Life with continuous subcutaneous insulin infusion (CSII) therapy: child and parental perspectives and predictors of metabolic control

Can continuous subcutaneous insulin infusion improve health-related quality of life in patients with Shwachman-Bodian-Diamond syndrome and diabetes?

We report the first case of the use of continuous subcutaneous insulin infusion (CSII) in a patient with Shwachman-Bodian-Diamond syndrome (SBDS) and diabetes. An Italian boy received diagnosis of SBDS at the age of 7 months (SBDS gene mutation: c.183-184TA → CT and c.258 + 2 T → C in compound heterozygous). The patient presented an impaired psychosocial functioning with difficulties in mental health, body pain experiences, attention deficit disorder, somatic complaints, behavioral and social problems. Total Intelligence Quotient (T-IQ) was within the normal range for age (T-IQ = 109). The patient developed clinical diabetes at the age of 13 years (glycemia 282 mg/dL at 120 min of oral glucose tolerance test, glycosylated hemoglobin level of 7.5%, anti-β-cell antibodies negative; glucagon test yielding a C peptide level at zero-time of 1.5 ng/mL and at 6 min of 2.0 ng/mL). Multiple daily injection therapy with insulin was started. Nevertheless, because of a relevant needle phobia and the recurrent hypoglycemia due to poor nutrition secondary to depression, after 3 years the patient started CSII. After 12 months a new evaluation showed (1) better social adaptation, (2) meliorated self-esteem and self-efficacy, (3) reduced psychosocial suffering, and (4) improved health-related quality of life, assessed by the Pediatric Quality of Life Inventory version 3.0 Diabetes Module. Thus CSII seems to be crucial to improve health-related quality of life in patients affected by diabetes and genetic disorders.

Insulin pump therapy: impact on the lives of children/young people with diabetes mellitus and their parents

BACKGROUND

Advances in medical technology and research documenting clinical effectiveness have led to the increased use of insulin pumps worldwide. However, their use by children in the UK is relatively limited and there is little evidence regarding their impact on patients' lives.

OBJECTIVE

This study aimed to examine the impact of switching from multiple daily injections to insulin pumps on the glycaemic control and daily lives of children/young people and their families.

SETTING

University College London Hospital, London.

METHOD

Face-to-face semi-structured interviews were conducted with children/young people with type 1 diabetes mellitus (5-17 years; N = 34) and their parents (N = 38), receiving insulin pump therapy and attending paediatric diabetes outpatients clinics at a major university teaching hospital in London. Glycated haemoglobin A1c values from 6 months prior to, and after pump therapy were obtained. Qualitative and quantitative approaches were undertaken for data analysis.

MAIN OUTCOME MEASURE

Glycated haemoglobin A1c and the impact of the use of insulin pumps on the children and their families.

RESULTS

The majority of parents (N = 32) and the children/young people (N = 30) reported that glycaemic control was easier to maintain within the target range with pumps compared to injections. This was supported by glycated haemoglobin A1c measures. Participants generally found the devices easy to use and more acceptable than injections. However, parents and children/young people reported many challenges in the early stages of pump therapy (e.g. 7 children/young had worse control at 6 months after starting CSII). Parents and children/young people reported an overall increase in lifestyle flexibility and an improved ability to participate in home, school and social activities whilst maintaining glycaemic control.

CONCLUSION

Administration of insulin via pumps rather than injections was generally preferred. Participants reported most difficulty at the commencement of use. Pump therapy conferred benefits in terms of glycaemic control, general well-being, enabling young people to be more in control of their condition and live more normal lives, as reported by most participants. These are important goals of health policy for children/young people with long-term conditions in the UK.

