Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

Abstract

Hypoglycaemia in children is a major risk factor for adverse neurodevelopment with rates as high as 50% in hyperinsulinaemic hypoglycaemia (HH). A key part of management relies upon timely identification and treatment of hypoglycaemia. The current standard of care for glucose monitoring is by infrequent fingerprick plasma glucose testing but this carries a high risk of missed hypoglycaemia identification. High-frequency Continuous Glucose Monitoring (CGM) offers an attractive alternative for glucose trend monitoring and glycaemic phenotyping but its utility remains largely unestablished in disorders of hypoglycaemia. Attempts to determine accuracy through correlation with plasma glucose measurements using conventional methods such as Mean Absolute Relative Difference (MARD) overestimate accuracy at hypoglycaemia. The inaccuracy of CGM in true hypoglycaemia is amplified by calibration algorithms that prioritise hyperglycaemia over hypoglycaemia with minimal objective evidence of efficacy in HH. Conversely, alternative algorithm design has significant potential for predicting hypoglycaemia to prevent neuroglycopaenia and consequent brain dysfunction in childhood disorders. Delays in the detection of hypoglycaemia, alarm fatigue, device calibration and current high cost are all barriers to the wider adoption of CGM in disorders of hypoglycaemia. However, machine learning, artificial intelligence and other computer-generated algorithms now offer significant potential for further improvement in CGM device technology and widespread application in childhood hypoglycaemia.

Congenital hyperinsulinism in infancy and childhood: challenges, unmet needs and the perspective of patients and families

“…Currently, there is no specialized equipment available for reliable home-based blood glucose monitoring in the hypoglycemic range. Continuous glucose monitoring (CGM) devices provide an alternative approach for subcutaneous glycemic monitoring that can increase the frequency of monitoring and may be especially useful at night [ 2 , 54 ]. Although the accuracy of CGM devices continues to improve, they are known to be less accurate in the hypoglycemic range and are liable to pressure-induced sensor attenuations in this range, potentially leading to false low-sensor readings [ 55 – 58 ].…”

“…Although the accuracy of CGM devices continues to improve, they are known to be less accurate in the hypoglycemic range and are liable to pressure-induced sensor attenuations in this range, potentially leading to false low-sensor readings [ 55 – 58 ]. Overall, their reliability in the hypoglycemic range has not been rigorously evaluated in the CHI setting [ 2 , 54 ].…”

Clustering of Hypoglycemia Events in Patients With Hyperinsulinism: Extension of the Digital Phenotype Through Retrospective Data Analysis

“…CGM measures subcutaneous glucose at frequent intervals over extended periods (7-10 days) to provide glycemic phenotypes in patients with hypoglycemia and diabetes and contributes to the digital phenotype [ 16 ]. The application of CGM may not yet be readily applicable in patients with HI as a reliable means of hypoglycemia detection or prediction [ 17 ]. However, as CGM is a passive form of monitoring, it can record data at a high granularity with very minimal response burden on users [ 18 ]; therefore, it has the potential to collect detailed glycemic data while being acceptable to patients on a long-term basis.…”

Experience with Real-Time Continuous Glucose Monitoring in Newborns with Congenital Hyperinsulinemic Hypoglycemia

“…Real-time CGMS is one of the promising technological methods in the follow-up and monitoring of treatment in children with hypoglycemia [11]. CGMS is safe, reliable, and useful in neonates at risk of hypoglycemia [4,12].…”

“…Under steady-state conditions, interstitial glucose levels generally correlated with the blood glucose with an average lag of 8-10 min [19]. Fortuitously, lag time problems may be useful in the identification of hypoglycemia in children with CHH where a spike in insulin and subsequent rapid drop in interstitial glucose may be earlier than a slower subsequent decrease in plasma glucose [11]. Current glucose monitoring requires frequent capillary sampling that exposes infants to procedural pain and stress that may contribute to altered neurodevelopment and affect short-term cog nitive scores in preterm infants [3,20].…”