Continuous Subcutaneous Insulin Infusion In Children Research Articles

Use of continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes mellitus: a systematic mapping review

BackgroundAmong the treatments for type 1 diabetes mellitus (T1DM), Continuous Subcutaneous Insulin Infusion (CSII) is a device that infuses insulin through the subcutaneous tissue in an uninterrupted manner and that comes closest to the physiological secretion of insulin. The use of CSII can provide the family with greater security and children and adolescents have more autonomy in relation to the treatment of T1DM. There is a lack of reviews that systematically gather the mounting evidence about the use of CSII in children and adolescents with T1DM. Therefore, the aim of this review was to group and describe primary and secondary studies on the use of CSII in children and adolescents with T1DM.MethodsA systematic mapping review was performed based on searches in the following databases: PubMed, Embase, CINAHL, Lilacs and PsycINFO, using a combination of descriptors and keywords. The screening of the studies was carried out with the aid of the Rayyan software and reading in full was conducted independently by two reviewers. The data extraction of the studies was performed using an extraction tool adapted and validated by researchers specialized in diabetes. The data were analyzed according to the content analysis technique. The map from geocoding of the studies was produced using the ArcGis 10.5 software.ResultsA total of 113 studies were included in the review, including primary studies, literature reviews and gray literature publications. The content analysis of the results of the studies allowed for the identification of four categories: 1) metabolic control; 2) support networks; 3) benefits of using CSII; and 4) challenges of using CSII, each category having its respective subcategories. The review also made it possible to conduct a rigorous mapping of the literature on the use of CSII considering the location of development and the design of the studies.ConclusionsThe use of CSII should be indicated by health professionals able to prepare children, adolescents, and their families for the treatment of T1DM, and, despite being a technological device, it may not be suitable for the entire pediatric population.

Длительный гликемический контроль и факторы, ассоциированные с ответом на помповую инсулинотерапию у детей

Background : In recent years, pump-based insulin therapy, also known as continuous subcutaneous insulin infusion (CSII), has become a common treatment for children with type 1 diabetes mellitus (T1DM). Despite the fact that, in general, children with type 1 diabetes achieve the best glycemic control indices during pump therapy, while there is a significant heterogeneity of metabolic outcomes among individual patients, many children with CSII do not reach the target level of HbA1c. Objective: To assess the level of glycemic control and factors associated by withdrawal of use, the response to treatment with prolonged use of CSII in children with type 1 diabetes. Materials and methods : The study included 458 children aged 1 to 18 years, treated to pump therapy at least 3 years before the study, the presence of the analyzed data in the register. Results: The level of HbA 1c decreased by -0.7% compared with the primary endpoint, which was accompanied by an increase in the number of patients who reached the target level of HbA 1c (<7.5%) from 17% to 36%. The best response was observed for patients under 6 years of age with HbA 1c over 9% for pump insulin therapy, as well as in patients who regularly use additional bolus and basal functions and CGM. The main reason for stopping the use of the insulin pump is the inconvenience of using and wearing — 47.7%. Risk factors for pump abandonment: later age of start treatment on CSII and frequent episodes of severe hypoglycemia. Conclusion: According to the results of the study, it was shown that pump therapy is an effective method of insulin therapy, which allows to achieve a lower level of HbA 1c compared to the initial values.

Systems of continuous subcutaneous insulin infusion to maintain metabolic compensation for type 1 diabetes mellitus among children and adolescents

