How strict should we be with children and teenagers?

Abstract

Landmark clinical studies have demonstrated that optimizing glycemic control reduces vascular complications in patients with type 1 (T1D) and type 2 (T2D) diabetes mellitus. At the same time, it is essential to avoid increasing the risk of acute complications, maintain quality of life, and ensure adequate growth and development in children and adolescents. Diabetes education is a fundamental pillar.

Advanced technologies, including continuous glucose monitoring (CGM) and automated insulin infusion (AID) systems, represent a paradigm shift. These tools decrease the risk of severe hypoglycemia, automatically correct hyperglycemia, and alleviate the burden. Their use is recommended regardless of age, metabolic control, or duration of diabetes.

In 2024, ISPAD updated the glycemic targets for children and adolescents: The glycated hemoglobin (HbA1c) standard remains at ≤7.0%. However, a new, stricter target of ≤6.5% was established for patients with access to advanced technologies (CGM or AID) if it does not negatively impact quality of life. In patients with type 2 diabetes, the target is set at ≤6.5% from diagnosis due to the rapid deterioration of beta cells and the accelerated progression of associated complications.

For CGM monitoring, the target glycemic index (GI) is above 70%. However, to achieve HbA1c ≤6.5%, a GI above 80% may be required. Additionally, time in narrow range (TITR, 70–144 mg/dL) is emerging as a more sensitive metric for assessing glycemic variability.

Accordingly, for capillary blood glucose self-monitoring, targets are set at 70-144 mg/dL pre-meal and before bedtime (the latter can be adjusted to 180 mg/dL) and 70-180 mg/dL post-meal. It is complementary to continuous glucose monitoring (CGM) or should be performed at least six times a day in insulin users.

Unfortunately, most patients do not achieve these targets. Other biopsychosocial factors and differences in access to the healthcare system determine the resources available for chronic care. For this reason, clinical strategies and glycemic targets must be individualized, and it is essential to reassess them periodically to avoid therapeutic inertia. It is our duty to always strive to reduce the gap between clinical reality and the recommended glycemic targets as early as possible.