The paper by Nevo-Shenker et al.1 presents the evidence available to support use of recently developed diabetes self-management technologies in very young children (<age 6-years-old) with type 1 diabetes (T1D). The specific technologies the authors write about include continuous glucose monitors (CGMs), continuous subcutaneous insulin infusion (CSII; aka insulin pump) therapy, sensor-augmented pump (SAP) therapy, predictive low-glucose suspend (PLGS) technology, and hybrid closed loop (HCL) insulin delivery. While the authors present promising early evidence for each technology, the limited number of studies, the small samples of young children in those studies, the limited cognitive and behavioral phenotyping of the children and caregivers in the studies, the lack of technologies designed specifically for young children, and the continued lack of well-designed longitudinal randomized clinical trials specifically addressing safety and efficacy in young children remain problematic. Collectively, these limitations constitute critical gaps in our approaches to optimizing care for young children with T1D and evoke multiple research questions that must be explored.

Recent studies highlight the limitations of hemoglobin A1c (HbA1c) as a biomarker of disease control. HbA1c relates strongly to recent average daily glucose levels, and through multiple historic trials, the evidence validates its importance as a proxy for risk of future health complications. Yet, as measures of disease control, there may be less bias in an individual’s average daily glucose levels, time in range, time spent hyper- and hypoglycemic, and glycemic variability derived from CGM data, and these measures may equally relate to future outcomes. It is also important that researchers, regulatory agencies, and policymakers consider the importance of non-glycemic outcomes. Young children can experience diabetic ketoacidosis (DKA), which is associated with significant in-hospital morbidity. The prevalence of severe hypoglycemia (SH) is also highest among very young children compared to older youth,2 and evidence suggests that SH can detrimentally impact cognitive development in young children.3 Similarly, hypoglycemia fear (FH) occurs frequently among parents of young children and evidence suggests that FH can impact parent mental health, affect sleep quality, adherence to the treatment plan, family quality of life, and family functioning.4,5 Finally, many individuals with diabetes and clinicians have endorsed the importance of optimizing quality of life (QOL) among children and families.6

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