BACKGROUND: Insulin pumps (IP) are a widespread treatment for type 1 diabetes mellitus (T1D) in children because of its several advantages over multiple insulin injection regimens (MII). However, the long-term effectiveness of continuous subcutaneous insulin infusion (CSII) in achieving and maintaining sustained metabolic compensation remains controversial.&#x0D; OBJECTIVE: To determine the factors affecting the long-team effectiveness of CSII in children and adolescents with T1DM in real clinical practice.&#x0D; METHODS: Data of 239 children and adolescents treated with CSII for 3 years were examined during the registration of patients receiving insulin pump therapy in Saint-Petersburg was formed. HbA1с level changes over time were analysed before switching to CSII and were assessed depending on sex and age, baseline HbA1с level and factors as the frequency of using continuous glucose monitoring (CGM), temporary transitions from CSII to MII with injection pens and use of bolus calculators (BC).&#x0D; RESULTS: The final HbA1с value showed no significant changes as compared with the HbA1с level before switching to CSII (baseline, 7.821.46%; final, 7.931.30%). Approximately 42% of patients had HbA1с level of 7.5%. Better results were observed in the 4.57-year age group, where 67% of patients had HbA1с level of 7.5%; in 1218-year age group, only 35% of patients reached the target HbA1с level. Majority of patients with baseline HbA1с level of 7.5% remained within the target level during the final examination, whereas only 23% of patients with HbA1с level of 7.5% before switching to CSII reached the target level. Better glycaemic control was also observed in patients treated with CSII regularly, as compared to patients who periodically switched to MII with the injection pen (p0.05). HbA1с appeared to be lower in the group of 1218-year-old adolescents who used CGM regularly, as compared to the group not treated with CGM (p0.05).&#x0D; CONCLUSION: Children and adolescents treated with CSII for 3 years did not experience a significant improvement in metabolic control. However, the influence of factors in maintaining the metabolic control, such factors as the patients age, initial HbA1с level, CGM use and frequency, and the presence or absence of changes in insulin therapy regimen is observed.

Health-related quality of life in paediatric patients with Type 1 diabetes mellitus using insulin infusion systems. A systematic review and meta-analysis.

BackgroundIn 2017, more than 1.1 million children were living with type 1 diabetes mellitus (T1DM) globally. The goal in paediatric diabetes therapy is reaching optimal glycaemic control as early as possible in order to avoid complications and early mortality without compromising the quality of life (QoL) of children. Several different insulin regimens are available for T1DM patients to reach this goal.AimsThis review set out to analyse whether continuous subcutaneous insulin infusion (CSII) regimens are superior to multiple daily injection (MDI) therapy in T1DM youth regarding QoL. Additionally, it assessed glycaemic control and adverse events as secondary outcomes and discussed potential future public health implications and justifications for using CSII as a first-line therapy in diabetic youth.MethodsA systematic review and random effects meta-analysis was performed on studies investigating the association between QoL and diabetes treatment regimen. Differences in adverse event rates between groups were analysed using a Mann-Whitney U test. Lastly, differences in glycaemic control were assessed using a random effects meta-analysis.ResultsQoL and glycaemic control was significantly better in CSII subjects at baseline and follow-up. No significant differences in adverse events were found between study groups. No significant changes over time could be shown for either QoL or glycaemic control.ConclusionCSII proved to provide similar or slightly better outcomes in all analysed fields. This is consistent with previous research. However, to make credible recommendations, better-designed studies are needed to investigate the impact of CSII in children.

Free-living use of artificial pancreas for children with type 1 diabetes: systematic review

BACKGRAUND: A closed-loop glucose control system or artificial pancreas consists of three components a Continuous Glucose Monitor (CGM), infusion pumps to deliver hormone(s) and a sophisticated dosing algorithm to control hormone delivery. In the past years, numerous studies with closed-loop system devices were conducted with gradual shift to out-of-hospital environment and with lengthening study duration.&#x0D; AIMS: To compare efficacy and safety of closed-loop insulin pump use in children with type 1 diabetes mellitus in compare with conventional insulin treatment (continuous subcutaneous insulin infusion (CSII) with our without CGM) based on randomized control trials data (RCT).&#x0D; METHODS: In the systematic review we have include 28 randomized controlled trials results indexed in PubMed, Medline databases published till 15 June 2017. The efficacy on metabolic control in this study evaluated by the proportion of time within target range (preferably 70 to 180 mg/dl if reported) and mean (median) glucose based on sensor measurements, and the safety evaluated by time in hypoglycemia (below 70 mg/dl if reported).&#x0D; RESULTS: Increased time in range in the night period was observed in all RCT. Only 3 RCT showed decrease of the time in range within 24 h evaluation period. In one RCT the significant positive differences have been shown in the time in range for dual hormone closed-loop glucose control system in compare with insulin-only artificial pancreas. Mean glycaemia and glucose variability changes were not in the same manner in different RCT, both in the night only and in 24 h estimation period. Night hypoglycemia duration decreased in most RCT with closed-loop control in compare with CSII, and increased only in 2 RCT. When all-day estimation period the time in hypoglycemia changed not in the same manner in different RCT. Valuable methodology differences of the glycaemic control estimation within observed RCT brought significant complications in the data analysis and made impossible the results quantitative estimation to prepare a metaanalysis.&#x0D; CONCLUSIONS: Much work has been done to develop effective and safe artificial pancreas, but not all RCTs confirmed advantages of closed-loop glucose control in compare with CSII in children and adolescents in real life. More research with prospective randomized control design required to prove benefits of closed-loop glucose control. Further RCTs should have an uniform methodology for glycemic control assessment and long duration that will allow to use cumulative measures in a closed-loop efficacy estimation (HbA1c).

