Daniel A. Nadeau, MD

Disclosures

October 16, 2003

Question

Is the insulin pump the insulin delivery method of choice in young children (under 3 years of age) with diabetes?

Response from Daniel A. Nadeau, MD

The short answer is yes, and the long answer is yes.

The use of insulin pumps in infants and toddlers continues to grow. Youngsters of this age are wonderfully unpredictable in terms of both activity and food intake. Just when you think the toddler is going to lap up the freshly milled organic sweet potatoes that have just been offered, he turns away suddenly with no interest. A pump can help anticipate and overcome such situations.

The insulin pump is a compact, ever more sophisticated, yet simple-to-use device. It delivers precise amounts of insulin via a small plastic catheter. Generally the tube is changed only once every 3 days, alleviating a need for 4 or more injections per day. Virtually eliminating injections for those younger than 3 years of age is a worthy goal for everyone involved.

In addition, the small amounts of insulin needed to maintain glucose in the ideal range make dosing as delivered by a pen or syringe too imprecise. Basal rates, which mimic the small amounts of insulin produced continuously by the pancreas, can be set in increments of as little as 0.05 unit per hour. For babies that may require only 0.1 unit per hour, such fine-tuning of basal rates is extremely helpful.

Bolus dosing is given before or just after food is consumed to correct blood glucose and cover carbohydrates. With the pump, bolus dosing is given in 0.1-unit increments. In a recent study of children with a mean age of 34 months, bolus dosing ranged from 0.1 to 0.4 units per 15 grams of carbohydrate.[1] Such precision is simply impossible with a vial and syringe where half-unit increments require some effort. With the pump and a few clicks, a portion of the bolus can be given before the meal, with the rest dependent on how the baby does with the organic sweet potatoes.

Children as young as 10 days old have used insulin pumps,[2] and a report from Duke University in toddlers and preschoolers demonstrated reductions in A1c from 9.5% to 7.9%, reductions in severe hypoglycemia from 0.52 to 0.09 episodes per month, and 80% reductions in parental contact with health personnel.[1] Numbers aside, this means a significant improvement in quality of life.

The pump is a fabulous tool when used intelligently. It does require a commitment to a minimum of 4 blood glucose checks per day, an ability to accurately count carbohydrates and determine appropriate insulin coverage, and a supportive and highly attentive family environment. The attentiveness is important, in part because if the catheter is dislodged, it must be attended to immediately.

There is no doubt that the use of pumps in infants and toddlers requires a team effort on the part of the family and healthcare team, but the effort pays off with better glucose control -- the bottom line in diabetes management.

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