Current practice of insulin pump therapy in children and adolescents - the Hannover recipe

Abstract

Increasing evidence points to the importance of achieving low blood glucose variability and also a low hemoglobin A1c (HbA1c) to prevent diabetic late complications. Continuous subcutaneous insulin infusion (CSII) is associated with lower blood glucose variability in children. Frequent indications for starting CSII in youth are recurrent hypoglycemia, need for increased flexibility, poor glycemic control, dawn phenomenon, or needle phobia. At our center, about one-third of all patients across all age groups are currently on CSII. Although the average glycemic control is not very different from those on multiple daily injections, fewer patients are seen in the segment of very high and very low HbA1c with CSII. Across centers, the 'recipes' tailoring CSII treatment to individual patients and cultures are based more on experience than on evidence. However, several typical pediatric features have been identified. Patterns of the hourly basal rate and prandial insulin requirements vary with age. While many adolescents have increased requirements at dawn and dusk, young children show increasing needs in the second half of the day. Low insulin requirements, particularly in neonates, may need insulin dilution. The selection of catheters and needles has to be appropriate for the age. The opportunity to have an electronic memory read-out of all entries and alarms offers new possibilities of therapeutic monitoring, particularly in those youth not keeping good logbooks. This feature can be helpful, if a trustful relationship between the diabetes team and the family is established.

Establishing glycaemic control with continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes: experience of the PedPump Study in 17 countries

“…Nevertheless, CSII remains largely underused: for example, recent data indicate that only 10-14% of paediatric diabetic patients in Germany are receiving CSII [19,20]. The key barrier to CSII therapy is economic, as there is no consistency regarding reimbursement from Health Authorities across Europe.…”

“…It is important to remember that CSII and multiple daily injections are both viable strategies in children and adolescents, and that the final choice of treatment for an individual patient will require a dialogue between the patient, their parents or guardians, and the physician. Currently, strategies for tailoring CSII regimens to the needs of the individual patient tend to be empirically based, rather than evidence based [20]. Aspects that require particular attention in children and adolescents include patterns of basal and prandial insulin requirements and the selection of catheters and needles [20].…”

“…Currently, strategies for tailoring CSII regimens to the needs of the individual patient tend to be empirically based, rather than evidence based [20]. Aspects that require particular attention in children and adolescents include patterns of basal and prandial insulin requirements and the selection of catheters and needles [20].…”

Insulin Doses before and One Year after Pump Start: Children Have a Reversed Dawn Phenomenon

“…6 A decrease of the total daily dose (TDD) of 10% when using regular insulin prepump, but no decrease in the case of rapid-acting insulin prepump, has been suggested unless the patient has frequent hypoglycemia before pump start. 7 Boland and colleagues 8 found a decrease from 1.2 to 1.0 U/kg/day (a decrease of 17%) with >90% of patients using regular insulin in the pump. Ahern and associates 4 noted a decrease from 1.3 to 0.9 U/kg/day in adolescents (a decrease of 30%) but no significant change in other age groups when rapidacting insulin was used.…”

Aktuelle Aspekte der Insulinpumpentherapie bei Erwachsenen

“…Klinisch auffällig ist zudem: Je höher der Insulinbedarf unter einer ICT, desto grö-ßer ist die Gesamtdosisreduktion mit der Pumpentherapie. Für den pädiatrischen Bereich gibt es ebenfalls für verschiedene Altersgruppen entsprechende Schemata [37,38,39]. 0,3 0,5 0,6 0,7 0,8 0,9 1,0 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,9 2,0 2,1 2,2 19:00-20:00 0,3 0,3 0,5 0,6 0,6 0,8 0,8 0,9 1,0 1,0 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 20:00-21:00 0,2 0,3 0,4 0,5 0,5 0,6 0,7 0,8 0,8 0,9 1,0 1,1 1,3 1,3 1,4 1,4 1,5 1,6 21:00-22:00 0,2 0,2 0,3 0,4 0,5 0,5 0,6 0,7 0,7 0,8 0,8 0,9 1,0 1,1 1,1 1,2 1,3 1,3 22:00-23:00 0,2 0,2 0,3 0,4 0,5 0,5 0,6 0,7 0,7 0,8 0,8 0,9 1,0 1,1 1,1 1,2 1,3 1,3 23:00-00:00 0,2 0,2 0,3 0,3 0,4 0,5 0,5 0,5 0,6 0,7 0,7 0,8 0,9 0,9 0,9 1,0 1,0 1,1 troffenen eine neue Dimension der Therapieführung ermöglicht.…”