Continuous subcutaneous insulin infusion: Special needs for children.

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.

Amélioration des fonctions cognitives de l’humeur et du comportement des enfants diabétiques de type 1, suite à l’initiation d’un traitement par pompe à insuline sous-cutanée

Aims/hypothesis Anecdotally, parents and teachers of children with type 1 diabetes mellitus report improvements in behaviour and learning following the commencement of continuous subcutaneous insulin infusion (CSII). This study aimed to investigate changes in cognition, mood and behaviour following commencement of CSII in children with type 1 diabetes.

Improvements in cognition, mood and behaviour following commencement of continuous subcutaneous insulin infusion therapy in children with type 1 diabetes mellitus: a pilot study

Anecdotally, parents and teachers of children with type 1 diabetes mellitus report improvements in behaviour and learning following the commencement of continuous subcutaneous insulin infusion (CSII). This study aimed to investigate changes in cognition, mood and behaviour following commencement of CSII in children with type 1 diabetes. Children (n = 32) with type 1 diabetes aged 6-16 years and starting CSII at two Australian centres underwent behavioural, cognitive and glycaemic assessments prior to the commencement of CSII and 6-8 weeks after its start. A comprehensive cognitive test battery was administered, comprising measures of intelligence, attention, processing speed and executive skills. Behaviour and mood were assessed using the Behaviour Assessment System for Children--Second Edition. Continuous glucose monitoring was performed over a 72 h period and HbA(1c) was measured at both time-points. After commencement of CSII, there were significant improvements in HbA(1c), a reduction in hyperglycaemia and blood glucose variation and an increase in normoglycaemia. Significant improvements were observed in perceptual reasoning, selective attention, divided attention, cognitive flexibility and working memory. Fewer mood-related symptoms were reported (parent, teacher and self-report) and fewer behavioural problems (parent reports) In this uncontrolled pilot study, children with type 1 diabetes demonstrated significant improvements in measures of metabolic control, mood and behaviour and in some complex cognitive skills after commencing CSII therapy.

NICE 2008 guidelines on continuous subcutaneous insulin infusion therapy and their impact on management of specific patient populations

Introduction We face a new chapter in the delivery of insulin in the management of type 1 diabetes. Continuous subcutaneous insulin infusion (CSII), or ‘insulin pump’, therapy may improve glycaemic control in some patients. It has a number of significant benefits over multiple daily injections for many patients, especially children, pregnant women and sports people. While these benefits have been supported and embraced by specialist CSII centres scattered across the UK, generally the use of CSII has been much lower in this country than in many others in Europe and North America. This is likely to change following the recent publication by the National Institute for Health and Clinical Excellence (NICE) of updated guidelines for CSII use. Accordingly, this supplement focuses on the implications of these guidelines for the management of various groups in the UK. Focusing on children with diabetes, Dr David Kerr (Bournemouth, UK) describes the current status of CSII use in the UK. He also reviews the new guidelines and the opportunities and challenges that they present for diabetes care delivery in the UK. Dr Fiona Campbell (Leeds, UK) outlines the pros and cons of CSII therapy in the paediatric population and the practical considerations when choosing and initiating CSII in children. Finally, Dr Peter Hammond (Harrogate, UK) discusses the use of CSII during pregnancy, surgery and exercise, and the associated role of continuous glucose monitoring. The new NICE guidelines are an important step forward in diabetes care. It is hoped that any historical limitations on CSII use will be reconsidered and the full benefits of the technology will be realised. Br J Diabetes Vasc Dis 2008; 8: (Suppl 1) S1

Review: The pros and cons of continuous subcutaneous insulin infusion (CSII) therapy in the paediatric population and practical considerations when choosing and initiating CSII in children

