Initiating Insulin Pump Therapy in Adolescents with Type 1 Diabetes

Patient Selection and Readiness

The American Diabetes Association recommends that insulin pump therapy should be offered immediately to adolescents with type 1 diabetes, as it can be safely started at diagnosis and provides superior glycemic control with reduced hypoglycemia risk compared to multiple daily injections 1, 2
Cognitive ability to understand pump operation and troubleshoot basic problems is essential for successful pump therapy 2
Manual dexterity to operate the device and change infusion sets is necessary for pump use 2
Willingness of both the adolescent and family to engage with the technology is crucial for adherence 2
Financial coverage and insurance approval for the device should be assessed before initiating pump therapy 2
Psychosocial factors, including anxiety or depression, that may affect adherence should be evaluated 3

The total daily insulin dose should be started at 0.5-1.0 units/kg/day, with adolescents typically requiring doses toward the higher end due to pubertal insulin resistance 4, 5
The total daily dose should be split approximately 50% as basal insulin and 50% as bolus insulin 6, 4
The basal dose should be divided by 24 hours to establish the initial hourly basal rate, with multiple basal rates programmed to account for dawn phenomenon and nocturnal insulin sensitivity 6
Basal rates should be adjusted in 0.05-0.1 unit/hour increments based on fasting glucose patterns 6

Carbohydrate counting should be taught as the foundation for bolus dosing 8, 7
Infusion set changes should be performed every 2-3 days to prevent site infections and lipohypertrophy 3, 2
Site rotation across abdomen, thighs, buttocks, and upper arms should be practiced to prevent lipohypertrophy and lipoatrophy 10
Recognition and management of pump malfunctions, including occlusions and disconnections, should be taught 3, 2

Real-time continuous glucose monitoring should be offered at pump initiation or as soon as possible to optimize outcomes 1, 11
Automated insulin delivery systems should be offered as first-line therapy if available and covered by insurance 1, 11

The A1C goal should be <7.0% for most adolescents, though <7.5% is acceptable if hypoglycemia risk is high 1, 11
Time in range (70-180 mg/dL) should be >70% of the time 1
Time below range (<70 mg/dL) should be <4%, and (<54 mg/dL) should be <1% 1
Time above range (>180 mg/dL) should be <25% 1

The student must be supported at school in using all diabetes technology, including the insulin pump, CGM, and any connected devices as prescribed 1, 11
A 504 Plan or Individualized Healthcare Plan should be provided to document pump use permissions 1

Initial follow-up should be within 1-2 weeks after pump start to review downloaded data and adjust settings 2
Subsequent visits should be every 3 months with A1C measurement 4, 5
Pump and CGM data should be downloaded at each visit to assess basal rates, bolus patterns, and glycemic trends 2

Rapid-acting insulin analogs should be used exclusively in pumps, and NPH or regular human insulin should not be used 4
Pump initiation should not be delayed waiting for "better control" on injections, as pumps can be started at diagnosis 2
Site rotation should not be neglected, as lipohypertrophy and lipoatrophy impair insulin absorption 3, 2
Frequent monitoring should not be assumed to be eliminated by the pump, as blood glucose or CGM checks remain essential 1, 11
Psychosocial factors, including anxiety, depression, and diabetes-specific family conflict, should not be forgotten, as they significantly impact pump success 3, 1