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Given the limitations in the access and license status of commercially developed automated insulin delivery (AID) systems, open-source AID systems are becoming increasingly popular among people with diabetes, including children and adolescents.
This study aimed to investigate the lived experiences and physical and emotional health implications of children and their caregivers following the initiation of open-source AID, their perceived challenges, and sources of support, which have not been explored in the existing literature.
Data were collected through 2 sets of open-ended questions from a web-based multinational survey of 60 families from 16 countries. The narratives were thematically analyzed, and a coding framework was identified through iterative alignment.
A range of emotions and improvements in quality of life and physical health were reported, as open-source AID enabled families to shift their focus away from diabetes therapy. Caregivers were less worried about hypoglycemia at night and outside their family homes, leading to increased autonomy for the child. Simultaneously, the glycemic outcomes and sleep quality of both the children and caregivers improved. Nonetheless, the acquisition of suitable hardware and technical setup could be challenging. The #WeAreNotWaiting community was the primary source of practical and emotional support.
Our findings show the benefits and transformative impact of open-source AID and peer support on children with diabetes and their caregivers and families, where commercial AID systems are not available or suitable. Further efforts are required to improve the effectiveness and usability and facilitate access for children with diabetes, worldwide, to benefit from this innovative treatment.
RR2-10.2196/15368
Type 1 diabetes (T1D) is a challenging chronic condition for children, adolescents, and their caregivers and is associated with long-term macro- and microvascular complications and the consequent risk of increased morbidity and mortality. Therapeutic guidelines of the International Society for Pediatric and Adolescent Diabetes recommend a target hemoglobin A1c (HbA1c) level of <7% for children and adolescents with T1D, albeit a target that must be balanced with the individual disease burden and risk of hypoglycemia [
The management of diabetes is particularly challenging during childhood and adolescence. Day-to-day tasks often involve an entire family. Children show variability in insulin sensitivity related to physical growth and sexual maturation, which requires frequent adjustments in insulin dosing [
Recent advances in diabetes technology have led to the development of automated insulin delivery (AID) systems, also known as hybrid closed-loop, closed-loop, or artificial pancreas systems. In AID, a control algorithm automatically adjusts the insulin delivery of an insulin pump in response to readings from a continuous glucose monitor (CGM) to help improve glycemic levels and variability and reduce the day-to-day burden in diabetes management [
Although commercially developed AID systems have recently become available in select countries, not all are licensed for use by children. Currently, CamAPS FX (CamDiab Ltd) is the only AID system that has received regulatory approval for children aged ≤7 years but is restricted in interoperability and only compatible with one specific CGM and pump model, only available in select European countries, and must be individually purchased on a subscription basis. Young children are often the last cohort to be included in a clinical trial. Off-label use of commercial AID in this group shows only minor time in range (TIR) and HbA1c improvements compared with older individuals, indicating a higher hypoglycemia risk for this age group [
Parents and caregivers of children with diabetes have been in the vanguard of the drive toward AID systems. Under the hashtag
Although evidence based on the clinical outcomes of open-source AID is growing, there are relatively few published studies on the lived experiences of people with diabetes using this technology and fewer still, concerning children and adolescents with diabetes and their caregivers. Previous studies have found improvements in HbA1c and percentage TIR in various age groups, including children and adolescents [
This study aimed to examine four specific, albeit interrelated, aspects of the lived experiences of children and adolescents with diabetes and their caregivers on their journey to becoming open-source AID users: (1) the emotional health implications of open-source AID, (2) the experience of changes to physical health using open-source AID, (3) perceived challenges with the implementation and maintenance of open-source AID, and (4) sources of support during the implementation and maintenance of open-source AID. Self-reported glycemic outcomes and sleep have also been reported to provide further context for lived experience data.
The results were obtained from answers to 2 open-ended questions included in a cross-sectional web-based survey examining the use of open-source AID. The survey titled “DIWHY” was conducted between November 2018 and March 2019 [
Ethics approval was provided by Charité—Universitätsmedizin Berlin (EA2/140/18).
The survey (
The first question inquired about the individual journey of the caregiver and child toward setting up and using an open-source AID system, including sources of information, support, motivation, and emotional impact:
If you would like, please share your personal story about why you decided to build your own artificial pancreas system and how you got started. Feel free to share any experiences that had a significant impact on how you manage your diabetes as well. This story can be as short or as long as you wish.
