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CSII in type 1 diabetic children
Original article:
Selection for and initiation of continuous subcutaneous insulin infusion.
Proceeding from a workshop. Hanas R. Horm Res 2002; 57 (suppl 1): 101–4.
Summary
Although continuous subcutaneous insulin infusion (CSII) has been used in
children for more than 20 years, the technique is not widespread in most
countries. However, there has recently been increasing interest in pump
therapy in young children, older children and adolescents. Swedish
pediatricians have been particularly involved in initiating pump treatment
in children with type 1 diabetes: the figure for CSII use rose from 7.5% in
1999 to 12% in 2002. Today, most pediatric centres in Sweden use pumps. A
particular effort in training pediatric teams and, since 1997, reimbursement
of the cost of pumps and supplies have helped further the use of the
technique.
In this paper, Ragnar Hanas, a specialist in CSII therapy in children in
Sweden, presents concise data for the pediatric endocrinologist drawn from
his wide experience (37% of the pediatric cohort of Uddevalla are treated by
CSII; Fig. 1) and from an analysis of the literature. Table I lists the
possible indications for insulin pump therapy in children. The clinical
benefits and risks, pump initiation and needle routine are carefully
presented.
Dr Hanas concludes that CSII therapy in children and adolescents is
feasible, well accepted and can be managed safely.
Fig. 1: Age distribution of children and
adolescents using insulin pumps at the Uddevalla Pediatric Clinic. |
Table I: Possible indications for using an
insulin pump.
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Comment
There has been a rapid increase in the number of reports of clinical
experience and studies of CSII use in type 1 diabetic children in recent
years. These reports have increased our knowledge about the technique and
provided evidence for its use in the pediatric population. Recommendations
for the most appropriate age ranges are currently available and most are
clearly presented in this paper.
At a recent meeting of the American Diabetes Association in June 2001, eight
oral communications addressed the question of the benefits of CSII in
children. Also in 2001, at a meeting in Siena of the International Society
for Pediatric and Adolescent Diabetes, a workshop gathered together 100
experienced pediatricians to discuss the topic. All recent papers presented
data strongly supporting the successful use of CSII in children and
confirming previously published data. In general, glycemic control was
improved or remained stable; there was a reduction in the frequency of
hypoglycemic events; and a better quality of family life (greater lifestyle
flexibility) was achieved.
Guidelines for the transition from multiple daily injections to CSII are
different for children and adults, especially prepubertal children. In a
recent study [1], a reduction in total insulin dosage was necessary at
initiation of pump therapy in pubertal (-18%) but not in prepubertal
children, confirming the findings of previous studies in young children.
Forty to fifty percent of the daily insulin dose is given as basal rates,
but timings of maximum basal rates were found to differ between adults and
children. Several studies in prepubertal children using pumps with insulin
lispro showed that the maximum basal rate was reached between dinner and
midnight. Pediatricians must be aware of this in order to optimize the
efficacy of CSII therapy. The number of basal rates is frequently reported
to be two or three per 24 h (early night, late night and daytime), whereas
Dr Hanas recommends starting with five separate basal rate profiles by
adding one basal rate for each main meal. Nevertheless, CSII allows adequate
profiles to be tailored to each patient in order to closely match individual
insulin needs.
CSII is a more physiological way of insulin delivery, which minimizes
unphysiological hyperinsulinemia, especially at night. Nocturnal basal rate
adjustment is an essential tool in reducing the risk of hypoglycemia in
diabetic children, especially in high-risk children below 5 years of age
[2]. On the other hand, few data are available on the different methods of
mealtime bolus administration in children. A recent paper by Chase et al.
[3] studied different methods of bolus administration for a high-calorie,
high-
carbohydrate meal (single bolus, two boluses and square-wave) in adults. The
lowest prandial blood glucose excursions were observed after dual-wave
administration when 70% of the insulin dose was given as a bolus and 30% as
a 2-h square-wave.
As Dr Hanas states, in children, small incremental changes in bolus and
basal rates are recommended in order to avoid blood glucose fluctuations.
Very small changes in boluses and basal rates, such as 0.1 or 0.2 units (per
h), are feasible and accurate with a pump, unlike with pens and syringes,
and are particularly suited to very young children.
The limits of pump therapy are well known: the risk of diabetic ketoacidosis
due to catheter obstruction can be prevented by specific parental education;
skin tolerance has considerably improved with the use of Teflon catheters,
which can also conveniently be disconnected for bathing or swimming. In
order to prevent complications, needles should be removed every 2 [4] to 3
days (Hanas), and testing for urine or blood glucose ketones should be
carried out in cases of hyperglycemia. Education of parents and children,
and supervision by a specialized pediatric diabetes team are the keys to
success of CSII therapy in children. If these are in place, CSII can safely
be used in diabetic children.
References
1. Conrad SC, McGrath MT, Gitelman SE. Transition from
multiple daily injections to continuous subcutaneous insulin infusion in
type 1 diabetes mellitus. J Pediatr 2002; 140: 235–40.
2. Tubiana-Rufi N, Czernichow P. Special problems and management of the
child less than 5 years of age. In: Sperling MA, ed. Type 1 diabetes:
etiology and treatment. Minneapolis, MN: Humana Press. In press.
3. Chase HP, Saib SZ, MacKenzie M et al. Post-prandial glucose excursions
following four methods of bolus insulin administration in subjects with type
1 diabetes. Diabetic Med 2002; 19: 317–21.
4. Litton J, Rice A, Friedman N et al. Insulin pump therapy in toddlers and
preschool children with type 1 diabetes mellitus. J Pediatr 2002; 141:
490–5.
Summary and Comment:
Nadia Tubiana-Rufi, Paris, France |
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