First International Survey on Diabetes Providers’ Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

Abstract

Background:

Advances in diabetes technological devices led to optimization of diabetes care; however, long-lasting skin exposure to devices may be accompanied by an increasing occurrence of cutaneous reactions.

Methods:

We used an open-link web-based survey to evaluate diabetes-care providers’ viewpoint on prevalence, management practices, and knowledge related to skin reactions with the use of diabetes technological devices. A post hoc analysis was applied to investigate differences in the level of awareness on this topic in relation to the experience in diabetes technology.

Results:

One hundred twenty-five responses from 39 different countries were collected. Most respondents (69%) routinely examine patients’ skin at each visit. All the preventive measures are not clear and, mainly, homogenously put into clinical practice. Contact dermatitis was the most frequently reported cutaneous complication due to diabetes devices, and its most common provocative causes are not yet fully known by diabetes-care providers. Almost half of the respondents (42%) had discussed the presence of harmful allergens contained in adhesives with device manufacturers. There is general agreement on the need to strengthen knowledge on dermatological complications.

Conclusions:

Although diabetes-care providers are quite aware of the chance to develop skin reactions in people with diabetes using technological devices, there are still some unmet needs. Large follow-up studies and further dissemination tools are awaited to address the gaps revealed by our survey.

Keywords

allergens contact dermatitis complications management physicians skin

Introduction

Advances in technological devices led to their increased use in people with diabetes (PWDs) of all ages and allowed the achievement of ambitious glycemic targets and overall improved diabetes management.¹ With this rising use of these devices, we are faced with an increasing occurrence of cutaneous reactions due to prolonged skin exposure to devices’ adhesives.² The prevalence of dermatological complications in children and adolescents with type 1 diabetes (T1D) ranges from 35% to 56% as revealed by recent observational studies.^3-5 In some cases, their occurrence leads to clinical and psychological implications such as the need to discontinue the use of technology and increased burden for both youth and their caregivers.^6,7 Despite the magnitude of the issue, it is unknown whether the majority of diabetes-care providers are aware of the specific skin complications related to diabetes devices, and whether they incorporate skin assessment and problem-solving strategies into their clinical practices.

The aim of this study, therefore, was to evaluate diabetologists’ and other health care professionals (HCPs) confidence concerning dermatological complications, especially contact dermatitis, caused by technological devices used for the management of diabetes in children and adolescents.

Methods

From August to December 2022, we conducted a web-based survey powered by Google forms (a cloud-based data management tool) containing 34 questions in English language. The survey was disseminated to diabetes team members by the JENIOUS group of the International Society for Pediatric and Adolescent Diabetes (ISPAD). Informed consent was obtained from all respondents through an online form. The survey included questions on the baseline profile of HCPs, characteristics of their clinical activity, and various aspects of their knowledge, awareness, and practical approach to skin reactions, especially contact dermatitis. The full survey is available as Online Supplemental File 1.

All the categorical variables were expressed as absolute frequencies and percentages. A post hoc analysis was applied to compare responses between two different subgroups, which differed for their experience in diabetes technology according to the percentage of patients followed in their clinics using at least one technological device (less or more than 75%). To compare the level of knowledge on screening, diagnosis, prevention, and treatment of skin reactions between subgroups of respondents, chi-square test and Fisher’s exact test, when appropriate, were used. Statistical analyses were performed using IBM SPSS for Windows, Version 22 (Armonk, NY, IBM Corp.). A P-value smaller than .050 was considered statistically significant.

Results

One hundred and twenty-five diabetes-care providers from 39 different countries worldwide, mainly aged between 30 and 60 years, participated in the survey. Most of them (82.4%) were physicians, other respondents were nurses (12%), diabetes educators (3.2%), and advanced practice educators (2.4%). ISPAD members represented most respondents (68.8%). Approximately half of the survey participants (51.2%) have been practicing pediatric diabetes for more than 10 years. Public health care system was the most represented (85.6%) among different practice settings. Almost all the respondents (88.8%) demonstrated experience in diabetes technology. Specifically, 40.8% of HCPs followed more than 75% of patients using insulin pumps, continuous glucose monitoring (CGM) systems, and/or sensor-augmented pumps. Online Supplemental File 2 summarizes survey participants’ characteristics.