The second question addressed the perceived changes following the initiation of open-source AID and the challenges experienced:
When reflecting on your personal DIY closed-loop story, you may want to consider the following: When did you first hear about DIY closed-loop systems and how did you look for further information? Were there any key events or experiences that were a factor in your decision to begin closed looping? Was there anyone else involved in helping you come to decision to begin DIY closed-looping? For example a friend, family member or an online support group? What were your emotions in the lead-up to building your DIY closed-loop system? For example, had you any major hopes or fears?
Participants were eligible if they were caregivers of a child or adolescent with diabetes (type 1, 2, or other), using an open-source AID. There were no restrictions on age, time since diagnosis, or commencement of open-source AID.
Participants were recruited using public announcements on the OPEN project website and social media channels, such as the Facebook groups “Looped” (>6000 members) and “AndroidAPS Users” (>1800 members as of November 2018), regional subgroups, and tweets under the hashtags
Data were collected and managed using the REDCap (Research Electronic Data Capture; Vanderbilt University) electronic data capture tools hosted at Charité. Following deidentification of the data set, qualitative analysis was performed using NVivo 12 (QSR International, 2018) software. The narratives were analyzed using an approach based on the principles of Template Analysis [
To test the utility and resonance of the themes as captured in the template, 2 coders (HB and BC) further used the template to analyze the narratives independently of one another. The initial group of coders (KB, CK, and NK) then refined the template based on the coding and feedback provided during this process. A third independent coder (SO) then analyzed the data using the refined template. After this final review of coded responses and the template, it was agreed that code saturation had been achieved, and all major themes were identified.
Retrospective and caregiver-reported clinical outcome data were analyzed within the R (R Foundation for Statistical Computing) programming framework. Only respondents who reported at least one value before and after open-source AID commencement were considered, leading to sample sizes of N=52 and N=36 for HbA1c and TIR, respectively. The HbA1c values were averaged. Moreover, 1-tailed Student
In total, 60 caregivers (35.7% of all 168 participants in the DIWHY study) from 16 countries responded to the open-ended questions on behalf of their children, and there were combined 107 responses to both questions. All children and adolescents were diagnosed with T1D, aged between 3 and 20 years, and using an open-source AID for a duration of <1 month and up to 3 years. The caregiver and child demographics as well as the clinical features of the 60 participants who responded to the open-ended questions are summarized in
Of the 60 children and adolescents, the average HbA1c levels (of participants with reported measures both before and after AID commencement, see Methods section) decreased from 7.0% (SD 0.8; 53 mmol/mol) to 6.3% (SD 0.7; 45 mmol/mol; 1-tailed paired
Children’s and caregivers’ demographic and self-reported clinical characteristics (N=60).
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Children and adolescents | |||
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Female | 26 (43) | ||
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Male | 34 (57) | ||
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Other | 0 (0) | ||
Child’s age (years), mean (SD) | 10.0 (4.5) | |||
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Type 1 | 60 (100) | ||
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Type 2 | 0 (0) | ||
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Other | 0 (0) | ||
Duration of diabetes (years), mean (SD) | 5.3 (4.3) | |||
Duration of open-source AIDa use (months), mean (SD) | 10.9 (9.2) | |||
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AndroidAPS | 28 (47) | ||
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OpenAPS | 21 (35) | ||
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Loop | 17 (28) | ||
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Otherb | 2 (3) | ||
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47 (78) | ||
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Germany | 12 (20) | |
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United Kingdom | 9 (15) | |
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Finland | 7 (12) | |
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Sweden | 5 (8) | |
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Czech Republic | 3 (5) | |
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Spain | 3 (5) | |
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Slovakia | 3 (5) | |
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Othersc | 14 (12) | |
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6 (10) | ||
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United States | 4 (7) | |
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Canada | 2 (3) | |
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South Korea | 3 (5) | |
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Australia | 5 (8) | |
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University degree or diploma | 38 (63) | ||
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Doctorate | 9 (15) | ||
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High school | 8 (13) | ||
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Other | 5 (8) | ||
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Full-time | 39 (65) | ||
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Part-time | 15 (25) | ||
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Unemployed | 3 (5) | ||
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Other | 3 (5) | ||
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<20,000 | 4 (7) | ||
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20,000 to 34,999 | 5 (8) | ||
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35,000 to 49,999 | 4 (7) | ||
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50,000 to 74,999 | 11 (18) | ||
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75,000 to 99,999 | 10 (17) | ||
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>100,000 | 16 (27) | ||
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I would rather not say | 3 (3) | ||
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Not stated | 7 (12) |
aAID: automated insulin delivery.
b“Open loop with AndroidAPS” and “custom development.”
cAustria, Bulgaria, Croatia, and Greece.
