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2	"`In the past we..." `In the past we had a light that flickered, in the present, a light that flames, and in the future we will have a light that shines over all the land and the sea’ Winston Churchill
3	Pump Gasoline?
4	Pump Iron?
5	Pump Breast Milk?
6	BANTING-1891-1941 & BEST-1899-1978
7	First commercial insulin
8	Prevalence of Diabetes in the US
9	Good Glycemic Control (Lower HbA_1c) Reduces Incidence of Complications
10	HbA_1c and Microvascular Complications
11	Every 1% HbA_1c Increase Above Goal Elevates the Risk of Diabetic Complications
12	Physiology of Insulin and blood glucose
13	Insulin Preparations
14	NPH and regular insulin - 2 injections
15	Disadvantages of NPH/ Regular regimen No flexibility: Required certain amount of calories a day Skipped meal - hypoglycemia (peak of NPH) Exercise - hypoglycemia (excessive glucose use) At night - hypoglycemia (peak of NPH) Overeating- hyperglycemia (not enough) Oversleeping- hyperglycemia (skipped dose)
16	Results of conventional therapy Poor control - HbA1C 10% and higher Fear of hypoglycemia - worsening of control Inability to exercise - poor fitness Early development of complications “OUT OF CONTROL”-Negative reinforcement “Don’t Do This, Don’t Do That” Mauriac syndrome - chronic insulin deficiency - stunted growth, hepatomegaly
17	"Some causes of hypoglycemia in..." Some causes of hypoglycemia in toddlers and preschoolers: Unpredictable food intake and physical activity. Imprecise administration of low doses of insulin. Frequent viral infections. Inability to convey the symptoms of low blood sugar.
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19	"IN SEARCH OF THE HOLY..." IN SEARCH OF THE HOLY GRAIL
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22	Humalog/Novolog versus Regular Rapid acting insulins: Start in 10min Peak in 1-2h Gone in 3.5-4h Regular insulin: Starts in 30min Peaks in 3-4h Gone in 6-8h
23	Benefits of rapid acting insulins May be given just prior to the meal or after meal in babies Time of action match rise in sugar caused by most meals No action left at the time of next meal - no boluses buildups Less activity at bedtime - less night “low’s” and no need for bedtime snack
24	New Long Acting Insulin (Glargine Insulin) Lantus is a new type of long acting insulin that has no peaks Mimics physiological insulin (basal)
25	INSULIN TACTICS The Basal/Bolus Insulin Concept Basal Insulin Insulin requirement to suppress hepatic glucose production between meals Bolus Insulin (prandial) Insulin requirement to maintain normal glucose disposal after eating Insulin:CHO Ratio = 500/(total starting dose) Correction Factor = 1500/(total starting dose) Correction factor in young children = 1800/(total starting dose)
26	LANTUS AND NOVOLOG-”POOR MANS PUMP”
27	Nine Preschool Patients Meticulously Cared For With MDI Switched To CSII: Mean A1c 9.5% reduced to 7.9%. Severe hypoglycemic events 0.52 per month reduced to 0.09 per month. Increased parental confidence and independence. All refused to relinquish pump at completion of study.
28	Better Control and Less Hypoglycemia in Young Children
29	Glycemic Memory: Sustained Beneficial Effect Of Prior Intensive Therapy 195 patients between the ages of 13 and 17 in DCCT: Decreased worsening of retinopathy by 74% (p < 0.001). Decreased progression to proliferative or severe non-proliferative retinopathy by 78% (p < 0.007).
30	Glycemic Memory: Sustained Beneficial Effect Of Prior Intensive Therapy 195 patients between the ages of 13 and 17 in DCCT: Relative risk of hypoglycemia < 1 among prior intensive group. Prevalence of microalbuminuria 48% less. It is vital to achieve the best glycemic control early in the course in diabetes during adolescence and childhood.
31	"“ Less than optimal glycemic..." “ Less than optimal glycemic control during the early years of diabetes has a lasting detrimental effect on the development and progression of complications, even after better glycemic control is established later in the course of the disease.”