Most diabetes-care providers (68.8%) reported paying attention to the appearance of skin adverse events, especially contact dermatitis and lipohypertrophy, in patients using diabetes devices at each diabetes follow-up visit. In most cases (59.2%), assessment of the skin condition consisted of asking patients for the occurrence of dermatological side effects and a careful physical examination of the skin, particularly of skin sites where devices are applied. Among general considerations on device placement, rotation through multiple sites of insertion, avoiding broken, unhealed, or irritated skin and avoiding proximity to another infusion set or glycemic sensors were the most frequently recommended. Conversely, general suggestions on skin protection (eg, regular use of soothing cream on skin sites of device placement, application of a thin layer of solid or spray antiperspirant before insertion, gentle exfoliation for oily skin) were rarely or never recommended by most respondents (Figure 1).

Figure 1.

Approach of diabetes-care providers to the most common recommendations on device placement and skin protection.

Prevalence of allergic or irritant contact dermatitis was mostly estimated between 5% and 20% (39.2%).

A combination of different therapeutic strategies has been commonly used to treat acute lesions of contact dermatitis. Various strategies were combined to prevent the occurrence of contact dermatitis in most cases (59.2%). Fifty percent of respondents were not confident with the most common allergens contained in diabetes device adhesives. Almost half of the respondents (42.4%) had discussed with device manufacturers the need to receive detailed information on adhesive compounds and reduce the amount of known harmful allergens. More than one-third of the respondents (35.2%) observed a worsening in glycemic outcomes in children and adolescents with contact dermatitis, but a larger number of diabetes-care providers (49.6%) were uncertain about the consequences on glycemic control. Discontinuation or the need to change brands of CGM and insulin pump due to contact dermatitis were reported in more than 5% of individuals by 36% and 22.4% of respondents, respectively. Almost all diabetes-care providers (98.4%) believed that the acquisition of specific knowledge and practical skills related to skin reactions should be part of the mandatory training of professionals dealing with diabetes. Table 1 includes responses of diabetes-care providers regarding the main items on contact dermatitis due to technological devices. Screening, diagnosis, prevention, and treatment of skin reactions were reported to be familiar to most respondents (70.4%, 75.2%, 65.6%, and 66.4%, respectively). A significant difference was found in knowledge of screening according to experience in diabetes technology (P = .027). No other differences were detected between the subgroups (Table 2).

Table 1.

Results of the Main Items on Contact Dermatitis Due to Technological Devices From the Perspective of Diabetes-Care Providers.

Item	Responses	Frequencies (%)
Estimate prevalence of contact dermatitis in patients on insulin pump therapy and/or CGM	<5% 5%-20% 20%-40% 40%-60% >60%	18 (14.4%) 49 (39.2%) 38 (30.4%) 12 (9.6%) 8 (6.4%)
Preferred prophylactic measures to prevent occurrence of contact dermatitis exacerbations	Hydrocolloid plasters Protective physical skin barriers Protective liquid sprays/wipes Nasal steroid applied topically Combination of products above None of these	8 (6.4%) 15 (12%) 11 (8.8%) 4 (3.2%) 77 (61.6%) 10 (8%)
Preferred therapeutic strategies to treat acute lesions of contact dermatitis	Topical corticosteroids Topical steroids + antibiotics Topical antihistamines Soothing/emollient creams Combination of products above None of these	21 (16.8%) 11 (8.8%) 1 (0.8%) 12 (9.6%) 74 (59.2%) 6 (4.8%)
How often do you consult or refer a patient to an allergy specialists or dermatologists in case of skin reactions in your patients?	Always Occasionally (in case of doubts) Very rarely (in difficult cases) Never	11 (8.8%) 41 (32.8%) 57 (45.6%) 16 (12.8%)
Awareness of any potentially harmful allergens contained in diabetes device adhesives related to the occurrence of allergic contact dermatitis	Yes No	62 (49.6%) 63 (50.4%)
Have you ever discussed with device manufacturers the need to receive detailed information on adhesive compounds and to reduce the amount of known harmful allergens?	Yes No	53 (42.4%) 72 (57.6%)
Do you observe a trend toward worsening of glycemic control in patients with contact dermatitis?	Yes No Not sure	44 (35.2%) 19 (15.2%) 62 (49.6%)
Estimate percentage of patients forced to discontinue/change brands of CGMs due to contact dermatitis	<5% 5%-20% 20%-40% >40%	80 (64%) 36 (28.8%) 6 (4.8%) 3 (2.4%)
Estimate percentage of patients forced to discontinue/change brands of pumps due to contact dermatitis	<5% 5%-20% 20%-40% >40%	97 (77.6%) 20 (16%) 6 (4.8%) 2 (1.6%)
Do you believe that acquisition of specific knowledge and practical skills related to skin adverse reactions should be part of the mandatory training of professionals dealing with diabetes?	Yes No	123 (98.4%) 2 (1.6%)
Preferred ISPAD dissemination tool to gain more knowledge on skin complications in children, adolescents, and young adults with T1D?	Online training webinars Dedicated updates by email Dedicated updates on the website Dedicated sessions focused during the annual conference	71 (56.8%) 8 (6.4%) 21 (16.8%) 25 (20%)