Outcomes of open-source automated insulin delivery (AID) implementation. Density distributions of hemoglobin A1c (HbA1c) before and after commencement of open-source AID (line colors); n=52.
Outcomes of open-source automated insulin delivery (AID) implementation. Density distributions of time in range (70-180 mg/dL/3.9-10.0 mmol/L) before and after commencement of open-source AID (line colors); n=36.
A total of 4 topics, “Emotional and Quality of Life Impact,” “Physical Health Impact,” “Challenges,” and “Support” were used to organize the qualitative data, recognizing the fact that participants’ responses were partially primed by the framing of the open-ended questions. The data were subsequently analyzed to generate codes within these topics to expand and illustrate them. The codes are described with examples of illustrative quotes, the number of occurrences, and the respondents’ profiles, as shown in
Final codebook template including deductively (A-D) and inductively (A1-D2) developed codes.
Topic | Occurrencesa, n | Illustrative quote | Respondent profile | |
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Worry and fear (A1): describes difficult emotions such as worry and fear of caregivers related to living with and managing diabetes, experiencing hypoglycemia, and developing long-term complications. It also refers to the concern of not being able to build and maintain the open-source AIDb. | 16 | “I was very skeptical and scared. Over time more information became available and the safety became clear and compelling. We realized we would be safer with a Loop than without. I was scared that others would not be able to comprehend this (because even endocrinologists fail to understand fully the burden and dynamism of type 1) and that they would question whether we were putting our child at risk and make a report about us to child well-being authorities.” | Caregiver of a boy aged 13 years, from Australia; aged 6 years at diagnosis; using Loop for 2.5 years |
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Desperation and frustration (A2): describes feelings of desperation and frustration of caregivers related to living with diabetes and caring for a child with diabetes, diabetes management, and the implementation of the open-source AID. | 14 | “As a mom I was desperate, I was tired from being up all night, I was getting frustrated from teen hormones and I was willing to try almost anything to help both of us.” | Caregiver of a girl aged 17 years, from the United States; aged 2 years at diagnosis; using Loop for 33 months |
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Uncertainty (A3): describes uncertainty and insecurities of caregivers regarding legal grounds, missing regulatory guidelines, and the trust of reliability in an open-source AID system. | 6 | “Nevertheless, there is still a legal uncertainty and at the moment we just dare to use the loop in our own four walls. In the morning we switch to the normal AnyDana A app, in the evening back to AndroidAPS.” | Caregiver of a boy aged 12 years, from Germany; aged 11 years at diagnosis; using OpenAPS for 2 weeks |
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Anticipation, hope, and wishes (A4): describes positive and hopeful emotional states of anticipation and great expectations of caregivers that lie on the AID for improved diabetes management and hope for improved quality of life. Also includes wishes for access to an AID system for everyone. | 24 | “Major driver for the project was to give my son more years without complications by lowering the HbA1cc.” | Caregiver of a boy aged 18 years, from Finland; aged 1 year at diagnosis; using OpenAPS for 1 year |
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Excitement, appreciation, and satisfaction (A5): describes all positive emotions of caregivers and children related to the experience with the open-source AID in daily use including excitement, happiness, satisfaction with the results, and appreciation. | 51 | “I remember the exact place I stood watching the [OpenAPS] log [roll] and seeing the [preflight] was successful and then that the loop was complete. I was in shock that we could do this and that I could afford it and that my child was going to [be] better off because of this. It was a defining moment in my life as a parent. No one could stop me giving my child the care they needed anymore. Especially not a company who places shareholders above clients (which legally they must do). I was no longer at the mercy of markets, profits, politics and whims, I had the capacity to provide for my child again.” | Caregiver of a boy aged 13 years, from Australia; aged 6 years at diagnosis; using Loop for 2.5 years |
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Security and reassurance (A6): relates to caregivers feeling more empowered, more secure, and reassured owing to the use of an open-source AID system, through automation, remote monitoring, and control, as well as experiencing success and observing the success of others using an open-source AID. | 45 | “Our child never woke up if she had a low even though her pump was sounding a very loud alarm. And because she slept in her own room we were afraid of sometimes not hearing the pump alarm either. So Nightscout sounded like the perfect solution, as we could then be woken up by any mobile phone or iPad. This added a lot to our feeling of security.” | Caregiver of a girl aged 10 years, from Finland; aged 7 years at diagnosis; using OpenAPS for 3 months |
