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Pediatric Pumps: UW Health Program Expands Options for Children with Diabetes

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MADISON - To five-year-old Aidan McLeod, 50 is a pretty big number. His mother, Laurie, happens to agree.

"Aidan was getting around 50 shots of insulin a week," says Laurie McLeod. "Now that we have the pump, we don't have to do any at all."

Diagnosed with Type 1 diabetes when he was two years old, Aidan made the transition from injections to a pediatric insulin pump in October 2007. He joins hundreds of youngsters who have been a part of UW Health's pediatric insulin pump program, now at the American Family Children's Hospital, which was among the first in the country to place children on insulin pumps, and the only pump program in Wisconsin to put preschoolers and elementary age children on the insulin pump.

"About half of our pediatric diabetes patients are on the pump," says UW Health pediatric endocrinologist Michael MacDonald, MD. "When both the child and parent are motivated to gain better control over blood sugar, this can be an incredible benefit to their physical health, mental health and overall quality of life."
 
About the size of a pager, a pump delivers a steady basal rate of insulin 24 hours a day. The basal rates are pre-programmed to rise and fall during the day to correspond with different levels of activity - an average 10-year-old might have between five and eight changes each 24-hour period. Insulin is delivered through a thin piece of flexible tubing worn subcutaneously in the thigh or buttocks for younger children, or the abdomen for older children and teens.

Programmable Insulin Pump a Good Fit for Kids
 
In addition to the basal rate of delivery, the child or parent can program the pump to deliver an instant bolus of insulin at any time to accommodate meals and snacks, based on grams of carbohydrates consumed.

"This makes the pump a good fit for younger children, who are often picky eaters or grazers," says clinical nurse specialist Sue Cornwell, a part of the team that launched the pediatric insulin pump program at UW Health in 1981. "With the pump, children can eat when they're hungry, instead of on a regimented schedule."

Managing a pediatric insulin pump still requires close attention to detail. Dr. MacDonald, along with UW Health pediatric endocrinologists Ellen Connor, MD, and M. Tracy Bekx, MD, say they look for children and parents who already have good diabetes management habits before assessing appropriateness for the pump.

"Parents or kids who are knowledgeable about insulin adjustment and who already check blood sugars regularly are good candidates," Dr. Connor says. "The pump doesn't cure diabetes, but it does make living with it easier if you are willing to put in the work."

That work includes counting every gram of carbohydrate the child eats and testing blood sugar at least four to six times a day to ensure the basic plan and the pump are working correctly. Dr. Connor notes that a kink in the tubing, slipped needle or empty insulin reservoir can cause blood sugar and ketone levels to steeply climb within three or four hours.

Three-Hour Insulin Pump "Boot Camp"
 
Before they are placed on a pump, parents and older children go through a three-hour "boot camp" that covers wearing, using and troubleshooting the pump. At that point they are allowed to take it home for a one-week trial, using saline instead of insulin. If the child is comfortable with the pump and parents confident with calculating and administering the bolus, they receive another one to two hours of education before transitioning fully to using the pump with insulin.

Cornwell says she cautions parents to be realistic about their expectations with the pump.

"There will still be fluctuations in blood sugar, still some highs and lows. It's like a teeter-totter. On one side we have what reduces blood sugar: insulin and exercise. On the other is everything that raises blood sugar: food, stress, illness, puberty and more. You're never going to get it perfectly balanced."

Newer insulin pumps are accompanied by a quarter-sized glucose monitor, which is also worn subcutaneously and can warn when blood sugar levels are dropping or rising as well as help calculate the appropriate bolus based on carbohydrate grams. The current monitors cannot, however, direct the pump to administer the bolus … yet.

"That's closing the loop, an artificial pancreas," Dr. MacDonald says. "We aren't there just yet. The technology is developing quickly, though - if the algorithms for blood sugar and insulin delivery are improved, it's not impossible to think we might see that even in the next five or 10 years."

Both the pump and the monitor have a built-in memory, allowing the physician to access the child's recent history of blood sugar levels and insulin use. That, combined with regular HbA1c level checks, allow for thorough follow-up care.

"It's a great tool for the right person at the right time," Dr. Bekx says. "If they're willing to see it through, it can really improve the quality of life for both the child and his or her parents."

For more information about the pediatric diabetes clinic and the pediatric insulin pump program at UW Health, call (608) 263-6420.
 
Date published: 4/28/2008