EASD/ISPAD Symposium
Challenges of therapy in children with diabetes Real time glucose sensing and pumps in children with diabetes

In current clinical practice, the use of intensified insulin treatment in type 1 (multiple daily injections or pump therapy) is the standard treatment not only in adult, but also in pediatric patients with type 1 diabetes.

The search for practical ways to imitate the age-dependent physiological circadian basal insulin profile and the prandial increments in different paediatric age groups has lead to a considerable increase in the number of subcutaneous continuous insulin infusion (CSII) patients in Germany and in many other countries. Recently, ISPAD has organised together with other stakeholders in the field a meeting of experts for pediatric insulin pump therapy, to put together the evidence base for this approach which was endorsed by the EASD. Studies show that CSII can lead to an improvement of glycaemic control in children and adolescents with Type 1 diabetes with concomitant reduction of events of severe hypoglycaemia and daily insulin requirements. Furthermore, frequent daily boluses during CSII treatment were associated with a significantly better HbA1c in children and adolescents with type 1 diabetes.

On the other side, novel technologies for continuous glucose monitoring (CGM) systems have become available. These have the advantage of providing information about the direction, magnitude, duration, and frequency of glucose excursions for up to seven days with a single sensor. In the GuardControl Study performed in children and adults with type 1 diabetes and poor glycaemic control, a new real-time glucose monitor that allows the user to see the glucose readings and trends and to set hypo- and hyperglycaemic alarms, was prospectively evaluated. Continuous usage of the sensor over 3 months improved glycaemic control significantly without an increase of hypoglycaemia compared to those patients using the system biweekly or using conventional self-monitoring blood glucose. A combined pump and Real-Time CGM system has recently been introduced with an automatic transfer of the measured value to the insulin pump. A dose calculator gives then advice on appropriate bolus doses.

Studies in paediatric patients with type 1 diabetes are now underway to investigate these devices in newly-onset patients as well as various patient groups of established diabetes. Potential applications for these systems are use as an educational tool or to improve treatment compliance and consequently metabolic control. Furthermore, adjusting the insulin treatment continuously without painful procedures may not only lead to a more stable glycaemic control, a better preservation of endogenous insulin production after diabetes onset but also to a better psychosocial wellbeing of the child with diabetes and his or her family.

Based on the first paediatric experience combining these systems with computerised calculations of the insulin dose using CGM and CSII indicate that this may eventually allow to “close the loop”.