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Question:

From Louisville, Kentucky, USA:

Why is my son's diabetes care team discouraging him from using the insulin pump? My six year old son has had type 1 diabetes for 17 months. His A1cs have ranged from 7.1 to 7.6. He checks his own blood glucose and helps us make food choices based on carbohydrates and the amount of sugar.

Like most six year olds, it is very important to him to be able to be like his friends, classmates and siblings (lunch and snack times, exercise, etc). He has two shots a day of NPH and Humalog: 10 units of NPH, 1/4 unit Humalog in the morning, and one unit of NPH, 1/2 unit of Humalog in the evening. He HATES shots and talks about going on the pump constantly.

We have had some really scary lows this summer due to his increased activities and his increased hypoglycemic unawareness. His diabetes care team has always discouraged the pump for various reasons, including insulin requirements that are too small; he's not mature enough; he is resistant to change. They base the resistance to change claim on the fact that he would only prick his finger with a disposable lancet that he first began using at a camp. I think that a five year old pricking his own finger and adjusting to shots, diets, etc. shows a remarkable ability to accept change! We discussed all of this with his team and were led to believe he could start the pump this summer. However, we have now been told he cannot start for at least a year. Everything I've read suggests that the pump is the standard now for excellent control and quality of life. Why would they discourage us? Is it time to find another team?

Answer:

What a difficult question, which means that the answer is difficult, too.

Certainly, you should continue to have a dialogue with your own diabetes team. The responses you have given are ALL EXCELLENT reasons for deferring a pump for now: lack of maturity, etc. But, that does not preclude the use of an insulin pump.

Does your son REALLY, REALLY, REALLY understand that a pump is not "a cure, " that he would still have to check his glucose readings several times a day (typically MORE OFTEN with a pump)? Does he understand that he is attached to a device that might get in the way when sliding into first base? And, if his glucose levels were high, you and he would have to go through a laundry list of things to troubleshoot for BEFORE you actually gave him extra insulin and which might still need to be given by shot? Does he know that the insertion site is changed every two to three days or more, depending on his glucose levels?

You should read Insulin Pump Therapy to help you decide if using an insulin pump is right for your son.

Studies that we have presented from our Division suggest the following: Children who go directly from the type of insulin plan your son is on (intermediate plus short-acting insulins) do LESS WELL on a pump than those that first go from your current insulin plan to a different insulin plan that uses multiple daily injections using an insulin combination that somewhat mimics the pump, and then to a pump. This would be a "basal-bolus" insulin plan using a combination of very long-lasting insulin, such as Lantus or UltraLente, as the baseline, background insulin and then rapid acting insulin at each meal and snack, with the amount of insulin given based on carbohydrate counting. Following this plan for as little as six months improved/prolonged the glucose control on the pump.

A pump can be a very good tool, but it is not an artificial pancreas: it is simply a way to give insulin.

Your son feels "different" because he takes shots? He is still different with a pump: he still checks his glucose levels and now he wears a device on his belt that broadcasts to the world that he has diabetes.

Your son is probably still in the diabetes honeymoon. I think that is a relative "iffy" time to start pumping because it is easy to think "look how well controlled my A1c is." You are certainly doing your hard share in controlling his diabetes. But, he likely still has some pancreatic reserve filling the gaps for those times when you haven't really meal planned terrifically.

By the way, who will calculate his carbohydrates and dose his insulin when he is on a pump in school? Can he recognize that he is eating 47 grams of carbohydrates? If he is supposed to take 1 unit for every 17 grams of carbohydrates, will he be able to do the math? Sure, some of the newer pumps can do the math for you and make a "suggested" insulin dose. But, the pumps do NOT automatically give that mealtime "bolus" of insulin. The pump only automatically provides the baseline, background insulin. Does your son have the ability to anticipate that: "gee, the pump suggests that I give 2.8 units of insulin for this 47 gram carbohydrate load. But, I will be at recess after lunch so I really need to give less." In other words, the pump does not factor in activities: it does not know you are playing kickball, or reading. It simply is a machine to infuse insulin.

In younger children, sometimes we use the pump more for the PARENTS than the child. You may have thought of all these issues and more. A pump may indeed be right for you. But, make an informed decision and work with your diabetes team. You live with your child, but they have hundreds of patient-years worth of experience between them in dealing with children with diabetes.

At our center, we send our families to our Certified Diabetes Education center for a "pre-pump assessment" to review the principles and nuances and pitfalls of pumping. I have the patient get a pump catheter needle inserted to wear for a bit. Sometimes, you can wear a pump that only infuses small amounts of salt water, rather than insulin, so that you can practice pumping and then see if the time is right for you and your child to pump.

I told you the answer was complex. And there is still more. I hope this gets you started.

DS

DTQ-20040720234024
Original posting 29 Jul 2004
Posted to Insulin Pumps and Daily Care

  
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Last Updated: Tuesday April 06, 2010 15:09:58
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