Can Glucose Alarm Fatigue Threaten the Absolute Clinical Benefit of Continuous Glucose Monitoring in Optimal Glucose Management in Children and Adolescents with Type 1 Diabetes? A Narrative Review.

1. Introduction

Technology has brought about a revolution in the management of type 1 diabetes (T1D). The adoption of continuous glucose monitoring (CGM) and insulin pump therapy in the everyday life of children and adolescents with T1D is a real innovation and the most promising choice for optimizing glycemic control in this population [1,2].

The mission of CGM is to provide a measurement of interstitial glucose levels. It is offered not only as a single value but also as a short-term trend, long-term tracking, and daily pattern. In other words, it serves as a real-time (RT) glucose level detector, including not only the most commonly used RT-CGM systems (Dexcom San Diego, CA, USA, Metdronic Northridge, CA, USA) but also the flash CGM system, FreeStyle Libre 2 (Abbott Diabetes Care). Last one also functions as an RT-CGM system after the recent upgrade of its smartphone application. The only difference remains the prerequisite of scanning the sensor in order to obtain data [1,3]. It becomes evident that the knowledge of glucose levels at every single moment facilitates clinical decisions and makes them more targeted and optimal in avoiding hypoglycemia and hyperglycemia, and achieving good metabolic control. A lot of clinical [4,5] and real-world studies [6], as well as systematic reviews and meta-analyses [7,8], have clearly proven the beneficial effect of CGM on glycemic control optimization. Targeting further improvement in the context of glycemia and safety, CGM systems incorporated RT alarms, alerts, and notifications with the marketing of Guardian (Medtronic, Minneapolis, MN, USA) and STS™ (Dexcom) in the mid-2000s [9].

In parallel, the evolution of the insulin pump came to enhance the effect of CGM on metabolic control, with the hybrid closed loop (HCL) being the most promising entry in diabetes technology, implementing the communication of CGM with the insulin pump in clinical practice. There is an increasing number of studies underlining the increase in time in range (TIR) without a concomitant increase in time below range (TBR) among users [10,11,12,13,14]. Insulin pump as a stand-alone device is designed to have safety notifications, but, as a sensor-augmented or HCL system, its functionality was upgraded with certain alarms, intending to warn patients about detected changes in glucose levels or events expected to negatively affect their health status [15].

Although the whole alarm system keeps a leading role in glucose management, alarm fatigue has been increasingly and inevitably recorded among diabetes technology users. Alarm fatigue is defined as the situation of inappropriate responsiveness to warnings or complete deactivation of them after a period of frequent exposure to false or unnecessary alarms. Such a phenomenon declines trust in the CGM or insulin pump and puts at risk the subsequent utilization of the device. It is an expression of burnout, as receiving a great number of notifications, of which some are proven to be false, may be stressful and exhausting [16]. An alert is really meaningful if the user is educated on the significance and utilization of the information provided and responds properly. Otherwise, lack of knowledge predisposes the individual to alarm fatigue.

In this narrative review of the literature published since the early 2000s, we aimed to briefly present the basic philosophy of the existing CGM alarm systems and their positive effect on glycemic management and focus on alarm fatigue: definition, frequency, effect on quality of life (QoL) and sleep, not only of T1D pediatric patients but also of their families, and methods of elimination. We will focus not only on CGM and insulin pumps used independently, but also as part of HCL systems. There is a narrative review [17] on the benefits of a diabetes alarm system, but only scarce and scattered data on alarm fatigue, negatively affecting glycemic control, QoL and sleep of T1D pediatric patients and their parents.

An alarm system can concern CGM, an insulin pump or an HCL system and can be categorized in the following four groups: (1) CGM threshold that sends a notification when glucose levels rise above or fall below a value set by the user, necessitating an action, CGM predictive, based on specific algorithms, activated before hypoglycemia or hyperglycemia occurs and giving time for preventive measures and CGM velocity rate, released in case of increased velocity of glucose level change, (2) CGM maintenance to ensure proper system operation (calibration, lost sensor, expired sensor, change sensor, sensor error, weak signal, low transmitter battery and transmitter failure), (3) HCL system-specific (auto mode exit, auto mode sensor integrity failure, basal delivery resumption, maximum suspension, blood glucose required, open loop and calibration required for closed loop), and (4) insulin pump-specific (active temporary basal rate, suspension, low battery, battery out and low reservoir). Similarly, to the HCL system, in the case of the paired use of a connected insulin pen and CGM, there are notifications for missed or correction doses [9,16,18].

