Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. 682 (doi:10.1542/peds.2008-1505)

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LETTER TO THE EDITOR

Safety of Insulin Pumps, Even in Adolescent Use, Depends on Thorough Patient Selection, Evaluation, and Education

Lois Love Exelbert, RN, MS, CDE, BC-ADM
Diabetes Care Center,
Baptist Hospital of Miami,
Miami, FL 33176

To the Editor.—

I found the report presented by Cope et al¹ to be interesting but fear that the conclusions drawn could deprive many of the benefits of pump technology,^2,3 particularly adolescents. The reasons are:

1. The report combining insulin pumps and patient-controlled analgesia pumps presumed that technology is the key factor. Not so. Plus, there is little similarity between adolescents using patient-controlled analgesia to those needing insulin to sustain their lives. We have assisted children, adolescents, and adults to use insulin pumps ever since the inception of this technology. They have all done well, but technology is the least of the considerations.
   
2. This report offered no analysis of the type of education received by the adolescents studied, only that "education" was one of the factors that may have contributed to adverse events. We require a very stringent and multifaceted evaluation, along with education prerequisites, before finally scheduling a patient and family members⁴ for an all-day pump initiation.
   
3. The many factors assessed included their commitment to the rigors of living with diabetes, such as (but not limited to) testing blood glucose levels many times a day (no pump at this time will automatically do that); counting carbohydrates to administer appropriate mealtime doses of insulin; successful approximation of the effects of exercise; and successful recognition and treatment of hypoglycemia.⁵ Then there's the emotional, psychological, and capability evaluation before even beginning to teach the hands-on technology of preparing, inserting, and programming an insulin pump.
   

This expensive device is often covered by third-party payers. None that we are familiar with require a thorough evaluation by certified diabetes educators before authorization. The presumption that this is adequately handled by physicians who write the prescriptions or by companies that sell the pumps is erroneous. We have seen horrendous pump habits in patients who come to us for the first time who were merely taught button pushing.

In conclusion, I hope all of the above factors are considered in insulin-pump initiation. Insurance companies would be wise to protect their investment and require a "pump certification" before covering this type of device. Perhaps insulin-pump companies, too, will realize it is in their financial, legal, and ethical interest to require such a certification and not be so eager to "sell" their product to anyone who asks for it. Not only might we reduce the exorbitant cost of health care, we might also save a few lives—what a unique thought!

REFERENCES

1. Cope JU, Morrison AE, Samuels-Reid J. Adolescent use of insulin and patient-controlled analgesia pump technology: a 10-year Food and Drug Administration retrospective study of adverse events. Pediatrics. 2008;121 (5). Available at: www.pediatrics.org/cgi/content/full/121/5/e1133
2. Boland EA, Grey M, Oesterle A, Fredrickson L, Tamborlane WV. Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes. Diabetes Care. 1999;22 (11):1779 –1784[Abstract/Free Full Text]
3. Bode BW, Tamborlane WV, Davidson PC. Insulin pump therapy in the 21st century: strategies for successful use in adults, adolescents, and children with diabetes. Postgrad Med. 2002;111 (5):69 –77[Medline]
4. Weissberg-Benchell J, Goodman S, Lomaglio JA, Zebracki K. The use of continuous subcutaneous insulin infusion (CSII): parental and professional perceptions of self-care mastery and autonomy in children and adolescents. J Pediatr Psychol. 2007;32 (10):1196 –1202[Abstract/Free Full Text]
5. Jansa M, Vidal M, Conget I, et al. Therapeutic education regarding type 1 diabetes: initiation of continuous subcutaneous insulin infusion. Diabet Med. 2007;24 (12):1419 –1423[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Exelbert, L. L. Search for Related Content PubMed PubMed Citation Articles by Exelbert, L. L. Related Collections Endocrinology Social Bookmarking                         What's this?