Continuous Glucose Monitoring for Glycemic Control in Children and Adolescents Diagnosed with Diabetes Type 1: A Systematic Review and Meta-Analysis

Abstract

Aim The aim of this meta-analysis was to evaluate the impact of continuous glucose monitoring (CGM) systems on short- and long-term glycemic control in children and adolescents diagnosed with diabetes type 1.

Methods The review was registered in PROSPERO (CRD42019135152). We partly updated a formerly published systematic review and searched several databases (Ovid MEDLINE, Embase, CENTRAL, and Clinicaltrials.gov) in May 2019. Summary measures were estimated as relative risks (RR) and standardized mean differences (SMD). The primary endpoint of our analysis was frequency of hypoglycemic events. Quality of evidence was evaluated using the GRADE approach.

Results Eleven studies with a total number of 818 patients were included in our review. Meta-analyses indicated a potential benefit of CGM systems regarding the relative risk of a severe hypoglycemic event (RR 0.78; 95% CI 0.29 to 2.04) and mean level of HbA1c at end of study (SMD -0.23; 95% CI -0.46 to 0.00). Certainty of evidence for effect estimates of these meta-analyses was low due to risk of selection bias and imprecision of the included studies. Qualitative analyses of the secondary outcomes of user satisfaction and long-term development of blood glucose supported these findings.

Conclusion CGM systems may improve glycemic control in children and adolescents diagnosed with diabetes type 1, but the imprecision of effects is still a problem. Only a few studies examined and reported data for pediatric populations in sufficient detail. Further research is needed to clarify advantages and disadvantages of CGM systems in children and adolescents.

