Parents of teens with diabetes have to make an endless amount of decisions with their teen about how to care for their diabetes, but there’s some good news too. By this time your teen should be taking on a lot of the responsibility for their own diabetes management, and you can start filling more of a support role than a command role (though, don’t get us wrong, sometimes you do have to step back in and be the voice of reason). Set right in the middle of the responsibilities quandary is the decision to use insulin pumps or multiple daily injections. Moira McCarthy in her book “Raising Teens with Diabetes” (Spry Publishing, 2013) has a great run-down on the pros and cons of pumps and MDIs.
Pumps versus MDI
It has almost become like the breast-feeding question, fraught with judgment: “Your child is pumping, right?” While insulin pumps are relatively new to the diabetes world (two decades ago you’d have had to search hard to find someone on one), they’ve leapt quickly to the forefront of care.
And for good reason. Pumping insulin can offer a person with diabetes more freedom, more precision, and less stress on a management basis. But they can be tricky, too: pumps need to be paid attention to quite closely. So what are the benefits of pumping, and what are the benefits of MDI? Both offer their own, and while many like to claim pumping is the only right choice, in reality, with the many types of insulin available today, the decision of pump versus MDI is mostly a personal one.
Pumping Pros and Cons
The pros of pumping are many. First of all, since the pump delivers Insulin Peaks and a “basal” insulin dose to the body 24/7, people with diabetes can tweak how much of that basal they are getting at any time. In theory, a well-planned basal profile should allow a person with T1D to go 24 hours without eating while staying in an acceptable glucose range. This means that if a person tends to go low in the late afternoon, he or she can adjust the pump to cut back on insulin just before that time. Or those who experience the pre-sunrise spike many have known as “dawn phenomenon” can dial up their basal to automatically give them more insulin to combat that occurrence.
Pumping makes bolusing for food or highs easy, too. Since your insulin is right in your pump and is delivered to your body via a tube under your skin, bolusing means simply adding up the carb count and pushing some buttons on the pump to deliver it. Most pumps even have programs that know how many carbs are in certain foods, or that allow you to input certain meals you like to eat. You dial them up, you push a button, and your insulin dose is done.
Pumping can also mean carrying around less, but in a perfect world, it should not. Since the “rules of pumping” advise that any highs are corrected via a shot, anyone on a pump should be carrying around a backup shot and insulin just in case. Pumpers also need to always have on hand a backup site change in case their pump sites go bad. Still, you won’t need to be married to having a vial of insulin and syringes with you at all times.
There are some red flags to pumping, too. First, since an insulin pump delivers only rapid-acting insulin, should a pump fail, or should there be a problem (such as a clogged site or a site falling out without notice), the risk of developing ketoacidosis is higher than on shots. This is because on MDI, your “basal” or “background” insulin is administered by shot and at one time, offering a “safety net” in the case of highs. In other words, once that shot is in you, it stays in you for 24 hours. On a pump, there is no long acting. This means a person on a pump must be vigilant about checking blood sugars and detecting highs, since all the insulin going into your body, be it via a basal pattern or a bolus, is rapid acting. That means that at any given time, you are three to four hours away from no insulin going into your body, in the case of a pump or site problem.
Pump users also need to rotate infusion sites as well. The site, which is the connection where the pump sends insulin into the body, can be placed in any area of the body with fatty tissue. But over time, overused sites can build up scar tissue and not work as well. Overuse of a site area can also cause “atrophy,” a denting in of the skin. While rotating shots is important, rotating site locations is very important as well.
Pumps are also, for the most part, visible. Some people do not like the visible reminder of their diabetes attached to them all the time. While there are many ways to wear a pump that keeps it out of sight (we share some later in this chapter), there are teens who just don’t like it. But for the most part, teens are happy to trade having to wear a device for the freedom they find it brings them.
