Insulin Pump vs.

Multiple Daily Injections in Pediatric Clients

Jeanine M. Diaz, SN
Cedar Crest College, Allentown PA

Significance Clinical Question (PICO): In pediatric clients with type 1 diabetes, does the use of an insulin Recommendations
pump compared to multiple daily injections result in lower glycated hemoglobin levels?
Proper management of type 1 diabetes (T1D)
•
Synthesis of Evidence • Utilize greater uptake of CSII in line with guidelines
requires lifelong administration of insulin (Woerner,
(Alsaleh et al., 2014).
2014). Research Study Variables:
Measures/
Author, Date, Title of Questions/ Methods Independent Results/Findings Limitations
Reliability • Tailor insulin pump therapy to the specific needs of
• Near-normalization of blood glucose levels is more Study, Journal Hypothesis/ (IV)
Validity
Rating of Evidence/
Purpose Dependent (DV) Recommendations client (Mameli et al., 2013).
difficult to achieve in adolescents and young Research (RV)
children than adults (Rica et al., 2017). Instruments:
Semi-structured
• Initiate pump therapy at correct time (Alsaleh et al.,
Alsaleh, F., Smith, F., Purpose: To Design: RV: interview created Parents and young children Small sample size Level = VI 2014).
• American Diabetes Association (ADA) and Thompson, R., Al-Saleh, examine the Observational Multiple daily by the researchers reported overall improvement makes it harder to Quality = B Good
International Society for Pediatric and Adolescent M., & Taylor, K. (2014) impact of
switching from
study injections (MDI)
Methods of Data
in ability to participate in
home, school and social
generalize findings to
greater population Recommendations:
Conclusion
Diabetes (ISPAD) established targets for glycated Insulin pump therapy: multiple daily Sample: A total Continuous Collection: activities with CSII use as well There is recognition of

hemoglobin (HbA1c) levels <7.5% across all ages

impact on the lives of
children/young people
injections to
insulin pumps on
of 42 families, 38
parents and 34
subcutaneous
insulin infusion
Cross-sectional
face-to-face
as significantly improved HbA1c
levels after switching to CSII
Foreign research adds
limitation to apply
the need for greater
uptake and appropriate
• Researchers showed significant improvement in
in pediatric clients (Rica et al., 2017). with diabetes mellitus and the glycemic children aged 5- (CSII) interview from multiple daily injections findings to the United use of CSII in line with HbA1c levels after switching from MDI to CSII in
their parents control and daily 17 years conducted by a Mean HbA1c values were States NICE guidance.
lives of Glycemic control researcher trained reduced from 8.25 to 7.6 % pediatric clients with T1D
• Diabetes Control and Complications Trial (DCCT) International Journal of children/young Setting: 25 (HbA1c) in qualitative after 6 months of CSII initiation
revealed strict diabetes management significantly Clinical Pharmacology and people and their families in interviewing and and sustained for 3 year follow- • Switching to CSII does not impose greater risk for
Therapeutics families. London home, 17 Impact of pump research with up
reduces risk of chronic complications in adolescents families at therapy on home, children
complications compared to MDI use
University College social and school
with TID (Rica et al., 2017). London Hospital lives HbA1c values • Reduced HbA1c levels were sustained after
recorded from
Process of Literature Search Age patients’ medical
multiple years of follow-up
records 6 months
• Database and search engine used: PubMed, Google Gender pre- and post- • More research needs to be done in the United
Scholar
initiation of pump
therapy
States

