A Spatiotemporal Deep Learning Framework for Scalp EEG-Based Automated Pain Assessment in Children.

OBJECTIVE: Common pain assessment approaches such as self-evaluation and observation scales are inappropriate for children as they require patients to have reasonable communication ability. Subjective, inconsistent, and discontinuous pain assessment in children may reduce therapeutic effectiveness and thus affect their later life. METHODS: To address the need for suitable assessment measures, this paper proposes a spatiotemporal deep learning framework for scalp electroencephalogram (EEG)-based automated pain assessment in children. The dataset comprises scalp EEG data recorded from 33 pediatric patients with an arterial puncture as a pain stimulus. Two electrode reduction plans in line with clinical findings are proposed. Combining three-dimensional hand-crafted features and preprocessed raw signals, the proposed transformer-based pain assessment network (STPA-Net) integrates both spatial and temporal information. RESULTS: STPA-Net achieves superior performance with a subject-independent accuracy of 87.83% for pain recognition, and outperforms other state-of-the-art approaches. The effectiveness of electrode combinations is explored to analyze pain-related cortical activities and correspondingly reduce cost. The two proposed electrode reduction plans both demonstrate competitive pain assessment performance qualitatively and quantitatively. CONCLUSION AND SIGNIFICANCE: This study is the first to develop a scalp EEG-based automated pain assessment for children adopting a method that is objective, standardized, and consistent. The findings provide a potential reference for future clinical research.

Evaluation of procedural pain for neonates in a neonatal intensive care unit: a single-centre study.

BACKGROUND: To evaluate the procedural pain experienced by neonates in a neonatal intensive care unit (NICU) setting and determine the corresponding pain grades. METHODS: Two experienced nurses independently used the Neonatal Infant Pain Scale (NIPS) to evaluate the neonatal pain during procedures taking place in the tertiary NICU and two level-two neonatal care units in the Children's Hospital of Zhejiang University School of Medicine. The mean and distribution of NIPS pain scores and the corresponding pain grades of participants when experiencing clinical painful procedures were analysed. RESULTS: A total of 957 neonates exposed to 15 common clinical painful procedures were included in the study. The clinical painful procedures experienced by 957 participants could be divided into three groups: severe pain (NIPS score 5-7: peripheral intravenous cannulation, arterial catheterisation, arterial blood sampling, peripherally inserted central catheter placement and nasopharyngeal suctioning), mild to moderate pain (NIPS score 3-4: finger prick, intramuscular injection, adhesive removal, endotracheal intubation suctioning, heel prick, lumbar puncture and subcutaneous injection) and no pain to mild pain (NIPS score 0-2: gastric tube insertion, enema and intravenous injection). CONCLUSIONS: The neonatal pain response to clinical procedures in NICU had certain pattern and preintervention drug analgesia could be taken for painful procedures with clustered high NIPS pain scores. Meanwhile, full coverage non-drug pain relief measures could be taken for procedures that are with scattered pain scores, and real-time pain evaluation should be provided to determine whether further drug analgesia is required.

Video-Based Neonatal Pain Assessment in Uncontrolled Conditions.

OBJECTIVE: Neonatal pain can have long-term adverse effects on newborns' cognitive and neurological development. Video-based Neonatal Pain Assessment (NPA) method has gained increasing attention due to its performance and practicality. However, existing methods focus on assessment under controlled environments while ignoring real-life disturbances present in uncontrolled conditions. METHODS: We propose a video-based NPA method, which is robust to four real-life disturbances and adaptively highlights keyframes. Our method involves a region-channel-attention module for extracting facial features under the disturbances of facial occlusion and pose variation; a body language analysis module robust to disturbances from body occlusion and movement interference, which utilizes skeleton sequences to represent the neonate's body; and a keyframes-aware convolution to get rid of information located at non-contributing moments. For evaluation, we built an NPA video dataset of 1091 neonates with disturbance annotations. RESULTS: The results show that our method consistently outperforms state-of-the-art methods on the full dataset and nine subsets, where it achieves an accuracy of 91.04% on the full dataset with an accuracy increment of 6.27%. Contributions: We present the problem of video-based NPA under uncontrolled conditions, propose a method robust to four disturbances, and construct a video NPA dataset, thus facilitating the practical applications of NPA.

Pose-invariant and occlusion-robust neonatal facial pain assessment.

