ketoacidosis in addition to improved glycemic control (Karges et al., 2017). While insulin pumps certainly provide added convenience, successful treatment is limited by patient adherence (ADA et al., 2022c). Education, monitoring, and individualized therapy are essential. Disadvantages to this method of administration include higher cost, risk of pump failure, and need for continuous wear (ADA et al., 2022d). Selection of an insulin pump will depend on patient preference, insurance coverage, insulin requirements, and other desired features. Some pumps are waterproof, others can be paired with serum glucose monitors, and select pumps feature automated suspension of basal administration upon detection of hypoglycemia. As technology continues to evolve, CSII will become even more user-friendly, discreet, and lower maintenance, which will hopefully improve adherence. It is important to note that insulin pumps do have the potential to fail, and failure may result in poor glycemic control or even DKA. Monitoring Glucose monitoring must be completed multiple times per day for two major reasons: correction of hyperglycemia and detection of hypoglycemia (ADA et al., 2022e). Correction of hyperglycemia or anticipated hyperglycemia takes place prior to meals and snacks. These values are used to calculate insulin requirements, as detailed in the insulin calculation section of this course. Detection of hypoglycemia is pertinent prior to bedtime, before exercise or driving, or if the patient exhibits any symptoms of hypoglycemia. Symptoms of hypoglycemia include dizziness, sweating, anxiety, irritability, and fatigue. Some pediatric patients may be too young to express symptoms, and caregivers must be attuned to their child’s behavior. This phenomenon is commonly referred to as “hypoglycemia unawareness.” When in doubt, it is always best to check a blood sugar. In fact, there is a demonstrated correlation between frequency of glucose monitoring and lower HbA1c (ADA et al., 2022c). Evidence-based practice! A recent study enrolled 80 children ages 2 to less than 6 years of age to evaluate efficacy of an insulin pump with an interoperable continuous glucose monitor linked to a smartphone application (Sherr et al., 2022). This age group presents unique challenges in insulin management, as they are dependent on caregivers and prone to hypoglycemia unawareness. After a 13-week investigational period, hemoglobin A1c decreased (7.4% vs. 6.9%), along with an associated reduction in hyperglycemia and hypoglycemia. As previously discussed, most patients will have a target HbA1c of <7%. This value corresponds with a goal pre-prandial blood glucose of 80–130 mg/dL and a peak postprandial blood glucose <180 mg/dL (ADA et al., 2022b). Blood glucose values <70 mg/dL are considered hypoglycemic and should be treated appropriately. Traditional methods of glucose monitoring require a lancing device, lancets, test strips, and a blood glucose meter (BGM; ADA et al., 2022c). Patients should be instructed to ensure meters and test strips are compatible for use, and test strips should be routinely checked for expiration. Instructions for use will differ with each manufacturer, but users should follow the same general steps. First, the patient should wash their hands and dry them well to optimize accuracy of the reading. Alternatively, an alcohol pad can be used to wipe the finger clean. Then a test strip should be inserted into the port of a compatible BGM to prepare for the blood sample. Next, using a lancing device and lancet, the side of a fingertip should be pricked, as lancing the side of the finger tends to be less painful than the tip. This will result in a drop of blood at the site of entry. If no blood appears, the finger can be gently massaged or squeezed around the lanced area. The user should then take the inserted test strip and touch the edge of the strip to the drop of blood. The BGM will display a blood glucose level, typically
As such, it is pertinent to frequently assess insulin pump function via glucose monitoring. Patients and caregivers must retain the ability to administer insulin via conventional intermittent methods as a back-up for failures (ADA et al., 2022c). Healthcare Consideration : Pediatric patients of lower economic status are less likely to use diabetes technology (Addala et al., 2021). One of the contributors to this disparity is provider implicit bias, or the unconscious and systematic discrimination of a subgroup. A recent study demonstrated that providers are less likely to recommend diabetes technology to pediatric patients with public insurance, which may deepen user inequity in the U.S. (Addala et al., 2021). Coverage policies are evolving to be more inclusive, and providers should promote expanded use of technology in diabetes, regardless of user coverage type. within seconds. The test strip can be disposed in a regular trash can, but the lancet should be ejected into a sharps container. For peace of mind and minimization of finger sticks, a continuous glucose monitor (CGM) may be a beneficial tool. A CGM trends serum glucose levels throughout the day and can be worn in the water and during sleep. Again, instructions for use are manufacturer-dependent, but generally, the site of injection must be cleaned and dried, and then the user inserts a sensor under the skin. The sensor stays in place with adhesive edges and may remain on the patient for up to two weeks, depending on the model. Blood glucose levels are then automatically checked by the sensor periodically, and these data can be linked to a smart device or receiver. Continuous glucose monitors greatly reduce the burden on glucose monitoring, but patients will still need a traditional BGM for calibration and device failure. Alarms may be set on the CGM for hyperglycemia or hypoglycemia, and historic data may be downloaded to share with providers for evaluation of glucose control. Metrics, such as time in range or time above target serum glucose, may be used in conjunction with HbA1c to assess treatment efficacy (ADA et al., 2022b). A recent clinical trial demonstrated modest improvement of glycemic control (HbA1c 8.9% vs. 8.5%) after 26 weeks of CGM use in adolescents and young adults (Laffel et al., 2020). Healthcare Consideration : Hemoglobin A1c represents an average blood glucose level over time and does not provide information about daily fluctuations in blood glucose levels. Continuous glucose monitors provide metrics that are more representative of short-term glycemic control and are an excellent tool for evaluation of insulin regimens. Three key metrics for evaluation include time in range, time below range, and time above range. In most children, recommended time in range is >75%, time above range is <25%, and time below range is <4%. These goals should be individualized, especially for those at high risk of severe hypoglycemia (Al-Gadi et al., 2021). As beneficial as CGMs are for many patients, they do have inherent limitations. The first and seemingly obvious caveat is that the patient must be adherent with use. As simple as this might seem, nonadherence is one of the major roadblocks in diabetes innovation. Second, most CGMs do not completely eliminate the need for finger sticks, as many must be validated with a standard glucose meter at least twice daily. Newer models may decrease the calibration requirement, which may improve impact on glycemic control over time. Third, select models may provide inaccurate readings in patients taking certain medications, including acetaminophen, or in certain conditions, including low oxygen environments (ADA et al., 2022c). This interference is secondary to the mechanism of glucose oxidase monitors and does not affect glucose dehydrogenase–based monitors. It is important to review model-specific limitations with patients and their caregivers as part of the device selection
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Book Code: AUS3024
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