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[IP] Re: The Pump

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> I just finished reading your article about Lily and the use of the
> pump. It caught my interest because just this week my daughter (10
> 1/2 years old and diagnosed for two years) had an appointment with
> her health care team to discuss the use of the pump.  They are very
> supportive of pump therapy but they basically advised us to wait
> until my daughter is around 12-14 to begin this type of therapy.  I
> think they were concerned with the process of having to change the
> infusion sight so frequently, (also they had a child in their
> practice that recently had a malfunction with his pump, causing him
> to become DK).  They also seemed to indicate that figuring out how
> much insulin to take for whatever you are eating might be a little
> more sophisticated than my daughter is ready for. 

This may be true.  See the website again. There is a lady there whose 
girl child (now 16) started pumping at age 3.  I believe there 
are several new members of the mailing list who have kids in the 7 
to 10 age group who either are pumping or will be shortly.

As I see it here is the problem.  One must be able to carbo count 
and to properly calculate the required boluses, and adjustments for 
high or low blood sugars.  You must be able to run a simple 
calculator and do fractions.  If you can do that in a routine manner, 
you can manage a pump.  My daughter Lily, at age 11, was able to 
manage routine boluses for food and figure out the carbo content.  
High or low blood sugar management involving projecting the effect of 
unused insulin in her body was difficult for her until last year.  
Now at 14, she manages everything herself.  It is my opinion (that of 
a non-medical lay person -- an engineer ) that a child younger than 9 
or 10 probably needs a lot of help managing the insulin doseage.  
That is only because when you use a pump, you are freed from the 
fixed carbo intake at fixed times, your schedule is no longer fixed, 
and thus your insulin requirements become highly variable.  One 
could, of course, use a pump with the better control and still 
maintain a fixed schedule -- probably your control would be better 
than ever.  But, part of the reason to pump insulin is to re-gain 
those freedoms.  Personally, I would do it for my child at any age, 
now that I have several years experience with Lily.  I probably would 
have been more hesitant had Lily been younger but now I see the 
results and I do not hesitate to encourage you to move forward.  The 
only advice I can really give is that one of you (not both) will have 
to become the child's pump mentor, to be available always to answer 
questions, do calculations and manage the diabetes on a day to day 
basis.  The docs and health care team see the patient far to 
infrequently to be able to do this for you or even give you good 
advice on dosage.  You must determine these things yourself and it is 
not that hard, just tedious.

> Maybe they are a
> bit wary.  I don't know.  I suppose, ultimately it will be our
> decision.  I just need to do more investigation.  In the meantime, I
> worry about the blood sugar levels (average 200) and how this is
> setting her up for later complications.  You just don't know what
> the future holds.  Her A1C taken this week was 8.3.  A little higher

Going on the pump will drop this into the 7's immediately.

Using Humalog (but not immediately) will further lower it into the 

Lily eats cake, ice-cream, hamburgers, fries, etc... even candy bars 
(after all the carbo is printed on the label)  all normal food with 
no artificial sweetners except for diet drinks instead of sodas or 
juice (by the way try Sunny Delight LITE  7 grams per 8oz). She is 
moderate with the cake and pie, usually no more than 30 or 40 grams 
of carbo at a time. Her hbA1c's are always in the 6's since she 
started Humalog in her pump.

> than I feel comfortable with.  Her Dr. assures us that this is good
> for a child her age and that she is doing a marvelous job at
> managing her diabetes.  Still, I worry.  You make the pump sound
> like it was the answer your daughter needed to live a "normal" life

I DEFINITELY was the answer!

> that young children should live, without always being bothered by
> the managment of their diabetes.  For the most part, our daughter is
> very mature about her managment.  Sometimes she is not very careful
> about her snacking and selection of food.  But then again, neither

She shouldn't have to be.

> is the rest our family.  Let's face it, we can't be perfect all the
> time.  The pump seems like it would take much of the pressure out of
> eating a snack or a meal. The process of having to wonder whether
> she should have it or not sounds like it would be eliminated with
> the use of the pump.
> We have been very pleased with the team of health care professionals
> providing service to our daughter.  Why do you think they would want
> our daughter to wait until she is older if the use of the pump would
> be most beneficial in achieving tight control?  Her doctor has
> currently started her using an insulin regime that simulates the
> pump use, in preparation for the pump in a few years.  However, we
> have seen much higher numbers because we are fussing with getting
> the ratio correct.  It goes something like this:

This is just as complicated if not more so than using a pump.

I bet you no one has actually measured her basal requirements, 
insulin to carb ratio and insulin to blood sugar ratios.

I will shortly have an article on the website detailing how to do 
this.  It will be geared toward pumpers, but any diabetic could do 
it. The same way.

>  AM	1 unit of H for every 50 pts. over 150 BG
>     and	
>   1 unit of H for every 30 grams of carbohydrate
>   17 units of Ultralente
>  Noon	1 unit of H for every 50 pts over 150 BG
>     and
>   1 unit of H for every 30 grams of carbohydrate
>  PM
>  Snack	If more than 30 grams of carbohydrate, take 1 unit of
>   H for each additional 30 grams of carbohydrate.
>  Dinner	Same as Lunch
>  Bedtime:	1 unit of H for every 50 pts over 200
>      and
>    1 unit of H for every 30 grams of carbohydrate over
>    45 grams of carbohydrate.
>    Approximately 18 units of NPH

That seems like a bunch of insulin to me.  Lily, 5-2 110 lbs uses 1 
unit for each 66 points.  Many adults on the list use 1 unit for 50 

> Seems like a lot of calculating.  Does this routine seem similar to
> what your daughter is learning to do with the pump?  Also, how

About the same, but only one kind of insulin and a simple fraction is 

Lily uses 1 unit of insulin for each 11 grams of carbo.

> involved are you or other adults in helping her determine just how
> much to take?  
Not anymore. But for a young child, management is just as necessary 
as with injections, more so with more freedom, they go hand in hand.

Has she had any episodes of extreme lows or highs
> with using the pump?
Of course, she is diabetic!  It has little to do with the pump, you 
can simply solve the problem faster with a pump and help to prevent 
recurrence.  i.e. if you eat something that has more carbo than you 
thought, you will get high, happens all the time -- doesn't matter if 
you pump or not.  The same is true if you take more insulin than you 
should have for the food you eat.  Your gonna get low. Eat glucose, 
turn off the pump for awhile.
> This sure seems like a bunch of questions.  I was happy to see this
> article at such an appropriate time for us since we had just
> discussed this issue earlier this week.

Keep asking.
> Your response is appreciated.
> Sincerely,
> Kellee Johnson

Michael <email @ redacted>