Treatment regimens and glycaemic outcomes in more than 100 000 children with type 1 diabetes (2013–22): a longitudinal analysis of data from paediatric diabetes registries

Background: Advances in paediatric type 1 diabetes management and increased use of diabetes technology have led to improvements in glycaemia, reduced risk of severe hypoglycaemia, and improved quality of life. Since 1993, progressively lower HbA_1c targets have been set. The aim of this study was to perform a longitudinal analysis of HbA_1c, treatment regimens, and acute complications between 2013 and 2022 using data from eight national and one international paediatric diabetes registries. Methods: In this longitudinal analysis, we obtained data from the Australasian Diabetes Data Network, Czech National Childhood Diabetes Register, Danish Registry of Childhood and Adolescent Diabetes, Diabetes Prospective Follow-up Registry, Norwegian Childhood Diabetes Registry, England and Wales' National Paediatric Diabetes Audit, Swedish Childhood Diabetes Registry, T1D Exchange Quality Improvement Collaborative, and the SWEET initiative. All children (aged ≤18 years) with type 1 diabetes with a duration of longer than 3 months were included. Investigators compared data from 2013 to 2022; analyses performed on data were pre-defined and conducted separately by each respective registry. Data on demographics, HbA_1c, treatment regimen, and event rates of diabetic ketoacidosis and severe hypoglycaemia were collected. ANOVA was performed to compare means between registries and years. Joinpoint regression analysis was used to study significant breakpoints in temporal trends. Findings: In 2022, data were available for 109 494 children from the national registries and 35 590 from SWEET. Between 2013 and 2022, the aggregated mean HbA_1c decreased from 8·2% (95% CI 8·1–8·3%; 66·5 mmol/mol [65·2–67·7]) to 7·6% (7·5–7·7; 59·4mmol/mol [58·2–60·5]), and the proportion of participants who had achieved HbA_1c targets of less than 7% (<53 mmol/mol) increased from 19·0% to 38·8% (p<0·0001). In 2013, the aggregate event rate of severe hypoglycaemia rate was 3·0 events per 100 person-years (95% CI 2·0–4·9) compared with 1·7 events per 100 person-years (1·0–2·7) in 2022. In 2013, the aggregate event rate of diabetic ketoacidosis was 3·1 events per 100 person-years (95% CI 2·0–4·8) compared with 2·2 events per 100 person-years (1·4–3·4) in 2022. The proportion of participants with insulin pump use increased from 42·9% (95% CI 40·4–45·5) in 2013 to 60·2% (95% CI 57·9–62·6) in 2022 (mean difference 17·3% [13·8–20·7]; p<0·0001), and the proportion of participants using continuous glucose monitoring (CGM) increased from 18·7% (95% CI 9·5–28·0) in 2016 to 81·7% (73·0–90·4) in 2022 (mean difference 63·0% [50·3–75·7]; p<0·0001). Interpretation: Between 2013 and 2022, glycaemic outcomes have improved, parallel to increased use of diabetes technology. Many children had HbA_1c higher than the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2022 target. Reassuringly, despite targeting lower HbA_1c, severe hypoglycaemia event rates are decreasing. Even for children with type 1 diabetes who have access to specialised diabetes care and diabetes technology, further advances in diabetes management are required to assist with achieving ISPAD glycaemic targets. Funding: None. Translations: For the Norwegian, German, Czech, Danish and Swedish translations of the abstract see Supplementary Materials section.