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Systematic review and meta-analysis of insulin pump therapy in children and adolescents with type 1 diabetes
  1. J Gane1,
  2. B White2,
  3. D Christie2,
  4. R Viner2
  1. 1Neonatal Intensive Care Unit, Lewisham Hospital NHS Trust, London, UK
  2. 2General and Adolescent Paediatrics Unit, UCL Institute of Child Health, London, UK

Abstract

Aims Continuous subcutaneous infusion of insulin (CSII) via an insulin pump is believed to provide more physiological and flexible control of type 1 diabetes compared with injection regimens such as intensive multiple daily injection (MDI) regimens. However, a number of small underpowered randomised trials have failed to provide conclusive evidence for this. The authors undertook a systematic review and meta-analysis to better estimate the effectiveness and safety of CSII compared with MDI.

Methods A systematic review was undertaken to identify randomised controlled trials (RCT) and unrandomised prospective controlled studies comparing CSII with MDI in subjects ≤18 years with established type 1 diabetes (≥6 months) and of duration ≥3 months. Meta-analysis for haemoglobin A1c (HbA1c), hypoglycaemia and quality of life outcomes was undertaken using random effects model in Review Manager 5.0.22.

Results 10 RCT s (n=307) and five prospective studies (n=318) were included. Overall quality of trials was poor.

Glycaemic control: At 6 months CSII was shown to provide a minor benefit in reduced HbA1c over MDI in RCTs (mean pooled difference = −0.24% (95% CI −0.48 to −0.00); minimal heterogeneity (I2=0%)) and prospective studies (−0.32 (95% CI −0.62 to −0.03); I2=0%). These benefits remained at 12 months in prospective studies although they failed to reach significance. There were insufficient data for analysis in RCTs at 12 months.

Hypoglycaemia: CSII was associated with reduced risk of severe hypoglycaemia at 6 months in RCTs (RR 0.66 (95% CI 0.32 to 1.36); not significant) and at 12 months in prospective studies (RR 0.50 (95% CI 0.28 to 0.88); I2=0%).

Quality of life: Data were sparse and inappropriate for meta-analysis.

Conclusion CSII in children and adolescents is associated with small mean reduction in HbA1c and a decreased risk of severe hypoglycaemia when compared with MDI in relatively unselected populations during short-term follow-up. There is little evidence that CSII improves quality of life compared with MDI. Larger better quality trials with longer-term follow-up are needed to establish the benefit of CSII in paediatric populations.

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