In the July 2014 issue of Diabetes Care, written by Chiang, Kirkman, Laffel, and Peters, (Diabetes Care 2014; 37:2034-2054 | DOI: 10.2337/dc14-1140), new guidelines were provided for hemoglobin (hb) A1c. No longer are A1cs stratified by different age groups. Rather, new guidelines have been developed according to recent evidenced-based literature. They are as follows:
Summary of A1C recommendations for non-pregnant people with diabetes*
Youths younger than 18 years less than 7.5 percent
Adults less than 7.0 percent
Healthy+ less than7.5 percent
Complex/intermediate health less than 8.0 percent
Very complex/poor health less than 8.5 percent
*Target must be individualized based on a patient’s circumstances
+No comorbidities, long life expectancy
This change in guidelines has incited much commentary in regard to expectations for children and adolescents. Many healthcare providers that work with these patients expressed concern over the lowering of hb A1c goals, especially in young children. These fears are prompted by worries in regard to overnight hypoglycemia and other potential conditions. In addition, the management of type 1 diabetes in very young children may be more difficult due to growth and mealtime behaviors.
Initially, I also was concerned about the change of the American Diabetes Association (ADA) guidelines and had the opportunity to speak to one of the authors of the study who explained the reasoning for the changes. We have always been concerned about the possibility of frequent hypoglycemia in young children causing neurocognitive defects; hence, one of the reasons for more liberal hb A1c guidelines. Indeed, there was some earlier literature noting possible cognitive defects of hypoglycemia in children. However, these were not borne out in recent evidence-based literature. To the contrary, hyperglycemia and blood sugar variability have led to short-term changes in neurocognitive functioning and changes in the white matter of the brain (see previous blogs). Thus, based on these studies and recommendations from the International Society of Pediatric and Adolescent Diabetes and the Pediatric Endocrine Society, the recommendation of hb A1c less than 7.5 percent for patients with diabetes under age 18 was issued by the ADA.
Therapy should be individualized based on the unique circumstances of the child and family. It is my view, especially with young children, that we do not add further pressure to already-stressed caregivers. Rather, we should support incremental improvements as the child with diabetes moves toward reaching the stated goal of 7.5 without significant hypoglycemia. However, it is also equally important that we dispel previous beliefs that hypoglycemia in young children will lead to decreased neurocognitive functioning and therefore provide support to encourage tighter glycemic control in young children.
It is also important to note that these are only guidelines that need to be interpreted based on the unique family circumstances. One must provide appropriate care based on the needs of the family and child or adolescent with diabetes family-centered care. In addition, if we state that an acceptable hb A1c is less than 8.0 percent, then many families will be happy with a 7.9 percent, for example, rather than working toward a lower hb A1c. Over the past few weeks, as I see my patients, I have been informing families about the new A1c guidelines. As such, I have been encouraging the continuation of all the diabetes self-care skills that have led to improved glycemic control, as I have emphasized in the past. The main difference, as I see it, is to try to push within limits the best possible hb A1c that the child or adolescent can achieve that avoids hypoglycemia and marked fluctuations of blood sugars along with the achievement of the best quality of life.