Neonatal Facial Pain Assessment (NFPA) is essential to improve neonatal pain management. Pose variation and occlusion, which can significantly alter the facial appearance, are two major and still unstudied barriers to NFPA. We bridge this gap in terms of method and dataset. Techniques to tackle both challenges in other tasks either expect pose/occlusion-invariant deep learning methods or first generate a normal version of the input image before feature extraction, combining these we argue that it is more effective to jointly perform adversarial learning and end-to-end classification for their mutual benefit. To this end, we propose a Pose-invariant Occlusion-robust Pain Assessment (POPA) framework, with two novelties. We incorporate adversarial learning-based disturbance mitigation for end-to-end pain-level classification and propose a novel composite loss function for facial representation learning; compared to the vanilla discriminator that implicitly determines occlusion and pose conditions, we propose a multi-scale discriminator that determines explicitly, while incorporating local discriminators to enhance the discrimination of key regions. For a comprehensive evaluation, we built the first neonatal pain dataset with disturbance annotation involving 1091 neonates and also applied the proposed POPA to the facial expression recognition task. Extensive qualitative and quantitative experiments prove the superiority of the POPA.

Video-Based versus On-Site Neonatal Pain Assessment in Neonatal Intensive Care Units: The Impact of Video-Based Neonatal Pain Assessment in Real-World Scenario on Pain Diagnosis and Its Artificial Intelligence Application.

BACKGROUND: Neonatal pain assessment (NPA) represents a huge global problem of essential importance, as a timely and accurate assessment of neonatal pain is indispensable for implementing pain management. PURPOSE: To investigate the consistency of pain scores derived through video-based NPA (VB-NPA) and on-site NPA (OS-NPA), providing the scientific foundation and feasibility of adopting VB-NPA results in a real-world scenario as the gold standard for neonatal pain in clinical studies and labels for artificial intelligence (AI)-based NPA (AI-NPA) applications. SETTING: A total of 598 neonates were recruited from a pediatric hospital in China. METHODS: This observational study recorded 598 neonates who underwent one of 10 painful procedures, including arterial blood sampling, heel blood sampling, fingertip blood sampling, intravenous injection, subcutaneous injection, peripheral intravenous cannulation, nasopharyngeal suctioning, retention enema, adhesive removal, and wound dressing. Two experienced nurses performed OS-NPA and VB-NPA at a 10-day interval through double-blind scoring using the Neonatal Infant Pain Scale to evaluate the pain level of the neonates. Intra-rater and inter-rater reliability were calculated and analyzed, and a paired samples t-test was used to explore the bias and consistency of the assessors' pain scores derived through OS-NPA and VB-NPA. The impact of different label sources was evaluated using three state-of-the-art AI methods trained with labels given by OS-NPA and VB-NPA, respectively. RESULTS: The intra-rater reliability of the same assessor was 0.976-0.983 across different times, as measured by the intraclass correlation coefficient. The inter-rater reliability was 0.983 for single measures and 0.992 for average measures. No significant differences were observed between the OS-NPA scores and the assessment of an independent VB-NPA assessor. The different label sources only caused a limited accuracy loss of 0.022-0.044 for the three AI methods. CONCLUSION: VB-NPA in a real-world scenario is an effective way to assess neonatal pain due to its high intra-rater and inter-rater reliability compared to OS-NPA and could be used for the labeling of large-scale NPA video databases for clinical studies and AI training.

Construction and validation of a predictive risk model for nosocomial infections with MDRO in NICUs: a multicenter observational study.