Abbreviations: CGM, continuous glucose monitoring; ISPAD, International Society for Pediatric and Adolescent Diabetes; T1D, type 1 diabetes.

Table 2.

Awareness of Screening, Diagnosis, Prevention, and Treatment on Skin Reactions According to the Experience in Technology of Study Participants.

	All respondents (n = 125)	Diabetes devices use ≤75% (n = 74)	Diabetes devices use >75% (n = 51)	P-value
Screening				.027^a
Not familiar	16 (12.8%)	13 (17.6%)	3 (5.9%)
Slightly familiar	21 (16.8%)	11 (14.9%)	10 (19.6%)
Moderately familiar	40 (32%)	28 (37.8%)	12 (23.5%)
Very familiar	48 (38.4%)	22 (29.7%)	26 (51%)
Diagnosis				.167
Not familiar	7 (5.6%)	4 (5.4%)	3 (5.9%)
Slightly familiar	24 (19.2%)	19 (25.7%)	5 (9.8%)
Moderately familiar	50 (40%)	28 (37.8%)	22 (43.1%)
Very familiar	44 (35.2%)	23 (31.1%)	21 (41.2%)
Prevention				.309
Not familiar	10 (8%)	6 (8.1%)	4 (7.8%)
Slightly familiar	33 (26.4%)	24 (32.4%)	9 (17.6%)
Moderately familiar	40 (32%)	21 (28.3%)	19 (37.2%)
Very familiar	42 (33.6%)	23 (21.1%)	19 (37.2%)
Treatment				.351
Not familiar	6 (4.8%)	5 (6.8%)	1 (2%)
Slightly familiar	36 (28.8%)	24 (32.4%)	12 (23.5%)
Moderately familiar	52 (41.6%)	29 (39.2%)	23 (45.1%)
Very familiar	31 (24.8%)	16 (21.6%)	15 (29.4%)

Responses are expressed by absolute numbers and frequencies within subgroups.

Significant P-value.

Discussion

Our survey revealed that skin care of PWDs is commonly focused by health care providers during follow-up visits. Diabetes providers following a larger number of technological devices users demonstrate greater awareness of cutaneous events, but only relating to screening methods. It is noteworthy that prophylactic and treatment strategies to address these complications are well known, regardless of the professional role and experience in diabetes technology. However, no homogeneous approach exists, especially in the field of prevention, also due to little availability of evidence-based literature resources. Messer et al⁸ proposed practical guidelines to aid physicians and diabetes educators to improve skin management, with primary emphasis on device placement and adhesion, preventing skin reactions, and healing existing skin reactions. Our findings demonstrated that those recommendations are not fully addressed by members of pediatric diabetes teams.

