1. Pediatric Pre-Pump Education Class University of Iowa Children’s Hospital Jeanne Sheetz RN BSN CDE Sue Huff RN BSN CDE Amy Sheehan RN BSN CDE Revised April 2008

2. This presentation is intended to be a general guide that will help you create a thorough staff training tool for your camp. It is not intended to be a comprehensive resource or to fully cover the topic. We hope you will take this presentation and adapt it so that it fits your camp’s specific needs and meets the guidelines established for the safe and effective operation of your program. Each diabetes camp operates under detailed policies and procedures that follow Board of Health and national accreditation standards that ensure the health and safety of children with diabetes. It is essential that camp staff be trained according to your camp’s policies and procedures. Staff should be encouraged to carefully review materials before arriving at camp, participate fully in pre-camp training, ask questions and use good judgment as they provide diabetes management supervision and educate youth with diabetes at camp. While doing so, it is equally important that camp staff not lose focus – camp is a place for youth to have fun with peers – to feel supported and understood, and to feel part of a passionate community. Good luck!

3. Many thanks to our friends at Camp Hertko Hollow for providing this presentation. Camp Hertko Hollow 101 Locust St. Des Moines, IA 50309 Ann Wolf, Executive Director 515-471-8523 a.wolf@camphertkohollow.com a.wolf@camphertkohollow.com Vivian Murray, Camp Director 352-750-6759 or 888-437-8652 (Toll free) v.murray@camphertkohollow.com v.murray@camphertkohollow.com

4. Insulin Pumps Over the Years

5. Pump Basics Pump Basics Battery operated device small like pager Humalog or Novolog in reservoir (cartridge) of pump delivers insulin through cannula (small plastic tube) into fatty tissue in abdomen, buttocks, arms, or legs Pump worn 24 hours a day (can take off for bathing or sports for one hour then reconnect for more insulin) Change cannula & tubing every 2-3 days

6. Pump Basics Basal Rate: Basal (background) insulin delivered 24 hours a day to cover basic body needs (takes the place of Lantus) Pump can be programmed to deliver different basal amounts at different times of day or night

7. Examples of Basal Rates Instead of 12 units of Lantus/day the basal rate is set for 0.5 units/hour for 24 hours (total 12) Instead of 12 units of Lantus/day the basal rate is set for the following: -midnight to 8:00am 0.6 u/hr = 4.8 units -8:00am-12:00pm 0.55 u/hr = 2.2 units -12:00pm-midnight 0.4 u/hr = 5 units The total is 12 units of insulin infusing over 24 hrs

8. Temporary basal rates Able to “temporarily” adjust basal rate for a selected amount of time May program temporary basal rate by percentage of programmed basal rate Increase basal rates during illness, or prolonged periods of inactivity (long car trip) Decrease basal rates during & after exercise

9. Examples of Temporary Basal Rates You are going to soccer practice and you usually get low about 6-8 hours after practice. To try to prevent that low later on you try setting a temporary decrease in the basal rate down to 70% for 8 hours right after practice is over You check blood sugars before, during, & after practice and again several times while the temp basal is running to determine if the setting worked to prevent lows. Use that info to change the temp basal next time if it didn’t work.

10. Examples continued You like to sleep in late & watch TV on Saturday mornings. Your blood sugar on Saturdays usually runs higher than during the week. With the pump you decide to set an increase in the temporary basal rate at 110% for 6 hours. Your blood sugars taken during this time will tell you if the setting worked or if you need to try something different next time

11. Pump Basics Food Bolus: Amount of insulin taken when eating carbs (think: “bowl” of food) Allows for flexibility in meal or snack timing and varying amounts of carbohydrate eaten. Correction bolus: given to correct for high blood sugars (correction factor or sensitivity factor)

12. Special Bolus Types Special Bolus Types Bolus can be delivered one of three ways to accommodate various situations

13. Normal Bolus Most common use of bolus Given all at once

14. Pump Settings Insulin to Carb Ratio Amount of insulin to give per gram of carb Example: one unit per 8 grams ( 1:8 ) You program in amount of carbs you will eat and pump figures amount of insulin to give