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Child empowerment and independence (A7): describes the degree of independence, autonomy, and self-determination in children and adolescents using the open-source AID, enabling them to participate in daily life and social activities in a responsible and self-determined way. | 25 | “Daughter can work without having to phone me for advice. She has been on holiday [for the] first time without parents. She[...] now feels confident to consider leaving home.” | Caregiver of a girl aged 20 years, from Croatia; aged 10 years at diagnosis; using OpenAPS for 3 months |
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Glycemic outcome improvement (B1): refers to improved time in range and HbA1c levels, less glucose variability, fewer hypo- and hyperglycemic events, and reduced long-term complication risk. | 36 | “Every single morning she’s in range. If at night she’s not, we know that by the morning she will be, and she [will get] there safely. It’s really good.” | Caregiver of a girl aged 18 years, from the United Kingdom; aged 11 years at diagnosis; using AndroidAPS for 8 months |
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Quality of life improvement (B2): refers to the mentioned improvements of quality of life and describes the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events. | 14 | “I keep a continuous discussion with my twins that both use DIY closed loops, through texting. I use this way to share my remote observations on their status, while they concentrate on their university studies, or simply enjoy their lives. I inform them this way about a failing connection, a reservoir getting empty, a battery needing charging, or to drink some juice to avoid a coming low.” | Caregiver of a boy, aged 20 years, from Greece; aged 2 years at diagnosis; using OpenAPS for 1 year |
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Improved sleep (B3): denotes all aspects of improved sleep quality for either caregivers or children such as increased sleep duration, fewer sleep interruptions, and feeling better rested in the morning. | 40 | “It’s been as good as expected, and better still as now we sleep. You forget how much sleep deprivation clouds your judgment.” | Caregiver of a boy aged 8 years, from the United Kingdom; aged 7 years at diagnosis; using AndroidAPS for 3 months |
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Facilitated diabetes management (B4): relates to the simplifications of the individual diabetes management due to the open-source AID, such as fewer interactions with the technology or between caregiver and child; for example, through remote control and automation. It also includes the age-appropriate transfer of responsibilities from caregivers to adolescents to self-manage diabetes therapy. | 42 | “There is no comparison with earlier. There used to be 5-6 blood measurements per child per day, and that was all. With or without a pump, every meal was a challenge. For 1.5 years, the APS has been adjusting the blood sugar value after the bolus, adding more insulin if the value increases, or adjusting the delivery if the value drops.” | Caregiver of a boy aged 20 years, from Greece; aged 1 year at diagnosis; using OpenAPS for 17 months |
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Access to technology (C1): relates to the issue concerning obtaining access to the component parts of an open-source AID system, such as loopable pumps and supplies, CGMd, and additional required hardware. | 27 | “Getting the hardware was most frustrating. I tried to buy the hardware from the manufacturer but in Sweden you could not do that without a subscription from your doctor. I ended up getting a second hand Dana R pump from another patient who upgraded to a newer pump.” | Caregiver of a boy aged 3.5 years, from Sweden; aged 2 years at diagnosis; using AndroidAPS for 4 months |
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Out-of-pocket expenses (C2): describes barriers regarding out-of-pocket expenses and cost for the hardware and supplies related to insurance coverage, household income, and other financial challenges in access. | 6 | “We were concerned about the cost of sensors. They are not covered by private health here and it cost approximately US $5000 a year when we started. Now kids are covered, but when they turn 21 that ends. We are still worried about covering that bill in the future.” | Caregiver of a boy aged 13 years, from Australia; aged 6 years at diagnosis; using Loop for 2.5 years |
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Self-perceived lack of technical skills (C3): denotes the issue of yet self-perceived limited knowledge and missing technical skills caregivers are experiencing to set up open-source AID initially. | 9 | “Major fears I wouldn't be able to understand the technology.” | Caregiver of a girl aged 12 years, from Australia; aged 11 years at diagnosis; using Loop for 1 month |