Objectives: This study aimed to construct and validate a predictive risk model (PRM) for nosocomial infections with multi-drug resistant organism (MDRO) in neonatal intensive care units (NICUs), in order to provide a scientific and reliable prediction tool, and to provide reference for clinical prevention and control of MDRO infections in NICUs. Methods: This multicenter observational study was conducted at NICUs of two tertiary children's hospitals in Hangzhou, Zhejiang Province. Using cluster sampling, eligible neonates admitted to NICUs of research hospitals from January 2018 to December 2020 (modeling group) or from July 2021 to June 2022 (validation group) were included in this study. Univariate analysis and binary logistic regression analysis were used to construct the PRM. H-L tests, calibration curves, ROC curves and decision curve analysis were used to validate the PRM. Results: Four hundred and thirty-five and one hundred fourteen neonates were enrolled in the modeling group and validation group, including 89 and 17 neonates infected with MDRO, respectively. Four independent risk factors were obtained and the PRM was constructed, namely: P = 1/ (1+ e-X), X = -4.126 + 1.089× (low birth weight) +1.435× (maternal age ≥ 35 years) +1.498× (use of antibiotics >7 days) + 0.790× (MDRO colonization). A nomogram was drawn to visualize the PRM. Through internal and external validation, the PRM had good fitting degree, calibration, discrimination and certain clinical validity. The prediction accuracy of the PRM was 77.19%. Conclusion: Prevention and control strategies for each independent risk factor can be developed in NICUs. Moreover, clinical staff can use the PRM to early identification of neonates at high risk, and do targeted prevention to reduce MDRO infections in NICUs.

Artificial Intelligence Based Pain Assessment Technology in Clinical Application of Real-World Neonatal Blood Sampling.

Background: Accurate neonatal pain assessment (NPA) is the key to neonatal pain management, yet it is a challenging task for medical staff. This study aimed to analyze the clinical practicability of the artificial intelligence based NPA (AI-NPA) tool for real-world blood sampling. Method: We performed a prospective study to analyze the consistency of the NPA results given by a self-developed automated NPA system and nurses' on-site NPAs (OS-NPAs) for 232 newborns during blood sampling in neonatal wards, where the neonatal infant pain scale (NIPS) was used for evaluation. Spearman correlation analysis and the degree of agreement of the pain score and pain grade derived by the NIPS were applied for statistical analysis. Results: Taking the OS-NPA results as the gold standard, the accuracies of the NIPS pain score and pain grade given by the automated NPA system were 88.79% and 95.25%, with kappa values of 0.92 and 0.90 (p < 0.001), respectively. Conclusion: The results of the automated NPA system for real-world neonatal blood sampling are highly consistent with the results of the OS-NPA. Considering the great advantages of automated NPA systems in repeatability, efficiency, and cost, it is worth popularizing the AI technique in NPA for precise and efficient neonatal pain management.

Knowledge, Attitudes, and Practices of NICU Doctors and Nurses Toward Prevention and Control of Nosocomial Infection With Multidrug Resistant Organism.

Background: Nosocomial infection with multidrug resistant organisms (MDRO) can directly influence the curative effect and the prognosis of neonates, bringing great difficulties to clinical treatment. As direct contacts of neonates, the knowledge, attitudes, and practices (KAP) of doctors and nurses are critical for the prevention and control of MDRO infection in neonatal intensive care units (NICUs). Purpose: This study describes the KAP of doctors and nurses in NICUs toward the prevention and control of nosocomial infection with MDRO and analyzes its influencing factors. Methods: This cross-sectional study used convenience sampling to survey 397 doctors and nurses from the NICU of 28 hospitals in 11 cities in Zhejiang Province, China. A univariate analysis and a multiple linear regression were used to analyze the data. Results: The median scoring rate (interquartile range) of the knowledge, attitude, and practice questionnaire was 0.86 (0.82-0.91), 0.98 (0.91-1.00), and 0.995 (0.97-1.00), respectively. However, the median scoring rate regarding "basic knowledge of MDRO" and "special prevention and control measures" was 0.50 in knowledge. The multiple linear regression showed that the influencing factors of KAP were hospital grade, professional title, gender, regular supervision, and training. Conclusions: There was still room for improvement in the KAP of NICU doctors and nurses, especially regarding the knowledge. Men, doctors and nurses in Grade II hospitals, and doctors and nurses with primary professional titles had worse KAP. Training and supervision helped improve the KAP. Relevance to Clinical Practice: To improve the KAP of doctors and nurses to enhance the prevention and control effect for the MDRO infection in NICUs, hospitals and departments should carry out targeted training and strengthen supervision, while Grade II hospitals, men, and doctors and nurses with primary professional titles need more attention.

