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Division of Pediatric Endocrinology
Department of Pediatrics
Yale School of Medicine
New Haven, Connecticut
Jennifer Sherr, MD, PhD, has disclosed that she has received funds for research support from Insulet, Lilly, and Medtronic Diabetes and consulting fees from Bigfoot Biomedical, Cecelia Health, Insulet, Lexicon, Lilly, Medtronic Diabetes, Sanofi, and Vertex.
Diabetes technologies, including continuous glucose monitors (CGM), connected/smart insulin pens, insulin pumps, and automated insulin-delivery systems, hold the promise to improve glycemia while reducing the burden of disease management. However, success with technology and persistence of device use requires those who care for youths to remember that children are not small adults. When thinking of the pediatric population, 3 age groups can be considered: preschoolers, school-age children, and adolescents/young adults. By considering how each of these developmental stages is unique, successful integration of these technologies may be feasible.
The Vulnerability of Very Young Children
Very young children with type 1 diabetes are entirely reliant on their adult care providers to manage this chronic medical condition. Often at this age, children are unable to recognize and/or verbalize if they are experiencing hyperglycemia or hypoglycemia. Unpredictable meal patterns, where a child may not eat their entire meal, and erratic physical activity, which makes insulin dosing even more complex, may further contribute to glycemic variability. Families may adopt a strategy of permissive hyperglycemia, as fear of hypoglycemia often exists. A recent randomized, controlled trial of CGM in youths aged 2 to <8 years demonstrated this, as children randomized to CGM use showed persistence of device wear and a reduction in time below range (<70 mg/dL) without improvement in time in range (70-180 mg/dL).
Data from the US-based Type 1 Diabetes Exchange has shown exponential growth of CGM use in this population, with a nearly 12-fold increase from 2010-2012 to 2016-2018. This growth is likely related to the vast technological advances that CGM has seen in recent years, including factory calibration of devices and the approval to use CGM data to make treatment decisions, thus allowing one to forgo the need for finger-sticks in most instances. In addition, remote-monitoring capabilities allow parents and day cares/schools to have “eyes” on the child at all times. With the ability to constantly view data, some care providers have begun to preemptively treat a predicted low based on CGM trend arrows and/or at a higher threshold than what we would recommend clinically. Providing concrete guidance on how to interpret the data and what thresholds should prompt action is invaluable.
With insulin-delivery systems, the history afforded through connected/smart pens or insulin pumps prevents stacking of insulin, as insulin-on-board calculators will prevent administration of repeated correction doses as children transition from home to day care/school or vice versa. Finally, recent studies of automated insulin delivery highlight the utility of these devices in the preschool population, showing improvement in time in target range without increasing time below range.
A Team Sport: Management of Diabetes in School-Age Children
For school-age children (aged 7-12 years), the network of adults who oversee their care increases beyond school staff to bus drivers, coaches, and after-school programs. The impact of parental oversight combined with a child who is more aware of their diabetes management may provide the foundations for treatment success. In the landmark JDRF CGM trial, use of the CGM for ≥6 days occurred in 50% of participants aged 8-14 years vs only 30% of participants aged 15-24 years. This would suggest parental influence in diabetes management may affect device integration.
Yet, providers and parents should embrace having the school-age child with diabetes become an active member in the development of their treatment plan. For some children, use of an insulin pump is palatable only if they can have a tubeless device. Sensor use may be feasible only if alerts and alarms are not a nuisance, leading to the child being singled out for their chronic medical condition.
Countless studies have included school-age children in assessments of insulin pump therapy and automated insulin delivery, and a clear picture has emerged: These technologies work. However, it is important to note that clinical trials may not represent the entire diverse population of youths with diabetes. For those who enroll in trials, there is a clear investment required from the parent to partake in a study. Determining strategies to keep parents engaged with care is crucial in this age group. Creating allies with school staff to support school-age children is also of benefit.
Adolescents and Young Adults: The Search for Autonomy
The hallmark of adolescence is the quest for independence. However, this can be tricky for someone living with diabetes. Insulin resistance in puberty leads to more rapidly evolving insulin requirements. In addition, this stage of life is often accompanied by a desire to “fit in” with peers, and diabetes devices may seem ever-present as part of the daily uniform. Sharing how more targeted glycemia can allow for fuller participation in activities—by avoiding both hypoglycemia and hyperglycemia—may help some engage in using these devices.
Because some parents have grown accustomed to watching their child’s sensor glucose data constantly, adolescence is a time when contracts may need to be developed between the parent and child regarding how the child should act on this data. Savvy teenagers undoubtedly will recognize that the power to follow sensor glucose data resides with them. In other words, they can shut off the remote-monitoring capabilities. To help allow for autonomy, parents can be advised to let an adolescent or young adult respond to alerts and to intervene only if a problem persists. Thresholds for alerts in a parent’s devices should mirror what is set for the person with diabetes. Guidance should be provided to parents that they should let their teenager respond to the first alert and intervene only if the alert reoccurs. This highlights the importance of appropriately programming the threshold and time for repeat alerts. In our practice, this often involves setting a low threshold alert of 70 mg/dL with a repeat alert set to occur in 20-30 minutes and a high threshold alert of 300 mg/dL, which can be lowered over time, with a repeat alert set to occur at 2 hours.
The beneficial impact of technology in diabetes management has been echoed by consensus guidelines that recommend the use of these therapies in youths living with this condition. Critical to the integration of technology for children is understanding the unique challenges faced at each developmental stage and how to encourage device persistence. Shared decision-making is a cornerstone to care and must involve parents, providers, and the child. Ongoing efforts to permit greater use of technologies, such as cell phones, in daily life will help ease the stigma that devices may impose, as will continued efforts for miniaturization of devices. As automated insulin-delivery systems overcome current limitations that exist—such as the inability to accommodate meal-related glycemic excursions and adapt to activity—the ability to allow youths with diabetes to “just be kids” will only increase.
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