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Lacking health care provider support (C4): relates to instances where caregivers reflect upon their children’s health care providers’ lack of support and negative attitudes. | 14 | “Fight with our own diabetologist to get a DANA RS prescribed. Although we didn’t talk openly about looping, she has repeatedly emphasized that we only want the DANA RS pump for looping, which is not allowed. We have won, but now hide the loop, which cannot be a permanent state. We need medical care in which we can communicate openly.” | Caregiver of a boy aged 12 years, from Germany; aged 11 years at diagnosis; using AndroidAPS for 2 weeks |
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Impracticability of carrying additional devices (C5): relates to the necessity for children and adolescents having to carry additional devices for open-source AID and protect them from breaking. | 9 | “It also meant that our daughter had to carry an extra item, i.e. the mini-computer, with her during the day.” | Caregiver of a girl aged 10 years, from Finland; aged 4 years at diagnosis; using OpenAPS for 2 months |
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Transition from childhood to adulthood (C6): describes challenges associated with the transition from childhood to adulthood, regarding physical and hormone-related changes during puberty and psychosocial challenges in adolescents living with T1De and taking over responsibility for their own therapy with an open-source AID. | 10 | “While our control has improved, it is still significantly more variable than I would expect based on the results I see from others in the community. My son is highly insulin sensitive [...], variable in his activity level and intensity [...], and experiencing substantial swings in carb ratios, basal rates, and insulin sensitivities as he is going through great physiological changes in puberty.” | Caregiver of a boy aged 11 years, from the United States; aged 8 years at diagnosis; using OpenAPS for 1 year |
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Setup and maintenance effort (C7): relates to difficulties caregivers experience while setting up open-source AID. This includes an unexpected high time effort and multiple throwbacks while initially setting up the system, technical difficulties with running and maintaining the system, and fine-tuning to find the right settings and parameters to accomplish desired results. | 54 | “As a family, we feel very happy that we can finally control the blood sugar levels of our children in the desired area, even if it takes great care to do everything right. Batteries (pump, CGM, mobile phone, OpenAPS computer) must be regularly charged or exchanged, the CGM must be continuously calibrated, insulin must be refilled, every 3 days you exchange the catheter, every 14 days the CGM, etc. With such a result, no problem. The hundreds of hours I've spent on it are worth it.” | Caregiver of a boy aged 20 years, from Greece; aged 1 year at diagnosis; using OpenAPS for 17 months |
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Community peer support (D1): includes actively received or provided community peer support. This support could either be provided on the web through social media groups and communities or in person through life events, individual people, or meet-ups. Does not include individual key people or role models. | 45 | “So in that same Facebook group I started to learn about DIY artificial pa[n]creases and I joined another, international group called Looped to learn more. I then asked around and I was told that OpenAPS was the most advanced of the three options and decided to go for that.” | Caregiver of a girl aged 10 years, from Finland; aged 7 years at diagnosis; using OpenAPS for 9 months |
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Individuals as role models (D2): describes one or multiple key people, often members of the #WeAreNotWaiting community, who inspired or directly supported caregivers and children in building an open-source AID. | 15 | “I found Tim Street’s Diabettech website and started following him on twitter/blog at [the] same time. He was coming to speak at a medical conference in Edinburgh and was going to a [type 1] meet up. I gate-crashed the meet in the pub and had to wait until the end[...] I asked him to show me his pancreas! [...] Tim organized the first U.K. meet up in London and offered me an old transmitter which would complete my build. My son and I flew to London and we got going that evening.” | Caregiver of a boy aged 12 years, from the United Kingdom; aged 8 years at diagnosis; using OpenAPS |
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Web-based resources (D3): describes web-based resources such as wiki blogs, tutorials, websites, webinars, and other documentation. | 19 | “Once I had the equipment, I set the system up in two nights, the instructions available on the web are very clear and I found it easier tha[n] expected.” | Caregiver of a girl aged 10 years, from Finland aged 6 years at diagnosis; using OpenAPS for 3 months |
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Health care professionals (D4): this code refers to the support provided by health care professionals, such as pediatricians, endocrinologists, and other members of the diabetes teams, including help with setup, access to components, and fine-tuning of settings. | 8 | “Endocrinologist was supportive even though legally couldn’t recommend it.” | Caregiver of a girl aged 12 years, from Australia; aged 11 years at diagnosis; using Loop for 1 month |
aDefined by the number of codes assigned to a text segment.
