Awareness and Practice among Parents of Type-1 Diabetic Children and Adolescent and their Glycemic Status

Diabetes Mellitus (DM) type 1 is a metabolic disorder, characterized by a partial or complete deficiency of the hormone insulin production, resulting from the destruction of pancreatic beta cells, usually caused by the auto immune or idiopathic process. It can occur in a quick and progressive way in children and adolescents [1]. Possible risk factors for type 1 diabetes include [2]: Genetics (genetic marker is located on chromosome 6 and it’s a human leukocyte antigen), Family history, Other autoimmune disease, including thyroid disease, Addison′s disease, celiac disease, and autoimmune gastritis, Viral infection early in life, Early dietary introduction of cereal and gluten. In addition to insulin therapy, diabetes management should include education, support and access to psychological services need.

genetic conditions (such as maturity-onset diabetes in the young) and other conditions (such as cystic fibrosis-related diabetes) may also lead to diabetes in children and young people [4]. In order for people with T1DM to maintain normal blood glucose levels (BGLs; norm glycaemia) and reduce the potential microvascular, macrovascular and neurologic complications that are associated with poor glycemic control, a daily management routine is required (The Diabetes Control and Complications Trial Research Group [DCCT], 1993). This daily management routine includes blood glucose monitoring (BGM), insulin administration, controlling dietary intake and partaking in physical activity [5].
The main immunological markers of pancreatic compromise are the anti-islet, anti-insulin and anti-glutamic acid decarboxylase (GAD) antibody levels present in 90% of patients at the time of diagnosis. Diabetes type 1 habitually occurs in children and adolescents. The main goal of treatment is to prevent the appearance or progression of chronic complications, such as microvascular (diabetic retinopathy, nephropathy and neuropathy) and macrovascular (cerebral vascular accident and peripheral arterial disease) complications, simultaneously minimizing the risks of acute complications such as severe hypoglycemia [6].
The therapeutic approach involves various levels of action, such as insulin therapy, dietary guidance, acquisition of knowledge about the disease, the ability to self-apply insulin, and selfmonitoring of glycaemia, maintenance of regular physical activity and psychosocial support [7]. The treatment of diabetes affects basic aspects of everyday life and this difficulty is reflected in their blood glucose level and body weight and may in great part be due to the lack of appropriate perception of the disease and its management resulting in poor compliance and hence suboptimal glycemic control [8].
Life with type 1 diabetes (T1DM) requires extensive selfcare and comprehensive knowledge. This implies that support for parents is needed concerning how to maintain a positive role in the relationship with their child. These approaches should be embedded in health care services in order to reduce parents' stress and empower them in supporting their child's self-care [9]. Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, family functioning, or parent -child relationship quality, has been linked to both metabolic control and psychosocial adjustment in youth with T1D. These findings support the need for familybased interventions that reduce family conflict while promoting family cohesion and supportive involvement [10]. Type 1 diabetes accounts for 5-10% of the total cases of diabetes worldwide. The global incidence of type 1 diabetes in children below 14 years is increasing with an estimated overall annual increase of around 3%.
The prevalence of type 1 diabetes for United States residents aged 0-19 years is 1.7 per 1000. In Saudi Arabia, the incidence rate was estimated among children between 0-14 years in 2003 to be 12.3 cases per 100,000 per year [11].
The incidence of type 1 diabetes (T1DM) has been increasing all over the world. Chronic complications of diabetes such as retinopathy, neuropathy, coronary heart disease and nephropathy, which are still present, might be prevented. Type 1 Diabetes (T1D) affects about one in every 400 to 600 children and adolescents which translates to approximately 186,300 youth under the age of 20 [12]. Lifestyle is an important determinant of glycemic control in diabetic type 1 and 2 patients. The treatment of DM1 interferes in the lifestyle, is complicated, painful, depends on self-discipline and is essential to the patient's survival. The therapeutic approach involves various levels of action, such as insulin therapy, dietary guidance, acquisition of knowledge about the disease, the ability to self-apply insulin, and self-monitoring of glycaemia, maintenance of regular physical activity and psychosocial support.
In DM1, the important of following a balanced diet, adopting knowledge about the correct consumption of carbohydrates, proteins and fats. Observation of the quantities and qualities required of each food group enables glycemic control and prevention of complications; and adhesion to treatment is the key to attaining the objectives desired [13]. This is especially true for parents of very young children who, themselves, are developmentally unable to assume the role of diabetes manager [14]. They also emphasize that sustained efficacy of these skills is critical to avoid diabetes-related complications. Follansbee (1989) asserted that "knowledge of diabetes care seems to be a necessary, but not sufficient, prerequisite of good self -management, adherence and metabolic control". Because of the complexities involved in diabetes management, children need knowledge and skills 'as a beginning step' towards compliance with a diabetes regimen and metabolic control [11]. Type 1 diabetes among children are becoming increasingly apparent. The development of Type 1 diabetes in early age is likely to be associated with earlier development of complications. As co-morbid characteristics of insulin resistance are commonly present at diagnosis or appear early in the course of Type 1 diabetes, they should be screened earlier, so complications of long-standing diabetes will be diagnosed.

