Growth failure in 600 children living with type 1 diabetes: evidence from a cross-sectional study in Kerala, India.

BACKGROUND: Growth failure remains a recognised complication of type 1 diabetes mellitus (T1DM), particularly in settings where optimal metabolic control is difficult to achieve. Indian data on the burden and determinants of impaired linear growth in children with T1DM are limited. We aimed at estimating the prevalence of growth failure in a state-wide representative cohort of children with T1DM in Kerala, India, and to examine associated clinical and metabolic factors. METHODS: We conducted a state-wide, cross-sectional study between September 2024 and May 2025 among 600 children and adolescents aged 5-18 years with T1DM across Kerala. For the purpose of this study, T1DM was defined based on a documented clinical diagnosis by a treating paediatrician/endocrinologist as childhood or adolescent onset of diabetes mellitus and continuous insulin dependence (basal-bolus regimen, multiple daily injections, continuous subcutaneous insulin infusion (CSII)) for at least 6 months prior to enrolment. Height and weight were measured using standardised techniques, and height-for-age percentiles and Z-scores were calculated using the Indian Academy of Pediatrics 2015 growth charts. Growth failure was defined as height-for-age Z-score<-2 or height for age below the third centile. A randomly selected subset (n=150) underwent biochemical evaluation, including laboratory-based glycated haemoglobin (HbA1c) and lipid profile. Multivariable binary logistic regression was used to identify independent predictors of growth failure. RESULTS: Among 600 participants (54.5% female), 150 children (25.0%) had height below the third centile, indicating a high prevalence of growth failure. Only 1% used a continuous glucose monitor (CGM), and 0.33% had access to a CSII pump. In the subset of children (n=150) where lab-based investigations were done, mean HbA1c was 9.65%, with nearly 60% having HbA1c>9%; dyslipidaemia was common, including elevated low-density lipoprotein (LDL) cholesterol in 26.7% and elevated triglycerides in 30.7%. On multivariable logistic regression analysis, growth failure was independently associated with duration of T1DM≥5 years (adjusted OR (aOR) 1.64, 95% CI 1.03 to 2.63), age at diagnosis≥10 years (aOR 1.74, 95% CI 1.08 to 2.78) and Glucose Management Index>9% (aOR 1.74, 95% CI 1.12 to 2.71). Lipid parameters were not independently associated with growth failure after adjustment. INTERPRETATION: One in four children with T1DM in Kerala experience growth failure despite care within a comparatively strong public health system. Longer disease duration, poor glycaemic control and vulnerability during adolescence independently increase the risk. Integrating routine growth monitoring with intensified metabolic support, together with access to diabetes technologies, within state-level diabetes programmes may reduce long-term developmental and cardiometabolic risk in children with T1DM.