What is the role of sensor-augmented pump therapy in young children with Type 1 diabetes?

Abstract

475 ISSN 1758-1907 10.2217/DMT.12.57 © 2012 Future Medicine Ltd Diabetes Manage. (2012) 2(6), 475–478 Over the last 10 years, children with Type 1 diabetes, their families and their healthcare providers have embraced techno logy in the form of insulin pump therapy. Patient and family satisfaction with pump therapy is high and discontinuation rates are generally low [1]. By contrast, the pediatric community has not responded as positively to real-time continuous glucose monitoring (CGM), even though it uses similar technology, namely, a subcutaneous catheter, changed at home by the user every 3–7 days, and an external ‘pager-size’ device or the pump itself with which the glucose sensor communicates. Several large randomized controlled trials have conclusively demonstrated a reduction in mean A1c in adult CGM users, but not in youths or children [2–4]. Given the results of these studies, what is the role for CGM in young children, especially in those using pump therapy (i.e., sensor-augmented pump therapy)? Systematic reviews have shown that in children, standard pump therapy with selfblood glucose monitoring (SBGM) leads, at best, to a modest improvement in A1c compared with multiple daily injections (MDI), but at twice the cost [5]. In the first months after pump initiation, when children and their parents are willing to perform SBGM six to ten times per day, including overnight, A1c improves significantly, but thereafter in many children, frequency of SBGM returns to prepump levels as does their A1c [6]. There are multiple reasons for this commonly observed deterioration in control in children on pump therapy, including missed boluses and decreased parental involvement [7,8]. However, the requirement for frequent SBGM for pump adjustments and day-to-day operation of the pump is a significant contributor to the rise in A1c. The insulin pump is a precision instrument designed to match insulin delivery to the child’s specific and changing needs throughout the day and night. However, the input provided to it through SBGM is inadequate to enable optimal pump functioning, especially given the human and behavioral factors affecting day-to-day glucose variability in children. CGM offers the promise of sufficiently accurate glucose trends and real-time readings to enable children to realize the full potential of insulin pump therapy, beyond the pump honeymoon period. What is the evidence that CGM can deliver on this promise in children?