It is useful to understand the differences between alarms, informing oneself about an immediate issue that needs an urgent action related to medication or diet, and an alert warning about an upcoming risk situation where a safe action must be taken. Users are notified by sound or vibration with a varying repetition interval and an option for delay [3]. Reliability, validity, timeliness and perceptibility are the prerequisites for an alarm system to be successful [15].

The mission of the diabetes alarm system is to warn one about out-of-range glucose levels and upcoming hypoglycemia or hyperglycemia, or notify users about technical issues. Informing users about glycemic events before or when they happen gives them the opportunity to understand their glucose level daily pattern and take action in order to attain euglycemia. Alarms serve as an additional valuable tool for optimizing glycemic management, reducing the incidence and severity of acute hypoglycemia and hyperglycemia, particularly among users who are not up to date on their glucose profile [16,18].

Besides protecting against hypoglycemia, it attains glycemic control, while hyperglycemia alerts have proven to reduce time above range (TAR) and decrease average glucose. The combined result is a decrease in glycemic variability and an increase in TIR [19,20,21,22]. Use of these alerts to adjust insulin delivery has the potential to improve glycated hemoglobin (HbA1c) [22].

Indeed, only the adaptation of a predictive hypoglycemia alert provided additional benefits over traditional low-threshold alerts, as TBR < 54 mg/dL, <70 mg/dL and TAR > 250 mg/dL decreased significantly regardless of the low-threshold alert setting [23]. Furthermore, in a prospective, observational study involving 47 children and adolescents with T1D, the possibility of optional alarms transitioning from FreeStyle Libre to FreeStyle Libre 2 for 14 days led to an increase in TIR and reductions in TAR, number of weekly hypoglycemic events and coefficient of variation [24].

The introduction of glucose alarms adds to the optimal glucose management and offers a sense of reassurance and safety [21,25,26]. Parents and young people report protection against hypoglycemic episodes as the primary cause of such feelings [25], while caregivers of children and adolescents using CGM find alarms useful in understanding the trending direction of glucose levels [27]. In the school environment, caregivers, teachers or school nurses consider an alarm system as a tool that simplifies glycemic management [22]. Accuracy improvement and the optional alarm feature of new-generation CGM systems can be rather useful for the adoption of this technology in the daily life of the pediatric population with T1D [28]. With the development of the HCL system, alarms ensure patients can take the minimal action necessary to maintain the optimal operation of the system, and manually control their glucose level in the presence of technical issues [9]. Furthermore, they are particularly useful for overnight management, as interruptions from alarms are fewer due to fewer glycemic events [29].

One of the main problems is alarm fatigue, which occurs due to too many and maybe false notifications that reduce the responsiveness of users to them. Another challenge is the embarrassment caused by notifications at an inappropriate time that produce a sense of loss of privacy [3]. Furthermore, children and adolescents, as well as their parents, were found to become upset with alerts, overtreating hypoglycemia with carbohydrates, even in the case of sensor-augmented insulin pumps. Such a reaction caused post-hypo peaks and threatened optimal glycemic control [30].

2. Materials and Methods

A comprehensive search was conducted on the PubMed/Medline database to identify relevant studies on the phenomenon of alarm fatigue in T1D children and adolescents and their parents and caregivers using one or more diabetes technology devices: CGM, insulin pump or HCL system. The literature search referred to manuscripts published between 1 January 2000 and 30 September 2025 using the following terms: “alarm fatigue”, “alarm frustration”, “alarm distress”, “device fatigue”, “technology fatigue”, “alert fatigue”, “notification fatigue”, “diabetes”, “glucose”, “CGM”, “insulin pump” and “HCL”. Exclusion criteria were articles with a non-English publication language, type 2 diabetes, exclusively adult population, clinical case reports, case series, editorials and letters to the editors. Studies including children and adolescents or parents/caregivers, observational and qualitative studies were included. The titles and abstracts of the retrieved manuscripts were scanned for relevance. Full-text articles of all the relevant studies were retrieved and reviewed. Comprehensive, narrative and systematic reviews were not included but used for the critical appraisal of studies included.