• Keywords: “pediatrics,” “type 1 diabetes,” “insulin

Design: RV: Gender
pump therapy,” “continuous subcutaneous insulin Observational
infusion,” “multiple daily injections,” and Mameli, C., Scaramuzza,
A., Ho, J., Cardona-
Purpose: To
evaluate the
retrospective
multicenter
Age Instruments: HbA1c significantly improve
Data collection tool after 1 year follow up, showing
Retrospective nature of Level = VI
study Quality = B Good
“hemoglobin A1c” Hernandez, R., Suarez- usefulness and cohort study Disease duration for chart review positive trend throughout
Ortega, L., & Zuccotti, G. safety of insulin follow-up, but varied according Unable to assess Recommendations:
• Limiters: dates 2011-2018, link to full text, last 5 (2013) pump therapy in
a large cohort of
Sample: 115
pediatric patients
Age at CSII
initiation
Methods of Data to country. No differences
Collection: observed regarding insulin
Canada for advanced
pump features
Future prospective
studies would be
years A 7-year follow-up pediatric aged 5-20 years Retrospective requirement according to useful to evaluate
retrospective, patients with with type 1 Body mass index review of charts country or gender. BMI Unable to assess reasons for differences
• Results: 361 international, multicenter
study of insulin pump
type 1 diabetes
mellitus during
diabetes and CSII
use for >5 years
(BMI) between January
2011 and
increased due to physiological
growth. Severe hypoglycemia
Tanner staging observed in trends of
sustained improvement
therapy in children and 7-year follow-up HbA1c December 2011 by decreased from baseline to end Foreign research adds of HbA1c level over 7
• 8 articles chosen for review adolescents with type 1 in 3 diabetes Setting: site investigator of follow-up and significant limitation to apply years among three
diabetes centers from 3 Ospedale Luigi Insulin decrease in DKA episodes was findings to the United countries such as
• 3 articles chosen for synthesis by strength and different Sacco (Milano, Requirement observed. Age and disease States different dietary habits,
Acta Diabetologica countries Italy), Alberta duration at CSII initiation was lifestyle and pump
quality Children’s Serious adverse found to have no influence on education Hoskins, M. (2016). Retrieved from
hospital (Calgary, events glycemic control. Patients using https://www.healthline.com/diabetesmine/taking-break-from-insulin-
• Tools used: Johns Hopkins Nursing Evidence-Based Canada), Hospital advanced pump features did pump#3
Sant Joan de Deu Advance pump show significantly better HbA1c
Practice Rating Scale (Newhouse, Dearholt, Poe, (Barcelona, features levels compared to those who References
Pugh, & White, 2005) & The Rating System for Spain) did not use them Alsaleh, F. M., Smith, F. J., Thompson, R., Al-Saleh, M. A., & Taylor, K. M. (2014). Insulin
RV: Gender
Hierarchy of Evidence (Melnyk & Fineout-Overholt, Age at enrollment
pump therapy: Impact on the lives of children/young people with diabetes mellitus and their
parents. International Journal of Clinical Pharmacy, 36(5), 1023-1030. doi:10.1007/s11096-
2005). Fendler, W., Baranowska,
A., Mianowska, B.,
Purpose: To
evaluate the
Design:
Prospective Duration of
Instruments:
Data collected by
Mean post-study HbA1c levels
were statistically higher in MDI
Non-random allocation Level = VI
of patients leads to Quality = B Good 014-9990-1
Szadkowska, A., & impact of observational diabetes at manually curated than in CSII-treated patients. potential for bias Fendler, W., Baranowska, A. I., Mianowska, B., Szadkowska, A., & Mlynarski, W. (2011).
Mlynarski, W. (2011) treatment with study enrollment in years database of Percentage of patients reaching Recommendations: Three-year comparison of subcutaneous insulin pump treatment with multi-daily injections on
CSII on the discharge the therapeutic goal of <7% of Foreign research adds Previous studies have HbA1c, its variability and hospital burden of children with type 1 diabetes. Acta
Three-year comparison of metabolic Sample: 454 Daily insulin dose summaries HbA1c equaled 32.9% in the limitation to apply shown increased long- Diabetologica, 49(5), 363-370. doi:10.1007/s00592-011-0332-7
subcutaneous insulin control children with C-peptide level CSII and 25.7% in the MDI findings to the United term complications Mameli, C., Scaramuzza, A. E., Ho, J., Cardona-Hernandez, R., Suarez-Ortega, L., & Zuccotti,
pump treatment with (expressed as type 1 diabetes Methods of Data group (P=0.12). Total duration States resulting from G. V. (2013). A 7-year follow-up retrospective, international, multicenter study of insulin
multi-daily injections on glycated level— HbA1c Collection: of hospital stays did not differ variability of HbA1c. pump therapy in children and adolescents with type 1 diabetes. Acta Diabetologica, 51(2),
HbA1c, its variability and HbA1c) and its Setting: Study Data collected from significantly between groups, Therefore further 205-210. doi:10.1007/s00592-013-0481-y
hospital burden of children variability in center within Multiple daily study center of however patients treated with studies aimed at Melnyk, B., M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and
with type 1 diabetes children with Lodz injections patients CSII had significantly lower interventions reducing healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams and Wilkins.
diabetes administration hospitalized number of total hospital days HbA1c variability would
Newhouse, R., Dearholt, S., Poe, S., Pugh, L., C., & White, K. (2005). The Johns Hopkins
Acta Diabetologica region, Poland Continuous between January per year compared to MDI be worthy.
Nursing Evidence-Based Practice Rating Scale. Baltimore, MD: The Johns Hopkins Hospital;
subcutaneous 2002 to December group
insulin infusion 2010 Johns Hopkins University School of Nursing.
Rica, I., Mingorance, A., Gómez-Gila, A. L., Clemente, M., González, I., Caimari, M., . . .
Days in hospital per Barrio, R. (2017). Achievement of metabolic control among children and adolescents with
year type 1 diabetes in Spain. Acta Diabetologica, 54(7), 677-683. doi:10.1007/s00592-017-0991-
0
Woerner, S. (2014). The benefits of insulin pump therapy in children and adolescents with
Dilgam, H. (2017) Retrieved from https://afdiabetics.com/pump-therapy- type 1 diabetes. Journal of Pediatric Nursing, 29(6), 712-713.
children/ doi:10.1016/j.pedn.2014.08.010