ISPAD Clinical Practice Consensus Guidelines 2018 ...

1 Received: 27 June 2018 Accepted: 16 July 2018. DOI: ISPAD Clinical Practice Consensus Guidelines . ISPAD Clinical Practice Consensus Guidelines 2018: Exercise in children and adolescents with diabetes Peter Adolfsson1 | Michael C. Riddell2 | Craig E. Taplin3 | Elizabeth A. Davis4 |. Paul A. Fournier5 | Francesca Annan6 | Andrea E. Scaramuzza7 | Dhruvi Hasnani8 |. Sabine E. Hofer9. 1. Department of Pediatrics, Kungsbacka Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2. Muscle Health Research Centre, York University, Toronto, ON, Canada 3. Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington 4. Department of Endocrinology and Diabetes, Princess Margaret Hospital; Telethon Kids Institute, University of Western Australia, Crawley, Australia 5. School of Human Sciences, University of Western Australia, Perth, Australia 6.

2 Children and Young People's Diabetes Service, University College London Hospitals NHS, Foundation Trust, London, UK. 7. Division of Pediatrics, ASST Cremona, Ospedale Maggiore di Cremona , Cremona, Italy 8. Diacare-Diabetes Care and Hormone Clinic, Ahmedabad, India 9. Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria Correspondence Peter Adolfsson, Department of Pediatrics, Kungsbacka Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Email: 1 | N E W I N F O RM A T I O N I N R E L A T I O N T O concentrations because of apparent lag time between blood glucose THE PREVIOUS GUIDELINE levels and interstitial glucose levels. Insulin pumps that include predictive low-glucose management In the field of technology, intermittent scanning continuous glucose (PLGM) systems may be advantageous as physical activity is associ- monitoring (isCGM) offers the opportunity to obtain glucose values ated with increased risk of hypoglycemia, not only during but also more easily than with self-monitored blood glucose monitoring after physical activity.

3 The step being currently evaluated is hybrid (SMBG). This technology also provides the user with information on closed loop where physical activity clearly represents one of the big- the direction and the rate of glucose value changes. However, the gest challenges for such a system. individual must actively scan the sensor to receive a value. Alerts or A variety of wearable technologies offer the possibility to track alarms are not currently linked to this technology. glucose values (eg, smart watches) as well as level of physical activity Real-time continuous glucose monitoring (rtCGM) is a technology (eg, wrist bands), heart rate, sleep quality, etc. The current trend is that also including the possibility to use individualized alerts and safety the different wearables are used to an increasing extent where device alarms besides information on glucose values on continuous basis connectivity and data openness might create new opportunities in the along with information on the direction and the rate of glucose value future.

4 Changes. Technology allows access to applications in smart phones to view and enable followers, for example, a legal guardian, teacher, coach, 2 | RE C O M M E N D A T I O N S / E X E C U T I V E. which may increase safety during and after exercise. SUMM ARY. Recent Clinical studies and Clinical experience suggest that exer- cise itself may be a setting in which both isCGM and rtCGM could Many recommendations provided in this guideline are based on work misrepresent the true dynamic changes in actual blood glucose performed in adults, thus raising the possibility that some of these 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Pediatric Diabetes October 2018; 19 (Suppl. 27): 205 226. 205. 206 ADOLFSSON ET AL. recommendations might not hold true for children and younger | General precautions prior to each exercise adolescents. session It should always be remembered that these Guidelines are general | Elevated ketones recommendations, and individual responses to exercise and physical It is important to identify the cause of elevated ketone levels.

5 Raised activity with type 1 diabetes (T1D) may vary. Thus, we emphasize that ketone levels are a safety concern before exercise. [E]. while exercise prescriptions and management plans (insulin and nutri- Where available, blood ketone measurement is recommended tion) can be based on known physiology and a limited number of clini- over urine ketone measurement see ISPAD Clinical Practice Consen- cal studies, they must often be individualized for young people in line sus Guidelines 2014 Assessment and monitoring of glycemic control with experience, goals, and safety in mind. in children and adolescents with diabetes. 1. By measuring blood ketones, changes in ketones may be detected significantly faster. Blood ketone monitors measure the dominant | Initial exercise management ketone of Clinical relevance that is, beta-hydroxybutyrate (BOHB). Children, adolescents, and relevant family members should be offered Elevated blood ketone between and mmol/L should be ongoing education about the latest in blood glucose management in addressed before physical activity.