3. Results

The initial literature search identified 1496 records, of which 915 were excluded as duplicates. Among the 581 reports that were retrieved, 540 were excluded as irrelevant, and 11 were excluded for reasons presented in detail in the screening flowchart. In the end, 30 articles were included in this narrative review (Figure 1). Table 1 presents the basic characteristics of the included studies and parameters recorded.

Studies recorded the impact of alarm fatigue among patients [18,29,31,33,34,36,43,44,45,47,49,53,55], their parents [22,27,32,35,38,42,46,50] or both [25,37,39,40,41,48,51,52,54]. Most of them were based either on an interview [25,29,31,35,38,42,46,51,52] or a questionnaire [27,32,33,34,37,39,41,43,54,55] and a few on CGM data [18,36,44,45,47,53]. The main studied parameters were quality of sleep [18,25,27,29,31,32,33,34,35,36,37,38,40,41,42,44,48,49,50,51] and QoL [22,25,29,31,33,34,37,39,41,43,45,46,49,51,52]. There were two studies being conducted with parental sleep [48] and QoL [42]. Frequency of alarm fatigue is either not recorded [22,25,29,31,32,33,34,35,36,37,38,50,51,52,53,54] or estimated in a rather variable way. Some studies aimed to detect alarm fatigue directly [18,27,40,41,42,46,48], while others used diabetes technology discontinuation percentage as an indirect estimation tool [39,43,47,49,55]. The frequency varied significantly from zero in a few studies that have not detected alarm fatigue at all [4,42,46] to 26–50% [18,39,41], while discontinuation percentage varied from 12 to 62% [39,43,45,49,55]. In the only study [48] that estimated parental sleep, alarm fatigue frequency was rather high (60%). However, not only the studies that have not detected alarm fatigue [4,42,46] but also those that recorded this phenomenon have identified the benefits of diabetes technology and more of CGM on glycemic control [22,25,29,31,34,47,52], hypoglycemia prevention and management [31,32,33,39,40,41,46,47,48,49,50,51,52,53,54], thus reducing the fear of hypoglycemia [39,40,41,46]. Although some studies detected the phenomenon of alarm fatigue, they underlined a positive effect on general well-being [29,31,32,33,34,37,46] and sleep [27,29,34,35,38,42,46].

The main reasons responsible for alarm fatigue concerned either everyday life [22,25,29,31,33,34,37,39,41,43,45,46,49,51,52] or sleep [18,25,27,29,31,32,33,34,35,36,37,38,40,41,42,44,48,49,50,51] and were provoked mainly by too many false alarms [22,47,49,54], although qualitative studies based on interviews also revealed factors that affected patients’ social well-being. Table 2 presents the main causes of alarm fatigue.

4. Discussion

As it was previously mentioned, alarm fatigue is the situation of reduced or absent responsiveness due to frequent false or unnecessary alarms, declining trust and long-term utilization of diabetes devices [16]. The concept of alarm fatigue can also include alarm embarrassment, an issue particularly affecting adolescents. It describes the negative feeling of loss of privacy experienced when users become the center of attention due to many alarms, and may also compromise further wearing a diabetes device. It is a kind of stigma produced when alerts go off in schools or social events [3]. Furthermore, too many alarms can produce disappointment, especially for users with sub-optimal self-management behaviors and/or a high HbA1c. They remind these patients of their diabetes diagnosis and imply a personal failure to achieve optimal blood glucose control [25]. In other words, there is a cycle of frustration, disappointment and embarrassment, leading to reduced adherence and maybe to discontinuation [26]. The patients discontinuing CGM as a result of alarm fatigue cannot take advantage of their beneficial effect on glycemic control [56,57].

The high frequency of alarms increases the potential of fatigue [9,16]. It is not known how CGM alarm settings are associated with the number of alarms, and whether the alarm frequency alters patients’ responses and, as a result, is associated with alarm fatigue [21]. The quantity of alarms may depend on a number of factors, including how often glucose is desirable to be checked, the glucose variability, the awareness of hypoglycemia and the level of low threshold alarm, considering that the higher the alarm is set, the more alarms occur [16,21].

