Children and A1c targets
Two articles have appeared less than 2 years about children and A1c targets. The first appeared in January, 2013. It warns parents and medical staff that “only approximately one-third of participants (in a study of over 60,000) met the age speciﬁc ADA and ISPAD targets for HbA1c. Although the majority of participants did meet BP, lipid, and BMI targets” (Wood et al., 2013, p. 3). Now as a reminder these targets at the time of publication of this article were as follows:
“8.5% for those younger than 6 years,
8.0% for those 6 to younger than 13 years old, and
7.5% for those 13 to younger than 20 years old” (Wood et al., 2013, p. 1)
Obviously this represents a clinical problem. Since not meeting targets presents at least the possibility of a greater risk for complications.
Flash forward to 2014 and there was a new paper published at the June ADA Scientific conference. The new paper sets out the ADA’s position with regard to glycemic control mostly in children (Chiang, Kirkman, Laffel, & Peters, 2014). The new guideline is as follows:
“The ADA will harmonize its glycemic goals with those of ISPAD (as well as the Pediatric Endocrine Society and the International Diabetes Federation) by using a single A1C goal of <7.5% across all pediatric age-groups” (Chiang et al., 2014, p. 2044).
First a note here, the ADA was not in sync with the International Society for Pediatric and Adolescent Diabetes (ISPAD) as well as the other two organizations mentioned specifically in the statement which had already adopted the less than <7.5% standard (Chiang et al., 2014).
Second each pediatric target except for those 13 - 20 was higher than the new pediatric target adopted in July.
Their rationale for setting the lower target really comes down to one thing in my opinion. With the advent of CGM monitoring it has been generally felt that tighter control can be achieved without the significant fear of low blood sugar which prompted the establishment of the prior guidelines (Chiang et al., 2014).
I happen to know one the authors of the new ADA position paper and I know her to be a fine physician and a caring person. But in order to be taken seriously I believe the ADA paper should have addressed the broader issue present in January 2013, which is that around 2/3rds of pediatric type 1’s were not meeting the higher previous targets (Wood et al., 2013).
The new ADA positon is not unreasonable when viewed from a high altitude. It is easy to tell parents and schools that clinicians want tighter control. It is entirely different to be a parent who wakes up every night to check their child’s blood sugar. I know we have many parents who are fundamentally stressed about blood sugar lows. Imagine a child of less than 3 having a low without a parent to intercede. It is unimaginable to me. And yet promoting tighter controls moves a child closer to that threshold in a body that is growing, changing and developing daily. I just do not know if I could even have a blood sugar target for my child if they were under 3 and yet here is a tighter target? If I were a parent of a type 1 child my goal would be to make it too tomorrow.
Then the new guiltiness go on to say the following:
“CGM is a useful tool to reduce A1C levels in adults without increasing hypoglycemia and can reduce glycemic excursions in children. Glycemic improvements are correlated with frequency of CGM use across all ages.
Children should have additional blood glucose checks if the parent/
caregiver is concerned that the child’s behavior may be due to low/high
blood glucose levels.
School employees and caregivers should be knowledgeable about
SMBG and equipped with all necessary supplies.” (Chiang et al., 2014).
I had to chuckle about these items. Yeah you know I agree with these conclusions. School personnel need to be more familiar with Self Monitoring of Blood Glucose and CGM’s ought to have widespread use. I think we all need to work toward that end.
Of course there is the cost issue, something these authors did not consider when drafting this paper and yes school personnel should be better informed about SMBG practices.
You know I am not against saying this or that is the best practice. I am against telling parents and others they are failing and oh by the way guess what we are making it more difficult for you to hit targets. Come on ADA consider the whole child consequences before putting more stress on families to comply. Also if you want full adoption of CGM’s, maybe it is best to pursue federal legislation, and instead of starting with kids, why not start with Seniors who are denied CGM because of Medicare?
Chiang, J. L., Kirkman, M. S., Laffel, L. M. B., & Peters, A. L. (2014). Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association. Diabetes Care, 37(7), 2034-2054. doi: 10.2337/dc14-1140
Wood, J. R., Miller, K. M., Maahs, D. M., Beck, R. W., DiMeglio, L. A., Libman, I. M., . . . Network, f. t. T. D. E. C. (2013). Most Youth With Type 1 Diabetes in the T1D Exchange Clinic Registry Do Not Meet American Diabetes Association or International Society for Pediatric and Adolescent Diabetes Clinical Guidelines. Diabetes Care. doi: 10.2337/dc12-1959