Key words

CGM - hypoglycemic event - pediatrics

Publication History

Received: 06 May 2020
Received: 15 September 2020

Accepted: 22 September 2020

Article published online:
10 December 2020

• References

• 1 Liese AD, D'Agostino RB, Hamman RF. et al. The burden of diabetes mellitus among US youth: Prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006; 118: 1510-1518 DOI: 10.1542/peds.2006-0690.
• 2 Patterson CC, Gyürüs E, Rosenbauer J. et al. Trends in childhood type 1 diabetes incidence in Europe during 1989-2008: Evidence of non-uniformity over time in rates of increase. Diabetologia 2012; 55: 2142-2147 DOI: 10.1007/s00125-012-2571-8.
• 3 German Diabetes Association. S3 Guideline - Therapy of Diabetes Type 1 (March 2018). Internet document: www.awmf.org/leitlinien/detail/ll/057-013.html, Accessed: 24.01.2020
• 4 National Institute for Health and Care Excellence. Continuous glucose monitoring in type 1 diabetes - Diabetes in children and young people (QS125) (14.07.2016). Internet document: www.nice.org.uk/guidance/qs125, Accessed: 04.03.2020
• 5 van den Boom L, Karges B, Auzanneau M. et al. Temporal Trends and Contemporary Use of Insulin Pump Therapy and Glucose Monitoring Among Children, Adolescents, and Adults With Type 1 Diabetes Between 1995 and 2017. Diabetes Care 2019; 42: 11 DOI: 10.2337/dc19-0345.
• 6 Langendam M, Luijf YM, Hooft L. et al. Continuous glucose monitoring systems for type 1 diabetes mellitus. Cochrane Database of Systematic Reviews 2012; DOI: 10.1002/14651858.CD008101.pub2.
• 7 Poolsup N, Suksomboon N, Kyaw AM. Systematic review and meta-analysis of the effectiveness of continuous glucose monitoring (CGM) on glucose control in diabetes. Diabetol Metab Syndr 2013; 5: 39 DOI: 10.1186/1758-5996-5-39
• 8 Golicki DT, Golicka D, Groele L. et al. Continuous glucose monitoring system in children with type 1 diabetes mellitus: A systematic review and meta-analysis. Diabetologia 2008; 51: 233-240 DOI: 10.1007/s00125-007-0884-9.
• 9 Benkhadra K, Alahdab F, Tamhane S. et al. Real-time continuous glucose monitoring in type 1 diabetes: A systematic review and individual patient data meta-analysis. Clin Endocrinol (Oxf) 2017; 86: 354-360 DOI: 10.1111/cen.13290.
• 10 Health Quality Ontario. Continuous Monitoring of Glucose for Type 1 Diabetes: A Health Technology Assessment. Ontario Health Technology Assessment Series [Internet] 2018; 18: 1-160
• 11 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6: e1000097 DOI: 10.1371/journal.pmed.1000097.
• 12 Higgins J, Green S.. (e). Cochrane Handbook for Systematic Reviews of Interventions: Version 5.1.0 (March 2011). Internet document: handbook.cochrane.org./ Accessed: 17.06.2019
• 13 American Diabetes Association. Glycemic targets. Sec. 5. In Standards of Medical Care in Diabetes. Diabetes Care 2016; 39: S39-S46 DOI: 10.2337/dc16-S008.
• 14 American Diabetes Association. Hypoglycemia (Low Blood Glucose) (11.02.2019). Internet document: www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html, Accessed: 02.07.2019
• 15 American Diabetes Association. 12. Children and Adolescents. Diabetes Care 2017; 40: S105-S113 DOI: 10.2337/dc17-S015.
• 16 U.S. National Library of Medicine. ClinicalTrials.gov.Internet document: clinicaltrials.gov/, Accessed: 13.07.2019
• 17 Ouzzani M, Hammady H, Fedorowicz Z. et al. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5: 210 DOI: 10.1186/s13643-016-0384-4.
• 18 Olofsson H, Brolund A, Hellberg C. et al. Can abstract screening workload be reduced using text mining? User experiences of the tool Rayyan. Res Synth Methods 2017; 8: 275-280 DOI: 10.1002/jrsm.1237.
• 19 Chandler J, Clarke M, McKenzie J. et al. Cochrane Methods 2016. Cochrane Database of Systematic Reviews 2016; 10 DOI: 10.1002/14651858.CD201601.
• 20 Schünemann H, Brożek J, Guyatt G. et al. GRADE handbook for grading quality of evidence and strength of recommendations (01.10.2013). Internet document gdt.gradepro.org/app/handbook/handbook.html, Accessed: 13.08.2020
• 21 GRADEpro GDT. GRADEpro Guideline Development Tool [Software] Internet document gradepro.org, Accessed: 13.08.2020
• 22 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) [Computer program] Version 5.3. Copenhagen (18.06.2019 Internet document community.cochrane.org/help/tools-and-software/revman-5, Accessed: 19.06.2019
• 23 Bergenstal RM, Tamborlane WV, Ahmann A. et al. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med 2010; 363: 311-320 DOI: 10.1056/NEJMoa1002853.
• 24 Bukara-Radujković G, Zdravković D, Lakić S. Short-term use of continuous glucose monitoring system adds to glycemic control in young type 1 diabetes mellitus patients in the long run: A clinical trial. Vojnosanit Pregl 2011; 68: 650-654
