Closed-loop in children with type 1 diabetes: specific challenges

Improving the Safety and Functionality of an Artificial Pancreas System for Use in Younger Children: Input from Parents and Physicians

BACKGROUND

Artificial pancreas (AP) systems have initially been designed for and tested in teens and adults, but there is evidence that an AP system with additional support and safety systems could greatly benefit younger children with type 1 diabetes (T1D).

SUBJECTS AND METHODS

Five pediatric endocrinologists and 15 parents of children aged 5-8 years with T1D participated in a total of four focus groups. Focus groups investigated current diabetes technology use and acceptance, as well as possible modifications to the current adult AP system, which would allow for safe and successful use in younger children. Modifications discussed include child-specific functionality for input tasks, safety features, and monitoring capabilities.

RESULTS

Participant suggestions included the following: passcodes for differential access to AP features by parents, ancillary caregivers, and the child; preset early, intermediate, and advanced child access categories; maximal customization for general and alarm settings; simplified meal screens utilizing the AP' corrective blood glucose (BG) ability; automated exercise mode; spoken and dictated messaging capabilities; emergency contacts; treatment instructions for the child and caregiver; remote monitoring website and application; animated continuous glucose monitor BG trace; gamification, such as rewarding diabetes-friendly behaviors; and comprehensive training of all individuals involved in the child's diabetes care.

CONCLUSION

Parents and physicians were eager for AP applications to be available for younger children, but stressed that a modified system could better serve this group's needs for safety and improved diabetes-related communication. The diverse and emerging needs of 5-8-year olds require flexible and customizable systems for T1D management.

Challenges and Recent Progress in the Development of a Closed-loop Artificial Pancreas

Pursuit of a closed-loop artificial pancreas that automatically controls the blood glucose of individuals with type 1 diabetes has intensified during the past six years. Here we discuss the recent progress and challenges in the major steps towards a closed-loop system. Continuous insulin infusion pumps have been widely available for over two decades, but "smart pump" technology has made the devices easier to use and more powerful. Continuous glucose monitoring (CGM) technology has improved and the devices are more widely available. A number of approaches are currently under study for fully closed-loop systems; most manipulate only insulin, while others manipulate insulin and glucagon. Algorithms include on-off (for prevention of overnight hypoglycemia), proportional-integral-derivative (PID), model predictive control (MPC) and fuzzy logic based learning control. Meals cause a major "disturbance" to blood glucose, and we discuss techniques that our group has developed to predict when a meal is likely to be consumed and its effect. We further examine both physiology and device-related challenges, including insulin infusion set failure and sensor signal attenuation. Finally, we discuss the next steps required to make a closed-loop artificial pancreas a commercial reality.