From Richmond Hill, New York, USA:
My 11-year-old son has had type 1 since the end of February 2008. We are using an endocrinology clinic with nurse practitioners, etc. My son lost approximately 40 to 45 pounds before being diagnosed, within a three to four month span. Since he began twice a day NPH and Humalog injections, he has gained 27 pounds. He has to eat 60 grams of carbohydrates for breakfast, 15 grams for snack, 45 grams for lunch, 30 grams for afternoon snack, and 75 grams for dinner and another snack before bed. I wanted him to go on a pump since the beginning, since we feel that he would be able to control what he wants to eat and when. The staff at the hospital don't want to give us the pump until we really have a 100% handle on the carbohydrate counting. I think that I already do and I have made up all the menus of his daily eating and glucose numbers, but they keep delaying, saying that I need more information on getting an educated decision on which pump, etc. It seems to be going on and on. Am I being silly trying to get the pump quickly or should I let things go as they go? Also, my son, being 11, will lie and cheat and eat things that he shouldn't and when he comes home with a sugar of 330 mg/dl [18.3 mmol/L], I know he cheated, but won't admit it. Will a pump or insulin injections make a difference if he will cheat?
You have asked a series of questions that are being asked more frequently. You might wish to search our web site for similar questions about Insulin Pumps.
I take away the following salient points from your letter:
- Your son (and thus your family) has only had diabetes for three and a half months.
- He already "will lie and cheat and eat things that he shouldn't." (I don't think that he gets an excuse to do that because he is 11. I'm not saying that any aged person with diabetes is perfect all the time, since no one is, and such poor choices are not at all unexpected but that doesn't mean that you should implicitly tolerate purposeful poor choices.)
- You count carbohydrates but, apparently, your son does not.
- He is followed by an endocrinology clinic. Is this a pediatric focused clinic? Do the staff members and health care professionals have specific or certified pediatric diabetes healthcare providers? Does he only see the nurse practitioner?
- Your son is "required" to eat three specified meals and three specified snacks. Apparently, this does not satisfy him, because he "will lie and cheat."
- He is on NPH and Humalog insulins twice daily.
You asked so I will tell you: Yes, I think you are a premature to be wanting him on an insulin pump at this juncture. But no, I don't think you should "let things go as they go." An insulin pump MIGHT make a difference if he "cheats," but only if it is used properly. Please review our page on Is the Pump Right for You?
An insulin pump IS NOT AN ARTIFICIAL PANCREAS! It only gives as much insulin as you program it to give. It does not measure the glucose level; it does not change the insulin dosage relative to the glucose level. Just as you program your VCR or DVD to record something at pre-set times of the day, an insulin pump is programmed to give a rapid-acting insulin (such as Humalog, NovoLog, or Apidra) at specific, low, continuous, infusion hourly rates based on times of the day and night. These rates are adjustable. Extra insulin must be given, via the pump, for meals, snacks, and for unanticipated higher glucose values. If between the hours of 2 to 3 p.m., the pump is pre-programmed to give 1.5 units/hour, it will do so, no matter if the glucose is 500 mg/dl [27.8 mmol/L], 50 mg/dl [2.8 mmol/L], or 15 mg/dL [0.83 mmol/L]. The person in charge of the pump MUST BE ABLE TO COUNT CARBOHYDRATES and THEN DOSE INSULIN APPROPRIATELY and to give "correction doses" as needed based on the glucose level. While your son might not be "in charge," he will be wearing it and, clearly, he is not always within your arm reach, so he must be responsible. If he is not responsible now to be counted on to eat the meal plan allotted to him, what makes you think he will be responsible for a $6000 piece of equipment attached to him?
Having said that, I do not think that his current insulin plan and meal plan are optimally matched. Hopefully, you have learned about the different onset and peak actions of various insulins, including the NPH and Humalog that your son has been prescribed. If not, you definitely need more education by a Certified Diabetes Educator before proceeding further. The Humalog insulin begins to work within about 15 minutes after each injection in the morning and evening; it's peak effect is about 90 minutes after the injection. The NPH insulin begins to work about two hours after the injection and it's peak effect is about six to 10 hours later. So, in my opinion, patients on this plan should not necessarily be automatically placed on an morning and bedtime snack plan, because I think that at those points, there is not good insulin coverage because the Humalog effect is waning and the NPH hasn't kicked in well. (Other clinicians certainly have different approaches.)
There is nothing wrong with the combination of NPH and Humalog, but the meal plan has to match. If there were persistently higher glucose readings in the morning or evening or lunch or bedtime, it suggests further mismatches of insulin.
If you really want to pursue insulin pumping, I'd suggest that you talk to your diabetes team about putting your child on an insulin regimen that mimics the effects of pumping much better. This would be in the use of a long-acting insulin (such as Lantus [and maybe Levemir]) as the "baseline-always present-background insulin" (the way the continuous infusion of insulin via a pump would work) and then to supplement with additional rapid-acting insulin (Humalog or NovoLog or Apidra) to cover EACH meal and snack, (if a snack is required or desired). The doses would be worked out by your diabetes team; the amount of insulin taken at meals would hinge on the amount of calories or carbohydrates consumed with the meal/snack, which emphasizes the critical importance of carbohydrate counting. Your diabetes team would also work out a "correction formula" to smooth out for unanticipated highs. This type of insulin plan has been referred to as a more physiologic insulin plan that better mimics Mother Nature and is the basic principle of insulin pumping. Taking insulin injections in this manner is often referred to as a Multiple Daily Injection (or MDI) plan. The cost of this is no more than the cost of insulin and needles -- you haven't spent $6000 on a device with which you might not have success.
My Division previously presented our experience that pediatric patients with type 1 diabetes who progressed from a MDI plan (for at least six months) to pumping transitioned better and succeeded better for one year on the pump than did patients who bolted directly to a pump from a plan such as what your son is on now.
Further complicating matters is the anticipation of your son entering the so-called "diabetes honeymoon."
So, keep a good dialogue with your diabetes team with pediatric expertise. Make your son "part of the team" with understanding that he must learn to make good choices. I would have you discourage his lying and cheating by having the registered dietitian from your endocrine clinic incorporate some of his favorite "cheat" items into his regular meal plan and then learn to take insulin accordingly. That way, he hopefully will not feel so "deprived."
Last Updated: Tuesday April 06, 2010 15:10:16
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