Position statement: Continuous subcutaneous insulin infusion in very young children with type 1 diabetes

Insulin pump therapy has become increasingly popular for the treatment of type 1 diabetes in pediatric patients. Although significant experience has accrued with the use of this modality in older children and adolescents, much less data are available regarding continuous subcutaneous insulin infusion in the very young. Policies of individual physician practices and insurance companies vary widely, and there is currently no consensus regarding the appropriateness of insulin pump therapy in the under 6 age group. However, we have witnessed in recent years a significant increase in the number of clinical trials investigating the use of continuous subcutaneous insulin infusion in young patients, and reports of > 100 preschool-aged diabetic children treated with insulin pumps are available in the literature. Although these studies have been of relatively short duration (< or = 12 months), the results are remarkably consistent. Although there is no evidence that insulin pump therapy results in a sustained improvement in glycemic control in this age group, risks associated with these devices in the hands of reliable adults who are managing diabetes in very young children are low. Parental satisfaction related to the increased flexibility that continuous subcutaneous insulin infusion affords anecdotally seems to be high, although formal examination of parental stress and health-related quality of life in this setting has been minimal. Important questions remain regarding selection of appropriate candidates for insulin pump therapy, whether benefits of continuous subcutaneous insulin infusion outweigh the costs, and what eventual outcomes will be in children treated with pumps from a very young age. Long-term follow-up of medical, psychological, and neurocognitive parameters in these young patients will be paramount. Our goal with this review is to summarize efficacy and safety of continuous subcutaneous insulin infusion in children < or = 6 years of age, present potential pros and cons of using insulin pumps in this population, and propose clinical management guidelines that could be useful for both practitioners and third-party payers alike.