CSII (continuous subcutaneous insulin infusion), has the potential to improve long-term glycaemic control in many patients with type 1 diabetes. CSII may also reduce the incidence of hypoglycaemic episodes, especially in patients prone to hypoglycaemia, and may reduce glycaemic variability. A pivotal advantage of CSII over MDIs (multiple daily injection), especially in children, is its superior convenience and flexibility. Programmable basal rates are delivered automatically and with unprecedented precision, while bolus doses can easily be used to titrate insulin exposure around meals and activities and to correct hyperglycaemia. The subcutaneous cannula needs to be re-sited only once every 2—3 days. In light of these advantages, CSII is generally preferred by children and parents. Careful patient selection is crucial, however, as CSII users and their carers must be willing and able to use the equipment correctly, as well as to perform general aspects of intensive self-care. Accordingly, CSII should be initiated only by a specialist, multidisciplinary team and in conjunction with a structured, ongoing educational and monitoring programme. Factors affecting the selection of a particular pump include the size and weight of the device, ease of use, range of dose modes and increments, cost, warranty and customer services.

A Randomized Trial Comparing Continuous Subcutaneous Insulin Infusion of Insulin Aspart Versus Insulin Lispro in Children and Adolescents With Type 1 Diabetes

The safety and efficacy of insulin aspart continuous subcutaneous insulin infusion (CSII) was compared with that of insulin lispro CSII in children and adolescents with type 1 diabetes. Children and adolescents aged 4-18 years with diagnosed type 1 diabetes >or=1 year previously and treated with insulin analog in a CSII >or=3 months were randomly assigned 2:1 to 16 weeks of insulin aspart CSII (n = 198) or insulin lispro CSII (n = 100) in this open-label, parallel-group, multicenter study. Standard diabetes safety and efficacy parameters were assessed. Baseline demographics, subject characteristics, and diabetes history were similar between treatment groups. After 16 weeks of treatment, insulin aspart CSII was noninferior to insulin lispro CSII as measured by change in A1C from baseline (aspart, -0.15 +/- 0.05%; lispro, -0.05 +/- 0.07% [95% CI of the treatment difference -0.27 to 0.07]; P = 0.241). No significant differences between treatment groups were observed in fasting plasma glucose, hyperglycemia, and rates of hypoglycemic episodes. At week 16, 59.7% of subjects in the aspart group and 43.8% of subjects in the lispro groups achieved age-specific American Diabetes Association A1C goals (<8.5% for subjects aged <6 years; <8% for subjects aged 6-18 years) (P = 0.040, corrected for baseline). Daily insulin dose (units per kilogram) was significantly lower at week 16 for subjects treated with aspart compared with those treated with lispro (0.86 +/- 0.237 vs. 0.94 +/- 0.233, P = 0.018). Insulin aspart was as safe and effective as insulin lispro for use in a CSII in children and adolescents with type 1 diabetes.

Indications for insulin pump therapy in different age groups—an analysis of 1567 children and adolescents

The German working group for pump therapy in paediatric patients has defined seven indications for continuous subcutaneous insulin infusion (CSII): dawn phenomenon, reduction of severe hypoglycaemia, improvement of hyperglycaemia, more flexibility, motivation, failure of injection therapy and pregnancy. In this study we analysed age-specific differences for starting CSII in four age groups (group A: 0-4 years; group B: 5-9 years; group C: 10-14 years; group D: 15-19 years). We also investigated whether glycaemic goals could be reached. A total of 1567 children and adolescents (mean age 12.4 years, mean diabetes duration 5.2 years) with documented indications for CSII from the DPV-database (December 2005) were included. Dawn phenomenon (27.4%), reduction of hypoglycaemia (20%) and improvement of hyperglycaemia (18.1%) were the commonest indications for starting CSII. Indications differed by age group (P < 0.0001). In infants and toddlers (group A, n = 138) reduction of hypoglycaemia (42.5%) was the commonest indication. For adolescents (group C, n = 789/group D, n = 408) dawn phenomenon (32.1/21.7%) and flexibility (21.7/25.8%) were the main indications. The rate of severe hypoglycaemia with coma in patients commencing CSII in order to reduce hypoglycaemia fell (12.1/100 patient years before CSII vs. 5.8 after 1 year, 4.49 at study end). Glycated haemoglobin (HbA(1c)) in patients with the treatment goal 'improvement of hyperglycaemia' was lowered significantly in the first year of CSII (HbA(1c) start: 8.8%; after 1 year: 8.5%, P < 0.01) and was stable thereafter (8.8% after 36 months). CSII in children and adolescents is safe and can reduce the rate of severe hypoglycaemia without deterioration in glycaemic control. In patients with poor glucose control, a significant reduction in HbA(1c) can be achieved in the first year.

