Diagnosed at the beginning of July, my son was started on NPH and NovoLog. My husband and I are in the process of trying to get him on an insulin pump for better management and a bit more freedom. My husband and I are both healthcare professionals and are aware of the work needed for an insulin pump. Our pediatric endocrinologist is open to starting my son on a pump, but he seems to want to wait until the honeymoon period is over. We would rather start him on a pump as soon as possible. Is there any reason why waiting may be better?

Well, I have to admit that I favor the approach suggested by your pediatric endocrinologist, although I certainly know colleagues who would start pumping sooner. I know of colleagues who will immediately start a child with type 1 on a pump.

My philosophy is as follows:

The learning of diabetes management (even to health care professionals) is overwhelming. Just as you would not give a middle schooler an algebra book and have him start on chapter 10 (because you need chapters 1 to 9 first), an insulin pump is not easy. You first have to be reintroduced to your child as to his/her activities, dietary (changes), and effects of insulin on the newly diagnosed diabetes. The majority of new onset type 1 patients enter the so-called “diabetes honeymoon” in the first weeks into the diagnosis. During this time, insulin requirements often decrease considerably. Experience shows that too often, patients (and their families – whether healthcare professionals or not) get a bit complacent during the honeymoon, which can last for several months. During this time, a LOT of bad habits can be picked up (such as moderate meal plan faux pas) which get “masked” by the honeymoon. But, when the honeymoon ends, they lead to major issues with diabetes management. (“We’re not doing anything different, but my child’s diabetes is SO out of control!”) And THAT is the problem: such parents do not do anything different – but they must! They need to learn correct management from the start and learn to make adjustments.

This is especially true for an insulin pump, which, I must emphasize, is NOT an artificial and mechanical pancreas. It simply is a device, albeit a sophisticated and good device, through which to administer insulin. It does not adjust the doses based on blood glucose. How will you learn to know how to adjust dosages if you start with a pump? What would you do if the pump fails? They do fail; insertion sites become dislodged or the tubing leaks or kinks. Serious diabetic ketoacidosis (DKA) can occur within hours in a pumper whose pump is malfunctioning. How do you know which pump and the associated features would fit best for you and your child?

Your pediatric endocrinologist prescribed your son NPH (as a basal insulin) and NovoLog as the bolus insulin. Are you learning to count carbohydrates? Are you dosing the NovoLog for each meal/snack? If your son is getting NPH at breakfast time, he may not be prescribed NovoLog at lunchtime. If so, who will be in charge of dosing at lunch when he is on the pump? What about so-called Untethered Regimen? (You probably don’t know what that is yet, because you are so new to the game.) There are so many possible nuances, including how will your child react to being constantly attached to a machine. Experience has shown that too often, parents push for pumps before the child is ready. The pump is about a $6000 investment. You can do a very similar, but not the same, job with a basal-bolus insulin plan for a fraction of the cost and probably with less risk for DKA in an active preschooler.

I previously reported my clinical study whereby I compared overall glycemic control in two groups of patients: The first group consisted of type 1 patients switched from an NPH and short-acting regimen to a pump while the second group consisted of type 1 patients who either started a basal-bolus (by injection) regimen or who were on NPH/short-acting and switched to basal-bolus regimen BEFORE they were switched to pumps. Group Two, who had some good basal-bolus experience before they pumped had better glycemic control – as judged by HbA1c values – after one year of pumping. The first group had higher HbA1cs at six months and certainly at 12 months compared to the basal-bolus ready Group Two. Granted, I did not study a group who pumped from the start. Nevertheless, it seemed that a minimum of six months experience with basal-bolus insulin was needed.

Depending on many factors, you and your child may do well with pumping sooner, but I wouldn’t push it.

I could go on with my point of view. Write again if you have follow up.

Keep in mind that YOUR pediatric endocrinologist has traveled this trip many times. Let him/her guide you since they probably know a lot of road hazards. I am not aware of any data that show that pumping from the start leads to better glycemic or complication outcomes than less sophisticated modalities.

DS