The average number of CGM alarms notifying pediatric users and their parents or caregivers is not known. Interdependently of it, a CGM user may perform from 15 to 48 glucose level checks a day [58], with the upper limit being approached in younger children due to the frequent and great fluctuations in blood glucose and the difficulty in recognizing or reporting symptoms of hypo- or hyperglycaemia [59,60].

A frequent cause of nuisance regarding hypoglycemia alarms, further predisposing users to alarm fatigue, is compression artifacts, caused by a decrease in glucose concentration in the interstitial fluid near the sensor tip when the CGM user sleeps on the CGM sensor [36].

It is not only the high frequency but also the sub-optimal accuracy of alerts that predispose to alarm fatigue and cause reduced adherence. Many alarms sound when glucose is already out of range, and some of them may be false or unnecessary [9,16]. Users feel overwhelmed and fatigued with the constant interruptions and tend to become unresponsive. As a result, alarms lose their urgent character [16,18].

It seems that alarm fatigue is caused by an imbalance between the sensitivity and specificity of CGM systems, as there is an inverse relationship between sensitivity and specificity [61]. Nowadays, some clinicians choose to counsel CGM users to set extremely low or high values as hypoglycemia and hyperglycemia alarm thresholds, respectively, in order to minimize early “nuisance alarms” [62,63]. On the other hand, there are clinicians who educate patients to choose a rather high hypoglycemia threshold as useful to detect and predict more hypoglycemic events [64,65]. The first approach favors specificity at the expense of sensitivity, while the second one promotes alarm fatigue by increasing sensitivity, allowing for more alarms that may be false. Such phenomena question the accuracy and credibility of CGM and make patients less reactive to alarms and less willing to retain them activated or even continue to use CGM [43,55]. In the same context, a too low threshold for hyperglycemia, intending to improve glycemic control, increases the risk of alarm fatigue [15]. However, retrospective studies of TITR do not support concerns that its use in clinical practice may contribute to alarm fatigue [66]. Scheinker et al. [53] found that hypothetical TITR alarms would trigger between 22% and 41% more frequently than TIR alarms. However, the use of robust TITR alarms, set to trigger on the basis of three consecutive readings below the threshold followed by three consecutive readings above the threshold, mitigated the increase in alarm frequency.

Decoding CGM alarms is not a black-or-white choice. The discrepancy between a low threshold alarm intended to prevent hypoglycaemia, more so when glucose is descending, and those requiring treatment, produces inconvenience and may be a cause of alarm fatigue, as there is a need for self monitoring blood glucose (SMBG) tests to confirm them [22].

Alarm fatigue is rather frequent. In an anonymous survey among parents and caregivers of children with T1D using CGM, approximately 25% admitted that they remained unresponsive when the CGM alarms went off repeatedly, with potential poor outcomes for their children [59]. Among 85 children and adolescents between 5 and 18 years old with T1D, alarm fatigue was found to be the main reason for discontinuing CGM [43], or at least one of the reasons [32,67]. Even adolescent HCL users reported frustration around the number of alarms and notifications associated with the system [52]. “Alarms” was reported by 40% of pediatric HCL users as the third most common issue and recorded as a cause of HCL discontinuation [49]. If patients feel that the increased mental burden of responding to frequent notifications and alarms is too much, it could be a barrier to the adoption of this new technology [37,68]. In a study, among CGM ex-users, 50% reported too many alarms as the cause of CGM discontinuation. It is a matter of trust in the device to reassure continuing utilization [43]. Some patients reported anxiety in response to the notifications and occasionally disabled the hyperglycemia alarms to avoid discomfort from constant alerts [69].

Some T1D patients believe that alarms may disrupt their daily life. About 40% of parents and caregivers of children with T1D using CGM reported the CGM device as a source of nervousness for them [59]. Interference in daily life was recorded among 38% of pediatric CGM users [39]. Alarms being released at inconvenient times draw attention to young users, producing embarrassment [51].

