Missed Insulin Meal Boluses and Elevated Hemoglobin A1c Levels in Children Receiving Insulin Pump Therapy

Abstract

ABSTRACT. Objective. To identify possible causes of suboptimal glycemic control (ascertained by hemoglobin A 1c [HbA 1c ] level) in youths using insulin pump therapy.Methods. Forty-eight youths who were receiving insulin pump therapy for >6 months, and who were using insulin pumps and blood glucose meters with data that could be downloaded at our facility, are included in this cross-sectional study. Possible causes of suboptimal glycemic control were evaluated by using 4 information sources: 1) insulin pump data downloads; 2) glucose meter data downloads; 3) patient/family questionnaire about insulin bolusing habits, eating habits, exercise, and blood glucose testing habits; and 4) a physician questionnaire. Physicians completed the questionnaire during the patient interview after reviewing the downloaded information and discussing these results with the patient/family.Results. In a previous report from a general pediatric diabetes clinic, 39% of children changing to insulin pump therapy showed improvement in HbA 1c levels (a decrease Ն0.5%), although 64% either showed improvement (of at least a 1.0% decrease of HbA 1c levels) or maintained a HbA 1c level Ͻ8%. 3 Unfortunately, 20% showed a worsening of their HbA 1c level from a mean of 7.8% to 8.8%. The clinical impression was that missed insulin boluses were a major reason for worsening glycemic control, although insulin pump data downloads were not available to confirm the impression. The purpose of the current study was to identify possible causes of suboptimal glycemic control in youths using insulin pump therapy. METHODSThe first 48 youths seen at our clinic who were using insulin pumps and glucose meters with data that could be downloaded were included in this study. All participants were receiving insulin pump therapy for at least 6 months before inclusion and had attended pump training classes. All had received training on counting carbohydrates for the calculation of mealtime insulin boluses and agreed to perform at least 4 blood glucose tests per day before initiating insulin pump therapy. In addition, all participants were using Medtronic MiniMed (Northridge, CA) insulin pumps, because this was the only type of pump with data that could be downloaded at our facility at the time. A variety of glucose meters were used in this study, all of which had data that could be downloaded at our facility. Before inclusion, participants were required to sign a consent/assent form and complete a questionnaire approved by the Colorado Multiple Institutional Review Board. Parents of youths Ͻ18 years of age also signed the consent form.A questionnaire was developed to identify possible reasons for suboptimal glycemic control in youths using insulin pumps, including missed mealtime insulin boluses, timing of meal boluses in relation to meals, pump disconnection and bolus for exercise, and number of blood glucose tests performed per day. Participants were asked to answer as accurately and honestly as possible and were told that they would not be criticized for their re...

Establishing glycaemic control with continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes: experience of the PedPump Study in 17 countries

“…This is consistent with the findings of a previous study with CSII, which showed a significant correlation between missed mealtime boluses and elevated HbA 1c [21]. Indeed, in the present study the use of more than seven boluses per day was the strongest single predictor of an HbA 1c level <7.5%; similar findings have been reported by Burdick et al [22]. The ability to deliver multiple daily doses represents an important potential advantage of CSII over multiple daily injections.…”

“…Several studies have shown that HbA 1c levels in adolescents are typically >8%, and that reduction is often difficult to achieve in this group [5,24]. Indeed there was a negative association between age and number of boluses, and it is likely that missed mealtime boluses in the adolescent age group contributed to this [22]. In this age group, it could be beneficial to support CSII with a higher basal dose to compensate for missed boluses or additional food intake.…”

The Use of Insulin Pumps in Youth with Type 1 Diabetes

“…17 Cited as the most common reason for missing boluses, ''forgetting'' to bolus is a significant challenge for children and adolescents using insulin pumps. Even missing a bolus for afternoon snacks leads to higher and longer glycemic excursions.…”

Impact of sensing and infusion site dependent dynamics on insulin bolus based meal compensation

“…But even several hours after the meal, slowly absorbed insulin can cause hypoglycemia. With that in mind, it is hardly surprising that many people are struggling to estimate the bolus size (Burdick et al, 2004;Brazeau et al, 2013). Furthermore, occasionally omitted insulin boluses compromise the outcome of the therapy.…”