Continuous subcutaneous insulin infusion: Special needs for children

Abstract

Continuous subcutaneous insulin infusion (CSII) is a very common therapy for children with type 1 diabetes. Due to physiological differences they have other requirements for their insulin pump than adults. The main difference is the need for very low basal rates. Even though most available insulin pumps reach a high accuracy at usual basal rates, accuracy decreases for lower rates. In addition, the lowest delivered amount at 1 time is limiting the fine tuning of the basal rate as well as the option for temporary basal rates. Alarms in case of occlusions depend on accumulation of a certain amount of insulin in the catheter, and therefore the time until such an alarm is triggered is much longer with lower basal rates. Accordingly, the risk for hyperglycemia developing into diabetic ketoacidosis increases. The availability of bolus advisors facilitates the calculation of meal and correction boluses for children and their parents. However, there are some differences between the calculators, and the settings that the calculation is based on are very important. Better connectivity, for example with a system for continuous glucose monitoring, might help to further increase safety in the use of CSII in children. When selecting an insulin pump for a child, the features and characteristics of available pumps should be properly compared to ensure an effective and safe therapy.

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies

“…More advanced features of pump therapy include the ability to set temporary basal rates and alter the pattern of bolus insulin delivery. Temporary basal rates allow for adjustments to the usually programmed basal rate: decreasing the delivery in the case of physical activity or increasing doses for situations like inter‐current illness, which may be further exacerbated by steroid therapy as would be used for an asthma exacerbation . Similarly, different preprogrammed basal patterns can be utilized when days of differing insulin sensitivity are predictable, for example, during menstruation in women.…”

“…Similarly, different preprogrammed basal patterns can be utilized when days of differing insulin sensitivity are predictable, for example, during menstruation in women. Bolus doses of insulin can be delivered: (1) immediately, known as a standard or normal bolus, (2) slowly over a certain duration of time, deemed an extended or square bolus, or (3) a combination of the two, that is, a combo or dual wave bolus . Foods that are higher in fat may lead to the need for an extended or combo bolus as the rise in glucose following the meal will be delayed by the high fat content.…”

“…Proportion basal vs bolus insulin delivery In older children and adolescents expect a 50/50 split In children <7 years, basal insulin delivery may make up ~30% to 35% of the TDD …”

Home Use of Day-and-Night Hybrid Closed-Loop Insulin Delivery in Very Young Children: A Multicenter, 3-Week, Randomized Trial

“…In preschool children, insulin infusion rates ,0.1 units/h may be required compared with higher rates of 1.0 units/h and above in adolescents and young adults. Modern insulin pumps allow adjustments of basal rates but are limited by minimum increments of 0.01-0.05 units/h (14), inherent inaccuracies at low infusion rates (15), and temporal silent occlusions (16). Diluting insulin is applied in pediatric diabetes centers to mitigate against these factors, but compelling evidence to support the use of diluted insulin is missing.…”

Continuous Subcutaneous Insulin Infusion Characteristics in Type 1 Diabetes Children and Adolescents in Qatar

“…Advanced CSII features [ 26 ] and the Bolus Wizard function [ 27 , 28 ] can improve glucose control, with patient use of these features reported to vary from 50 to 100%. Our results are similar to these findings, with 92% of the patients in our study using the Bolus Wizard function on a regular basis.…”