When a child is diagnosed with diabetes, parents most often want to know what care options are available to limit restrictions on their child’s life — while also keeping them tuned in to safety. One of the most common questions the child wants to know is if they can still eat cake at their friends’ birthday parties.
Technology related to diabetes care and monitoring has sprinted forward on both of these fronts in recent years. Quarterly A1C blood tests (also known as HbA1C or hemoglobin A1C), daily fingerstick blood tests using a blood glucose monitor and glucose testing strips still play a foundational part in care. However, technological developments in glucose monitoring and insulin delivery can significantly supplement these tools, and the often-challenging calculations involved in their use.
Ana L. Creo, M.D., director of the Pediatric Diabetes Clinic at Mayo Clinic, has the task of matching the best mix of care to each family’s technology preferences, budget, lifestyle and insurance coverage.
But before diving into the technology options, let’s get to the birthday cake question first.
The short answer is “yes,” you can have birthday cake. However, whether your child has been diagnosed with type 1 or type 2 diabetes, moderation is important.
“Type 1 diabetes is caused by an autoimmune disorder that destroys insulin-producing cells in the pancreas, and no amount of healthy eating will remedy that,” says Dr. Creo. “However, we want the growing and developing child to continue to participate in birthday parties. It’s a common misconception that children with type 1 diabetes can never again have sweet things. The key is to have a plan on how to incorporate sweets into the child’s meal plan and do so in moderation.”
Moderation is also important in the management of type 2 diabetes, since it is typically caused by a combination of excess body weight and limited exercise — and by consuming too many calories in the diet, particularly those low in nutritional value, such as soda, juice, ice cream and other sweets.
“With type 2,” Dr. Creo says. “there is that real hope and silver lining that, if you improve diet and exercise, it will get better with time.” That doesn’t mean zero birthday cake, but rather keeping the amount and frequency of sweets in check.
Glucose monitors — minimizing finger sticks
So where does Dr. Creo start a conversation about a diabetes diagnosis?
“For most cases,” she explains, “the big question families want to know right away is this: ‘Is this type 1 or type 2?’ ‘And will it go away?’ ” The next big question is around whether their child needs insulin, which is always the case with type 1 and often the case with type 2. “Regardless of which diagnosis it is, we’re teaching families about blood sugar (glucose) monitoring and insulin.”
With glucose monitoring, Dr. Creo typically discusses a traditional fingerstick glucose meter first, before introducing a range of modern blood glucose monitoring devices and systems that do not involve routine fingersticks. She then points to the growing number of the 230,000 children the Centers for Disease Control projects as living with diabetes in the U.S wearing a glucose sensor. Two types of glucose sensors are available, and their benefits depend on how much technological engagement a family feels comfortable with. They include:
- Continuous Glucose Monitoring (CGM) sensors — Wearable CGM devices — such as the Dexcom G6 and Guardian Sensor 3 — involve inserting a tiny sensor under the skin of the arm or stomach. This measures levels of glucose found in the fluid between cells (interstitial fluid) and transmits blood glucose readings around the clock to a paired device, such as a smartphone.
- Flash Glucose Monitoring — A Flash system, such as the Freestyle Libre 2, works in the same way as a CGM, only you need to scan the sensor to see results.
One downside, Dr. Creo says, is that with these devices blood glucose changes a little slower compared with traditional fingerstick glucose reading meters because when a child’s blood sugar level drops (hypoglycemia), it occurs first in the blood, and then in interstitial fluid. However, she says this time lag is not significant enough to negate the usefulness of these lifestyle adaptive devices and the precision of data is the same, just the rate at which they change differs. In addition, CGMs, Flash sensors and glucose meters can tend to read about 10% off the true value of a clinical blood draw test. Despite this, their value in avoiding frequent fingersticks remains the reason why children often prefer them.
For parents, a major advantage to glucose sensing devices is their alarm systems.
“With pediatric diabetes,” says Dr. Creo, “my preference is for systems with alarm options. We can achieve more-aggressive insulin targets and A1C targets without fear of low blood glucose levels that goes unnoticed, such as nighttime hypoglycemia.