Acute Complication in Children with Type 1 Diabetes
It was reported that, among the central complications of type I children's diabetes is the Diabetic ketoacidosis (DKA) and severe hypoglycemia. Although that both of them are life-threatening, yet they can be prevented. US children with type 1 diabetes are at high risk for DKA (8 per 100 patient-years) and severe hypoglycemia (19 per 100 patient-years [15]. Diabetic ketoacidosis often leads to an emergency department (ED) visit and hospital admission and contributes to the high costs of care for children with type 1 diabetes. Cerebral edema, a devastating complication of DKA, is one of the leading causes of mortality among children with type 1 diabetes. Children with type 1 diabetes can be subjected to serious and acute complications among them: Poor glycemic control, family and school problems, low socioeconomic status, ethnicity, sex, and lack of adequate health insurance have been reported.

Methods and Materials
The study is cross sectional study. Parents of Type 1 diabetic children who attended CDIC (Changing diabetes in Children Program) pediatric outpatient departments in BIRDEM General Hospital-2, (Segunbagicha) in Dhaka were included consecutively.
The study was carried out from March 2019 to June 2019. Face to face interview were taken by using a questionnaire was designed based on objectives. The specific objective was measured by using appropriate statistical tests.

Ethical Issues
Taken approval was obtained from the ERB, AIUB.

Socio-Demographic Information
In the present study, out of total 101 participants about 42 percent respondents age is more than 46 years, however there is a gap between male and female participants age i.e. 49.3 percent male respondents age is 46+ years and 23.3 percent female age are 46+ years. Female respondents mean (SD) age in years is 37.70 (8.74 and male is 44.96 (9.90), Table 1 shows respondents detail age in years by their sex (Table 1 and, Figure 1). Out of total respondents nearly half of the respondents live in the Urban area, 34.7 percent Rural and 16.8 percent lives in the semi urban area ( Table 2).   Among children, the duration of diabetic and found one fifth of the children duration of diabetic is less than equals 4 years. During face-to-face interview with respondents a specific question ("Any one of your family members having diabetic?") was asked to respondents to find out their family members having diabetic. Out of total respondents' majority (66.3 percent) replied "YES" i.e. their family member having diabetic and there is difference between boy and girl's family's diabetic history but no statistically significant (Table 5).       i.e., their child maintains healthy life (Table 12).    Regarding the children insulin taking status, in replied this question majority respondents replied "YES" i.e. their child taking regular insulin as per the physician advice and found significant difference between male (64.4%) and female (35.6%) response (Table 14).
During face-to-face interview with using a prescribe questionnaire to find out study participant's child performed his/her own blood sugar test. Out of total respondent majority (78.2 percent) replied "YES" i.e. their child performing their blood sugar by using glucometer. However about 23 percent respondents replied "NO" i.e. their child not performed blood sugar test. According to study participants response majority (59.4 percent) child received insulin as per the physician specific advice and there is small gap between male and female respondents but is not statistically significant.   Note: There is significant p value (p=0.003) between urban and rural participant's children where glycemic control are good. Note: There is significant p value change between primary level and secondary level education participant's child where HbA1C level are well controlled. Note: There is significant change between the participants who attended health education class in CDIC, those children's glycemic control are good.

Discussion
Mellitus (Type1diabetes (T1D) is a chronic disease that unusually appears in the pediatric age, whose proper management avoids short and long-term complications [16]. Diabetes DM) type1 is a metabolic disorder, characterized by a partial or complete deficiency of the hormone insulin production, resulting from the destruction of pancreatic beta cells, usually caused by the auto immune or idiopathic process. [ [23,24]. Diabetes education must be targeted toward parents to help them to be in possession of relevant management and interpersonal skills for providing some elements of guidance and counseling relating to students with DM when necessary [25]. The proper management of the disease in children and adolescents has been a challenge, because of the presence of behaviors, skills and inadequate knowledge that contribute to non-adherence to treatment and the significant increase in long-term complications [26].
The challenges of T1DM include awareness of the disease which is very poor amongst the general public and also in parents of T1DM children, and this needs to be improved to effectively counter the problem of T1DM [27,28]. Adherence to the dosage of the medication regimen; Adequate self-monitoring of blood glucose; Reduction of the risk of chronic complications (improvement in glycemic control); Individual´s ability to properly correct hypoglycemia and hyperglycemia and the results of this study, it was observed that the education program in diabetes has good efficacy. However, it is necessary to consider and strengthen some important aspects of the management of diabetes to be adequate and provide a better quality of life of affected children [29][30][31][32][33][34][35][36].

Conclusion
In this study most parent age was 41-46 years. Half of the participants were from urban area and are with HSC education level. 86.1% parent know the long-term complication of diabetes but only 43.6% unknown the diabetic ketoacidosis. 82% parents maintain healthy lifestyle, 60% patients took balance diet, and 64% patient took regular insulin. So, in this study significant association of good glycemic control was found those were living in urban area, education level HSC or more, regular attended at CDIC education session and good knowledge about consequence of diabetes and maintain healthy life style.