Are You Ready for Pump Therapy?
If you are thinking about pump therapy for your child, we want you to know the process we use to identify and train successful pump candidates. This process, although somewhat time consuming, has proven to be effective in preparing patients and their families for the challenge of pump therapy.
1. Realistic Expectations
Pumps offer diabetes patients choices that do not exist in other insulin regimens. However, pumps are not a good choice for everyone. If you are looking for a way to avoid injections, pump therapy is not a viable option. Patients using pumps must be able to give injections and to change the pump site without hesitation. If blood sugars go up and there is no other explanation for the rise, the site must be changed immediately. This is true for any time of day or night. If you have difficulty giving injections, this problem must be dealt with before moving to pump therapy. Please talk to your health care professional before proceeding any further. The patient must also be willing to receive injections in the abdomen and buttocks, as these are areas used for pump sites. A child currently experiencing difficulty using these areas will not be considered for pump therapy.
Likewise, it is not realistic that pump therapy will simplify diabetes care enough so that the child can handle it for himself. Although children and teens are sometimes very proficient with the technical aspects of the pump, no child should be expected to take care of diabetes on his/her own. Treating diabetes takes problem-solving skills that children and teens do not yet possess. If the parents are not willing to learn how the pump works, they will not be adequately prepared to supervise the child, and a pump will not be prescribed.
2. Core Skills
The pump is only a tool to deliver insulin; the user must still set up the pump correctly, monitor blood sugars, make adjustments and trouble-shoot problems. These are skills that must be attained before starting a pump:
- Injects insulin without hesitation; uses abdominal and buttock sites.
- Measures blood sugar routinely, four times a day and per hypoglycemia guidelines.
- Follows nighttime hypoglycemia guidelines.
- Counts carbohydrates accurately in grams.
- Correctly uses an insulin-to-carb ratio and correction factor to determine dose.
- Keeps appointments every three months with appropriate lab drawn.
- Communicates by phone with diabetes team regarding ketones, vomiting, etc.
- Records blood sugar, grams eaten and insulin dose for at least one month and agrees to keep records while on pump therapy.
- Child and parent work as a team (parents review blood sugars and discuss with child on regular basis) and have realistic expectations.
- Makes routine insulin adjustments according to guidelines as appropriate.
3. Continuous Glucose Monitoring Sensor (CGMS)
In order to get baseline information so that basal insulin rates can be estimated, wearing a Continuous Glucose Monitoring Sensor (CGMS) is the next step in the pump process. The sensor is inserted under the skin in the clinic. It measures blood sugar every five minutes and is worn like a pump for five days. During this time the patient measures blood sugar before each meal, two hours after each meal, midnight, and 3 a.m. The patient records everything he or she eats, so that when the sensor is downloaded, we have a great deal of information, including how the patient tolerates wearing a device, how willing he or she is to follow a meal plan, do frequent blood sugars, recording, etc. A pump will not be prescribed for a patient who has been unable to successfully follow instructions for the CGMS.
After wearing a CGMS, you will come back to the clinic for a visit to review the downloaded data. You should have your pre-pump checklist completed and bring it to this visit. If you have had difficulty with any of the 'core skills', a review of these skills will be required before a pump is prescribed.
4. Pump Class
Once the physician has prescribed a pump, you will need to schedule pump class. In this class you will learn about what pumps can do, trouble-shooting practices and how pump therapy differs from multiple injection therapy. This class is only for patients for whom a pump has been prescribed. It does not cover set-up of the pump, which is specific to each brand. This will be done when you actually have the pump and are ready to put it on. You will review carbohydrate counting and use of an insulin-to-carb ratio, goal and sensitivity factor to arrive at a customized dose of insulin. You also will be asked to commit to a meal plan that you can follow for 6 weeks. Although pump therapy can offer great flexibility with what and when the child eats, we must first find pump settings that are appropriate for the child. To do so we need a few weeks of data using a consistent amount of carbohydrates.
5. Final Preparations
It is the parents' responsibility to call their insurance company and find out how much of the pump and supplies will be an out-of-pocket expense. This should be done early in the process. Click here for a checklist for you to use when preparing to get a pump.
When the checklist is complete, a letter of medical necessity will be sent to your insurance company. After receiving word that the pump has been approved you may set up a time for the pump-start education. This session will take a full day. These appointments can be scheduled with your doctor and the trainer. (The trainer is employed by the company that sold you the pump.) Prepare for the pump-start by viewing the video or CD included with your pump.
Although this process may seem daunting, many other patients and families have successfully completed it and are now wearing pumps. It is important to complete the steps in order. Each step has a purpose and will make your transition to the pump more trouble-free. And if, along the way, you decide that you are not quite ready for this commitment, it is perfectly all right to put it on hold. Many kids are just not ready for pump therapy at one point in their life, but may be very ready later on.