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[IP] Article from Diabetes Source on Kids on the Pump
Who? When? Why? How? Where?... Children & The Pump
by Jo Ann Ahern, APRN, MSN, CDE Coordinator of the Yale Program for
Children with Diabetes
Questions I often encounter... Who is the right candidate for the
insulin pump? How old should he/she be? These questions are always
difficult to answer. Past history (DCCT) indicates there is no way to
predict who will do well on a pump. Before initiating pump therapy, it
is important to know the child well enough to be confident they will
have the necessary support and motivation to be a successful pump user.
I most often recommend pump treatment to children who:
1.are working very hard to maintain normoglycemia, 2.are not achieving
goals or are having too much hypo or hyperglycemia, 3.ask about pump
treatment and how it might help them, 4.have hypo or hyperglycemia that
is effecting their school work, sports, and normal day-to-day living.
These children must consider the pump as something that will help them
achieve treatment goals and make them feel better and not simply
something that will make their parents feel better.
The age of the child should be taken into consideration. Young children
are very concerned when glucose levels are not in the normal range.
Children are also concerned about hypoglycemia episodes, especially
those occurring at night. I recently put an eight year old patient on an
insulin pump. She was having difficulty with hyperglycemia during the
day and hypoglycemia during the night, even with no insulin in the
evening. She was checking glucose levels 4-6 times per day and growing
very discouraged. When I see a child and parent having a difficult time
achieving normoglycemia, its time to consider other options. I have
other 8 and 9 year old patients scheduled for pump treatment who are all
very motivated and involved in their own care. One of them has even bee
concerned when glucose levels are not in the normal range. Children are
also concerned about hypoglycemia episodes, especially those occurring
at night. I recently put an eight year old patient on an insulin pump.
Some children do well clinically but would like the flexibility a pump
has to offer such as the elimination of frequent glucose swings. Parents
need to be reliable and understand that parental input is essential. A
child simply cannot be left alone to take care of his/her own diabetes.
Once a decision to go forward with pump treatment is made, it is
important for healthcare providers to explain the pump's capabilities in
great detail. All of our young patients are instructed to obtain at
least 4 glucose levels per day. The pump does not change this
requirement! A child would not be considered for pump treatment if this
requirement was not being met.
Patients frequently have misconceptions about pump treatments. Some
patients believe the pump minimizes the need to continue checking
glucose levels while others believe it will take care of their diabetes
all together. These issues are immediately addressed! The "eating
anything you want" idea is also discussed with encouragement to continue
watching total caloric intake.
Following the discussion about the pump's capabilities, the child and
parents are shown an insulin pump and how it works. Sometimes this
demonstration relieves fears while other times it makes them more
fearful. My goal is to address and alleviate these fears upfront.
Children often worry about things such as: Will the pump fall out when
playing on the monkey bars or jumping rope? What happens when I swim,
play soccer or baseball? We need to remember to address all fears in a
calm, non-judgmental way. I always reassure each child that they are
still capable of doing everything they did before.
There is some controversy as to where insulin pump treatment should be
initiated: inpatient or outpatient. We admit all of our children for
initiation of pump treatment. The comfort level for parents and staff to
normalize overnight glucose levels is greatly increased if the child is
closely monitored at the Children's Clinical Research Center (where all
of our patients are admitted). To monitor hourly glucose levels, an IV
is inserted in the child's arm (after using Emla Cream) allowing them to
sleep. This gives the child a break from using fingersticks, eases my
feelings of guilt and gives me confidence in calculating the correct
basal rate. To find the basal rate in units per hour, a child's total
daily insulin dose is divided in half and again divided by 24 hours. The
remainder is divided among the meals and snacks. The largest proportion
is given for breakfast with less given for lunch and more for su
inpatient or outpatient. We admit all of our children for initiation of
The child is sent home in 24 hours with instructions to call the
diabetes nurse daily for adjustments. Glucose levels must be obtained at
midnight and again at 3AM until basal rates are accurately calculated
for overnight requirements. This treatment is usually continued for 3
more days (unless hypo or hyperglycemia continue to be a problem). Once
everyone (child, parent and health care provider) feels comfortable with
the glucose levels and treatment, calls are initiated only for changes.
After the initial adjustment to the child's usual routine, carb/insulin
ratios can be investigated with the child, parent and dietitian. Our
social worker on staff will discuss adjustment problems that the child
or family are experiencing. After approximately 3 to 4 weeks, the
diabetes team (child, parents and care providers) feel quite comfortable
and the initial trials and worries subside.
Reading Suggestion: Boland EA, Ahern JA, Grey M.
A primer on the use of insulin pump therapy in adolescents.
The Diabetes Educator 24:78-87, 1998.
Insulin-Pumpers website http://www.bizsystems.com/Diabetes/
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