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April 5, 2008

Daily Care, Insulin Pumps

Question from Cherokee, Iowa, USA:

My will be four in May. She has had type 1 for three months. First, when we talked to our endocrinologist about pumps and CGMS, he thought our daughter was too young for them both, saying he was more willing to write a prescription for someone that is 14 rather than three because the former can say when they're low. But, he did agree to it so we started researching and trying pumps. We decided to go with OmniPod. When we told our doctor of our choice, he said my daughter didn't need a pump because she's still honeymooning and that an OmniPod wasn't reliable and not available in South Dakota. Well, it is available in my area and the parents that I talk to love it. My daughter tested it for a week and loved it. The same day, I was told about my doctor not giving her a prescription for the OmniPod, it turns out he had written one a month ago for a MiniMed pump. One morning, my daughter wouldn't get up, just laid there with her eyes open. I tested her and her blood sugar was 67 mg/dl [3.7 mmol/L]. I had to force juice down her throat. Within five minutes, she became responsive. I called my endocrinologist who called me back two days later, advising me to stop giving my daughter NovoLog, to continue with 0.5 units Lantus only twice a day. We didn't follow through with that because she usually runs between 150 mg/dl [8.3 mmol/L] and 300 mg/dl [16.7 mmol/L] and is just low a few times a week when she�s very active, misses a snack or is late eating. What do you recommend?

Answer:

There is no way really to answer your questions except for some general advice. The key to excellent control always will be frequent blood glucose monitoring. The best teaching manual is Type 1 Diabetes in Children, Adolescents and Young Adults, Second Edition by Ragnar Hanas, M.D. that will give you lots of good information. Little kids can use insulin pumps and parents can be responsible. We and many others have recommended this frequently. In a honeymoon period, there is not much benefit for all the cost and hassle. If your blood sugars fluctuate between 100 mg/dl [5.6 mmol/L] and 300 mg/dl [16.7 mmol/L], though, I am not sure that this would qualify as a honeymoon phase. Decisions about insulin should be made based upon bracketing and checking pre-food and post-food blood glucose levels and looking to optimize insulin delivery 15 minutes before food to catch the post-meal highs. The Lantus is then used usually twice-a-day (same as Levemir) for basal insulin effect and through the night coverage. But, all the decisions come from analyzing the frequent blood glucose levels to look for patterns. I would suggest going back to the pediatric diabetologist and reviewing all of this in some more detail so that everyone can be working on the same issues together.

As far as which pump to use, every team has individual preferences. All the available pumps are good. Medtronic MiniMed is the only one with an incorporated glucose sensor so that if you are thinking of CGM, then this is the way to go. OmniPod has had problems with shallow catheters in very active people and also with their software downloading. The others (Disetronic/Roche, Animas, Deltec, etc.) do not yet have a CGM sensor available and there continue to be delays that are unexplained with their own sensor technology coming to market. If you want separate sensors, then the DexCom is a possibility as well.

SB