Effect of chlorhexidine cleansing on healthcare-associated infections in neonates: a systematic review and meta-analysis.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on neonatal morbidity, mortality and long-term prognosis, which have a high incidence in neonates. Many studies have shown that chlorhexidine cleansing is effective in reducing HAIs in adults, but the effect of chlorhexidine cleansing on HAIs in neonates remains controversial. AIM: The purpose of this study was to conduct a systematic review and meta-analysis of the effect of chlorhexidine cleansing on HAIs in neonates. The protocol of this review has been registered with the PROSPERO international prospective register of systematic reviews. METHODS: A systematic literature search was performed on five medical literature databases, namely MEDLINE, Web of Science, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL), published up until 3 March 2021. In the end, six studies were eligible for inclusion, including four randomised controlled trials and two quasi-experimental studies. Version 2 of the Cochrane tool for assessing risk of bias in randomised trials and the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies were used for quality assessment. Pooled risk ratios (RRs) and their associated 95% CIs were calculated using the fixed effects model (I2 <50%) or the random effects model (I2 ≥50%). FINDINGS AND CONCLUSIONS: The results of the meta-analysis revealed that chlorhexidine cleansing had no significant effect on neonatal sepsis (RR: 0.49, 95% CI 0.18 to 1.38, p=0.18, I2=0%), but significantly reduced neonatal skin bacterial colonisation (RR: 0.61, 95% CI 0.42 to 0.90, p=0.01, I2=50%). In addition, this systematic review showed that chlorhexidine cleansing could significantly reduce central line-associated bloodstream infection in neonates based on large-sample studies. However, more studies are needed to determine the optimal concentration and frequency of chlorhexidine cleansing. PROSPERO registration number CRD42021243858.

Insertion of a 1.9F central venous catheter via the internal jugular vein in neonates.

OBJECTIVE: This study aimed to develop a technique for placing a 1.9 French (F) central venous catheter in the internal jugular vein of newborns. METHODS: In this retrospective study, punctures were performed with a modified ultrasound-guided Seldinger technique with 57 1.9F catheters in 48 newborns. Punctures were performed in the right internal jugular vein in 43 (75.4%) patients and in the left internal jugular vein in 14 (24.6%) patients. RESULTS: We included 33 (57.9%) boys and 24 (42.1%) girls, aged a median 38 days (range, 2-135 days). The puncture success rate was 100%. Catheterization duration was a median 14 days (range, 1-70 days). Among the catheters, 94.1% were removed after completion of therapy or upon death. Fifty-three (93%) patients experienced no complication, whereas a small amount of bleeding was observed in 2 (3.5%) patients, inflammation of puncture in 1 (1.8%) patient, and occlusion in 1 (1.8%) patient. The method of placement of 1.9F catheters in the internal jugular vein of newborns had a high success rate, with minimal trauma and few complications. CONCLUSIONS: Our method of placing a 1.9F central venous catheter in the internal jugular vein is suggested for level III to VI neonatal intensive care units.

[Emergency plan for inter-hospital transfer of newborns with SARS-CoV-2 infection].

Since December 2019, the outbreak of coronavirus disease (COVID-19) has become the most serious public health issue. As the special population with immature immune function, newborns with COVID-19 have been reported. Newborns with suspected or confirmed COVID-19 should be transferred to designated hospitals for isolation treatment. An emergency transfer response plan for newborns with COVID-19 has been worked out. This plan puts forward the indications for neonatal COVID-19 transfer, organization management, protection strategies for medical staff, work procedures, and disinfection methods for transfer equipment, in order to provide guidance and suggestions for the inter-hospital transfer of suspected or confirmed neonatal COVID-19.

Medical management of a child with congenital generalized lipodystrophy accompanied with progressive myoclonic epilepsy: A case report.

RATIONALE: Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive hereditary disease. It is associated with metabolic complications and epilepsy is rare. PATIENT CONCERNS AND DIAGNOSES: One child with BSCL2 mutation and CGL accompanied by progressive myoclonic epilepsyDiagnosis: He was diagnosed with epilepsy, CGL, and severe malnutrition. INTERVENTIONS: He was treated with sodium valproate, baclofen, aripiprazole, benzhexol, and lamotrigine for epilepsy. OUTCOMES: After 16 days of medical treatment for epilepsy, the disease was improved and the child was discharged with gastric tube inserted for the management of malnutrition. LESSONS: CGL and progressive myoclonic epilepsy is rare, and the epilepsy is partially refractory to treatments. In this particular case, the nutritional status was compromised as a complication of progressive myoclonic epilepsy and had to be managed.