A 7-year follow-up retrospective, international, multicenter study of insulin pump therapy in children and adolescents with type 1 diabetes

We evaluated the long-term glycemic control in children with type 1 diabetes, using continuous subcutaneous insulin infusion (CSII) for at least 5 years in three diabetes centers from three different countries: Canada, Italy and Spain. This was an observational retrospective multicenter cohort study. Subjects were included if they were followed at one of the participating centers, had type 1 diabetes, age 5-20 years at time of data collection and used CSII for more than 5 years. Data collected included gender, age, disease duration, age at CSII initiation, body mass index (BMI), hemoglobin A1c (HbA1c), insulin requirement and serious adverse events (SAE) at baseline and every 12 months during follow-up. One hundred fifteen patients were included in the study (55% males), aged 5-20 years (mean: 13.5 ± 3.8 years), with mean diabetes duration of 6.3 ± 3.4 years, using CSII for mean of 6.9 ± 1.2 years (range 5-12 years.). HbA1c significantly improved after 1 year of CSII treatment and during follow-up (p = 0.02). When HbA1c was compared between countries, a difference was observed, with slightly lower values in Italy than in Canada and Spain (p = 0.04). When evaluated by gender, HbA1c was similar at baseline, but significantly improved only in males during all follow-up (p = 0.004). No significant differences were observed for BMI, insulin requirement or SAE. Insulin pump therapy is safe and effective in the pediatric population, although in this study, the major benefit in HbA1c was seen in males. The use of advanced pump features was associated with greater improvement in HbA1c.

Insulin pump therapy in children and adolescents: changes in dietary habits, composition and quality of life

AIM

Continuous subcutaneous insulin infusion (CSII) can improve glycaemic control and dietary flexibility compared with conventional insulin therapies. There is little information on whether users are utilising this increased dietary flexibility, and whether dietary quality is affected.

METHODS

A pre-post observational study was undertaken in 28 children and adolescents with type 1 diabetes commencing CSII. Meal pattern and dietary composition was examined from 3-day food diaries completed before and 3-6 months after CSII commencement. Participants completed the Diabetes-Specific Quality of Life for Youth Short Form, and body mass index z-score, and glycated haemoglobin were measured. A second posttest was undertaken at 18 months with those who were still on CSII and contactable (n = 18).

RESULTS

Energy and macronutrient intake before and 18 months after CSII commencement were unchanged. Mean snacking events decreased significantly by 1.2 snacks per day (P = 0.009), as did the percentage energy derived from snacks (28.8%, 95% confidence interval (CI) 21.5-36.1 vs. 19.3%, 95% CI 13.2-25.4; P = 0.045). Diabetes-Specific Quality of Life for Youth Short Form score was not significantly affected by pump commencement (25.9 95% CI 18.2-33.6), and body mass index z-score remained similar before and after CSII. Glycated haemoglobin decreased by 0.5% in the 3-6 months following CSII commencement, but was similar to baseline at 18 months.

CONCLUSIONS

This study demonstrates that the commencement of CSII did not lead to an abandonment of healthy eating principles, and that patients utilised the increased dietary flexibility to make changes to their snacking pattern.

Experiences of children/young people and their parents, using insulin pump therapy for the management of type 1 diabetes: qualitative review

WHAT IS KNOWN AND OBJECTIVE

Advances in medical technology have made insulin pumps an attractive treatment option for patients with type 1 diabetes and in particular for children and young people. Previous studies have accounted the experiences and views of children/young people and their parents for the use of the injection therapy, but very few have focused on the use of insulin pumps. The objective of this review was to identify studies that explore the experiences of children/young people and their parents on the transition from injections to insulin pump therapy, in the context of their social life.

METHODS

A systematic literature search was conducted, and six studies meeting the inclusion and exclusion criteria were identified.

RESULTS

  Views and perspectives from the studies identified mainly focused on: introduction to the pump; reasons for the transition to pump therapy; advantages and disadvantages of this treatment option; and impact on quality of life (QoL). Parents and/or children reported that they learned about pump therapy either formally from a healthcare professional or informally from a friend or the internet. Many reasons were identified for the transition, the most important being the pursuit of stable and controlled blood sugar levels and the desire for a more flexible lifestyle. Participants highlighted the advantages of insulin pumps in terms of improved diabetes control. Moreover, there was a positive impact on the QoL, as insulin pumps provided children greater flexibility in lifestyles especially with regards to meals and socialization. In contrast, psychosocial issues such as pump visibility and physical restrictions were highlighted as disadvantages. Issues such as day-to-day management were also discussed.

