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September 29, 2004

Insulin Pumps

Question from Clifton, Virginia, USA:

We are trying to convince our doctor to put our 12 year old on an insulin pump. We have a prescription for the pump and, in fact, have been “pumping saline” for about two weeks now following training with the pump company’s representatives. Our doctor is insisting that our son go into the hospital for a minimum of 24 hours for the “changeover” from two to three injections per day to pumping insulin. Our insurance company (I believe rightly) is refusing to authorize a hospital stay. What is the standard of care for transitioning responsible pre-teens to a pump? What might be the medical “logic” for insisting on a hospital stay?


From: DTeam Staff

This question has, purposely or not, been sent to a pediatric endocrinologist who also initiates pump therapy to include a (less than) 24 hour observational stay in the hospital.

The “standard of care” is what your community supports. There is no universally applied standard of care for pumping. As an example, I also used to prescribe saline infusion pumps for a few weeks for my patients as well, so that the patient and families could get used to pressing buttons, making mock bolus changes, changing insertion sites, etc. Now, I simply have them insert a catheter and wear the pump for a few hours? Why? Because I did not find the pump manufacturers willing to “loan” pumps for weeks at a time.

My rationale for a brief observational stay is the following: the basal dosing rates are extrapolated from the child’s “usual” basal doses, factoring in total dose, activities, pubertal status, degrees of insulin resistance, etc. In general, the basal rate comprises about 40 to 60%, typically, of the total daily insulin requirement. There are a number of “Rules of Thumb” to help estimate the doses. But, those are not REAL; wearing the pump and dosing insulin is REAL. While, certainly, most of my patients do well during the overnight stay, I have had several patients whose glucose levels skyrocketed due to catheter/tubing problems. I have had patients who dropped dramatically low as we misjudged the child’s real requirement in the transition from glargine to continuous infusion. Typically I will only progress from a basal-bolus plan using very long and short-acting insulins by injections before pumping. The very long-acting insulin is typically glargine (Lantus).

Not a single family, including those who also wished to avoid the brief hospital stay, regretted it. On your first night, if there is a problem, it is more than just a convenience to have nursing right there to help you walk through all the new logistics of going through the pump to troubleshoot or restart a new catheter. You certainly don’t want to wake up after overnight pumping and find the child in DKA because of a pump issue. It is very easy to slip into DKA while pumping, if the infusion is somehow incomplete or interrupted.

I don’t have any problems with our insurers in the region authorizing this ” less than 24 hour, observational stay.” It is considered and billed as outpatient.

Other options as a compromise? Home health nursing with a qualified nurse? Your being completely capable and willing to stay up all night checking glucose levels hourly to account for basal and post meal checks?

I certainly know of colleagues, in my region, who do not typically hospitalize their pumpers for the first night. I do not have their data from which to draw comparisons. But, as an aside, we have presented our data analysis of the one year outcome of patients who follow my protocol versus that of a former colleague’s (non)-protocol (which is not just different in terms of overnight pump starts), and at one year, we have clinically and statistically lower A1c values. This colleague did NOT typically transition patients to a basal-bolus insulin plan by shots prior to pumping; he went from rather fixed two to three shot regimens straight to pumping such as you are inferring for you. Be careful.

I would presume that your physician, who must have written the prescription for the pump, written a Letter of Medical Necessity for the pump, and has worked with you with the saline infusions and diabetes care to this point and whom you presumably trust and with whom you presumably have good rapport, wants to work with you on this and is your child’s advocate. Why would you resist his/her advice? There is nothing so spectacularly “in it” for them.