Insulin pumps in children - a systematic review

Table 1 Comparison between the different types of insulin boluses

Bolus type	Normal	Extended	Dual wave	Super bolus
Indication	With most diets, 10-20 min before the meal	Rarely needed: With lengthy mealtime & gastroparesis	With low carb & high protein & fat (> 25 gm fat) meals	With high carbohydrate meal
Method of insulin delivery	Deliver insulin immediately	Deliver all the insulin in an extended fashion over a chosen duration which may be the meal length.	60%-70% of the bolus is delivered immediately, while 30%-40% is delivered over 2-4 h	The basal insulin units of the next 1-4 h are added to the bolus, followed by a temporary 0% of basal rate for that 1–4 h
When to test blood glucose	Before bolus and after 4 h	Before bolus, after the end of the bolus, & after 4 h	Before bolus, after the end of the bolus, & after 4 h	Before bolus, after one & 4 h after the bolus

Table 2 Special situations with insulin pumps

Situation		Management
Air travel		The patient should have a note from the physician about the need for the pump before traveling
		The patient should inform the security about the pump before passing through the security checkpoint with an X-ray detector
		All the suppliers and the accessories should be carried in a separate bag for easy inspection
		The metal detectors and whole-body scanners do not damage the device
Shower and bathing		A warm shower is associated with more rapid insulin absorption than usual, increasing the risk of hypoglycemia
		A warm bath (e.g., hot tub or sauna) can expose insulin to high temperatures, which could be spoiled when exposed for an extended period
		High temperatures can also damage the pump, so it is crucial to check the owner manual for temperature specifications about ideal operating temperatures for the pump
		Knowing the type of the pump as waterproof, watertight, water-repellent, and water-resistant is essential
		If the insulin pump is not water waterproof, it is better to disconnect the pump and keep it in a dry place
Swimming		Knowing the type of the pump as waterproof, watertight, water-repellent, and water-resistant is essential
		If the pump is waterproof, they should know how many feet in-depth and how long
		The patient also should know the maximum time the pump can be removed without affecting its performance, e.g., one hour for the Aviva Combo insulin pump
		Some pumps can be worn while swimming. It will be adjusted to deliver a specific basal rate throughout the swimming
		If the pump is not compatible with swimming according to the manufacturer's guidelines, the pump can be removed, leaving the cannula attached in place and covered with a dressing and a cap
		If the pump is removed for more than one hour, testing the blood glucose using a glucometer is advised with the recommended amount of carbohydrates and insulin intake, and continue swimming
Contact sports		All types of sports, including martial arts and those with possible body contact, are permitted if there are no other systemic contraindications
		Contact sports may increase the risk of dislodgement of the pump cannula
		Ensure adequate hydration during any exercise
		The pump can be removed for up to one hour
		After one hour, testing the blood sugar using a glucometer is advised with the recommended amount of carbohydrates and insulin intake, and continue sports
Imaging	X-ray	Radiation can provoke electrical currents in the electric circuit, impairing the pump function
		The pump should be removed when possible
		Safe to keep on an insulin pump in position if the x-ray beam is less than 3 seconds at a time and if a lead apron protects the pump
	Dental X-ray	The patient should ensure that the pump is covered by the lead apron he wears
	Ultrasound	The ultrasound beam should not directly point at the pump or the insertion site
	CT-scan and Fluoroscopy	The pump should be removed when possible
		If unable to remove the pump, relocate it to another area away from the anatomic examination site and cover it with a lead apron
		Switch off the pump during the examination and set a reminder timer to reoperate the pump just after finishing the radiological procedure
		After finishing the procedure, the pump should be checked for any possible malfunction with frequent blood glucose monitoring
	MRI	The MRI magnetic field is strong enough to magnetize the pump's motor and thus damage it
		The pump should be removed and kept outside the MRI room whenever possible
		If it is impossible to remove the pump and the patient uses a metal cannula or an Omnipod, he/she must remove it before entering the room and insert a new cannula after finishing the test
		If the pump is accidentally exposed to an MRI field, it should be stopped and disconnected immediately and checked by the maintenance team for any malfunction before resuming its use
Insulin pump renewal		The pump is renewed if there is evidence of clinical benefits over the past four years
		The pump is renewed after warranty expiration to obtain the safest result. However, it can still be used but with an increased risk of malfunction
The transition from Pediatric to the adult pump user		The child pump users can shift to MDT between 12-18 yr of age. However, they can continue using the pump as an adult
		They need at least three monthly follow-up appointments to ensure the adequacy of MDT with a smooth transition to the adult clinic
		Pediatric pump users can take a holiday off from the pump therapy. During this holiday, they can receive MDT as a training period and are not considered as a pump therapy failure
		Strong cooperation between the pediatric and the adult pump therapy clinic is needed to ensure a smooth transition of the adolescent to an adult pump or MDT user

CT: Computed tomography; MDT: Multidose therapy; MRI: Magnetic resonance imaging.