bAID: automated insulin delivery.
cHbA1c: hemoglobin A1c.
dCGM: continuous glucose monitor.
eT1D: type 1 diabetes.
For respondents, experiences with the initiation of open-source AID were associated with a range of emotions, from worry, despair, and great hopes before use, to excitement, relief, and a feeling of empowerment after implementing the system. Caregivers in the sample expressed concerns when opting to choose an open-source AID, but it also highlights the deep-rooted frustration and dissatisfaction with commercially available solutions for diabetes management. Therefore, choosing to opt for an open-source AID was never a decision taken lightly but at the point when all other options appeared inadequate and insufficient.
Once the choice was made, quality of life improvements and reductions in the burden of diabetes management were frequently mentioned. With the automation of insulin delivery, families could reboot everyday life without diabetes management being constantly the center of attention, empowering children and caregivers to experience more freedom and flexibility:
Now we plan for things in our lives. We have been thinking of getting a pet, [and have] started to remodel our house. [We] made sure both kids have passports because now it feels like we actually can travel and show them the world.
The option to remotely follow and control glycemic levels, treatments, and insulin delivery via Nightscout reassured caregivers was specifically mentioned as a reason to choose open-source AID. Caregivers experienced fewer worries about their children experiencing hypoglycemia at night or away from home, which led to greater independence, empowerment, and age-appropriate participation of children in their own treatment.
The complexity of the implementation process of open-source AID raised concerns among some of the respondents, who were initially worried about not being able to manage the technical setup on their own. Uncertainties regarding the safety of new and unfamiliar therapies have also been mentioned. Furthermore, they were unsure whether the new treatment would be accepted by their children’s health care team as well as their wider social environment. In addition, some expressed the need for regulatory approval and improved access to AID for everyone:
I wonder how it can be that such a development is not already established? Why does it take so long? Do the old systems have to be remunerated? The loopers show how it works, how can it be that with so much added value, the professional institutions are still so lethargic?
Overall, caregivers described the transition to open-source AID as a predominantly positive experience for the entire family. They were highly satisfied with the outcomes and benefits for their children’s emotional and physical health and perceived open-source AID as the best therapy option available:
If I could give my pancreas to my son, I would. This is the next best available option.
Improvements in glycemia, such as improvements in HbA1c and TIR levels, as well as less hypoglycemia and fewer glucose fluctuations, have been extensively described:
Every single morning she's in range. If at night she's not we know that by the morning she will be, and she [will get] there safely.
In addition to diabetes-related health improvements, better sleep quality was frequently highlighted by the respondents. Before using an open-source AID, many caregivers were not able to sleep through the night as they were concerned with nighttime hypoglycemia or the administration of correction doses of insulin, poor sleep, and reduced quality of life. With an open-source AID, they were released from frequent check-ups and the associated emotional pressure:
We were waking at 11 pm, 2 am, 5 am, etc to manually [blood glucose] check our daughter. We haven't done that in years. I was having seizures from almost 5 years of not sleeping more than a couple [of] hours at [a] time. Now, we all sleep all night.
Even in cases with little improvement in glycemic outcomes, where HbA1c and TIR levels were in or close to the recommended targets before the initiation of open-source AID, caregivers noted that the amount of effort required to achieve these results was significantly diminished. As this point highlights, the data repeatedly pointed to the ways in which physical outcomes are inextricably intertwined with emotional outcomes when considering diabetes management.
Difficulties in accessing compatible hardware have frequently been reported. This was mainly associated with differences in the availability of insulin pumps and sensors and reimbursement policies among countries and also with out-of-pocket expenses. Some participants raised concerns regarding access to components and financial aspects of maintaining their open-source AID system in the future:
We were concerned about the cost of sensors. They are not covered by private health here and it cost approximately US[D] 5000 a year when we started. Now, kids are covered, but when they turn 21 that ends. We are still worried about covering that bill in the future.