6 Exercise. [E] In the presence of elevated blood ketones ( mmol/L) or urine Children, adolescents, and relevant family members should be ketones (2+ or mmol/L) exercise in children is contraindicated. provided with a written or online copy of up-to-date and user-friendly High intensity exercise is potentially dangerous and should be evidence-based Guidelines focusing on blood glucose management in avoided if preexercise blood glucose levels are high >14 mmol/L. exercise. [E] (250 mg/dL) with any evidence of elevated ketone levels (ketonuria, Sedentary lifestyle behaviors should be routinely screened for small or more/ketonemia (> mmol/L). In the setting of high glucose and discouraged in the diabetes clinic. [E] and high ketone levels, an insulin bolus using half the usual correction Practical strategies to improve engagement with an active life- factor (or U/kg) should be administered. Ideally, exercise should style should be offered to all patients. [E]. be postponed until evidence of ketonemia has cleared.)

7 [B]. An individualized blood glucose management plan should be developed for each patient as careful advice and planning on exercise | Recent hypoglycemia and management is essential (eg, insulin dose reduction, carbohydrate Severe hypoglycemia (here defined as blood glucose mmol/L. intake, exercise timing). [E] [50 mg/dL]) or an event including cognitive impairment requiring This plan should specifically include the following: external assistance for recovery within the previous 24 hours is a con- traindication to physical activity. Discuss the type and amount of carbohydrate required for spe- Significant hypoglycemia (defined as blood glucose < mmol/L. cific exercise. [<54 mg/dL]), is clinically significant and requires immediate attention. Discuss the percentage reductions in insulin before exercise. [C] It will result in the subsequent deterioration of hormonal counterregu- Discuss when best to exercise safely. lation during physical activity, in turn leading to an increased risk for recurrent hypoglycemia.

8 Written advice about exercise and sports should be included Non-severe hypoglycemia (defined as blood glucose within the school management plan for carers/teachers. [E] mmol/L [52-70 mg/dL]) which occurred relatively recently Care should be taken that the blood glucose meter and test strips before planned exercise can result in the subsequent deterioration of chosen are suitable for the environment where they will be used. [C] hormonal counterregulation during physical activity, in turn leading to Where appropriate and available, patients and families should be an increased risk for recurrent hypoglycemia. informed that multiple daily injections or a pump may be easier to In all situations of documented hypoglycemia prior to physical combine with exercise. [E] activity, we recommend vigilance regarding glucose monitoring. Physi- Patients should be encouraged to keep detailed records of cal activity should be avoided if it is associated with elevated risk for their physical activity, insulin, food, and glucose levels as these injury/accident (eg, Alpine skiing, rock climbing, swimming, scuba records are important for blood glucose management and Clinical diving).

9 Advice. [E]. New technologies, for example, embedded into smart phones | Access to effective monitoring may be of use. [E] Children and adolescents should be counseled that they are best pre- Although the prevalence of diabetes complications is low in chil- pared for exercise when blood glucose meters and test strips are read- dren, medical clearance should be provided to inform professionals ily available, particularly if they are not using glucose monitoring (eg, coaches) and carers of any restriction to exercise participation. [E] devices (isCGM or CGM). Patients who have proliferative retinopathy or nephropathy Children and adolescents should be encouraged to measure their should avoid resistance-based exercise or anaerobic exercise that blood glucose level before, during and after exercise or, alternatively, results in high arterial blood pressure. [E] to check sensor-based glucose values on a regular basis and have ADOLFSSON ET AL. 207. predictive alerts and low glucose alarms activated to help prevent or the duration of action to achieve a lower insulin concentration during reduce the risk of hyperglycemia.

10 And after a physical activity. Exercise with duration <90 minutes could easier be balanced by extra carbohydrate intake. | Access to carbohydrates High glycemic index snacks should be readily available during any | Carbohydrate intake for blood glucose form of physical activity. [E]. management High glycemic index snacks and hyperglycemia remedies should always be readily available at school. [E] | Carbohydrate intake prior to and during exercise The type and amount of carbohydrates required should be tailored to | Communication and safety specific activities. [B]. Advice about safety should be given; children and adolescents should Carbohydrate intake may not be required prior to moderate be encouraged to wear or carry diabetes ID when exercise is per- intensity exercise if of short duration (<30 minutes). formed in the absence of a responsible adult. Counseling should When circulating insulin levels are high and preexercise insulin include consideration of access to a mobile or alternative communica- doses are not decreased, up to g of carbohydrate per kilogram of tion method in case urgent help is required.