of the children, up to 16 years of age, are recruited through advertisements in healthcare facilities, and those with chronic, chromosomal or syndromic diseases are excluded. The study complies with the Declaration of Helsinki and was approved by the Ethics Committee of the Medical Faculty of the University of Leipzig (number 264/10ek). All parents provided written informed consent. This study analysed the data from an online survey designed by the authors. The link was sent to 2114 participants in February 2022, 2 years after the pandemic started, when infection rates were high and a number of antipandemic measures were in place. These included wearing masks and limited access to shops and leisure facilities. The survey was completed by the parents of 465 (51% girls) subjects from 1– 18 years of age, with a mean age of 8.6 ± 4.8 years. The response rate was 22%. The SES of the participating families, based on parental education, occupation and income,4 were middle (50%) and high (50%), which reflected the general underrepresentation of lowSES families in the wider study. Ttests and chisquared tests showed that the distributions of age, sex and SES did not differ significantly between responders and nonresponders (all p > 0.05). The survey asked parents whether the COVID19 pandemic had positively or negatively affected their children's health, wellbeing, family relationships, friendships, autonomy, learning ability and school performance. The options were negative change, rather negative change, no change, rather positive change and positive change. Multiple ordinal mixedeffect models were used to assess associations between the perceived changes and the child's age, sex, fear of COVID19 and a continuous measure of SES, ranging from low to high.4 The data were controlled for siblings in the sample. The associations are reported as odds ratios and 95% confidence intervals (Table 1). Overall, 40%– 60% of parents perceived no changes in the various areas of their children's lives (Figure S1). Changes to health, wellbeing, friendships, learning ability and school performance were more frequently perceived as negative than positive, in line with previous studies.1,3 Possible explanations include reduced contact with peers,1 lack of exercise during restrictions2 and limited support during distance learning.3 Changes in family relationships and autonomy were more frequently perceived as positive than negative, probably because school closures triggered more time alone and more time with families. Table 1 shows the regression analyses. As the children aged, the parents perceived significantly more negative changes in their wellbeing, family relationships and learning. That normal tendency may have been increased by the pandemic. There were significantly more positive changes in autonomy in older children, possibly because they were more likely to be left alone at home during school closures than younger children. The parents of girls perceived more positive changes in autonomy, friendships, school performance and learning. Other studies have shown that girls were more vulnerable to pandemicrelated mental health problems,1 but our findings suggest that they coped better with the social and schoolrelated burdens of the pandemic. Increasing SES was associated with increasingly positive perceptions of the children's school performance, learning and autonomy, supporting the assumption that families with a lower SES suffered most during the pandemic.5 The perceived changes in children's health and autonomy were more negative, if they were afraid of COVID19, supporting previous study findings.1 However, we did not use a longitudinal design or investigate the reasons for these fears, such as the infection or the antipandemic measures. Overall, we found that pandemicrelated changes in healthy children from middle to high SES families were more frequently perceived as negative than positive, particularly for mental and physical health, friendships and education.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/apa.16435

An online survey carried out in 2022 showed that COVID‐19 was associated with negative changes in children's lives

Die klinische Notfallausbildung von WeiterbildungsassistentInnen (WBA) ist uneinheitlich. Padiatrische Reanimationen sind seltener erforderlich als Reanimationen erwachsener Patienten; erstversorgende Teams treffen ad hoc zusammen und stehen initial oft unter der Leitung junger ArztInnen. Die Teamzusammenarbeit ist von besonderer Bedeutung fur das Uberleben und Outcome der PatientInnen. Die subjektive Sicherheit im Notfallmanagement der WBA in sachsischen Kinderkliniken sollte ermittelt werden. Hierzu wurde ein Erhebungsbogen fur eine webbasierte Umfrage entwickelt, die folgende Aspekte umfasste: Berufserfahrung, innerhausliche Ausbildung, Erfahrung und gefuhlte Sicherheit im Management von Notfallsituationen. Von geschatzten 230 Padiatrie-WBA in Sachsen antworteten 66 (ca. 29 %). Es fuhlten sich 14 % der WBA gut (3 % sehr gut) fur Notfallsituationen ausgebildet, wobei 11 % auch eine (sehr) gute Sicherheit in der Teamleitung von Notfallen angaben. Demgegenuber hatten 42 % bereits eine oder mehrere Reanimationen als TeamleiterInnen erlebt. Von den befragten WBA gaben 42 % an, in den letzten 12 Monaten kein Simulationstraining absolviert zu haben; die Mehrzahl der WBA wunscht sich jedoch mehr Training. Die Ergebnisse zeigen, dass sich viele WBA in sachsischen Kinderkliniken im Notfallmanagement unzureichend ausgebildet fuhlen. Es besteht eine deutliche Diskrepanz zwischen den tatsachlichen Anforderungen und der innerklinischen Ausbildung.

