Updated August 31, 2006

To Pump, or Not to Pump?

by Deborah Butler, M.S.W., L.I.C.S.W.

Your 10-year-old daughter just returned from diabetes camp. She said that everyone was using an insulin pump, and she wants one too. You are worried about having a tiny computer deliver insulin into her body. Should you ask your daughter’s health-care team about pumps?

Your three-year-old son is a very picky eater and you are having a very hard time controlling his blood glucose levels, even with multiple injections every day. You have heard about insulin pumps, but is he too young for one?

Your teenager has been using a pump for about three years. She is now on the cheerleading team and she does not like being connected to the pump because of how it looks on her clothes. Should she switch back to injections?

These are all common scenarios for parents of children or teens with diabetes. If you’re facing a decision about whether your child should use a pump, this article may help by explaining some of the advantages and challenges of insulin pump therapy for children and teens.

Pump basics
An insulin pump is a small, computerized device that is programmed to continuously deliver basal, or background, insulin and that also allows bolus doses of insulin to be delivered to cover meals and snacks. The pumps currently on the market are about the size of a beeper.

An insulin pump is worn outside the body; no surgery is necessary for insulin pump therapy. Instead, an infusion set is used to connect the pump to the body. An infusion set consists of a small plastic cannula, or catheter, that is connected to a length of plastic tubing, which transports insulin from the pump reservoir to the body. The cannula is inserted into the fatty tissue just under the skin with a small needle, either manually or with an insertion device. The needle is removed after the cannula is inserted, and the cannula is held in place with tape.

Most children place their infusion sets on their abdomen or buttocks or occasionally their thighs. Infusion set site locations should be rotated just like injection site locations are rotated. It is advised that the cannula, tubing, and insulin in the pump reservoir be changed every two days in children and teens, both to prevent infection at the insertion site and because insulin tends to degrade when kept at warm temperatures, as it is in an insulin pump worn close to the body.

Only rapid-acting or short-acting insulin is used in an insulin pump. Because the pump is programmed to deliver a small amount of insulin continuously to keep blood glucose levels in target range between meals, there’s no need for injections of long-acting insulin. Pumps on the market today can be programmed to deliver different basal rates at different times of day or for the duration of particular activities.

Bolus doses are not preprogrammed the way basal rates are. Instead, a bolus dose must be programmed every time your child eats. Bolus doses are based primarily on the amount of carbohydrate the child is expected to eat. The bolus dose can also be fine-tuned based on the child’s blood glucose level before the meal or snack. If the blood glucose level is higher than desired before a meal, the mealtime dose might be increased. If it’s lower, the mealtime dose might be decreased.

Because bolus doses are tailored to the meal they precede, pump users (or their families or caregivers) must be willing to check their blood glucose level before each meal or snack (as well as at other times recommended by the health-care team) and must know how to count carbohydrates.

Bolus doses can also be used to bring down random high blood glucose levels between meals. However, the need to give frequent between-meal boluses suggests that something in the diabetes regimen needs to be changed to prevent high blood glucose levels.

Advantages of pump therapy
One of the advantages of using an insulin pump is having flexibility with regard to mealtimes, sleeping, physical activity, and family schedules. People who inject longer-acting insulins often must eat at particular times because their insulin is “peaking,” or reaching maximal effectiveness, at that time. Were they to skip a meal or snack, they might develop hypoglycemia (low blood glucose). But the slow, steady, basal infusion of rapid-acting insulin supplied by a pump doesn’t have a peak, so it is not as important to maintain a rigid schedule for when your child eats, as long as any food is covered with a bolus dose of insulin when it is eaten.

Also in this article:
Before You Get a Pump…

Deborah Butler is a clinical social worker in the Pediatric and Adolescent Unit at the Joslin Diabetes Center in Boston, Massachusetts. She leads support groups for family members of people with diabetes and moderates Web site discussion boards for teens with diabetes and their families.

This column is edited by Jean Betschart Roemer, a Pediatric Nurse Practitioner at the Children’s Hospital of Pittsburgh and the author of Type 2 Diabetes in Teens: Secrets for Success, which is available through www.learningdiabetes.com.

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