Preventing severe hypoglycemia in children and adolescents with type 1 diabetes

The care and management of type 1 diabetes in this modern era is becoming increasingly complex and demanding for patients and families with this condition. Despite multiple advances in therapy for type 1 diabetes, most children with type 1 diabetes fail to meet glycemic targets and there is a critical need for better management and understanding of the complications of this condition. Hypoglycemia is one of the most common acute complications of type 1 diabetes. The risk of recurrent and severe hypoglycemia causes significant anxiety and emotional morbidity for patients and families and is a limiting factor in achieving optimal glycemic control. Preventing hypoglycemia in children requires an understanding of the physiological differences in children and adolescents and the effects of clinical precipitants such as exercise and sleep. Recent reports have suggested that the frequency of severe hypoglycemia has reduced. This is likely to have been the result of the increased use of improved insulin delivery methods both with pump therapy and also with analog insulin injection therapy. Although it is probable that this trend will continue, hypoglycemia and the fear of hypoglycemia will remain a major barrier to intensive therapy until such time as hypoglycemia can be reliably prevented. Unless cell replacement therapy for type 1 diabetes becomes feasible as a clinical therapy, the use of technological approaches is likely to provide the most effective method to reduce the impact of hypoglycemia. Hypoglycemia prevention using continuous glucose monitoring offers significant promise to reduce hypoglycemia incidence, particularly as the devices improve in accuracy and become more comfortable and affordable for the patient. The use of sensor-augmented pump therapy with automated insulin suspension with hypoglycemia and impending hypoglycemia will not only reduce hypoglycemia exposure but also fear of hypoglycemia. This in turn is likely to reduce the prevalence of impaired hypoglycemia awareness and potentially the incidence of severe hypoglycemia. This body of work highlights various risk factors for severe hypoglycemia and describes our experience with various technologies designed to prevent hypoglycemia and improve the quality of life for patients and families with type 1 diabetes.