32	From Preschool to Prom 161 patients with type 1 diabetes: 26 ages 1 to 6 76 ages 7 to 11 59 ages 12 to 18 98% remained on CSII Reduced hypoglycemia (events/year) Age 1 to 6: 0.42 to 0.19 Age 7 to 11: 0.33 to 0.22 Age 12 to 18: 0.33 to 0.27
33	World youngest pumper in 1999: 5mo old
34	World youngest pumper 2003: 10 d old
35	I WAS A NON-BELEIVER TOO HARD/TIME CONSUMING I WAS UNINFORMED ON HOW TO USE THEM NOT FOR THE VERY YOUNG OR THE UNMOTIVATED ONLY AFTER HONEYMOON YOU HAVE TO TEST FOR ME TO PUT YOU ON PUMP YOU WILL SUFFER PSYCHOLOGICALLY
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37	Introduction Test the feasibility and efficacy of insulin pump therapy initiated within the first month of diagnosis N=28 consecutive. mean age 12.1+ 6.2 years Range of start 1-30 days None discontinued after up to three year follow-up 2 sites Cornell Medical Center and Maimonides Medical Center
38	Hypothesis Our hypothesis are: Patients on pump have better control of their blood glucose level Better control allows extension of the “honey moon” period
39	Rationale and Hypothesis Earlier aggressive glucose control leads to lower incidence of long-term complications Insulin pump therapy resembles physiology more closely than multiple daily injections Lower incidence of occult and overt serious and moderate hypoglycemia Would there be benefit to introducing pump therapy earlier rather than waiting until further insulinopenia sets in?
40	Demographics
41	Mean HbA1c Levels Pre and Post Initiation
42	HbA1c
43	Insulin Burden (U/kg)
44	C Peptide AUC-In response to MMTT (Boost)
45	Other Significant Findings BMI-No significant gains or losses in BMI SD over study time All patients were “self-sufficient” within 3 months
46	Conclusions Starting patients on insulin pump therapy is a viable option at or soon after diagnosis Further studies need to be performed to see if quality of life and long term complications are affected Despite the labor intensivity of this approach the benefits were clear and patients opted to remain on pump therapy after treatment Apparent prolongation of the honeymoon
47	Candidates for pump therapy Typical Criteria Only motivated patients only patients who showed good compliance on previous regimen Adults and children > 6y old My Criteria Any patient who is willing to start and has abilities to learn May improve compliance Any age adults and children of any age (independent users 7-80 y old) Particularly “non-compliant” patients
48	ADVERSE EVENTS
49	PSYCHOSOCIAL OUTCOMES
50	The Yale Experience > 200 children started on pumps over last 5 yrs No difference in severe hypoglycemia Parents report less mild hypoglycemia
51	Additional Evidence From Yale
52	CSII vs. MDI With Glargine in Children
53	Pump Group Achieved Better Control Overall
54	More Pump Wearers Achieved HbA1c 6.9%
55	Sweden’s Experience 89 children 3-21 y.o Diabetes duration 6.1 years 30% using CSII HbA_1c decreased from 9.2% to 8.4% after CSII start Severe hypos Pump: 11.1/100 pt years MDI: 40.3/100 pt years
56	Patient Characteristics of Successful Pediatric Pumpers Able to maintain follow up appointments with health care provider Willing to record blood glucose values Able to count carbohydrates Good family/social support system
57	Pump therapy benefits Improved control - more physiological basal rates (“dawn phenomenon” match), different boluses for food, less absorption variability Less hypoglycemia More flexible lifestyle and possibility to exercise Precise dosing - 0.1u - 0.025u increments for basal rate and boluses Less injections - improved quality of life Less possibility of overdose
58	Pump Use in Children Is Increasing 200,000 users (adults and kids in the US). 10,000 are adults with type 2 diabetes ~ 20,000 children using pump therapy 10% of all children with diabetes Penetration as high as 90% in some pediatric clinics (ours) Increasing use in younger children (as young as 10 months) Current outcomes indicate CSII is safe and effective in children Increasing acceptance likely due to DCCT findings as well as the introduction of smaller, safer insulin pumps There are approximately 400,000 insulin pump users worldwide
59	Avoiding DKA Give a pen with the pump Instruct that any time the patient feels nauseated or has abdominal pain -- change the site Blood sugar is greater than 250 mg/dl Take correction dose Check for ketones Recheck in 60 minutes If coming down, leave alone If not, take a shot and change the site
60	Summary Pump therapy is an intensive process for pediatric patients and their families and the diabetes education team. Successful pumpers are motivated and willing to maintain follow-up, carbohydrate count, and check blood glucose frequently. Benefits of pump therapy for pediatric patients include: improved lifestyle, decrease in hypoglycemia, accurate dosing , ability to review history to see if doses were actually given.
61	Summary Children with diabetes should be intensively treated to avoid short and long term complications Insulin pumps can provide better control and less hypoglycemia than MDI With good support and a standardized process, insulin pump therapy can help to improve diabetes management in children Insulin pump therapy should be the only form of therapy offered to children with diabetes
62	When meditating over a disease, I never think of finding a remedy for it, but rather, a means of preventing it. Louis Pasteur, 1884
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