• 25 Hommel E, Olsen B, Battelino T. et al. Impact of continuous glucose monitoring on quality of life, treatment satisfaction, and use of medical care resources: analyses from the SWITCH study. Acta Diabetol 2014; 51: 845-851 DOI: 10.1007/s00592-014-0598-7.
• 26 Kordonouri O, Pankowska E, Rami B. et al. Sensor-augmented pump therapy from the diagnosis of childhood type 1 diabetes: Results of the Paediatric Onset Study (ONSET) after 12 months of treatment. Diabetologia 2010; 53: 2487-2495 DOI: 10.1007/s00125-010-1878-6.
• 27 Kordonouri O, Hartmann R, Pankowska E. et al. Sensor augmented pump therapy from onset of type 1 diabetes: Late follow-up results of the Pediatric Onset Study. Pediatr Diabetes 2012; 13: 515-518 DOI: 10.1111/j.1399-5448.2012.00863.x.
• 28 Ly TT, Nicholas JA, Retterath A. et al. Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: A randomized clinical trial. JAMA 2013; 310: 1240-1247 DOI: 10.1001/jama.2013.277818.
• 29 Olivier P, Lawson ML, Huot C. et al. Lessons learned from a pilot RCT of simultaneous versus delayed initiation of continuous glucose monitoring in children and adolescents with type 1 diabetes starting insulin pump therapy. J Diabetes Sci Technol 2014; 8: 523-528 DOI: 10.1177/1932296814524855.
• 30 Rubin RR, Peyrot M. Health-related quality of life and treatment satisfaction in the Sensor-Augmented Pump Therapy for A1C Reduction 3 (STAR 3) trial. Diabetes Technol Ther 2012; 14: 143-151 DOI: 10.1089/dia.2011.0162
• 31 Slover RH, Welsh JB, Criego A. et al. Effectiveness of sensor-augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study. Pediatr Diabetes 2012; 13: 6-11 DOI: 10.1111/j.1399-5448.2011.00793.x.
• 32 Burckhardt MA, Chetty T, Smith GJ. et al. Use of continuous glucose monitoring trends to facilitate exercise in children with type 1 diabetes. Diabetes Technol Ther 2019; 21: 51-55
• 33 Guilmin-Crepon S, Carel JC, Schroedt J. et al. Is there an optimal strategy for real-time continuous glucose monitoring in pediatrics? A 12-month French multi-center, prospective, controlled randomized trial (Start-In!). Pediatr Diabetes 2019; 20: 304-313
• 34 Battelino T, Conget I, Olsen B. et al. The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial. Diabetologia 2012; 55: 3155-3162 DOI: 10.1007/s00125-012-2708-9.
• 35 Battelino T, Phillip M, Bratina N. et al. Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. Diabetes Care 2011; 34: 795-800 DOI: 10.2337/dc10-1989.
• 36 Mauras N, Beck R, Xing D. et al. A randomized clinical trial to assess the efficacy and safety of real-time continuous glucose monitoring in the management of type 1 diabetes in young children aged 4 to <10 years. Diabetes Care 2012; 35: 204-210 DOI: 10.2337/dc11-1746.
• 37 Robinson-Vincent K. A Pilot Randomized Controlled Trial of the Effects of Continuous Glucose Monitoring on Metabolic Control in Children with Type 1. Diabetes (unpublished doctoral dissertation). 2015;
• 38 Ferris J. Continue Glucose Monitoring Before Insulin Pump - ClinicalTrials. gov: ID: NCT02813421. Internet document.clinicaltrials.gov/ct2/show/NCT02813421?term=Hypoglycemia&type=Intr&cond=Diabetes+Mellitus%2C+Type+1&intr=Continuous+glucose+monitoring&age=0&draw=5, Accessed: 06.07.2019
• 39 Hood K. Initiation of Continuous Glucose Monitoring at Diagnosis of Type 1 Diabetes - ClinicalTrials.gov: ID: NCT02734667. Internet documentclinicaltrials.gov/ct2/show/NCT02734667?term=continuous+glucose+monitoring%2C+hypoglycemia%2C+children&rslt=Without&type=Intr&cond=Diabetes+Mellitus%2C+Type+1&draw=5, Accessed: 06.07.2019
• 40 Jaeb Center for Health Research. CGM Intervention in Teens and Young Adults With Type 1 Diabetes (T1D) - ClinicalTrials.gov: ID: NCT03263494.Internet document clinicaltrials.gov/ct2/show/NCT03263494?term = Hypoglycemia&type=Intr&cond=Diabetes+Mellitus%2C+Type+1&intr=Continuous+glucose+monitoring&age=0&draw=5, Accessed: 06.07.2019
• 41 Gandhi GY, Kovalaske M, Kudva Y. et al. Efficacy of continuous glucose monitoring in improving glycemic control and reducing hypoglycemia: a systematic review and meta-analysis of randomized trials. J Diabetes Sci Technol 2011; 5: 952-965 DOI: 10.1177/193229681100500419.
• 42 Healthcare Improvement Scotland. Advice Statement 09-18: What is the clinical and cost effectiveness of Freestyle Libre flash glucose monitoring for patients with diabetes mellitus treated with intensive insulin therapy? (July 2018).Internet document www.healthcareimprovementscotland.org/our_work/technologies_and_medicines/topics_assessed/shtg_009-18.aspx, Accessed: 20.01.2020
• 43 Ontario Health. Flash Glucose Monitoring System for People with Type 1 or Type 2 Diabetes: A Health Technology Assessment. Ont Health Technol Assess Ser 2019; 19: 1-108