Understanding the documentation and initial setup process is time consuming and challenging, especially for caregivers with little pre-existing knowledge in technology. Ultimately, the complex setup procedure led to a better understanding of the functionalities of open-source AID, enabling caregivers to better respond to technical issues when they occurred. Being part of the
Once the setup was successfully managed, the next perceived challenge was the iterative determination of the appropriate settings and therapy parameters to generate satisfactory results. This “fine-tuning” was described as requiring considerable time and endurance. The need to carry around additional devices (eg, a microcontroller or bridge device to remotely communicate between the phone and insulin pump) poses further practical challenges for children in daily life.
The attitudes of HCPs involved in diabetes care of children were described as mixed, ranging from proactive support to refusal:
After detailed research, the reserved position of our center could not stop us either. In the past year, I have repeatedly had the impression of knowing more about the disease and the possible forms of therapy than the doctors at our center.
Despite these reported clinical and quality of life improvements, some expressed uncertainty arising from a lack of support from health care providers. Consequently, a family decided not to disclose the use of open-source AID to their health care team, which caused feelings of isolation, disappointment, and misunderstanding:
Although we didn't talk openly about looping, [our diabetologist] has repeatedly emphasized that we only want the DANA RS pump for looping. [...] We[...] now hide the loop, which cannot be a permanent state. We need medical care in which we can communicate openly.
Participants frequently approached the
So in that same Facebook group I started to learn about DIY artificial pa[n]creases and I joined another, international group called Looped to learn more. I then asked around and I was told that OpenAPS was the most advanced of the 3 options and decided to go for that.
Besides the peer support caregivers found on the web, they attended in-person meetings and local meet-ups with members of the community. Lectures, workshops, and public presentations of open-source AID developers, researchers, and other users and parents enhanced their motivation to start their own journey toward open-source AID. Key individuals who were integral in the development of open-source AID are personally named on a number of occasions. The perceived integrity and altruism of these individuals were also key in creating a sense of confidence and trust in the systems:
I found Tim Street's Diabettech website and started following him on Twitter [...]. He was coming to speak at a medical conference in Edinburgh and was going to a [type 1] meet up. I gate-crashed the meet in the pub and had to wait until the end[...] I asked him to show me his pancreas! [...] My son and I flew to London and we got going that evening.
Although HCPs could not prescribe open-source AID systems owing to the absence of regulatory approvals, some were very supportive of the children’s and caregivers’ decision to use open-source AID. Support by HCPs has mostly been reported regarding access to compatible components, such as specific insulin pumps and CGM types that are prescriptible. In a small number of cases, individual caregivers reported that their health care provider initiated a discussion about open-source AID and directed them to relevant sources of information. Conversely, a lack of support from HCPs was also articulated in a number of accounts, although this usually took the form of “turning a blind eye” and passivity, and very few reported being actively opposed by their health care provider. Where such cases did occur, it usually took the form of preventing caregivers from acquiring the hardware needed to set up an open-source AID system.
In this qualitative analysis, we described the emotional and physical health impact of open-source AID use in children or adolescents and their caregivers, as well as their perceived challenges and sources of support.
Overall, caregivers reported a range of emotions before and after the initiation of open-source AID use. Before initiation, for example, participants reported frustration and dissatisfaction with their existing diabetes management solutions and anticipation and excitement—sometimes marked with anxiety and trepidation—at the prospect of using an open-source AID. Likewise, the experience of using open-source AID evoked both great joy and relief, but this was also tinged, for some, with frustration and worry. Improvements in children’s diabetes management, glycemic outcomes, physical health beyond diabetes, and emotional well-being were highlighted in the narratives. Furthermore, sleep quality and quality of life improved for both children and caregivers. The initial challenges were difficulties in accessing the required components, lack of confidence in technical skills for setup and maintenance, concerns about the response from health care teams, and the wider social environment of the family. Later, finding and “fine-tuning” of the right therapy settings, as well as the impracticality of carrying additional devices for the children, were described. The
This study can inform stakeholders regarding the unmet needs of children and adolescents with T1D regarding the therapeutic options available to them. Furthermore, our findings highlight how children might benefit from customizable open-source AID systems where commercial options are not accessible, approved for certain age groups, or limited in their functionality to cover the lower and variable insulin requirements of children.
