Type 1 diabetes in children: from closed loops to delaying the disease

Type 1 diabetes is one of the most common chronic diseases of childhood. The immune system destroys the insulin-producing cells of the pancreas, and children depend on insulin for the rest of their lives. Two developments are changing what that means.

Closed-loop systems

Hybrid closed-loop systems, sometimes called artificial pancreas systems, link a continuous glucose monitor to an insulin pump through an algorithm that adjusts insulin delivery automatically. They reduce the time children spend with glucose too high or too low, and reduce the burden on families, especially overnight.

Systems have been approved for children as young as two, and health systems including the NHS in England have begun wider roll-outs. The main constraints now are cost, training and equitable access.

Delaying the disease

Type 1 diabetes develops in stages. Autoantibodies appear in the blood years before symptoms, and children with two or more autoantibodies are very likely to develop clinical disease.

In 2022 the FDA approved teplizumab, an anti-CD3 antibody, to delay the onset of stage 3 type 1 diabetes in people aged eight and over who are in stage 2. In the pivotal trial, it delayed diagnosis by around two years on average compared with placebo. It does not cure the disease, but two extra years without insulin dependence matters to a child and family.

The screening question

A drug that works before symptoms only helps if children are identified before symptoms. That has revived interest in population screening for type 1 diabetes autoantibodies in childhood. Screening also reduces the number of children diagnosed in diabetic ketoacidosis, a dangerous complication at onset.

The open questions are who to screen, at what age, how to support families who receive a result for a disease that may be years away, and how to pay for it.