This post was written by David Segal, MD, Parkview Physicians Group - Pediatric Specialties, Endocrinology.
Children with type 1 diabetes require insulin replacement, at a minimum to stay alive, but ideally to maintain blood glucose levels as close to normal as possible to prevent complications of diabetes. Up until recently, caregivers or patients have had to inject insulin under the skin multiple times per day to achieve control (together with a number of other self-management behaviors). But the introduction of insulin pumps for pediatric patients is offering a welcome new option.
What is an insulin pump?
The first insulin pumps were developed in the 1970s. Over time, they have become more discreet.
The insulin pumps of today are small wearable devices that deliver insulin through a tiny tube under the skin, bypassing the need for daily injections that are replaced roughly every three days. They are worn on the skin, not implanted. The person living with diabetes, or a caregiver is trained to attach the pump, so there is no need to have trained medical staff available to care for the pump.
What does it do?
With typical injection therapy, two types of insulin are injected every day – A long-acting background insulin that is injected once or twice daily to control blood glucose levels between meals and during fasting and a short-acting meal or snack insulin to help the body store the incoming glucose from a meal, thereby bringing the blood glucose back into range after a meal.
An insulin pump only delivers short-acting insulin, but it does so in a continuous fashion by delivering a tiny amount every few minutes, replacing the long-acting insulin. It can also deliver larger doses on demand, with the push of a button for meal and snack coverage.
What are the benefits of an insulin pump?
There are a number of benefits derived from insulin pumps.
- The pump, and hence, the insulin, is always attached to the body. This eliminates the need to walk to the refrigerator or another room to grab an insulin pen for injections.
- No daily injections, just a site change every three days.
- The pump can deliver tiny doses of insulin, which is very useful for small children and babies.
- The pump can deliver a different amount of background insulin at different times of the day and night, which can keep the blood glucose levels more stable than we see with injected long-acting insulin.
- The pump can communicate with a continuous glucose monitoring system.
- The pump, together with a glucose sensor and an appropriate closed loop algorithm, is the closest we can get to an artificial pancreas.
Tell us more about “closing the loop.”
The greatest advancement in recent years has been the real-time communication between a pump, a glucose sensor and an intelligent algorithm. This has restored two of the major functions of the pancreas.
- Creating a glucose set point (setting a target glucose level).
- Actively managing insulin delivery to maintain the blood glucose around this set point. (The pump can increase insulin delivery on its own if the blood glucose is rising above target and reduce the insulin if the blood glucose is trending toward a low.)
What should caregivers consider when choosing an insulin pump for their child?
Given the advances in closed loop technology, it’s hard to justify using an insulin pump outside of a closed loop. So, if one were to consider moving from injections to a pump, I would recommend selecting a closed loop system, of which there are a number on the market.
There are two pump options: 1) Tubeless patch pumps with the insulin tube situated under the patch pump, and 2) Pumps that deliver insulin through a 12- to 24-inch tube connected to a small patch containing a tiny tube that goes through the skin.
Caregivers need to be aware that, with closed loop options, the child will need to wear both a pump and a sensor 24/7/365. There are no real age restrictions, but closed loop algorithms can struggle in small children who use very little insulin on a daily basis.
Unfortunately, insurance considerations and lack of funding are still hampering access to these devices.
What expectations should caregivers have?
- Expect life with diabetes to be better!
- The child will wake up with perfect blood glucose levels every day, less to no severe lows, shorter durations of highs, and greater time with blood glucose levels within the target range
- Better sleep (for the pump user and the caregivers)
- Lower burden of care – no injections, and greater margin of error with carbohydrate counting accuracy
- Be prepared to troubleshoot high blood glucose readings
- Be prepared to manage ketones
- Be prepared to go back onto injections temporarily to fix high blood glucose levels with ketones
How much time and effort does a pump require?
Managing diabetes is still a serious job, requiring sacrifice, discomfort and attention to performing appropriate diabetes behaviors that have been proven to achieve and maintain near-normal blood glucose levels.
Caregivers and patients who are old enough will need to receive training on the pump and the sensor, in addition to ongoing education around general diabetes management.
Caregivers and patients also have to maintain a commitment to being part of the closed loop. These pumps have not yet advanced to the point where the wearer can be completely outside of the glucose control loop.
Being part of the loop entails:
- Monitoring food intake
- Telling the pump how many carbohydrates you are eating before you eat them
- Monitoring the glucose data and aiming to achieve the highest possible time in range (blood glucose between 70 and 180 mg/dL)
- Troubleshooting when things are not going as expected
- Refilling the insulin reservoir and changing the pump site as often as recommended
- Having an open mind and being willing to work with the machine.
Closed loop insulin pump and sensor technology has been the biggest advance in diabetes since the discovery of insulin 100 years ago. Every person living with type 1 diabetes who is willing to do the work it takes to achieve and maintain optimal blood glucose control deserves to have access to this technology.