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Zucchini S, Tumini S, Scaramuzza AE, Bonfanti R, Delvecchio M, Franceschi R, Iafusco D, Lenzi L, Mozzillo E, Passanisi S, Piona C, Rabbone I, Rapini N, Rigamonti A, Ripoli C, Salzano G, Savastio S, Schiaffini R, Zanfardino A, Cherubini V. Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia. Front Endocrinol (Lausanne) 2024; 15:1387537. [PMID: 38894740 PMCID: PMC11183505 DOI: 10.3389/fendo.2024.1387537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.
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Affiliation(s)
- Stefano Zucchini
- Study Group of Diabetology of the Italian Society for Pediatric Endocrinology and Diabetes (I.S.P.E.D.,) University Hospital of Ferrara, Ferrara, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Annunziata Hospital, Chieti, Italy
| | - Andrea Enzo Scaramuzza
- Division of Pediatrics, Pediatric Diabetes, Endocrinology and Nutrition, Azienda Socio Sanitaria Territoriale (ASST) Cremona, Cremona, Italy
| | - Riccardo Bonfanti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Maurizio Delvecchio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Franceschi
- Department of Pediatrics, S. Chiara Hospital of Trento, APSS, Trento, Italy
| | - Dario Iafusco
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Lorenzo Lenzi
- Diabetology Unit, Pediatric Department, Anna Meyer Children’s Hospital, Florence, Italy
| | - Enza Mozzillo
- Section of Pediatrics, Regional Center of Pediatric Diabetes, University Federico II, Naples, Italy
| | - Stefano Passanisi
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, Verona, Italy
| | - Ivana Rabbone
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Novella Rapini
- Diabetes Unit, Bambino Gesú Childrens’ Hospital, Rome, Italy
| | - Andrea Rigamonti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Carlo Ripoli
- Pediatric Diabetology Unit, Department of Pediatrics, ASL 8 Cagliari, Cagliari, Italy
| | - Giuseppina Salzano
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Silvia Savastio
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | | | - Angela Zanfardino
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Valentino Cherubini
- Department of Women’s and Children’s Health, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, ‘Salesi Hospital’, Ancona, Italy
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Sakane N, Kato K, Hata S, Nishimura E, Araki R, Kouyama K, Hatao M, Matoba Y, Matsushita Y, Domichi M, Suganuma A, Sakane S, Murata T, Wu FL. Protective and risk factors of impaired awareness of hypoglycemia in patients with type 1 diabetes: a cross-sectional analysis of baseline data from the PR-IAH study. Diabetol Metab Syndr 2023; 15:79. [PMID: 37095537 PMCID: PMC10127054 DOI: 10.1186/s13098-023-01024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/11/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Hypoglycemia in type 1 diabetes (T1D) is associated with mortality and morbidity, especially when awareness of hypoglycemia is impaired. This study aimed to investigate the protective and risk factors for impaired awareness of hypoglycemia (IAH) in adults with T1D. METHODS This cross-sectional study enrolled 288 adults with T1D (mean age, 50.4 ± 14.6 years; male, 36.5%; diabetes duration, 17.6 ± 11.2 years; mean HbA1c level, 7.7 ± 0.9%), who were divided into IAH and non-IAH (control) groups. A survey was conducted to assess hypoglycemia awareness using the Clarke questionnaire. Diabetes histories, complications, fear of hypoglycemia, diabetes distress, hypoglycemia problem-solving abilities, and treatment data were collected. RESULTS The prevalence of IAH was 19.1%. Diabetic peripheral neuropathy was associated with an increased risk of IAH (odds ratio [OR] 2.63; 95% confidence interval [CI] 1.13-5.91; P = 0.014), while treatment with continuous subcutaneous insulin infusion and hypoglycemia problem-solving perception scores were associated with a decreased risk of IAH (OR, 0.48; 95% CI, 0.22-0.96; P = 0.030; and OR, 0.54; 95% CI, 0.37-0.78; P = 0.001, respectively). There was no difference in continuous glucose monitoring use between the groups. CONCLUSION We identified protective factors in addition to risk factors for IAH in adults with T1D. This information may help manage problematic hypoglycemia. TRIAL REGISTRATION University hospital Medical Information Network (UMIN) Center: UMIN000039475). Approval date 13 February 2020.
