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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 
pump tre

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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