CGM-Assisted Management of PN
brief summary
The purpose of this study is to learn more about changes in glucose levels in hospitalized infants with intestinal failure receiving parenteral nutrition or PN (nutrients delivered intravenously), as they transition from continuous PN (given 24 hours a day) to cycled PN (given less than 24 hours a day). There is an increased risk of glucose abnormalities with cycled PN, which can be harmful to infant growth and brain health. Continuous glucose monitors (CGM) will be used to measure interstitial glucose levels (in the tissue under the skin), which are similar to blood glucose levels. CGM is a small, minimally-invasive sensor worn on the thigh, which gives a glucose measurement every 5 minutes, and can help us understand changes in blood sugar levels without having to do a blood draw or fingerstick. CGM will be used during PN cycling for up to 30 days or until hospital discharge. If target GIR cycled PN is not reached following 3 sensor periods (up to 10 days per sensor), the parent/guardian will be approached to accept or decline participation in an optional extension phase. In the extension phase, the primary study will be repeated and CGM monitoring will continue until target GIR cycled PN is reached, up to an additional 3 sensor placements. CGM data will be hidden from the clinical team, there will be no change to routine clinical care. CGM may provide false low glucose readings when the tissue around the sensor is compressed (compression lows), such as when laying on the sensor during sleep. We will generate data during the study to help identify and filter the final dataset to remove likely compression lows. This study may help us understand how cycled PN affects glucose levels in infants with intestinal failure, which may help other children treated with cycled PN in the future.
detailed description
The objective of this investigation is to quantify dysglycemia associated with cycled parenteral nutrition (PN) and elevated glucose infusion rates (GIR) in infants with intestinal failure and PN-dependence, leveraging high-frequency continuous glucose monitor (CGM) sensor glucose values in a prospective, observational study.
Intestinal failure is a malabsorptive state which necessitates PN in its most severe form. PN is ideally transitioned from continuous (24 hr/day) to cycled PN (\<24 hr/day), requiring higher glucose infusion rates (GIR) to provide the same nutrition content over a shorter time-period. Patients on cycled PN, especially infants, are vulnerable to dysglycemia (abnormal glucose levels), specifically hyperglycemia during PN infusions (due to inadequate insulin relative to high GIR) and hypoglycemia when PN is cycled off (due to delayed insulin suppression after PN suspension). There is no established pediatric GIR threshold above which the risk of abnormal glucose levels significantly increases.
While current practice relies on intermittent blood glucose checks, continuous glucose monitors (CGM) measure high-frequency glucose profiles via minimally-invasive sensors, and are capable of precisely detecting clinically-actionable trends that may otherwise go unrecognized. The CGM sensor measures interstitial glucose, an accepted proxy for blood glucose in patients \> 2 years old with diabetes or glycemic variability. CGM has been successfully used in infants and can fulfill the need for greater quantitative insight into glucose trends in metabolically and neurologically fragile populations, including infants with intestinal failure.
The investigators hypothesize that during high-GIR, cycled PN: a) trough glucose while PN is suspended is less than normal (statistically defined as 100 mg/dL), and b) average glucose while receiving the target (highest) GIR is greater than normal (statistically defined as 120 mg/dL).
Eligible infants will be identified among hospitalized infants at Boston Children's Hospital and followed by the Home Parenteral Nutrition (HPN) program and the Center for Advanced Intestinal Rehabilitation (CAIR). All enrolled participants will have a Dexcom G6 Pro CGM placed within 1 week prior to the anticipated initiation of PN cycling, and CGM will be worn using blinded mode for up to 30 days until target GIR cycled PN is reached (3 sensors maximum). If target GIR cycled PN is not reached following 3 sensor periods (up to 10 days per sensor), the parent/guardian will be approached to accept or decline participation in an optional extension phase. In the extension phase, the primary study will be repeated and CGM monitoring will continue until target GIR cycled PN is reached, up to an additional 3 sensor placements. No CGM will remain in place at the time of discharge.
official title
CAMP: CGM-Assisted Management of PN