Continuous glucose monitoring for children with hypoglycaemia: Evidence in 2023

Abstract

In 2023, childhood hypoglycaemia remains a major public health problem and significant risk factor for consequent adverse neurodevelopment. Irrespective of the underlying cause, key elements of clinical management include the detection, prediction and prevention of episodes of hypoglycaemia. These tasks are increasingly served by Continuous Glucose Monitoring (CGM) devices that measure subcutaneous glucose at near-continuous frequency. While the use of CGM in type 1 diabetes is well established, the evidence for widespread use in rare hypoglycaemia disorders is less than convincing. However, in the few years since our last review there have been multiple developments and increased user feedback, requiring a review of clinical application. Despite advances in device technology, point accuracy of CGM remains low for children with non-diabetes hypoglycaemia. Simple provision of CGM devices has not replicated the efficacy seen in those with diabetes and is yet to show benefit. Machine learning techniques for hypoglycaemia prevention have so far failed to demonstrate sufficient prediction accuracy for real world use even in those with diabetes. Furthermore, access to CGM globally is restricted by costs kept high by the commercially-driven speed of technical innovation. Nonetheless, the ability of CGM to digitally phenotype disease groups has led to a better understanding of natural history of disease, facilitated diagnoses and informed changes in clinical management. Large CGM datasets have prompted re-evaluation of hypoglycaemia incidence and facilitated improved trial design. Importantly, an individualised approach and focus on the behavioural determinants of hypoglycaemia has led to real world reduction in hypoglycaemia. In this state of the art review, we critically analyse the updated evidence for use of CGM in non-diabetic childhood hypoglycaemia disorders since 2020 and provide suggestions for qualified use.

Current understanding on pathogenesis and effective treatment of glycogen storage disease type Ib with empagliflozin: new insights coming from diabetes for its potential implications in other metabolic disorders

“…Another report from a GSDIb patient with bowel disease treated with G-CSF and continuous gastric deep feeding showed events of asymptomatic mild hypoglycemia < 3.3 mmol/L (range 2.6-3.3) measured by flash glucose monitoring during the first week of treatment and promptly corrected by oral glucose administration (24). Notably, accuracy of CGM devices in the hypoglycemia range is low and hypoglycemic events should be always verified by glucometer (114)(115)(116). However, time below range (TBR) decreased and time in range (TIR) increased also after oral refeeding.…”

Hypoglycaemia in adrenal insufficiency

“…In a recent review by Worth et al. on the use of CGM, they found that hypoglycaemia sensitivity reduces as the threshold for hypoglycaemia decreases ( 61 ). The lowest hypoglycaemia sensitivity was reported at 17% with a hypoglycaemia threshold of 2.6mmol/L ( 62 ), as opposed to the highest hypoglycaemia sensitivity of only 86% with a hypoglycaemia threshold of 3.9mmol/L ( 63 ).…”

Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus

“…However, unlike diabetes, evidence for use in CHI is scant (60-62). Accuracy is lower than that of glucometer testing and any hypoglycaemia detected by a CGM device must be verified with a point of care glucometer before treatment is administered (62,63). In hospital, CGM can be used to provide reassurance about normoglycaemia and thus reduce the number of point of care glucose tests (64).…”