There are also many negative comments about alarms being annoying, as well as a life “living by alarms” [27]. Furthermore, they may promote a perception that CGM users lead a life dominated and dictated by their diabetes, with the alarms acting as reminders of their continuing struggle to cope with diabetes and achieve optimal glycemic control [25]. Alarms may produce unwelcome distractions at school, with many children reportedly switching alarms off in school due to concerns about drawing attention to themselves and distracting peers [22].

However, alarm fatigue is not a one-way potential for CGM users. As the integration of alarms into CGM systems improves, metabolic control can be achieved in the short term, without worsening the duration and quality of sleep, measured by actigraphy, not only in children and adolescents but also in their parents [24].

Alarm fatigue can be expressed as nighttime sleep disruption not only for T1D children and adolescents but also for their families [24,25,41,70]. The transition from the SMBG to CGM did not protect T1D children and adolescents and their families from waking up multiple times during the night due to their CGM alarms. It is not only the fear of hypoglycemia but also caution about correction boluses overnight that disturbs sleep [59].

However, nocturnal hypoglycemia deserves special attention due to the urgency of coping with it, as it is reasonable for diabetes technology device users and their parents to be less willing to respond to alarms during the night and, as a result, more vulnerable to alarm fatigue. Parents and caregivers can be awakened many times during the night to administer insulin or provide carbohydrates for repetitive high or low glucose levels, respectively. Utilizing the 0–3 scale for the seven subscales of the Pittsburgh Sleep Quality Index, with 0 being the best and 3 being the worst, over 50% of parents and caregivers of children with T1D using CGM scored a 2 or 3 on the sleep disturbance subscale. About 70% of them scaled their sleep quality as fairly bad or very bad. It is interesting that 30% of caregivers worried they would incorrectly set alarm limits on the CGM device at night [59]. In a qualitative study, caregivers of minors with T1D reported waking frequently to check CGM, while several ones confessed that they additionally set clock alarms to make sure that their child’s glucose was in range, despite having a CGM system, revealing a deficiency of trust in CGM alarms, not fulfilling their mission [71].

In another study, disrupted sleep was commonly reported, with 73% of parents/caregivers reporting waking up because of diabetes technology. Of these, 54% reported waking at least four times a week, and one of the main reasons reported was CGM alarms (38%). About 10% reported false alarms occurring more than once a week. However, participants graded the impact of diabetes technology for their child as generally positive [60].

Overnight awakening due to CGM alerts and notifications was also reported in two other studies, performing qualitative narrative analysis of CGM and evaluating its impact on parental sleep [27,35].

A great number of false alarms were detected [62]. Awaking was more common among parents “sleeping lightly” and especially mothers [48]. The high frequency of alarms is a cause of nocturnal awakenings, poor sleep quality, and reduced long-term device use [18]. Overnight alarm fatigue preserves the vicious cycle of unresponsiveness as patients with hypoglycaemia react only to 29% of alarms [27], while parents only wake to 37% of them [36].

Even insulin pump and HCL system users may suffer from alarm fatigue. Even with closed-loop systems, T1D patients experience nocturnal hypoglycemia 25% of the time [41]. Waking up due to alarms was reported as frustrating for sensor-augmented pump therapy users, because it was frequently unclear why they went off [51]. In regard to HCL, the causes of nocturnal alarms were evenly distributed among the four different types of alarms. During the first 2 weeks after initiation of HCL mode, the mean number of nocturnal alarms increased significantly, followed by a steady decline in HCL mode and sensor use. Nocturnal alarms may be a contributing factor to the decline in system use, as has been described previously [18].

In order to successfully face the phenomenon of alarm fatigue, alarms should be designed in a way that they fulfill their mission, to reliably detect and warn for upcoming events that require action [72], in the most user-friendly way. In other words, increasing accuracy and reliability translates to less alarm fatigue and greater safety and more trust in the device. Their adjustment must achieve a balance between safety and QoL, avoiding unnecessary notifications that can generate alarm fatigue [16].

The option to turn off alarms has the potential to reduce alarm fatigue among users who are more prone to experience annoyance at the expense of treatment satisfaction and adherence [3]. The flexibility to turn off the alarms when needed and eliminate disruptions at inappropriate times were recorded as the two greatest benefits of optional alarms, offering a sense of control, freedom and strength [26]. Some CGM users deactivate all alarms overnight and swithch on only hypoglycemia alerts as a solution to cope with alarm fatigue [69].

