Persistent Burden and Management Gaps of Hypoglycemia in Pediatric Type 1 Diabetes: Insights from the Epi-GLUREDIA Study.

BACKGROUND/OBJECTIVES:- Despite advances in automated insulin delivery, hypoglycemia remains a major challenge in pediatric type 1 diabetes. We aimed to characterize, in real-world practice, the burden, awareness, and daily-life impact of hypoglycemia and severe hypoglycemia (SH), and to identify gaps in perception and management. METHODS:- We conducted a prospective, descriptive, multicenter study using the new GLUREDIA questionnaire, administered during routine pediatric diabetes visits across six centers in Belgium and Luxembourg. This structured, study-specific, semi-quantitative tool assessed hypoglycemia frequency, symptom severity, perceived glycemic thresholds, SH history and management, and post-SH behavioral adaptations. Hypoglycemia awareness was evaluated using items aligned with Clarke score domains. RESULTS:- Among 232 participants, 55.9% reported hypoglycemia at least weekly, with moderate-to-high symptom severity. Cognitive and daily-life symptoms (impaired focus, fatigue, hunger, tremor) were reported by >60% and interfered with activities. Hypoglycemia was identified as the dominant disease burden by 39.7% of participants. Hypoglycemia-related symptom burden remained substantial and was not fully explained by CGM-derived metrics. SH was reported by 45.7%, without clear cause in 29.1%. Recommended management, including glucagon use, was inconsistently applied, even in recurrent SH. Following SH, participants reported insulin dose reductions (27.4%), increased sugar intake (21.1%), and avoidance of physical activities (22.1%), as adaptations. The Epi-GLUREDIA questionnaire demonstrated promising discriminative ability against the Clarke score (AUC = 0.84), supporting its construct validity. CONCLUSIONS:- Despite advances in diabetes technology, hypoglycemia remains highly prevalent, impactful, and often poorly anticipated in pediatric type 1 diabetes. Gaps in SH management and hypoglycemia awareness, together with post-event adaptations, highlight the need for integrated strategies combining education, behavioral support, optimized use of technologies, and improved implementation of guidelines, including appropriate glucagon use, to improve hypoglycemia safety, recognition, and long-term outcomes in pediatric type 1 diabetes. SUMMARY:Hypoglycemia remains frequent and impactful in pediatric type 1 diabetes, with variable symptom thresholds, unexplained severe hypoglycemia, management gaps, and post-event adaptations that may impair glycemic control.