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October 16, 2007

Insulin Pumps

Question from Plymouth, Devon, UK:

Is it important to have a saline trial before starting pump therapy? We are trying to obtain an insulin pump for our 33-month-old son (type 1 since 11 months old). Although he has an A1c around 6.5%, he is extremely insulin sensitive on three to four units of insulin daily (1.75 units of Lantus and diluted NovoRapid) and suffers from frequent, unpredictable hypoglycemia with very little hypoglycemia awareness. So far, our local hospital has four teenage children on pumps and says it will be easy to start our son on a pump. After initial training, they would put him straight onto insulin in the home setting. Is this advisable or should we push for a saline trial? I would feel more comfortable with us parents having an opportunity to wear the pump and have practice bolusing.I have asked for a trial, but we have been told our hospital doesn't do saline trials as pump therapy is "not rocket science" and a saline trial is a waste of time. Also, how well do small children tolerate wearing an insulin pump? I am apprehensive that our team plans to start our son straight on insulin in the home setting and he will be trying to tear off the pump for the next few days and interrupting the insulin supply. Is it advisable with a child of two to see how well they will tolerate wearing the pump with just saline before starting insulin in the pump? Are there any articles, research or pump therapy start protocols online I could show my diabetes team which could be helpful in this situation? Our nurse says starting a two-year-old on a pump is no different than starting a 12 year old on a pump and she foresees no problems. Are there differences?


It is not necessarily important to do a saline trial. Although it is useful to familiarize yourself with the workings of a pump, a saline infusion can be somewhat uncomfortable and is not necessary for learning how to use a pump. We have, in young children, had them “carry” the pump around in a pouch or pocket for several days prior to the pump start, so the child can become familiar with the pump and the parents can figure out how best to attach the pump to the child once the insulin infusion starts.

In our experience, young children tolerate wearing the pump. We have had a few pumps break when toddlers have worn them. I have only once seen a child intentionally remove an infusion set (to get her mother�s attention). In general, young children seem to respect the pump and understand that it�s giving their insulin. We have used pumps with child blocks so that very young children can’t self-administer insulin, but, usually, parents only set the pump to block when the child is with playmates or will be with younger siblings out of their site.

In response to your last questions, although the “mechanics” of pumping are the same regardless of the age of the pumper, there are differences in the insulin requirements of toddlers and teenagers. There are also differences in the basal rate profiles. There is some published literature on this, including two studies we have authored, Preschoolers: Are Not Miniature Adolescents: A Comparison of Insulin Pump Doses in Two Groups of Children with Type I Diabetes and A Randomized, Controlled Study of Insulin Pump Therapy in Diabetic Preschoolers.