Who? When? Why? How? Where?... Children & The Pump
by Jo Ann Ahern, APRN, MSN, CDE Coordinator of the Yale Program for Children with Diabetes
Questions I often encounter... Who is the right candidate for the insulin pump? How old should he/she be? These
questions are always difficult to answer. Past history (DCCT) indicates there is no way to predict who will do well
on a pump. Before initiating pump therapy, it is important to know the child well enough to be confident they will
have the necessary support and motivation to be a successful pump user.
I most often recommend pump treatment to children who:
1.are working very hard to maintain normoglycemia,
2.are not achieving goals or are having too much hypo or hyperglycemia,
3.ask about pump treatment and how it might help them,
4.have hypo or hyperglycemia that is effecting their school work, sports, and normal day-to-day living.
These children must consider the pump as something that will help them achieve treatment goals and make them
feel better and not simply something that will make their parents feel better.
The age of the child should be taken into consideration. Young children are very concerned when glucose levels are
not in the normal range. Children are also concerned about hypoglycemia episodes, especially those occurring at
night. I recently put an eight year old patient on an insulin pump. She was having difficulty with hyperglycemia during
the day and hypoglycemia during the night, even with no insulin in the evening. She was checking glucose levels 4-6
times per day and growing very discouraged. When I see a child and parent having a difficult time achieving
normoglycemia, its time to consider other options. I have other 8 and 9 year old patients scheduled for pump
treatment who are all very motivated and involved in their own care. One of them has even been recommended to
learning disabled classes because his hyperglycemia leads to hyperactivity and the inability to focus. When
hypoglycemic, he cannot concentrate or learn. This is a case that requires intervention.
Some children do well clinically but would like the flexibility a pump has to offer such as the elimination of frequent
glucose swings. Parents need to be reliable and understand that parental input is essential. A child simply cannot be
left alone to take care of his/her own diabetes.
Once a decision to go forward with pump treatment is made, it is important for healthcare providers to explain the
pump's capabilities in great detail. All of our young patients are instructed to obtain at least 4 glucose levels per day.
The pump does not change this requirement! A child would not be considered for pump treatment if this requirement
was not being met.
Patients frequently have misconceptions about pump treatments. Some patients believe the pump minimizes the need
to continue checking glucose levels while others believe it will take care of their diabetes all together. These issues
are immediately addressed! The "eating anything you want" idea is also discussed with encouragement to continue
watching total caloric intake.
Following the discussion about the pump's capabilities, the child and parents are shown an insulin pump and how it
works. Sometimes this demonstration relieves fears while other times it makes them more fearful. My goal is to
address and alleviate these fears upfront. Children often worry about things such as: Will the pump fall out when
playing on the monkey bars or jumping rope? What happens when I swim, play soccer or baseball? We need to
remember to address all fears in a calm, non-judgmental way. I always reassure each child that they are still capable
of doing everything they did before.
There is some controversy as to where insulin pump treatment should be initiated: inpatient or outpatient. We admit
all of our children for initiation of pump treatment. The comfort level for parents and staff to normalize overnight
glucose levels is greatly increased if the child is closely monitored at the Children's Clinical Research Center (where
all of our patients are admitted). To monitor hourly glucose levels, an IV is inserted in the child's arm (after using
Emla Cream) allowing them to sleep. This gives the child a break from using fingersticks, eases my feelings of guilt
and gives me confidence in calculating the correct basal rate. To find the basal rate in units per hour, a child's total
daily insulin dose is divided in half and again divided by 24 hours. The remainder is divided among the meals and
snacks. The largest proportion is given for breakfast with less given for lunch and more for supper. Snack doses are
determined by how high the glucose goes after each snack.
The child is sent home in 24 hours with instructions to call the diabetes nurse daily for adjustments. Glucose levels
must be obtained at midnight and again at 3AM until basal rates are accurately calculated for overnight
requirements. This treatment is usually continued for 3 more days (unless hypo or hyperglycemia continue to be a
problem). Once everyone (child, parent and health care provider) feels comfortable with the glucose levels and
treatment, calls are initiated only for changes.
After the initial adjustment to the child's usual routine, carb/insulin ratios can be investigated with the child, parent
and dietitian. Our social worker on staff will discuss adjustment problems that the child or family are experiencing.
After approximately 3 to 4 weeks, the diabetes team (child, parents and care providers) feel quite comfortable and
the initial trials and worries subside.
Reading Suggestion: Boland EA, Ahern JA, Grey M.
A primer on the use of insulin pump therapy in adolescents.
The Diabetes Educator 24:78-87, 1998.