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Klinische Notfallausbildung in der Pädiatrie

ZUSAMMENFASSUNG Die Beurteilung der Pubertätsentwicklung sowie Übergewicht und Adipositas sind tagtäglicher Bestandteil der pädiatrischen Praxis. Dabei beeinflussen sich Pubertätsentwicklung und Adipositas wechselseitig. Während Mädchen mit Adipositas häufig eine Pubertätsakzeleration aufweisen, sind die Daten bei Jungen weniger eindeutig. Möglicherweise verursacht Übergewicht hier eine Pubertätsbeschleunigung und Adipositas eine Pubertätsverzögerung. Leicht erhöhte Androgenspiegel bei Mädchen sowie leicht erhöhte Östrogenspiegel bei Jungen und eine präpubertäre Wachstumsakzeleration bei beiden Geschlechtern sind häufige Phänomene bei Kindern mit Adipositas. Die Ursachen sind multifaktoriell. Hierbei spielt das Fettgewebe eine entscheidende Rolle, sowohl durch die zentrale Aktivierung der Hypothalamus-Hypophysen-Gonadenachse über Leptin und Kisspeptin als auch durch periphere Effekte, wie beispielweise die Umwandlung von Androgenen zu Östrogen. Syndrome, welche sowohl Störungen der Pubertätsentwicklung als auch Adipositas umfassen, dürfen bei der klinischen Einschätzung nicht übersehen werden. Zur Einschätzung der altersgerechten Pubertätsentwicklung bei Kindern und Jugendlichen mit Adipositas kann in Kenntnis der typischen Veränderungen und Warnzeichen in den meisten Fällen jedoch auf weitere Diagnostik verzichtet und der Verlauf vorerst beobachtet werden.

Pubertätsentwicklung und Adipositas

Background: Traumatic dental injuries (TDIs) in toddlers and preschoolers are a common problem and numerous risk factors are known. Behavior problems have also been identified as a possible influencing factor, but data are not yet available for this age group.Objectives: The present study aimed to explore the association between behavioral difficulties and TDIs in toddlers and preschool children. In addition, age, gender, socioeconomic status (SES), and an anterior open bite were included as possible confounders.Materials and methods: This cross-sectional study was part of the Life Research Center for Civilization Diseases (LIFE Child Study) in Leipzig, Germany. We were able to include 566 children aged 2 to 6 years in the analyses. A comprehensive clinical dental examination was performed, during which the status of occlusion (open anterior bite) was also recorded. In addition, there was a large interview component in which parents were also interviewed. For the precise assessment of possible behavioral difficulties of the children, the Strength and Difficulties Questionnaire (SDQ) was used. In the parent version used here, information had to be provided on 25 different attributes. These were then divided into 5 corresponding scales, i.e. conduct problems, hyperactivity, emotional symptoms, peer problems, and prosocial behavior. An SDQ total score was calculated as the sum of the individual scales. Based on specific cut-off points, children with abnormal behavior were classified as cases and children with normal behavior were classified as non-cases. Social status was determined according to the WSI (Wirtschafts- und Sozialwissenschaftliches Institut) stratification index. Household income, parental education, and occupational prestige were taken into account. This resulted in the classification into low, medium and high SES.Results: TDI was reported in 98 cases (17.3%). The SDQ total score was in the abnormal range for 12.2% of the children but was not associated with TDI in either the unadjusted or adjusted model (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.38-1.60 and OR 1.14, 95% CI 0.39-3.36, respectively). None of the individual SDQ scales showed significant results (p > 0.05). The prevalence of TDI increased significantly when an anterior open bite was diagnosed (OR 2.29, 95% CI 1.04-5.04 and OR 2.88, 1.08-7.68, respectively) and with increasing age (OR 1.50, 95% CI 1.23-1.83 and OR 1.59, 1.16-2.22, respectively). No significant differences were found between boys and girls. The same applies to social status (p > 0.05).Conclusion: The results do not suggest an association between problem behavior and TDI in toddlers and preschoolers. Confounder results showed a positive correlation between an existing anterior open bite and trauma frequency. Older children also tend to suffer dental trauma more frequently, but this is likely due to a cumulative effect. 

Assoziation von Problemverhalten und selbst berichteten Zahntraumata im Milchgebiss

Einleitung Die Maßnahmen zur Eindämmung der COVID-19-Pandemie brachten für einen Großteil der Kinder und Jugendlichen erhebliche Einschränkungen ihres Alltags mit sich. Der Wegfall vom Besuch des Kindergartens oder der Schule, die Schließung von Sportstätten, der eingeschränkte Kontakt zu Freunden und Familie: viele Experten befürchteten schon früh, dass die eingeschränkten Gelegenheiten sich zu bewegen, Übergewicht und Adipositas bei Kindern befördern würden. 

Wieland Kiess

Papers

An online survey carried out in 2022 showed that COVID‐19 was associated with negative changes in children's lives

Klinische Notfallausbildung in der Pädiatrie

Pubertätsentwicklung und Adipositas

Assoziation von Problemverhalten und selbst berichteten Zahntraumata im Milchgebiss

Gewichtsentwicklung und Adipositas bei Kindern und Jugendlichen während der COVID-19-Pandemie – Ergebnisse aus dem Kinderärztenetzwerk CrescNet