Factors Correlating With Improved A1C in Children Using Continuous Subcutaneous Insulin Infusion

The Diabetes Control and Complications Trial demonstrated that tight metabolic control in patients with type 1 diabetes reduces the risk of microvascular complications (1). Subsequently, the use of continuous subcutaneous insulin infusion (CSII) to achieve strict metabolic control increased exponentially. The advantages of CSII over multiple daily injections include increased lifestyle flexibility, variable basal infusion rates with boluses given before meals, and only one injection for insulin administration every few days (2). CSII in children lowers A1C and decreases hypoglycemia (3,4). The American Diabetes Association recommended A1C treatment goals for pediatric patients of 7.5–8.5% for those aged <6 years, ≤8% for those aged 6–12 years, <7.5% for those aged 13–19 years, and <7% for those aged 19–22 years (5), but few children and adolescents reach these goals. The reason for this remains unclear. We conducted this study to determine the percentage of children using CSII who reached their A1C goal and to identify differences between children who met their goal and those who did not. Medical records of all patients (aged 2–22 years, n = 236) with type 1 diabetes for ≥1 year using CSII for ≥6 months who were followed at the University of Wisconsin pediatric diabetes clinic were reviewed. Data from the time of initiation of CSII were analyzed. Age, duration of diabetes, …

The renaissance of insulin pump treatment in childhood type 1 diabetes

Current goals for the treatment of children and adolescents with type 1 diabetes mellitus include achieving near-normal blood sugar levels, minimizing the risk of hypoglycemia, optimizing quality of life, and preventing or delaying long-term microvascular and macrovascular complications. Continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, provides a treatment option that can assist in the attainment of all of these goals in all ages of children. In pediatric patients, CSII has been demonstrated to reduce both glycosylated hemoglobin levels and frequency of severe hypoglycemia, without sacrifices in safety, quality of life, or weight gain, particularly in conjunction with the use of new insulin analogs and improvements in pump technology. Clinical studies of safety and efficacy of CSII in children are reviewed, as well as criteria for patient selection and practical considerations using pump therapy in youth with T1DM.

Continuous subcutaneous insulin infusion (CSII) in children with type 1 diabetes

Recent studies have shown that continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, provides a treatment option that can assist in the attainment of current goals of treatment in children and adolescents with type 1 diabetes (T1DM). In pediatric patients, CSII has been demonstrated to reduce both glycosylated hemoglobin levels and frequency of severe hypoglycemia, without sacrifices in safety, quality of life, or excessive weight gain, particularly in conjunction with the use of new insulin analogs and improvements in pump technology. Clinical studies of safety and efficacy of CSII in children are reviewed.

Continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes: Do the benefits outweigh the risks?

Intensive management of diabetes is the gold standard in the treatment of children with type 1 diabetes. Novel insulin delivery techniques have been developed to improve the ability to administer multiple daily doses of insulin. Continuous subcutaneous insulin infusion (CSII) is a method of insulin delivery that is increasing in popularity. The present article reviews the risks and benefits of CSII in children. At this time, there is limited quality published evidence to make a definitive claim about the potential risks and benefits of CSII in children. The risk of diabetic ketoacidosis and individual family factors must be considered before initiation of treatment.

Continuous Subcutaneous Insulin Infusion in Children

Insulin-dependent diabetes mellitus usually presents in childhood. Since it i is generally accepted that persisting metabolic derangements contribute to the development of micro- and macrovascular complications, a primary aim of the management of children with diabetes is to achieve near normalization of metabolism. In adults continuous subcutaneous insulin infusion (CSII) has been used to optimize control. Despite a reluctance amongst paediatricians to use CSII in children, several studies with pumps have been performed in adolescents. The results of these studies are contradictory with respect to acceptability and achieved metabolic control. Thus, some authors report a near normalization of blood glucose concentrations, whereas others only find a temporary improvement. Patient selection seems to account for many of these differences. This suggests that methods ought to be developed to predict success or failure of CSII in a particular adolescent patient. For diabetic toddlers with their age-specific problems CSII may be a therapy of choice. So far, good acceptability and improved metabolic control are reported in this group. More studies are needed to confirm this. It is important that the diabetic clinic as well as the patient is organized to high standard before starting CSII. Home blood glucose measurements, education, and a 24-h telephone service are essential factors for the management of diabetic children, treated conventionally or with CSII.