Relationships between Stigma, Social Support, and Distress in Caregivers of Chinese Children with Imperforate Anus: A Multicenter Cross-Sectional Study.

PURPOSE: This study was conducted to explore the relationships between stigma, social support, and distress in caregivers of children with imperforate anus (IA) and determine whether social support mediates the relationship between stigma and distress. DESIGN AND METHODS: This cross-sectional study was conducted in three tertiary children's hospitals in Eastern China. Primary caregivers completed the Social Support Scale and the Chinese versions of the Parent Stigma Scale and Kessler Psychological Distress Scale, and provided their demographic information. The children's demographic and clinical data were also collected. The hypothesized relations were explored using structural equation modeling via the bootstrap method. RESULTS: A total of 229 caregivers were enrolled. Distress was positively associated with stigma (r = 0.396, P < 0.01) and negatively associated with social support (r = -0.413, P < 0.01) in all dimensions (r = 0.314-0.346, P < 0.01). Stigma was also negatively correlated with social support (r = 0.280, P < 0.01). Furthermore, social support could partially mediate the relationship between stigma and distress (b = 0.135; 95% confidence interval: 0.072, 0.233). CONCLUSIONS: Stigma can increase caregivers' distress, while social support can reduce it. Stigma can also negatively influence caregivers' social support. Therefore, stigma should be mitigated to enhance caregivers' social support and decrease their distress. PRACTICE IMPLICATIONS: The study findings may aid in the identification of the psychological status of caregivers of children with IA, and also inform targeted intervention programs.

Medical Adhesive-Related Skin Injuries and Associated Risk Factors in a Pediatric Intensive Care Unit.

OBJECTIVE: To investigate the prevalence of medical adhesive-related skin injuries (MARSIs) and associated risk factors in a pediatric ICU (PICU). METHODS: A cross-sectional design was adopted in the PICU of a university-based children's hospital in eastern China. A total of 232 patients were enrolled, and 611 person-days were analyzed. MAIN OUTCOME MEASURES: Researchers assessed all patients daily for 2 weeks. The use of adhesives and prevalence of MARSIs were recorded. The patients' clinical data were also collected. The prevalence of MARSIs was calculated daily, and the risk factors were examined statistically. MAIN RESULTS: The MARSI prevalence ranged from 23.53% to 54.17% (mean, 37.15%). Multivariate analysis identified being female, age 2 years or younger, hospital stays longer than 5 days, infection, edema, and surgery as independent risk factors. Prevalence by product ranged from 19 to 53 per 1,000 product-days with a mean of 34 MARSIs per 1,000 product-days. The major MARSI types were epidermal stripping and skin tear. The face was the most common MARSI site, and tracheal intubation was the most common inciting condition. Implicated products were acrylate tapes with elastic cloth backings. CONCLUSIONS: Researchers concluded that MARSI is common in the PICU. Skin stripping and skin tear were the most common types, and the face was the most vulnerable site for MARSI, typically attributable to the cloth tape used to affix tracheal intubation. Careful attention should be paid to children with identified risk factors (females, age 2 years or younger, longer hospital stays, edema, infection, or surgery).

A Video Database of Neonatal Facial Expression based on Painful Clinical Procedures.

Neonatal pain assessment has gained more and more attention from clinical care, and pain scales are usually adopted as the main assistants for neonatal pain rankings. Due to the large time and manpower consumption of pain scales, automatic pain assessment for neonates during painful clinical procedures is of great requirements. A video database of neonatal facial expression, containing pain intensity labels obtained from two different pain scales, is constructed in this paper as a pre-work for automatic pain score evaluation. Uniform and rotation invariant local binary patterns (LBP) are implemented as feature descriptors and the effectiveness of the extracted features is validated. As a result, a feature set of 144 dimensionalities is established and with the implementation of dimension reduction, new feature sets ranging from 40 to 60 dimensionalities, accounting for more than 90% of original data, are preserved as the input data for future pain classification.

Beneficial effects of Huaiqihuang on hyperglycemia-induced MPC5 podocyte dysfunction through the suppression of mitochondrial dysfunction and endoplasmic reticulum stress.