The ethical and legal aspects of the off-label use of unregulated medical devices in children and adolescents are multifaceted and complex. Although the off-label use of pharmaceuticals is both common practice and a necessity in pediatrics, it is still uncommon in medical devices. HCPs were sometimes perceived to be reticent in their support of the decision to use open-source AID. This reticence is understandable given that many HCPs, as indicated by the caregivers in this study, had very little knowledge of the systems and uncertainty regarding what legal ramifications there might be in providing support for a system not approved by regulatory bodies. Following a number of position papers from several local diabetes organizations, a group of international HCPs recently provided an international consensus statement for practical guidance on the safe and ethical use of open-source in clinical settings [
Although there are numerous studies about the clinical outcomes of the use of open-source and commercially available AID systems in adults and children [
This study has several strengths and limitations. Of particular strength is its patient and public involvement in the study design process and its multinational scope. Limitations include that the anonymous study design did not allow participants to follow up for clarification or further questions, to strictly follow the General Data Protection Regulation guidelines. A selection bias may be present with the survey only being available in German and English, which may have excluded users not proficient in these languages in the first place. Furthermore, those within the sample might not have responded in detail, or not at all, to the open-ended questions owing to language barriers among other factors. In addition, a significant proportion of the OPEN team was German, with strong links to the German diabetes community; therefore, the teams’ ability to reach people was particularly high in that country. Finally, the challenges in building and setting up an open-source AID had to be overcome by caregivers with perseverance and self-motivation in the first place, potentially resulting in a selected population that limits broad generalizations to all people with diabetes.
With frequent changes in insulin requirements, glycemic variability due to counterregulatory hormones, and physical activity, children are ideal candidates for AID. Although the uptake of insulin pumps and CGM is high among children in countries where access to diabetes technology is facilitated, the uptake of AID in children is protracted owing to the license status of commercially available AID systems. However, their efficacy in young children and those with low insulin requirements remains limited. Furthermore, glycemic outcome improvements in the off-label use of commercial AID systems by very young children are suboptimal, although they experience similar glycemic improvements as older children, adolescents, and adults with commercial systems approved for their age [
Similar to commercial AID systems, there remains much room for improvement in open-source AID systems, and further research is needed to improve the effectiveness of algorithms and usability of AID systems in general, particularly in young children where approved therapy options remain limited. To achieve this, concerted efforts are required using a multi-stakeholder approach, an approach in which the diverse and valuable experiences of caregivers and children who have opted to move into the vanguard of AID need to be heard and appreciated.
Questionnaires for caregivers of children and adolescents with diabetes, using open-source automated insulin delivery.
Demographic and clinical characteristics of participants of the DIWHY study who have not responded to any of the open-ended questions.
automated insulin delivery
continuous glucose monitor
Checklist for Reporting Results of Internet E-Surveys
hemoglobin A1c
health care professional
Outcomes of Patients’ Evidence with Novel, Do-it-Yourself Artificial Pancreas Technology
Research Electronic Data Capture
type 1 diabetes
time in range
The authors would like to thank the members of the
The authors acknowledge the support of Dana Lewis, developer of OpenAPS, and Adrian Tappe, developer of AndroidAPS, for the study design. We further acknowledge the support of Dr Henriette Langstrup as mentor for the interpretation and discussion of the findings of this study.
The authors acknowledge support from the German Research Foundation and the Open Access Publication Fund of Charité—Universitätsmedizin Berlin.
KB received fees for medical consulting and public speaking from Roche Diabetes Care, Dexcom, Medtronic Diabetes, Diabeloop, Novo Nordisk, Sanofi Diabetes, Diabetes Center Berne, Abbott and BCG Digital Ventures; outside the submitted work. KR received fees for medical consulting and public speaking from Dexcom, Abbott, Lilly Diabetes Care, Novo Nordisk (Germany), and Springer Healthcare United Kingdom; outside the submitted work.
KR received fees for medical consulting and public speaking from Dexcom, Abbott, Lilly Diabetes Care, Novo Nordisk (Germany), and Springer Healthcare United Kingdom; outside the submitted work.