1.7.0.0 Glycemic Con­trol

Table 13.1—Blood glu­cose and A1C tar­gets for chil­dren and ado­les­cents with type 1 di­a­betes

Please refer to Sec­tion 7 “Di­a­betes Tech­nol­o­gy” for more infor­mation on the use of blood glu­cose me­ters, con­tin­u­ous glu­cose mon­i­tors, and in­sulin pumps. More infor­mation on in­sulin in­jec­tion tech­nique can be found in Sec­tion 9 “Phar­ma­co­log­ic Ap­proach­es to Glycemic Treat­ment,” p. S90.

Cur­rent stan­dards for di­a­betes man­age­ment reflect the need to lower glu­cose as safe­ly as pos­si­ble. This should be done with step­wise goals. When es­tab­lish­ing in­di­vid­u­al­ized glycemic tar­gets, spe­cial con­sid­eration should be given to the risk of hy­po­glycemia in young chil­dren (aged <6 years) who are often un­able to rec­og­nize, ar­tic­u­late, and/‍or man­age hy­po­glycemia. How­ev­er, reg­istry data in­di­cate that lower A1C can be achieved in chil­dren, in­clud­ing those <6 years, with­out in­creased risk of se­vere hy­po­glycemia (51,52).

Type 1 di­a­betes can be as­so­ci­at­ed with ad­verse ef­fects on cog­ni­tion dur­ing child­hood and ado­les­cence. Fac­tors that con­tribute to ad­verse ef­fects on brain de­vel­op­ment and func­tion in­clude young age or DKA at onset of type 1 di­a­betes, se­vere hy­po­glycemia at <6 years of age, and chron­ic hy­per­glycemia (53,54). How­ev­er, metic­u­lous use of new ther­a­peu­tic modal­i­ties such as rap­i­dand long-‍act­ing in­sulin analogs, tech­no­log­i­cal ad­vances (e.g., con­tin­u­ous glu­cose mon­i­tors, low-‍glu­cose sus­pend in­sulin pumps, and au­to­mat­ed in­sulin de­liv­ery sys­tems), and in­ten­sive self-‍man­age­ment ed­u­ca­tion now make it more fea­si­ble to achieve ex­cel­lent glycemic con­trol while re­duc­ing the in­ci­dence of se­vere hy­po­glycemia (55-64). In­ter­mit­tent­ly scanned con­tin­u­ous glu­cose mon­i­tors (some­times re­ferred to as “flash” con­tin­u­ous glu­cose mon­i­tors) are not cur­rently ap­proved for use in chil­dren and ado­les­cents. A strong re­la­tionship ex­ists be­tween fre­quen­cy of blood glu­cose mon­i­tor­ing and glycemic con­trol (57-66).

The Di­a­betes Con­trol and Com­pli­ca­tions Trial (DCCT), which did not en­roll chil­dren <13 years of age, demon­strat­ed that near nor­mal­iza­tion of blood glu­cose lev­els was more difficult to achieve in ado­les­cents than in adults. Nev­er­the­less, the in­creased use of basal-‍bolus reg­i­mens, in­sulin pumps, fre­quent blood glu­cose mon­i­tor­ing, goal set­ting, and im­proved pa­tient ed­u­ca­tion in youth from in­fan­cy through ado­les­cence has been as­so­ci­at­ed with more chil­dren reach­ing the blood glu­cose tar­gets rec­om­mend­ed by ADA (67-70), par­tic­u­lar­ly in those fam­i­lies in which both the par­ents and the child with di­a­betes par­tic­i­pate joint­ly to per­form the re­quired di­a­betes-‍re­lat­ed tasks. Fur­ther­more, stud­ies doc­u­ment­ing neu­rocog­ni­tive imag­ing dif­fer­ences re­lat­ed to hy­per­glycemia in chil­dren pro­vide an­oth­er mo­ti­va­tion for low­er­ing glycemic tar­gets (6).

In se­lect­ing glycemic tar­gets, the long-‍term health benefits of achiev­ing a lower A1C should be bal­anced against the risks of hy­po­glycemia and the de­vel­op­men­tal bur­dens of in­ten­sive reg­i­mens in chil­dren and youth. In-ad­di­tion, achiev­ing lower A1C lev­els is like­ly fa­cil­i­tated by set­ting lower A1C tar­gets (51,71). A1C and blood glu­cose tar­gets are pre­sent­ed in Table 13.1. Lower goals may be pos­si­ble dur­ing the “hon­ey­moon” phase of type 1 di­a­betes.

Key Con­cepts in Set­ting Glycemic Tar­gets

Tar­gets should be in­di­vid­u­al­ized, and lower tar­gets may be rea­son­able based on a benefit-‍risk as­sessment.

Blood glu­cose tar­gets should be modi­fied in chil­dren with fre­quent hy­po­glycemia or hy­po­glycemia un­awareness.

Postpran­di­al blood glu­cose val­ues should be mea­sured when there is a dis­crep­an­cy be­tween prepran­di­al blood glu­cose val­ues and A1C lev­els and to as­sess prepran­di­al in­sulin doses in those on basal-‍bolus or pump reg­i­mens.