Closing the Loop in Our Youngest Kids

January 26, 2022

Automated Insulin Delivery is something that people with diabetes have been dreaming of for decades. Thanks to the advent of technologies such as the continuous glucose monitor (CGM), this dream has become more of a reality for people who have access to the latest hybrid closed-loop systems. These systems use the CGM data to adjust the insulin given through the insulin pump, allowing for decreased burden and more time in range. There is still work required by the user, but it’s certainly a step up from what we’ve had for the last 100 years.

There also is usually a lag-time for when these hybrid closed-loop (HCL) systems become available to some of the most insulin sensitive: very young children. As you can imagine, it can be difficult to manage blood sugars in a toddler or young child. Much like it’s a challenge to get their shoes on in the morning or brush their teeth before bed, making sure that they eat all the food they’ve received a bolus for or drink water when their blood sugar is high is also a challenge.

For this reason, the recommendations for young children with diabetes used to be focused on prevention of hypoglycemia and allowing for higher HbA1c levels due to this concern.1 But when more recent data showed the negative impact on both high blood sugars and large fluctuations in blood sugar levels, the American Diabetes Association updated their standards of care to recommend HbA1c goals be the same for children of all ages.2

 The hybrid closed loop technologies have helped reduce hypoglycemia for people of all ages with T1D, and, luckily, young children are no exception.1,3 The HCL systems help improve time in range and reduce the frequency and duration of low blood sugars, instead of increasing lows, which often happens when trying to achieve tight glycemic control. HCL systems also reduce the anxiety that goes along with hypos, which can be a major barrier to meeting the newer glycemic goals.4

There are three HCL systems that have been studied in young children: Tandem Control-IQ, Minimed 670G, and a study system called CampAPS FX.1,3,5 The results were very encouraging, and showed the following benefits compared to the control group:

  1. Decreased time in hyperglycemic range, defined as >180 mg/dl (10 mmol/L)
  2. Decreased time spent in hypoglycemic range, defined as <70 mg/dL (3.9 mmol/L)
  3. Increased Time-In-Range (TIR), defined as 70-180 mg/dl (3.9-10 mmol/L)

For now, the only systems approved for young children in the U.S. are the Tandem Control-IQ down to age six years, and the Medtronic 770G for children down to age two years. This does not mean that your healthcare team would not recommend or even prescribe systems for your family, depending on the circumstances and everyone’s level of comfort. This is called off-label prescribing. There are also systems that are not approved by the Food & Drug Administration (FDA), such as Loop and DIY APS systems, that people use off-label as well.

The Android APS system was also recently studied in children three to seven years old, and it helped improve time in range compared to SAP (Sensor Augmented Pump, which suspends or lowers insulin with lows, but does not adjust for highs).6 Unfortunately, the Android APS did not improve time spent in hypoglycemia, but the time spent was minimal for both HCL and SAP groups.

Closed Loop Systems may not be able help with the highs and lows of parenting toddlers, but they can improve the time in range for those who live with type 1 diabetes. It’s worth asking your diabetes care team if these systems could be helpful for you and your family.

If you’re looking to start a new diabetes technology, there is a great unbiased website,, that can help you determine what is best for you and your family.

  1. Safety and Performance of the Tandem t:slim X2 with Control-IQ Automated Insulin Delivery System in Toddlers and Preschoolers
  2. Children and Adolescents: Standards of Medical Care in Diabetes—2021
  3. Glycemic Outcomes of Children 2-6 Years of Age with Type 1 Diabetes during the Pediatric MiniMed™ 670G System Trial
  4. Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes
  5. Randomized Trial of Closed-Loop Control in Very Young Children with Type 1 Diabetes
  6. Pre-school and school-aged children benefit from the switch from a sensor-augmented pump to an AndroidAPS hybrid closed loop: A retrospective analysis

Written and clinically reviewed by Marissa Town, RN, BSN, CDCES