Contact dermatitis caused by devices’ adhesives is the most insidious among skin reactions and it represents a challenging complication for diabetologists. It can be classified into two distinct forms based on its pathogenesis: irritant and allergic contact dermatitis. Irritant contact dermatitis is a non-specific skin response to harmful substances, leading to direct chemical damage and the subsequent release of inflammatory mediators from epidermal cells.⁹ Allergic contact dermatitis is a delayed, type IV hypersensitivity reaction to specific antigens, resulting in immunological responses characterized by the interaction of cytokines and T cells.¹⁰ The question regarding the prevalence of contact dermatitis yielded various responses, but the common choice fell within the range of 5% to 20%. It is noteworthy that precise epidemiological data on the prevalence of contact dermatitis in PWDs are limited. Recent studies have reported rates ranging from 5.5% to 8.4%.^11-13 However, all these studies have been conducted on relatively small study cohorts. In our survey, diabetes-care providers demonstrated a clear understanding of the main therapeutic and preventive tools, which are used to manage this harmful complication. In both cases, respondents predominantly indicated a preference for a combination of products. This choice aligns with the recognition that the identification of the most suitable treatment for acute skin lesions can be challenging and varies according to the specific subtype of contact dermatitis. The first-line treatment for allergic contact dermatitis involves the use of topical corticosteroids, skin lesions resulting from irritant contact dermatitis can be effectively managed with soothing and emollient creams.¹⁴ In case of severe lesions, topical antimicrobials may be indicated to reduce the risk of bacterial infections.¹⁵

To minimize the risk of contact dermatitis, protective physical skin barriers, such as films, tapes, or adhesives, are used and often combined to increase their prophylactic effect. These products are applied before the insertion of devices and can offer sufficient protection from offending agents contained in adhesives. The cutaneous application of nasal steroid spray has been anecdotally proposed to protect skin from adverse events¹⁶; however, potential long-term consequences, such as skin atrophy, likely limit its use.

Interestingly, our survey revealed that confidence in the most harmful allergens is still very low among diabetes-care providers. In recent years, several case reports and observational studies have provided an extensive list of the culprit substances contained in the adhesives of diabetes devices. A systematic review including 50 studies on allergic contact dermatitis due to diabetes devices reported that the primary allergens responsible for these reactions were predominantly colophonium and acrylates.¹⁷ Colophonium, a complex mixture consisting of more than 100 compounds derived from pine trees, has been detected in both insulin infusion sets and glucose sensors.^18,19 Among the acrylates, the most frequently identified allergens found in the adhesives of diabetes devices include cyanoacrylate, isobornyl acrylate, and N-N dimethylacrylamide.^20-23 One of the most encouraging findings of our study was that almost one in two respondents had discussed with device manufacturers the need to receive detailed information on the exact composition and preparation of adhesive and to reduce the amount of known harmful allergens. Unfortunately, complete information on adhesive compounds used by various manufacturers remains a trade secret.²⁴ Despite several management strategies mentioned above, the most severe cases of contact dermatitis remain untreatable and avoiding offending allergens included in the adhesives of technological devices is the only therapeutic choice available. The percentage of children and adolescents forced to discontinue or change brands of CGM systems and/or insulin pumps due to contact dermatitis is not negligible as revealed by our survey. Notably, one-third of respondents reported the need to choose other CGM systems, or even to switch to self-blood glucose monitoring. In the current era leading to the advent of artificial pancreas, it is of primary importance to ensure that all PWDs can wear long-lasting skin-adhered devices. Another intriguing aspect is the uncertainty about the real clinical impact of skin reactions. Almost half of the survey respondents are not able to declare whether the achievement of glycemic goals is impaired due to dermatological concerns. To date, there are no studies that have investigated the close relationship between the occurrence of skin reactions, above all contact dermatitis, and glycemic outcomes.

The growing evidence of dermatological concerns has led to expand the section on skin disorders into the chapter focusing on other complications and associated conditions in children and adolescents with T1D included in the latest ISPAD Clinical Practice Consensus Guidelines.²⁵ As found in our survey, other dissemination tools should be considered to strengthen knowledge on skin care of children and adolescents with diabetes. In this context, ISPAD’s training programs, postgraduate courses, and webinars can be valuable because they extend their reach beyond its members, serving a broader audience seeking education on this topic.