For a teen, pumping can mean the ability to tweak insulin doses to help with sports days and no-sports days, longer and shorter busy days, and special activities. It can mean being able to simply pull out a pump and bolus, rather than deal with using needles and insulin vials in school or at work. It can mean being able to take the pump off and stop delivery if they are going low or heading into a big game. On the con side, the pump means responsibility for a teen. It is up to them to push those buttons and to make sure they are paying attention to the pump as it functions, as well as not losing it (this happens!).
MDI Pros and Cons
Multiple daily injections are still the way a majority of people treat their diabetes, although pump use is increasing daily. MDI used to mean a set schedule and lack of freedom, but with today’s insulins patients can work with their medical teams to come up with an MDI plan that still gives them much freedom.
The benefit of MDIs is that people can give themselves a shot of their long-acting and know, for sure, that their body has insulin in it for at least those 24 hours. With rapid-acting combined, MDIs mean that diabetes sufferers can have flexibility of when to eat or when not to eat, since they simply need to add up their carbs and administer a shot any time they need to.
Insulin pens have made MDIs friendlier as well. Pens look like, well, pens. Almost all types of insulin can be administered via pen now, which means a person can pull one out just about anywhere and not get the looks one might get with a syringe and vial. Pens also mean a person can dial up his or her dose, instead of having to pull insulin out of a vial and into a syringe (which means worrying about things like air bubbles). Pens make carrying around your MDI supplies easier and less bulky.
The con of MDIs is that you don’t have as much flexibility in your basal insulin. Since you have to pick a dose and stick with it, you cannot tweak it by the hour as you can on a pump. However, with things like split doses, you can have some flexibility. Another con is the amount of material you need to carry around with you.
For teens, MDI is sometimes preferable because they are tired of, or not interested in, having something attached to their bodies. A pump is a constant reminder of diabetes, and some just need to get away from that. Some teens find that MDI forces them to comply more as well, since taking shots tends to be more of a routine.
So, what about the idea of switching back and forth from pumps to MDI, and then to pumps again? This is becoming more and more popular, and could be a great strategy to help a teen get through these rough years when burnout always seems to be hovering on the horizon.
Most parents feel that once children switch over to pumping, they never want to go back to shots. In fact, for parents who get used to pumping, the idea of MDI can be frightening. Pump advocates believe there is little chance of having tight control on MDI. But in reality, you can have tight control on either.
Usually, if teens are looking for a pump break, they have a reason. It might be they are tired of having a piece of machinery attached to them 24/7. It could be they’ve become lackadaisical about their diabetes care and realize they are not giving the pump the time and attention it requires. It could be they are feeling the need to begin to separate from their parents, and since their parents know pump care inside and out, they wonder if shots might help them begin that process. It could be they are just feeling the need for a change. Whatever the reason a teen asks for a pump break (or “pumpcation,” as we are calling it here), parents need to listen.
Taking a break from pumping does not have to be a big deal. In some ways, it can even be helpful. Since it’s always a good idea to be up-to-date on MDI and how to manage with it (in case of a pump problem or another kind of emergency), taking a break from time to time will force your child—and you—to brush up on MDI basics. (It’s easy to forget them over time. And if your child has been pumping for years, you may never have experienced MDI with Lantus or Levemir.) A pump break can also give those pump sites a short rest, something that can be good for them over the long haul.
But most of all, the pumpcation might just give teens something they crave more than they can express: a sense of control and choice in a world that seldom gives them that. You cannot give your teen a vacation from diabetes. Even if you offer to take over all the care, it’s still the teen’s body living with it and experiencing it. That can be frustrating and grinding for a teen, particularly one who has been facing diabetes for a long time. If taking a break from the pump makes him or her feel in control, then why not?
Some teens report that either switching off the pump for a while or going back on it gives them a new chance to focus and forces them to pay more attention to their daily care. Teens get complacent, be it toward their longtime pumps or their longtime MDI plans. A switch can help them re-focus.
It’s also okay to go off the pump for a special occasion such as the prom or some other event for which the teen might not want the pump around. In all these cases, you’ll want to talk to your teen’s medical team to come up with a plan for that time.
Raising Teens with diabetes is available on Amazon.