Technology in young people: when and what should we use?
Current technologies and hopes for the future were hot topics at October’s GAED Annual Virtual Congress.
There is one treatment target in all age groups at all times and that is good metabolic control, said Professor Carine de Beaufort, paediatric endocrinologist at the Centre Hospitalier de Luxembourg and President of the International Society for Paediatric and Adolescent Diabetes (ISPAD).
Speaking at the Gulf Association of Endocrinology and Diabetes 2021 virtual congress, she told delegates that achieving this in young people is all about education on insulin action and duration, food and carb counting, and the factors that interact with insulin, such as stress, illness and hormonal changes.
In very young children (under six years old), obtaining good metabolic control is tough because of factors such as small insulin doses (so shorter duration) and unpredictable lifestyle with food and activity and frequent infections.
In adolescents, we have to contend with unpredictable hypoglycaemia, hormonal variations and peer-group influence on lifestyle. Poor control leads to problems such as tiredness and low mood, they get fed up with bad results and stressed at sometimes not being able to participate in peer-related activities.
Professor de Beaufort highlighted data from the SWEET database, a global registry with over 80,000 patients, including almost 19,000 12-18 year olds and 6600 18-25 year olds. The data shows that the percentage of young people meeting HbA1c targets is low. Just 22% of 12-18 year olds are achieving <7% and 19.2% in 18-25 year olds. And it’s >9% for 25.6% and 31.1%, respectively, in those groups.
Do pumps have an influence? In 12-18 years olds, 28.9% use a pump. HbA1c values are slightly lower in this group at 7.7% versus 8% without a pump. Figures are similar in the 18-25s. In the over 25s, you start to see a value closer to ideal at 7.1% versus 8% with no pump. Data is not yet available on the impact of continuous glucose monitoring (CGM) alone or CGM with pump.
We have technologies now that are helping, but we have quite a bumpy road in front of us, said Professor de Beaufort. It is a road that we have been on since the 1970s towards fully closing the loop.
Closing the loop
In looking at what young people expect from closed-loop or hybrid closed-loop systems, she drew attention to 2015 UK data from an online survey. When asked why participants would want to use an artificial pancreas, responses included: to keep blood glucose in range at a specific level, less hypo-/hyperglycaemia, less variability, less worry, better sleep and less interference with daily life.
A later study from 2018 looked at perceptions, reflections and expectations that children, adolescents and adults with type 1 diabetes and their families have for automated insulin delivery systems, covering issues such as human versus system, trust in handing over control to a device, financial impact, etc.
The first theme that came from their findings was life becoming less about diabetes and more about life – less discussion about diabetes and the constant burden; another theme was that it may lead to decreased family stress, alleviating the tasks of counting carbohydrates and bolusing. The third theme was improving the quality of relationships within the family by reducing conflict around daily self-care tasks and reduction of negative mood associated with hypo-/hyperglycaemia.
However, said Professor de Beaufort, every positive has a negative – in all systems, there are factors such as alarms, continuous information, a visible device (some young people find this difficult), device dependency, only rapid insulin, fear of devices, always still needing to take accessories and insulin with you, and, of course, device failure.
On the positive side, more sleep is of great value, and Professor de Beaufort highlighted a study on 1-7 year olds using CamAPS, an app that uses a hybrid closed-loop system – the outcome was very positive on glucose values when comparing before and after closing the loop. It also led to much more sleep in the families studied and she said that some parents cried with happiness when they were told that they could continue to use the system after the research project had ended.
When to start using technology in young people depends on the setting of the clinic and the family, said Professor de Beaufort. At onset is her preference, but they only do this with the very young in her clinic. It also depends on the team as you need to work in close collaboration with the family and assess the patient to ascertain whether they want to use technology.
In very young children, she was clear that use of technology should be advised wherever it’s available as it creates less burden than injection therapy. In older children, it should always be individualised and take into account what the child considers to be a lesser or greater burden.
In summary, what we have now is good but not perfect. Future expectations of metabolic improvement and better quality of life are partially met, but we should try to continuously move forward, rather than sitting and waiting.