Pediatric insulin pumps are changing the face of childhood diabetes worldwide, and The Montreal Children's Hospital is leading the way with this technology in the province of Quebec.
"We prescribe more pediatric insulin pumps than any other hospital in the province, and we're getting referrals from all over Quebec because of our efficient protocol," says Anne Bossy, nurse educator at the diabetes clinic of The Children's.
The scientific evidence is mounting in favour of insulin pumps - not only because they offer a vastly improved quality of life for people with diabetes, but also because of their superiority over insulin injections in maintaining near normal blood sugars, regardless unpredictable changes in a patient's eating habits or activity levels.
And early control of fluctuating blood sugar and hemoglobin A1c levels (HbA1c) is now universally accepted as the key to the reduction and delay of future complications such as retinopathy, nephropathy, neuropathy and cardiac problems, says Dr. Laurent Legault, head of the clinic.
"Probably the most prominent advantage of insulin pumps is improved quality of life and this is not a minor thing, it is ver dramatic," he says. "Under the classic regimens, many patients feel deprived of a normal lifestyle because they're somewhat enslaved to strict meal and snack schedules, whereas they can have a much more spontaneous lifestyle with the pump."
Insulin pumps, which are computerized devices not much bigger than a pager, deliver a steady infusion of fast-acting insulin analogue through a cannula which is inserted subcutaneously. This infusion, called the "basal rate", is used to cover hepatic glucose output, with the goal of maintaining a patient's blood sugar level between 4 and 6 mmol/L in the absence of food intake. The patient then administers a "bolus" of insulin (units of insulin per grams of carbohydrate consumed) to cover carbohydrates consum d during meals and snacks.
The pump's superiority in maintaining blood glucose within a more desirable range comes from its virtually constant delivery of fast acting insulin - in contrast to the classic injection regimen, which includes both fast-acting, but also the long-acting, or "NPH" insulin.
"Patients on two to three daily insulin injections start the day with a large pool of "N" insulin, which is very unpredictable. The absorption rate can be very erratic," says Bossy. "In contrast, the pump's basal rate is pre-set, so it's predictable, and you have the power to adjust it at any given time during the day, during exercise for example. As a result, pump patients have less frequent and less severe hypoglycemia - and because they're precisely dosing their insulin according to their meals, they have less post-prandial hyperglycemia as well." Even people who are on the "multiple injection" regimen cannot achieve the level of control or the quality o life that is possible with the insulin pump, she adds.
Both the basal rate and the bolus ratio of any given pump are individualized according to the patient's needs.
"We start with a very careful analysis of the patient's blood sugars during the initial phase of pump therapy, to determine their basal rate profiles, and bolus ratios," says Bossy. "This means asking patients to take 10 blood sugar readings over 24 hours, for a period of about one month" She says unlike some hospitals, which may require
patients to be hospitalized during this set-up period (thus creating long waiting lists for new pump patients),
staff at The Children's clinic are comfortable with patients faxing, phoning or e-mailing their blood sugar levels into the clinic. "We believe in being flexible to the needs of the individual and the family."
Before beginning insulin therapy on the pump, patients are given a trial of saline, while they continue their insulin injections. This is to familiarize them with wearing the device, and with changing the insertion site ñ which is done every two to three days. Once the first catheter change has been supervised at the clinic, and insulin is started in the pump, the patient is then followed with daily phone calls. Bossy says the starting basal rate and
bolus ratio are continually monitored and adjusted at the beginning, until the ideal formula is reached on "it usually takes about four weeks."
It is this familiarity with insulin pumps, shared by all the staff, that puts The Children's diabetes clinic ahead of all other pediatric diabetes clinics in Quebec.
"About 10 percent of our patients are on pumps right now, and what is significant is that the numbers are
rising quickly," she says. "Many clinics do not have a full protocol because they may have only five or 10 "pumpers", and may often have only one physician and no nurses to follow these patients. In contrast, our entire team of physicians and nurses is comfortable with the pump, and we are actively recruiting new patients."
The protocol includes the following contraindications for pump therapy: 1) learning problems in either the
patient or the parents; 2) concomitant illness; 3) frequent diabetic ketoacidosis (although some
experts argue that this is actually an indication for the pump); 4) infrequent blood glucose monitoring;
5) infrequent rotation of injection sites; 6) extreme fear of hypoglycemia; 7) psychological problems, and; 8) eating problems such as anorexia or bulimia.
Insulin pumps are not covered by Quebec Medicare and cost approximately six-thousand dollars per unit, plus an additional $250 to $350 per month for supplies.
"Fortunately, most private insurance companies today will cover from 80 to 100 percent of these costs, " says
Bossy.
But whether it's through insurance coverage or entirely an out-of-pocket expense, Bossy and Dr. Legault agree that for the appropriate patient, the cost of an insulin pump is well worth the dramatic improvement it brings to quality of life.
"I have one patient who is nine years old and when he got his pump he declared that he didnít have diabetes any more because he could eat four waffles with maple syrup for breakfast. That's what it feels like for a patient, and that's priceless," says Bossy.
Insulin Pump Program
Tel: (514) 412-4400 ext. 22860