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Affiliation(s)
- Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan.
| | - Ken Kato
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Sonyun Hata
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Erika Nishimura
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Rika Araki
- Department of Diabetes and Endocrinology, National Hospital Organization Mie National Hospital, 357 Ozatokubota-cho, 514-0125, Tsu, Mie, Japan
| | - Kunichi Kouyama
- Department of Diabetes and Metabolism, National Hospital Organization Hyogo-Chuo National Hospital, 1314Ohara, 669-1515, Sanda, Hyogo, Japan
| | - Masako Hatao
- Department of Diabetes and Endocrinology, National Hospital Organization Himeji Medical Center, 68 Honmachi, 670-0012, Himeji, Hyogo, Japan
| | - Yuka Matoba
- Department of Diabetes, Endocrinology and Metabolism, National Hospital Organization Kokura Medical Center, 10-1 Harugaoka, Kitakyushu Kokuraminami-ku, 802-0803, Fukuoka, Japan
| | - Yuichi Matsushita
- Department of Diabetology and Metabolism, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Okayama Kita-ku, 701-1192, Okayama, Japan
| | - Masayuki Domichi
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Akiko Suganuma
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Seiko Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Takashi Murata
- Department of Clinical Nutrition, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
- Diabetes Center, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Fei Ling Wu
- Department of Nursing, Chang Gung University of Science and Technology, No. 261, Wenhua 1st Rd, Guishan District, 333, Taoyuan City, Taiwan
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Ray MK, McMichael A, Rivera-Santana M, Noel J, Hershey T. Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies. JMIR Diabetes 2021; 6:e27027. [PMID: 34081017 PMCID: PMC8212634 DOI: 10.2196/27027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/26/2021] [Accepted: 04/03/2021] [Indexed: 11/13/2022] Open
Abstract
Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.
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Affiliation(s)
- Mary Katherine Ray
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Alana McMichael
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Maria Rivera-Santana
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Jacob Noel
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Tamara Hershey
- Department of Psychiatry, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
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Ziegler R, Heinemann L, Freckmann G, Schnell O, Hinzmann R, Kulzer B. Intermittent Use of Continuous Glucose Monitoring: Expanding the Clinical Value of CGM. J Diabetes Sci Technol 2021; 15:684-694. [PMID: 32064909 PMCID: PMC8120049 DOI: 10.1177/1932296820905577] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In addition to the continuous use, the intermittent use of continuous glucose monitoring (CGM) is an application of CGM, expanding the typical medical use cases. There are a variety of reasons and occasions that speak in favor of using CGM only for a limited time. To date, these circumstances have not been sufficiently discussed. In this article, we define discontinuous or intermittent CGM use, provide reasons for using it, and expand on the benefits and possibilities of using CGM on a temporary basis. We aim to draw attention to this important topic in the discussion of CGM use and give examples for a different method of CGM use. As well, we would like to foster the allocation of CGM to the right patient groups and indications, especially in cases of limited resources. From a global point of view, intermittent CGM use is more likely to occur than continuous use, primarily for economic reasons.
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Affiliation(s)
- Ralph Ziegler
- Diabetes Clinic for Children and
Adolescents, Muenster, Germany
- Ralph Ziegler, MD, Diabetes Clinic
for Children and Adolescents Mondstr. 148, Muenster 48155, Germany.
| | | | - Guido Freckmann
- Institut für Diabetes-Technologie,
Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm,
Germany
| | - Oliver Schnell
- Forschergruppe Diabetes e.V.,
Helmholtz Zentrum, Munich, Germany
| | | | - Bernd Kulzer
- Diabetes Center Bad Mergentheim,
Research Institute of the Diabetes Academy, Bad Mergentheim, University
Bamberg, Germany
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