Limitations of our study include the little number of responses from countries with high diffusion of technological devices. Although the survey was disseminated to all clinical figures involved in diabetes care, most respondents were physicians, reflecting the larger representation of this group within the ISPAD community. Consequently, there is a lack of data on the knowledge of other diabetes providers regarding this topic. Furthermore, the survey format, which included pre-selected answer options, restricted our ability to collect detailed information on specific items. For example, we were unable to explore the use of alternative prophylactic or therapeutic tools. In addition, the format did not provide a comprehensive understanding of the reasons behind certain responses, such as the frequency of requests for dermatological consultation. On the contrary, our study represents the first investigation into diabetes providers’ assessment of skin reactions in youth with type 1 diabetes, which involved a large variety of practice settings and countries, including low- and middle-income countries.

Conclusions

Skin reactions related to the use of long-standing technological devices are real concerns in the management of PWDs. Despite diabetes-care providers demonstrating a high level of awareness on this topic, there are still some unmet needs. Large follow-up studies are needed to explore the exact prevalence, prevention, and solutions to contact dermatitis, which likely represents the most feared dermatological complication. Studies investigating the real influence of achieving glycemic targets in subjects with technologies-related skin issues are also awaited. Finally, further dissemination tools are required to improve all diabetes-care providers’ knowledge on this topic worldwide.

Supplemental Material

sj-docx-1-dst-10.1177_19322968231206155 – Supplemental material for First International Survey on Diabetes Providers’ Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

Supplemental material, sj-docx-1-dst-10.1177_19322968231206155 for First International Survey on Diabetes Providers’ Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices by Stefano Passanisi, Anna Korsgaard Berg, Agata Chobot, Tiago Jeronimo Dos Santos, Claudia Anita Piona, Laurel Messer and Fortunato Lombardo in Journal of Diabetes Science and Technology

Supplemental Material

sj-docx-2-dst-10.1177_19322968231206155 – Supplemental material for First International Survey on Diabetes Providers’ Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

Supplemental material, sj-docx-2-dst-10.1177_19322968231206155 for First International Survey on Diabetes Providers’ Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices by Stefano Passanisi, Anna Korsgaard Berg, Agata Chobot, Tiago Jeronimo Dos Santos, Claudia Anita Piona, Laurel Messer and Fortunato Lombardo in Journal of Diabetes Science and Technology

Footnotes

Acknowledgements

The study was conducted on behalf of the ISPAD group of young investigators (JENIOUS group). The authors thank all the diabetes team members for their study participation.

Abbreviations

CGM, continuous glucose monitoring; HCPs, health care professionals; ISPAD, International Society for Pediatric and Adolescent Diabetes; PWDs, people with diabetes; T1D, type 1 diabetes.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Anna Korsgaard Berg has received project grants from Medtronic and received speaking honoraria from Rubin Medical and Convatec. Laurel Messer has received speaking/consulting honoraria from Tandem Diabetes, Dexcom, Inc., Capillary Biomedical, and Lilly. Her institution receives research/project grants from Medtronic, Tandem Diabetes, Beta Bionics, Dexcom, Abbott, and Insulet Corp. As of 2023, Laurel Messer is also an employee of Tandem Diabetes Care. No conflict of interest exists for the other authors.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Stefano Passanisi

Laurel Messer

Supplemental Material

Supplemental material for this article is available online.

References

Phillip

Nimri

Bergenstal

, et al. Consensus recommendations for the use of automated insulin delivery technologies in clinical practice. Endocr Rev. 2023;44(2):254-280.

Heinemann

Kamann

Adhesives used for diabetes medical devices: a neglected risk with serious consequences?

J Diabetes Sci Technol. 2016;10(6):1211-1215.

Lombardo

Passanisi

Tinti

Messina

Salzano

Rabbone

High frequency of dermatological complications in children and adolescents with type 1 diabetes: a web-based survey. J Diabetes Sci Technol. 2021;15:1377-1381.

Asarani

NAM

Reynolds

Boucher

de Bock

Wheeler

. Cutaneous complications with continuous or flash glucose monitoring use: systematic review of trials and observational studies. J Diabetes Sci Technol. 2020;14(2):328-337.

Berg

Olsen

Thyssen

, et al. High frequencies of dermatological complications in children using insulin pumps or sensors. Pediatr Diabetes. 2018;19(4):733-740.

Christensen

Berg

Rytter

, et al. Skin problems due to treatment with technology are associated with increased disease burden among adults with type 1 diabetes. Diabetes Technol Ther. 2019;21(4):215-221.

