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[IP] Pumping for Children

Friends --

Here's the abstract of a paper I cited last week:

Asitides K. Maniatis, MD; Georgeanna J. Klingensmith, MD; Rober H. Slover,
MD; Cathy J. Mowry, RN, CPNP, and H. Peter Chase, MD.  Continuous
Subcutaneous Insulin Infusion Therapy of Children and Adolescents: An Option
for Routine Diabetes Care.  Pediatrics 107(2):351-356, February 2001.

The purpose of this study was to determine the feasibility of continuous
subcutaneous insulin infusion (CSII) (insulin pump) therapy in routine
pediatric diabetes care by comparing the HbA1c, body mass index (BMI), and
hypoglycemic episodes before and after initiation of CSII therapy.

Research Design and Methods: 
Data from 56 patients (7-23 years old) were collected during regularly
scheduled visits at a frequency similar to non-CSII patients.

The data were analyzed for the entire cohort and 3 subgroups (decreased,
stable, or increased HbA1c) stratified according to a >= 0.5% change in
HbA1c.  The total cohort demonstrated a decrease in HbA1c from 8.6% to 8.3%.
The decreased cohort (39.4% of the total cohort) demonstrated a significant
decrease in HbA1c from 8.6% to 7.6%.  The mean HbA1c of the stable cohort
(41.0%) was 8.7%.  The increased cohort (19.6%) had an increase in HbA1c
from 7.8% to 8.8%.  Thirty-six patients (64.3%) maintained or achieved a
HbA1c <8.0% or achieved a HbA1c at least 1% lower than their pre-CSII level.
Of concern, 6 patients (10.7%) demonstrated a clinically significant
increase in HbA1c from 8.3% to 9.6%.  For the entire cohort, the rate of
severe hypoglycemia before and after CSII therapy was 12.3 and 9.5 events
per 100 patient-years, respectively.  A statistically significant proportion
of patients reported a decrease in seizure frequency versus an increase
(17.9% vs. 1.8%) as well as a decrease in overall hypoglycemic frequency
versus an increase (41.1% vs. 17.9%).  There was not a clinically
significant increase in BMI, even in the decreased HbA1c cohort.

CSII therapy is an appropriate option for some children in routine diabetes
care.  It can effectively decrease HbA1c and reduce hypoglycemic episodes,
without producing an abnormal increase in BMI.  

JH Comment:  
It would have been helpful had the authors specified what the target ranges
were.  The only assumption one can make is that they were held constant.
I'm not familiar with typical target levels for children.  I was a little
surprised that there was no apparent attempt to bring the HbA1c down below
7% (the accepted cutoff level for increased risk of retinopathy based on the
DCCT).  From a purely scientific point of view, it is helpful to make the
assumption that targets were maintained as it allows a more intuitive
analysis regarding the effect of CSII versus MDI.  One does wonder, however,
whether a lower mean target level would have been appropriate even under
MDI.  Better yet would have been to report the targets pre- and post-CSII.

Still, this is a good paper for parents to be aware of if considering
pumping for their diabetic kids - and make extra copies to send to their
insurance provider(s).

Jim Handsfield
email @ redacted OR
email @ redacted

The opinions expressed are mine and may not represent those of my wife who
runs our house and makes more important decisions than I do.
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