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Diabetes Care 28:710-711, 2005
© 2005 by the American Diabetes Association, Inc.

Clinical Care/Education/Nutrition
Brief Report

Alternate-Site Testing Is Reliable in Children and Adolescents With Type 1 Diabetes, Except at the Forearm for Hypoglycemia Detection

Nadine Lucidarme, MD1, Corinne Alberti, MD2, Isabelle Zaccaria, MD2, Emmanuel Claude, MD3 and Nadia Tubiana-Rufi, MD1

1 Department of Endocrinology, Robert Debre Teaching Hospital, AP-HP, Paris, France
2 Center of Clinical Epidemiology, Robert Debre Teaching Hospital, AP-HP, Paris, France
3 Ypsomed, Paris, France

Address correspondence and reprint requests to Dr. Nadine Lucidarme, Department of Endocrinology, Robert Debre Teaching Hospital, 75019 Paris, France. E-mail: nadine.lucidarme{at}jvr.ap-hop-paris.fr

Abbreviations: AST, alternate-site testing • SMBG, self-monitoring of blood glucose


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
Self-monitoring of blood glucose (SMBG) is crucial to the management of type 1 diabetes (1,2). Until recently, SMBG relied only on capillary blood sampling by fingerstick (a source of pain) and other forms of patient discomfort likely to diminish adherence to SMBG. After approval of alternate-site testing (AST), clinical studies found differences across measurement sites (3) in diabetic adults experiencing rapid blood glucose variations (4). Although pediatric patients with type 1 diabetes may be particularly likely to benefit from new methods that decrease pain and other burdens associated with frequent SMBG, alternate-site SMBG in this age-group has not been fully validated.

The objectives of this study were to determine whether blood glucose measured at alternate testing sites (thenar and forearm) in diabetic children showed clinically significant differences compared with fingertip values and to evaluate patient satisfaction with AST.


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
We included 29 children (aged 5–17 years) who had type 1 diabetes of at least 1 year’s duration and performed SMBG three or more times a day. The ethics committee of the St. Louis Hospital, Paris VII University, approved the study.

For each SMBG over two consecutive randomized 8-day periods, each patient used two sampling sites: the fingertip and either the thenar or the forearm. SMBG was done three times a day before meals and once a day after the evening meal, using the FreeStyle Papillon glucose meter. The patients were not instructed to rub the site before sampling, since the benefits of rubbing remain controversial (4,5).

At the end of this 16-day period, patient preference for fingertip or AST was recorded. During a second study period, which lasted 1 month, the patients were free to choose between fingertip and AST following recommendations for adults at the time of the study. At study completion, each patient was asked this question: "In your opinion, is alternate-site testing a progress?"

Data were analyzed using a mixed-effects linear regression model (SAS version 8.02; SAS Institute, Cary, NC). Clinical accuracy was assessed using Clarke error grid analysis (6–8).


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
Table 1 reports the differences in blood glucose between the fingertip and alternate sites for the preprandial, postprandial, and hypoglycemic episode samples, taking intraindividual correlations into account. The differences were minimal (near zero) for all comparisons, except for the fingertip versus the forearm for samples taken during hypoglycemia (≤60 mg/dl).


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  		Table 1— Differences in blood glucose values between the fingertip and alternate sites and Clarke error grid analysis in preprandial, postprandial, and hypoglycemic episode samples, with the 95% limits of agreement

 
The clinical relevance of correlations was analyzed using Clarke error grids (Table 1). The 95% limits of agreement showed no differences in Clarke grid distributions for preprandial or postprandial comparisons. Differences were found across sites for hypoglycemia samples: 20.4% of forearm values were in region D, whereas 100% of thenar values were in region A.

After 16 days, 66% of patients reported a preference for AST over the fingertip, citing easier sampling in larger zones and decreased pain, whereas habit was the main reason for fingertip preference. At study completion, 73% of patients overall perceived AST to be a progress.