The development of algorithms may serve in this context [16], for learning individual glucose profiles and providing earlier and more accurate prediction of glucose levels, focused on hypoglycemia [33,73,74]. Maximizing model performance for glucose risk prediction and management is crucial for reducing the burden of alarm fatigue on CGM users [74]. There is a need to develop more accurate and reliable CGM systems. Even the compression artifacts should be eliminated [60].

Furthermore, there is a need for efforts to make some alarms and alerts more discreet, like a mobile text notification, in order to eliminate social and emotional embarrassment. In this context, vibrating alarms possess an advantage compared with audible alarms, as they are noticeable even in a noisy environment and they cause less embarrassment. Different kinds of alarms should be distinctive for easier and quicker recognition of the nature and severity of the problem, with a gradual escalation in case the users remain unresponsive in order to increase the possibility of reaction [16]. However, during the night, it is important for the children or adolescents and their parents/caregivers to be aware of the alarms, as many of them are not heard at night by those who oversee their treatment [27,75]. Sharing alarms with parents may reduce some of the load of responsiveness undertaken by the users, and systems have been developed to support that need [75]. Furthermore, the selection of rather necessary hypo-and hyperglycemia threshold alarms over velocity rate alerts may be an attempt to prevent alert fatigue or to limit the number of alert disturbances both in the classroom and overnight [22].

It is important for alarms to overcome the role of automated reminders and be connected with real-life circumstances, promoting targeted and supportive interventions. CGM is something more than a “hypoglycemia or hyperglycemia detector”. It is a monitoring device that has the ability not only to detect but also to avoid hypoglycemia and hyperglycemia. There are periods of time when an “alarm not necessitating treatment” may be valuable, such as in severe hypoglycemia unawareness [22]. On the other hand, in periods of fatigue, customization of alarms to provide meaningful support in the form of notifications is recommended. Health professionals should help patients and their families handle any difficulty associated with alarm fatigue in order to overcome any resistance to use and take advantage of alarms, or avoid their deactivation or diabetes technology rejection [3]. At last, it is a matter of choice between risk and nuisance when the scale moves towards timeliness of excursion detection or false alarm, respectively [61].

Therefore, it is essential to individualize the activation threshold for each person, ensuring a balance between effectiveness and OoL. Patient-centered alarm configuration in daily life includes even varying alarm settings according to time of day or special situations such as physical activity or sick days [16] and adjusting them according to the course of glycemic control [22]. At first, it is recommended to set extremely low and high hypoglycemia and hyperglycemia alarm thresholds, respectively, to eliminate false alarms in favor of effective long-term use. Setting higher hypoglycemic thresholds predisposes users to the alarm fatigue phenomenon, not necessarily improving glycemic control, as alarms are ignored and no action is undertaken. The option to delay the hyperglycemia alert has been shown in some studies to reduce the incidence of hypoglycemia due to overcorrection by avoiding unnecessary insulin administration [75]. As glucose control improves with concomitant reduction in TBR, a more aggressive level of 60 and 140 mg/dL for hypo- and hyperglycemia threshold could be selected, respectively. On the other hand, in a patient without optimal glycemic control, such alarm settings would be out of scope and rather bothersome [22]. Furthermore, the discrimination of hypo-and hyperglycemia in regard to the urgency of treatment is in favor of a delay in the alarm release in the second situation.

An alarm threshold of 75 mg/dL was the optimal cutoff for hypoglycemia alarms in order to achieve a TBR < 1% as it offered the essential time for CGM users to react and overcame the obstacle of the deficits in the counter-regulatory mechanisms of euglycemia restoration, and kept the false positive rate at a low level. In the majority of cases, a hypoglycemic alarm threshold at around 70 mg/dL reduces TBR > 50% [21]. The alarm threshold should be adjusted according to age, medical history, and hypoglycemia awareness, as well as the frequency of hypoglycemic events during certain periods [75].