“With kids entering their teens and becoming more independent, alarms are helpful when they function as a system that communicates to multiple phones. The Dexcom G6, for example, can transmit data to five other phones, so parents, teachers and grandparents can jointly monitor a child’s blood sugar. Families find that very helpful.”
With older teens, Dr. Creo recommends developing a family communication plan.
“Let’s say a 17-year-old boy is having low blood glucose, the alarm goes off on his parents’ phones and they’re thinking: Where is he? Is he driving? The plan therefore is for teens to have a preplanned texting codeword or emoji they can send to relatives — even just a thumbs-up emoji — that says, “Mom, Dad, I got it.” That way, parents don’t always need to be glued to their phones or on their kid’s back, because monitoring is stressful for parents too.”
Insulin: fewer injections, better calibration
To manage insulin, Dr. Creo likes to offer several options. One option is an insulin pump. These small electronic devices come in tethered or pump formats and involve the fitting of a thin tube (cannula) under the skin. With a tethered pump, a tube connects to the cannula and a control pump is worn on a belt or in a pocket. A patch pump fits directly to the skin and is controlled by a remote device. One example, the Dash, a tubeless, waterproof, wearable pod, offering 72 hours of nonstop insulin delivery synced to Bluetooth-enabled personal diabetes management software, was showcased on the runway at Milan Fashion Week last year by Kate Moss’ daughter, Lila Moss, who has type 1. And coming to the fore is an even newer technology — closed loop insulin delivery systems . These systems, also known as artificial pancreas technology, include the MiniMed 780G, Omnipod 5 and Tandem t:Slim Control IQ. These systems pair a pump, an app and a control algorithm to imitate the pancreas by continuously monitoring glucose data and automating insulin delivery through a pump to match.
“Insulin pumps add convenience without injections, without being quite so regimented about eating,” Dr. Creo reflects. “But they add a technology burden. The average child with type 1 diabetes makes around 180 decisions per day on a pump. A closed loop system conversely is very good for keeping time and range and suspending insulin to avoid low blood sugars. So if your daughter rushes out in the morning and eats breakfast but doesn’t put her card in the pump, a closed loop system will still monitor and depending upon the system, may deliver an estimated 60% of the insulin dose and keep her safe. For parents, this removes a lot of stress. “
Dr. Creo also favors smart insulin pens. Her preference, the InPen, is Bluetooth enabled and pairs to an app. Just like an ordinary insulin pen, the smart insulin pen gives injections, but with the added benefit of detailed tracking. Dr. Creo can program a smart insulin pen app for a child, so all a family has to do is enter the grams of carbohydrates in a meal. Then, the app and sensor interpret this data and calculate the appropriate insulin dose.
“All the data we need is on these platforms,” says Dr. Creo of the increasing pandemic-accelerated trend towards digital diabetes care. “A parent can plug in whatever device they have at home and I can assess their child’s data and give dose adjustments remotely.”
The future of diabetes treatment (but no smartwatches yet)
Dr. Creo is often asked if she expects glucose monitoring to become a feature of smartwatches the way the Apple Watch Series 4 unveiled ECG heart monitoring.
“The logistical question here is what device would it pair to,” Dr. Creo contemplates, “and how good would a watch with a cannula be? Considering all glucose testing is still carried out by blood and interstitial fluid, I don’t think we’re anywhere near there yet with the prospect of glucose monitoring using smartwatch technology; however, many CGMs now pair to smartwatches.”
Looking to a broader future, Dr. Creo sees three areas of therapeutic breakthrough for diabetes.
“One is stem cell treatment for type 1 diabetes, which is exciting but won’t reach the pediatric diabetes population for many years. The second is ongoing technology, which is getting better and better. And the third is prevention. My department here at Mayo Clinic is part of Trialnet, a type 1 diabetes trial screening relatives of type 1 status to see if they carry antibodies that put them at risk. If a relative has positive antibodies, they may qualify for experimental treatments that aim to delay, if not prevent, the onset of diabetes. With type 2, though, it’ll long continue to be about preventive lifestyle messaging around obesity management, improving diet and exercise.”
Overall, treatment options for managing pediatric diabetes have never had more range and by embracing innovative options, a family has a very real chance of finding that sweet spot where at birthday parties, their diabetic child still gets a slice of cake.