   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
This study is the first evaluation of AST conducted in children and under real-life conditions. We found that prepandial SMBG data in pediatric patients were consistent with reported data from adults at the same sampling sites (3,4,9). Postprandial SMBG values in our pediatric population showed no significant differences between the fingertip and the forearm or thenar, whereas studies in adults found that fingertip postprandial values differed from forearm values but not from thenar values. It should be noted that published studies usually evaluated these differences in individuals experiencing rapid blood glucose variations during oral glucose tolerance testing (4,10). Our study was conducted in a very different situation, namely, routine SMBG. Clarke error grid analysis confirmed the agreement for postprandial values by establishing that alternate-site results were clinically relevant. During hypoglycemic episodes, however, we found major differences between the fingertip and forearm. Because forearm values are not reliable during hypoglycemic episodes, forearm sampling is not appropriate in this situation or in patients with hypoglycemia unawareness (11). In contrast, thenar sampling is reliable.

Whether AST improves patient compliance with SMBG, as demonstrated in a study in adults (12), remains to be determined in pediatric studies conducted over longer periods, especially in adolescents. The implications of our study go beyond conventional SMBG, since they are also relevant to new techniques for continuous blood glucose measurement with glucose sensors, which is prone to the AST-like phenomenon (13).

In conclusion, SMBG at alternate sites (thenar and forearm) was clinically reliable before and after meals in type 1 diabetic children, who perceived this alternative as a progress in their daily management. Therefore, SMBG at alternate sites can be recommended with the caveat that forearm sampling should not be used in children with symptoms of hypoglycemia or in specific conditions carrying a high risk of hypoglycemia. These recommendations should be incorporated into educational programs for children with diabetes.


   Footnotes
 
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Received for publication September 25, 2004. Accepted for publication December 12, 2004.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. The Diabetes Control and Complication Trial Research Group: Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus. J Pediatr 125:177–188, 1994[Medline]
  2. American Diabetes Association: Tests of glycemia in diabetes (Position Statement). Diabetes Care 25 (Suppl. 1):S97–S99, 2002
  3. Jungheim K, Koschinsky T: Risky delays of hypoglycemia detection by glucose monitoring at the arm (Letter). Diabetes Care 24:1303–1304, 2001[Free Full Text]
  4. Jungheim K, Koschinsky T: Glucose monitoring at the arm: risky delays of hypoglycemia and hyperglycemia detection. Diabetes Care 25:956–960, 2002[Abstract/Free Full Text]
  5. McGarraugh G, Price D, Schwartz S, Weinstein R: Physiological influences on off-finger glucose testing. Diabetes Technol Ther 3:367–376, 2001[Medline]
  6. Clarke WL, Cox D, Gonder-Frederick L, Carter W, Pohl S: Evaluating clinical accuracy of systems for self-monitoring of blood glucose. Diabetes Care 10:622–628, 1987[Abstract]
  7. Cox DJ, Gonder-Frederick L, Julian DM, Clarke WL: Understanding error grid analysis (Editorial). Diabetes Care 20:911–912, 1997[Medline]
  8. Stöckl D, Dewitte K, Fierens C, Thienpont LM: Evaluating clinical accuracy of systems for self-monitoring of blood glucose by error grid analysis (Letter). Diabetes Care 23:1711, 2000[Free Full Text]
  9. Bina DM, Anderson RL, Johnson ML, Bergenstal RM, Kendall D: Clinical impact of prandial state, exercise, and site preparation on the equivalence of alternative-site blood glucose testing. Diabetes Care 26:981–985, 2003[Abstract/Free Full Text]
  10. Ellison JM, Stegmann JM, Colner SL, Michael RH, Sharma MK, Ervin KR, Horwitz DL: Rapid changes in postprandial blood glucose produce concentration differences at finger, forearm, and thigh sampling sites. Diabetes Care 25:961–964, 2002[Abstract/Free Full Text]
  11. Beregszaszi M, Tubiana-Rufi N, Benali K, Noel M, Bloch J, Czernichow P: Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus: prevalence and risk factors. J Pediatr 131:27–33, 1997[Medline]
  12. Suzuki Y, Atsumi Y, Matusoka K: Alternative site testing increases compliance of SMBG (preliminary study of 3 years cohort trials) (Letter). Diabetes Res Clin Pract 59:233–234, 2003[Medline]
  13. Koschinsky T, Jungheim K, Heinemann L: Glucose sensors and the alternate site testing-like phenomenon: relationship between rapid blood glucose changes and glucose sensor signals. Diabetes Technol Ther 5:829–842, 2003[Medline]

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