Hyperglycemia alerts are rather helpful in young children with a greater risk of diabetic ketoacidosis, for insulin pump users, and for patients with good glycemic control who want to further ameliorate glycemic parameters [75]. An alarm threshold of 170 mg/dL was the optimal cutoff for hyperglycemia alarms in order to achieve a TAR < 5% and HbA1c ≤ 7%. Gradually lowering hyperglycemia alarm thresholds leads to greater numbers of alarms, predisposing users to alarm fatigue. Thus, this practice could be considered to be adapted in the daily life of CGM users who need to further optimize HbA1c or reduce TAR, without increasing TBR, but until the level where there is no further improvement in glycemic control. Then, under the risk of alarm fatigue, alarm adjustments should stay stable or even loosen moderately [21].

There is a need for substantial personalized training aiming to strengthen patient confidence, reduce disease-related anxiety and encourage active participation in daily self-care. Clear communication reduces anxiety, facilitates learning and promotes greater adherence to treatment. It is important to optimize alarm settings with respect to each user’s preferences regarding frequency, timing, and content of notifications [69], in order to improve user engagement and long-term adherence [76,77]. For HCL users, there is a need for re-education in the timing of sensor calibrations, reacting to system alerts and setting alerts to reduce the number of nuisance alarms [78]. Identifying the source of alarms, especially nocturnal ones, on an individual basis, is essential in order to make the appropriate clinical interventions that can alleviate the recurrence of specific alarms for each person [18]. It is essential to configure only the alerts necessary for decision-making and adjust them to each person. This can be mitigated by adjusting thresholds according to time, activating vibration mode, or temporarily disabling some alerts. Diabetes education is the key for the user to know how to act in response to each alert and avoid unnecessary corrections.

There are specific recommendations regarding CGM glucose alarms for individuals who are new to CGM. The process of adaptation in daily life passes through education on alarms, psychological support to handle related symptoms and concerns, regular review of glucose data, a gradual approach to set up alarms starting with the most important ones and sharing data with parents/caregivers [17].

Directed towards T1D patients resistant to using CGM alarms, Miller et al. [3] published a five-step practical approach. After uncovering patients’ anxieties, health professionals should discuss how the upcoming change could meet their needs. It is important to analyze the benefits of CGM, how they can integrate it into their lives and use optional alarms/alerts. For those patients, the best way is to make them experience in their daily life how alarms have the ability to eliminate anxiety and improve QoL. This opportunity may be made available gradually, choosing to turn on and adjust alarms properly without pressure and deactivate them at any time. Patients should be encouraged to review their glucose reports and daily graphs in order to identify trends, when and why they occur, and how to prevent hypo- or hyperglycemic events. This is the critical point to offer the alternative of alarms, if they can understand the significance of potential warnings on upcoming glycemic events, to take action. In case the patients choose to use alarms, counseling on effective utilization according to their needs is suggested. By analyzing their glucose pattern, glucose thresholds are properly set, and alarms are appropriately activated. There may be differentiation from patient to patient according to the level of glycemic control, but also, in every single patient, throughout the day according to the current glucose pattern, the aimed glucose target and social circumstances. Finally, there may be an adaptation over time or to special cases.

5. Conclusions

In summary, with the utilization of technology for optimal glucose management in T1D, the phenomenon of alarm fatigue has arisen in parallel. It substitutes a situation of inappropriate response to a high frequency of alarms, even more so when some of them are proven to be false. Unfortunately, it is not limited only to pediatric patients, as it also affects their parents/caregivers. A cycle of frustration, disappointment and embarrassment is evoked and maintained, leading to reduced adherence and maybe to the discontinuation of diabetes technology devices. As alarms are a valuable tool of CGM, insulin pumps and HCL systems for optimal glycemic management, it is essential to find a way to reinforce their incorporation in the everyday life of children and adolescents with T1D. There is a need for an individualized approach, including education on alarms, psychological support, regular review of glucose data, gradual adoption of personalized alarms and sharing of the load of handling with parents/caregivers. This kind of approach should be a lifelong process. Furthermore, efforts should be made in the direction of improved accuracy and development of user-friendly settings and algorithms to further increase users’ trust in diabetes alarm systems. Only then, optimal and long-term utilization of alarms can ensure the best possible glycemic control for every patient without compromising QoL. Although alarm fatigue is a phenomenon that cannot be ignored, it is not able to threaten the undeniable positive effect on glycemic control.