WHAT IS NEW AND CONCLUSION

Exploring children/young people's perspectives on the use of pump therapy for managing their diabetes, and parental reflections in caring for those children is important as it provides evidence informing policy for the wider implementation of this technology in the management of diabetes in children. However, the review revealed that there is a scarcity of data in this area and that further research is needed.

Parental involvement buffers associations between pump duration and metabolic control among adolescents with type 1 diabetes

OBJECTIVES

To examine pump duration associations with adolescents' metabolic control and whether parental involvement moderated this association.

METHODS

This study used a cross-sectional sample of 10- to 14-year-olds with diabetes (N = 252, 53.6% female) and parents' reported parental involvement; HbA1c was obtained from medical records. Half (50.8%) were on an insulin pump (continuous subcutaneous insulin infusion, CSII), with the remainder prescribed multiple daily injections (MDI).

RESULTS

Adolescents on CSII displayed better HbA1c than those on MDI. A curvilinear association revealed that participants on CSII for <2 years showed a positive pump duration-HbA1c association, while those on CSII longer showed no association. Parental involvement interacted with pump duration to predict HbA1c. Pump duration was associated with poorer HbA1c only when parents were relatively uninvolved.

CONCLUSIONS

Within the limitations of a cross-sectional design, data suggest that adolescents on CSII have better HbA1c than those on MDI, but may experience a period of deterioration that can be offset by parental involvement.

The experiences of school nurses caring for students receiving continuous subcutaneous insulin infusion therapy

Diabetes mellitus is the most common metabolic disorder in childhood. Today, children with diabetes are receiving new technologically advanced treatment options, such as continuous subcutaneous insulin infusion (CSII) therapy. School nurses are the primary health caregivers of children with diabetes during school hours. Therefore, it is important to determine their perceptions, resources, and resource needs when caring for students with continuous subcutaneous insulin infusion or insulin pump therapy. This study uses a phenomenological approach to examine the experiences of school nurses caring for students receiving insulin pump therapy. Eleven school nurses were interviewed using semistructured taped interviews. The nurses' responses indicated that they were "scared" when first caring for students with continuous subcutaneous insulin infusion therapy. However, they were able to work through their fear by using their resources and gaining more knowledge and hands-on experience with insulin pumps. The data also revealed that school nurses who were able to learn the language of continuous subcutaneous insulin infusion therapy and successfully deal with pump problems developed trusting and knowing relationships with students, teachers, and parents.

Predictors of glycaemic control in patients with Type 1 diabetes commencing continuous subcutaneous insulin infusion therapy

AIMS

To identify variables that predict glycaemic control in Type 1 diabetic patients switched to a continuous subcutaneous insulin infusion (CSII) regimen, in order to improve patient selection for this treatment.

METHODS

The notes of 421 Type 1 diabetic patients aged 2.6-39.8 years (median 19.4) who initiated CSII treatment in 1998-2007 and used it for > or = 1 year were reviewed. Details about their background and disease-related and treatment-related variables were recorded. At pump initiation, the mean age was 15.9 +/- 7.2 years, mean diabetes duration 6.4 +/- 5.8 years. Mean time of CSII use was 4.1 +/- 2.1 years. Good glycaemic control was defined by glycated haemoglobin (HbA(1c)) stratified by age (American Diabetes Association target levels). Improvement in glycaemic control was defined as a reduction of > or = 0.5% in HbA(1c) from baseline. The change in the rate of severe hypoglycaemic or diabetic ketoacidosis events was also determined.

RESULTS

There was a significant sustained decrease in HbA(1c) with CSII for an average of 6 years, without increased rates of hypoglycaemia. Achievement of target HbA(1c) was significantly associated with the following parameters at pump initiation: lower HbA(1c) (P < 0.001), younger age (< 12 years), shorter diabetes duration (P < 0.001) and more frequent daily self blood glucose monitoring (SBGM) (P < 0.01). Improved glycaemic control was associated with longer CSII use (P = 0.032) and higher HbA(1c) at CSII initiation (P < 0.001).

CONCLUSIONS

Switching patients to CSII resulted in sustained decrease in HbA(1c) and improved glycaemic control in patients with high HbA(1c). Young age, frequent SBGM and lower HbA(1c) at pump initiation were identified as predictors of achieving glycaemic targets with CSII.

