We recently moved to a small town and their are no pediatric endocrinologists. We are currently going to an endocrinologist who sees patients five years old and up. I don’t particularly trust him with my son’s care.

My son was diagnosed at 22 months with type 1 and is now five. We currently use two injections a day and his most recent A1c was 6.7. He does have many swings, but his A1c has always been perfect and he only gets two shots a day. We have recently started thinking about a pump, however, my son keeps saying, “No, thanks!” Because of the small town, the schools do not have nurses except one day a week, so, I have chosen to keep him out one more year until he is able to tell someone when he is feeling bad. He shows no signs then we check him and he could have a blood glucose of 30 mg/dl [1.7 mmol/L].

Should we force my son to start on a pump now so that this year off school will give him, and us, more time to learn something new before he starts? Or, should we stick with what got us here? I currently keep a very tight ship while he’s at home so his numbers are okay. My fear is when he does grow up and goes to school, he will be out of my tight control and he will either crash or be sky high with the shots. What do you think?

My current endocrinologist suggested the OmniPod for him to try. Finally, should I drive to a bigger city to find a more specialized pediatric endocrinologist?

Well, your son is five years old and is on “two shots” of insulin daily. What kind, specifically? His A1c value that you report is excellent. All good. But, you see a doctor who doesn’t typically take care of children and you “don’t trust him.” You question whether your child should be on an insulin pump and should you “force him.”

In my view, and I admit my preferences here, there are two main reasons to switch to insulin pump therapy from injections:

Control is SO AWFUL and there is repeated bouts of health/life-threatening diabetic ketoacidosis because injections are missed, that you want “some” insulin always on board. This reasoning has been typically supplanted given the availability of long-lasting insulins, such as Lantus.

Control is SO FANTASTIC, but the patient needs more flexibility in their life to allow for different meals at different times, adjustments for different activities, etc.

So, for a five year old in good control, I do not see a MEDICAL reason to go to a pump. There might be social reasons, but mostly on your part (allowing you sleep in some days, etc). You are a self-described “panicked-mom,” so you probably won’t change your daily routines yet.

I would in NO WAY have you switch to a pump if you do not have good (or trusted) medical support for a pump for a pre-schooler. The lack of the school nurse doesn’t bother me as much, as long as there is a responsible adult. If this were public school (and some private schools), you will want to complete a 504 Plan and maybe an IEP given his diabetes. Schools that receive federal dollars are REQUIRED to accommodate, in some fashion, the child with special needs and diabetes mellitus does fall under that umbrella.

Personally, I think that switching to a different basal-bolus insulin plan would be preferable, but this would likely require three or four insulin injections daily comprised of long-lasting insulin for the “background” or “basal” insulin and then rapid-acting insulin for all meals and significant snacks. I think it is in the child’s best interest for you to have him seen, at least periodically, by a pediatric endocrinologist specialist.

Finally, the “hypoglycemia unawareness” that you describe can be worrisome (especially during activities such as swimming or driving a car when older). Believe it or not, this is often nicely responsive by allowing his control to slack off for a few weeks. However, I would only do that with assistance from your pediatric endocrinologist or other “trusted” healthcare worker in diabetes.

DS