15. Pump Settings Sensitivity or Correction Factor Amount of extra insulin given to bring high blood sugar down to target Amount of insulin subtracted from bolus to bring low blood sugar up to target Example: Correction factor of 50 means pump will give one unit for every 50 points the blood sugar is over the target

16. Pump Settings Target or Target Range Number programmed into pump we desire a blood sugar to return to after correction for high or low blood sugar Example: If target is 120 then we expect a correction for a high or low blood sugar to return it to target after 3-4 hours

17. Pump Settings Insulin Duration or Active Insulin Number of hours we think a bolus of insulin will last in the body Important feature so “over correcting” doesn’t occur and cause a low Example: BS 286 before meal & correction given. Two hrs later BS is 199 so you try another correction. The pump knows how much of previous bolus is still active & will subtract it so you don’t give too much

18. How Does It Work? At mealtime you either enter your blood sugar into the meter or use the meter that sends the blood sugar to your pump (Deltec & MiniMed) Enter in amount of carbs you will eat Pump does all the calculations and tells you what it recommends for a bolus If you agree you tell the pump “OK” If you disagree you have ability to override pump

19. Benefits of Pump Therapy in Kids Eliminates need for shots (except in rare circumstances) Reduces extreme highs Quickly corrects high blood sugars Reduces low blood sugars May reduce HgbA1c which may reduce risk of future long term complications

20. Benefits-continued Improved absorption of insulin Accurate insulin delivery in small steady doses Matching food with insulin Flexibility for kids with poor appetites or picky eaters

21. Pump Challenges in Kids Advanced education required Close attention to details of record keeping in order to make changes when needed Accurate carb counting to be successful Cannula site change every 3 days or more often if problems Tubing or cannula can get blocked or bent leading to highs and quick development of ketones (only short acting insulin in pump) Expensive (insurance usually covers most of cost )

22. Challenges-continued Subject to human error Risk of skin infection at site Always attached to pump 24 hours a day Must test minimum of 4-6 times daily At initiation of pump therapy must test 10 times a day for first 4-8 weeks (twice in night) Requires strong support team of parents, child, medical staff, and school or daycare (Parents need to stay involved even as kids become more independent and capable of own care)

23. Pump Myths “The insulin pump will allow me to eat whatever I want, whenever I want it!” FACT: Using an insulin pump for this reason will lead to poor control of blood sugars. You still need to be very aware of carbs and good nutrition habits.

24. Pump Myths “I want an insulin pump because it will give me perfect control of my blood sugars!” FACT: The insulin pump is only as good as the person operating it.

25. Pump Myths “A friend of my dad’s has a pump and he just loves it!” FACT: Adults have easier time transitioning to a pump because they are not growing. Starting on pump requires lots of work especially in the first few months.

26. Risks of Pump Therapy Ketones and Development of Diabetic Ketoacidosis (DKA) Blood sugars rise after 90 minutes of disconnect DKA can occur within 4-8 hrs of partial interruption of insulin delivery Skin infection – usually due to set not changed often enough or skin not cleaned well enough

27. When do we consider insulin pump therapy? Someone who is currently working hard to achieve good blood sugar control Someone with good knowledge base of: -carb counting -exercise -insulin adjustment -low blood sugar treatment -treatment of sick days -ketone management

28. When Insulin Pump Therapy is Considered Motivated child and involved parents Someone who keeps detailed records Someone who measures food & reads labels & counts carbs accurately Someone who contacts diabetes team when help is needed Someone who comes to regular follow-up appointments 3-4 times a year

29. Are You Ready For a Pump? Do you test your blood sugar at least 4-6 times a day AND record your results? Are you and your parents motivated to do the work to achieve good control? (extra blood tests, independent decision making, frequent phone calls in first few months) Are you currently looking for patterns in your blood sugars and adjust doses when needed? Are you an accurate carb counter? Do you check for ketones when necessary and treat appropriately if needed?

30. Quick Quiz Do you adjust insulin if the carb content varies? Do you adjust insulin to correct highs? Do you think about exercise, illness, travel, etc. and how they relate to changes in blood sugars? Do you wear medical identification?

31. If you answered “no” to any of these questions you have work to do!