Passanisi

Salzano

Galletta

, et al. Technologies for type 1 diabetes and contact dermatitis: therapeutic tools and clinical outcomes in a cohort of pediatric patients. Front Endocrinol (Lausanne). 2022;13:846137.

Messer

Berget

Beatson

Polsky

Forlenza

GP.

Preserving skin integrity with chronic device use in diabetes. Diabetes Technol Ther. 2018;20(suppl 2):S254-S264.

Kostner

Anzengruber

Guillod

Recher

Schmid-Grendelmeier

Navarini

AA.

Allergic contact dermatitis. Immunol Allergy Clin North Am. 2017;37(1):141-152.

10.

Novak-Bilić

Vučić

Japundžić

Meštrović-Štefekov

Stanić-Duktaj

Lugović-Mihić

Irritant and allergic contact dermatitis—skin lesion characteristics. Acta Clin Croat. 2018;57(4):713-720.

11.

Lombardo

Salzano

Crisafulli

, et al. Allergic contact dermatitis in pediatric patients with type 1 diabetes: an emerging issue. Diabetes Res Clin Pract. 2020;162:108089.

12.

Pyl

Dendooven

Van Eekelen

, et al. Prevalence and prevention of contact dermatitis caused by FreeStyle Libre: a monocentric experience. Diabetes Care. 2020;43(4):918-920.

13.

Vidal-Albareda

Yelmo-Valverde

Solórzano-Zepeda

Rodríguez-Muñoz

de-la-Hoz-Caballer

González-de-Olano

Prevalence of contact dermatitis to glucose sensors in pediatric population and the main allergens involved. Contact Dermatitis. 2020;83(1):47-49.

14.

Contact dermatitis: classifications and management. Clin Rev Allergy Immunol. 2021;61(3):245-281.

15.

Johnston

Exton

Mohd Mustapa

, et al. British association of dermatologists’ guidelines for the management of contact dermatitis 2017. Br J Dermatol. 2017;176(2):317-329.

16.

Paret

Barash

Rachmiel

“Out of the box” solution for skin problems due to glucose-monitoring technology in youth with type 1 diabetes: real-life experience with fluticasone spray. Acta Diabetol. 2020;57(4):419-424.

17.

Cameli

Silvestri

Mariano

Messina

Nisticò

Cristaudo

Allergic contact dermatitis, an important skin reaction in diabetes device users: a systematic review. Dermatitis. 2022;33(2):110-115.

18.

Hyry

HSI

Liippo

Virtanen

. Allergic contact dermatitis caused by glucose sensors in type 1 diabetes patients. Contact Dermatitis. 2019;81(3):161-166.

19.

Lombardo

Passanisi

Caminiti

, et al. High prevalence of skin reactions among pediatric patients with type 1 diabetes using new technologies: the alarming role of colophonium. Diabetes Technol Ther. 2020;22(1):53-56.

20.

Mowitz

Herman

Baeck

, et al. N, N-dimethylacrylamide—a new sensitizer in the FreeStyle Libre glucose sensor. Contact Dermatitis. 2019;81(1):27-31.

21.

Herman

Aerts

Baeck

, et al. Allergic contact dermatitis caused by isobornyl acrylate in Freestyle® Libre, a newly introduced glucose sensor. Contact Dermatitis. 2017;77(6):367-373.

22.

Oppel

Högg

Summer

Ruëff

Reichl

Kamann

Isobornyl acrylate contained in the insulin patch pump OmniPod as the cause of severe allergic contact dermatitis. Contact Dermatitis. 2018;79(3):178-180.

23.

Passanisi

Salzano

Lombardo

Skin involvement in paediatric patients with type 1 diabetes. Curr Diabetes Rev. 2022;18(4):e030921196145.

24.

Herman

Uter

Rustemeyer

, et al. Position statement: the need for EU legislation to require disclosure and labelling of the composition of medical devices. J Eur Acad Dermatol Venereol. 2021;35(7):1444-1448.

25.

Fröhlich-Reiterer

Elbarbary

Simmons

, et al. ISPAD Clinical Practice Consensus Guidelines 2022: other complications and associated conditions in children and adolescents with type 1 diabetes. Pediatr Diabetes. 2022;23(8):1451-1467.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.33 MB

0.02 MB