Long-term benefits of continuous subcutaneous insulin infusion in children with Type 1 diabetes: a 4-year follow-up

AIM

To determine the safety and effectiveness of continuous subcutaneous insulin infusion (CSII) in attaining long-term glycaemic control in paediatric patients with Type 1 diabetes and to compare the results with those previously recorded in the same patients taking multiple daily injections (MDI) (four injections a day).

METHODS

Forty-two patients (mean age 12.2 +/- 3.4 years; range 4.5-17 years; 24 males; mean duration of Type 1 diabetes 5.1 +/- 3.0 years) were studied. The following parameters were assessed in the year before starting CSII treatment (during MDI treatment) and during the 4 years of insulin pump treatment: annual mean HbA1c, insulin requirements (U/kg per day), annual mean of body mass index (BMI) z scores, and adverse events (severe hypoglycaemia and diabetic ketoacidosis/patient per year). Two patients discontinued pump therapy (after 1-year and 2-year follow-up, respectively) because of non-compliance with CSII therapy.

RESULTS

Compared with the annual mean HbA1c observed prior to CSII therapy (8.9 +/- 1.0%), the mean HbA1c levels were lower during the first (8.2 +/- 0.9%; P = 0.00), second (8.6 +/- 1.0%; P = 0.05), third (8.4 +/- 0.9%; P = 0.01) and fourth (8.2 +/- 1%; P = 0.00) year of CSII therapy. The insulin requirements (U/kg per day) decreased during CSII treatment compared with MDI treatment. Compared with the annual mean of BMI z scores prior to CSII therapy, BMI z scores were significantly lower during the third and fourth years of CSII therapy. Through the first, second, third and fourth years of follow-up the number of episodes of severe hypoglycaemia (20.0, 20.0, 20.0 and 0 episodes/1000 patient-years, respectively) and diabetic ketoacidosis (0.05, 0.00, 0.03 and 0.00 episodes/patient per year, respectively), events were similar to that in the year preceding CSII therapy (20.0 and 0.03, respectively).

CONCLUSION

In this population of selected patients in our clinic, CSII appears to be a safe and effective therapeutic alternative to MDI treatment. This therapy may ensure a stable improvement in long-term glycaemic control in paediatric patients, with no increase in diabetic ketoacidosis and severe hypoglycaemic events and, on the other hand, with a trend of reduction in BMI z scores.

Case study: contrasting challenges of insulin pump therapy in a toddler and adolescent with type 1 diabetes

PURPOSE

To describe the challenges and outcomes of continuous subcutaneous insulin infusion (CSII) pump therapy in a toddler and adolescent with type 1 diabetes. Insight into patient-family aspects motivating pump use is provided.

METHODS

Two cases treated at the Pediatric Diabetes Clinic at Yale University.

RESULTS

Upon parental request, CSII was initiated to improve glycemic control in a 4-year-old boy (case 1) with unpredictable food intake. During 68 months of CSII therapy, hemoglobin A1C levels averaged 6.3% +/- 0.6%. Severe hypoglycemic episodes ceased 36 months ago, and occasional postprandial hyperglycemia during early school years was corrected with school nurses' reminders about premeal insulin bolus doses. Currently 9.5 years old, he independently manages all his insulin injections with parental assistance only to change the catheter site. Case 2 is a girl who was nearly 12 years of age when diagnosed with type 1 diabetes. Initially managed with daily injections, hypoglycemic episodes were interfering with her physically active lifestyle. At age 13 years, she elected CSII therapy, and glycemic control improved. Temporarily erratic in the immediate period pre- and postmenarche, metabolic control has since stabilized. At 15 years old, she successfully manages her diabetes independently.

CONCLUSIONS

To optimize glycemic control, CSII can be initiated and used effectively, both in children of all ages and in adolescents with type 1 diabetes. CSII may be ideal therapy for toddlers, with no apparent lower age boundary for initiating CSII; however, the parenting challenges and requirements for supportive education differ between toddlers and adolescents. When disease and pump management are appropriately individualized, CSII therapy can help children with diabetes achieve and sustain glycemic control. Lifestyle flexibility, quality-of-life improvement, and independence can thus begin early in childhood and be maintained throughout young adulthood.