What can be done to support a new wave of young diabetics?
In the wake of the COVID-19 pandemic, a recent BBC article highlighted a new study which unearthed an unusual rise in the number of children and teenagers around the world who have been diagnosed with type 1 diabetes. The COVID-19 pandemic completely altered the way we lived our lives, causing us to rethink how we engage with the world around us. A recent study by JAMA Network, revealed how the impacts of the pandemic are still very much being felt by a proportion of the population, despite lockdowns and health measures being relaxed.
General medical journal, JAMA Network, conducted research on the Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic, collating available data from different countries on more than 38,000 young people diagnosed during the pandemic. Forty-two studies, including 102,984 incident diabetes cases, were included in the systematic review. Their research found that the incidence rate of childhood type 1 diabetes rose 14% during the first year of the pandemic and climbed even higher to 27% in the second year of COVID compared to pre-pandemic levels i.
Whilst the exact reason for this increase incidence of childhood type 1 diabetes remains unclear, researchers have several theories. Part of the rise could be attributed to catch-up from backlogs and delays when health services were shut ii. One such theory suggests that COVID-19 can trigger a reaction in some children which increases the risk of diabetes, whilst another hypothesis is that exposure to some germs in childhood can help guard against several conditions, including diabetes. It is possible that lockdowns and physical distancing during the pandemic meant many children did not get sufficient exposure to germs and thus missed out on this additional protection ii. Despite not knowing the finite causes, action must still be taken to ensure this new population of young diabetics can easily access the resources and support they need.
The most concerning factor of this substantial rise of diabetes in children and adolescents is that it ran in parallel with an increase in reports of diabetic ketoacidosis (DKA). Of the studies identified, 15 countries reported an increase in DKA incidence in the first year of the pandemic, resulting in a rate 1.26 times higher compared with that pre-pandemic i. DKA develops when the body doesn’t have enough insulin to allow blood sugar into cells for use as energy. Instead, the liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in the body iii.
With the potentially life-threatening impacts that DKA presents, one of the most crucial aspects of diabetes management involves the safe administration of insulin via injections. The correct dose could be the difference between life and death. For children and teenagers, being diagnosed with diabetes, and having insulin injections as the treatment, can be particularly daunting and often causes anxiety and stress, with one study revealing that 63% of children (aged 6-17) reported a fear of needles iv. Considering the stress factors associated with needles, it is important that the implications of flinching or squirming away from an injection are factored in by medical device manufacturers who design safety pen needles, used to administer insulin, and that a device will administer full dose delivery without disruption.
There are two safety mechanism options when designing a safety pen needle: the passive device or the active device. The key difference is that along with the automated safety mechanism, passive devices typically cover the needle before and after the injection process, which protects from needlestick injury but may make it difficult to see the needle and require the use of a different injection technique. Additionally, if the patient is anxious and moves during injection the automatic safety mechanism of a passive device can activate too early and interrupt administration of the full medication dose. Active devices have a visible needle from the moment the safety cap is removed until the safety mechanism is manually activated. Visibility of the needle throughout the injection experience can offer better confidence and requires the user to be actively involved in the safety process, granting them full control over the dose delivery.
In 2020 a clinical evaluation of safety pen needles was conducted by the medical device manufacturer, Owen Mumford, that surveyed the opinions of healthcare professionals delivering insulin injections to children using both an active and a passive safety pen needle device. The findings showed a strong preference amongst the participants for an active safety mechanism. On the subject of accurate dosage, 98% of respondents agreed they were in control of the dose delivery, with 96% agreeing that they were confident they were able to deliver the full dose of medication with no leakage when using an active safety pen needle v. Comparatively, there was a significant difference with those using a passive device; 59% of respondents agreeing they were in control of the dose delivery and 41% agreed they were confident they were able to deliver the full dose of medication with no leakage using a passive safety pen needle v. Considering the importance of accurate insulin dosage in preventing the occurrence of DKA, this data suggests that active devices provide more confidence and control when it comes to dose delivery.
Further research was conducted in 2022 by independent research company MindMetre, who published the results of a UK study into the use of safety devices among NHS trusts following anecdotal evidence of incorrect insulin dosage. The results found that 36.4% of NHS Trusts said they had experienced insulin pooling, and 25% experienced incorrect dosage of insulin evidenced by an on-premises adverse event by the patient vi. Both situations occurred when using a passive device. Trusts were also given the option to provide additional context to their responses – with one Trust noting that “inaccurate insulin dosage was seen as a result of passive safety needles, due to this [we] moved to active safety needlesvi,” and “pooling of insulin was observed when using passive safety needles… again [we] moved to active safety needles for this reason vi.”
As we navigate the aftermath of the COVID-19 pandemic, it is crucial to address the increasing prevalence of type 1 diabetes among young individuals by ensuring that patients are offered the best treatment based on their specific needs. The research conducted by Owen Mumford and MindMetre suggests that an active safety pen needle can provide more confidence in full dose delivery and give users more control of the injection experience – specifically when tackling insulin pooling and potentially life-threatening DKA events. As with any clinical scenario, healthcare professionals must evaluate each patient on a case-by-case basis to determine the care needed and the device solution that is best suited to the situation.
i D’Souza D, Empringham J, Pechlivanoglou P, Uleryk EM, Cohen E, Shulman R. Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(6):e2321281. doi:10.1001/jamanetworkopen.2023.21281
ii Roberts, M. (2023) Covid pandemic linked to surge in child and teen diabetes, BBC News. Available at: http://www.bbc.co.uk/news/health-66054946 (Accessed: 03 July 2023).
iii Diabetic ketoacidosis (2022) Centres for Disease Control and Prevention. Available at: http://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html (Accessed: 03 July 2023).
iv Orenius, T. et al. (2018) ‘Fear of injections and needle phobia among children and adolescents: An overview of psychological, behavioural, and contextual factors’, SAGE Open Nursing, 4, p. 237796081875944. doi:10.1177/2377960818759442.
v Project Tarvos, 2020 (Data on file) vi Passive or active delivery devices in diabetes administration? (November 2022). MindMetre. Available at: http://www.mindmetreresearch.com/report/passive-active-delivery-services-nov-2022/