The present study was performed to investigate the effect of Huaiqihuang (HQH) on hyperglycemia (HG)-induced mitochondrial dysfunction and endoplasmic reticulum (ER) stress in MPC5 podocytes. The effects of HQH and HG on cell viability were assessed using an MTT assay. mRNA and protein expression levels were evaluated using reverse transcription-quantitative polymerase chain reaction and western blot analysis, respectively. Cell apoptosis was assessed using terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling, whereas reactive oxygen species production and alterations in mitochondrial membrane potential were assessed using flow cytometry. DNA damage was evaluated using a comet assay. The results demonstrated that treatment of podocytes with HQH markedly suppressed the HG­induced generation of reactive oxygen species. HQH also significantly improved mitochondrial membrane potential in podocytes exposed to HG. When the podocytes were treated with HG, Ca2+ levels were significantly increased, compared with those in the control group, whereas treatment of the podocytes with HQH significantly reversed the HG­induced upregulation of Ca2+ secretion. Treatment of the podocytes with HQH significantly reversed the HG­induced upregulation of glucose­related protein 78 (GRP78) and C/EBP­homologous protein, which were used as indicators of ER stress. Furthermore, GRP78 loss­of­function attenuated HG­induced podocyte dysfunction, including cell apoptosis and DNA damage. In conclusion, beneficial effects of HQH on HG­induced MPC5 podocyte dysfunction were observed, and occurred through the suppression of mitochondrial dysfunction and ER stress.

Huaiqihuang may protect from proteinuria by resisting MPC5 podocyte damage via targeting p-ERK/CHOP pathway.

The purpose of this study was to investigate the potential effects of Huaiqihuang (HQH) granule, a Chinese herbal medicine, in treating proteinuria and to reveal its possible mechanism. MPC5 podocytes were cultured in vitro at 37°C and induced with tunicamycin (TM). The TM-induced cells were treated with HQH at different concentrations. The cell proliferation was detected using the MTT assay. The optimal effective dose of HQH for MPC5 cells was determined by the MTT assay and LDH assay respectively. The influences of HQH on the proteinuria-related protein expression and the signaling pathway associated protein expression were also detected using quantitative reverse transcription PCR and Western blotting analysis. The results showed that the MPC5 cell model was successfully constructed in vitro. The HQH application could improve the harmful effects induced by TM on the MPC5 cells, including promoted cell proliferation and suppressed cell apoptosis. Furthermore, the protein expression, including podocin, nephrin, and synaptopodin was down-regulated by the TM treatment in the MPC5 cells. On contrary, the expression of these proteins was up-regulated after the HQH application. Also, the effect of TM on integrin α3 and integrin ß1 expressions was also reversed by the HQH treatment. Moreover, the HQH application decreased the expression of p-ERK and DNA-damage-inducible transcript 3 (DDIT3 or CHOP) in the MPC5 cells, which was opposite to the effect observed in the cells treated with TM. Taken together, our study suggest that HQH application may protect podocytes from TM damage by suppressing the p-ERK/CHOP signaling pathway.

Psycho-behavioral changes in children with type 1 diabetes mellitus.

BACKGROUND: Type 1 diabetes mellitus (T1DM) is the most common type of diabetes in children. This study aimed to investigate psycho-behavioral changes in Chinese children with T1DM and to provide some advices for nurses, parents and other persons. METHODS: Forty-five patients with T1DM (26 boys and 19 girls with a mean age of 10.40±3.01 years) were enrolled. According to the glycosylated hemoglobin levels recommended by the American Diabetes Association, the patients were subdivided into a well-controlled group and a poorly-controlled group. Fifty-three healthy children served as a control group. Psycho-behavioral changes were investigated by using Achenbach's Child Behavior Check List. RESULTS: Compared with the control group, the patients with T1DM had significantly higher mean scores for withdrawal, anxiety/depression, attention problems, delinquent behavior, aggressive behavior, externalizing problems, and internalizing problems (P<0.017). Moreover, the mean scores for somatic complaints in the poorly-controlled subgroup were significantly higher than those in the well-controlled subgroup (t=3.582, P=0.001). Compared with the control group, the well-controlled subgroup had higher scores for withdrawal, anxiety/depression, and internalizing problems (P<0.017). But the poorly-controlled subgroup had higher scores for withdrawal, somatic complaint, anxiety/depression, delinquent behavior, aggressive behavior, externalizing and internalizing problems (P<0.017). CONCLUSIONS: Children with T1DM may have some psycho-behavioral problems. Timely nursing interventions must be conducted to solve these problems.