Children,Teens and Continuous Glucose Monitoring
Fellow blogger, Dr. Bill Quick, recently commented on his experiences with the continuous blood glucose monitoring system. He described the four systems that are currently available. Technology is an outstanding adjunct to improving diabetes self-care skills. However, in terms of quality of life (especially in young children and teens), when is it justified to add another layer of complexity to diabetes management? The American Association of Clinical Endocrinologists (AACE) recently published a Consensus Statement on Continuous Blood Glucose monitoring. The task force authors included diabetes specialists in all related subspecialties including pediatrics. The task force based its recommendations on a summary of randomized, controlled clinical trials using CGMS in type 1 diabetes patients. The studies include: STAR-1 for adults and adolescents greater than 12 years of age, JDRF for adults and teens greater than or equal to 15 years, DirecNet and JDRF CGM for children 8 to 14 years. These studies revealed an important consideration for children and adolescents. Children and teens were much less likely than adults to use CGM devices on a near-daily basis and the best results in the lowering of hb A1c were noted in those study participants who used the sensors 6 to 7 days per week. Another key finding was that pediatric patients who successfully lowered their hb A1c in the JDRF trials did so without increasing the amount of severe hypoglycemia. Indeed, the rates of severe hypoglycemia in the randomized trials were lower in pediatric patients in both the SMBG and personal CGM groups compared with previously reported data for intensively treated adolescents in the Diabetes Control and Complications Trial.
Overall Patient selection recommendations include:
- T1DM persons characterized by hypoglycemic unawareness or frequent hypoglycemia.
- Hb A1c above the target range with marked glycemic variability (major glucose fluctuations) that are judged to be very serious and life threatening.
- Persons with T1DM that need to lower hb A1c without increasing hypoglycemia.
- Preconception and pregnancy in women with T1DM.
- Children and adolescents with T1DM with hb A1c of less than 7.0.
- Children and adolescents with T1DM with hb A1c levels of 7.0 percent or higher who are able to use the device on a near-daily basis.
- Other children and adolescents considered to be good candidates for personal CGM along with a 2 to 4 week trial period include:
- Children and teens who monitor blood sugars frequently.
- Committed families of young children (younger than 8 years) especially if the child is having issues with hypoglycemia.
- Intermittent use of professional CGM in children and teens with T1DM may be useful for those undergoing changes to their diabetes regimen or are having problems with the following:
- Nocturnal hypoglycemia or the dawn phenomenon.
- Hypoglycemia unawareness.
- Postprandial hyperglycemia.
The question remains: Is CMG right for your child or adolescent?
The supporting data and information are supplied in the above discussion. However, what emotional and other factors must be considered when adding another level of technology? What if your child is already employing insulin pump therapy? There will be yet another device with an additional sensor to be applied to your child's body. What about a child who is very involved with sports? Would he consider wearing both a sensor and an insulin pump (even if it actually is disconnected during the event)? The other issue to consider is the level of actual comfort that the caregiver/child/teen will experience using the continuous glucose sensor. Will the caregivers finally be able to sleep through the night, knowing that they will be alerted by the sensor alarms? Will the child/teen respond to the alarms and act accordingly? Or, will the child/teen just turn off the alarm and ignore suggestions? Thus, before consideration of CGM, one must evaluate both the supportive scientific data as well as the practical and emotional factors. Clearly, the best approach would be to meet with your diabetes healthcare team and decide what would be in your child's best interests based on individual needs and lifestyle. Remember, CGM works very well...when it is utilized in the way it was meant to be utilized: by wearing it nearly all the time, noting the data provided, and responding with the appropriate action!