Children with diabetes, and especially their parents, must learn to be relentlessly vigilant about planning and watching their diet and administering regular insulin shots. It is a lot for a child to endure, and a lot for a parent to manage.
Cincinnati Children’s Hospital Medical Center (CCHMC) has begun offering patients and their families a new insulin protocol that allows for greater flexibility and requires less stringent management. CCHMC is a participant in the Pursuing Perfection program, an initiative of the Robert Wood Johnson Foundation for which IHI is the National Program Office.
“The standard type of insulin protocol calls for patients to inject a combination of short-acting and long-lasting insulin, carefully timed to peak at mealtime,” says David Repaske, PhD, MD, who, along with colleagues Susan Allen, RN, MSN, and Lisa Campbell, led the effort to change the insulin protocol.
There are two main problems with this therapy, says Repaske. “First, sometimes the peaks are so broad that you have a lot of insulin at the wrong times, and need to eat when you wouldn’t normally want to. Second, you have to choose the amount of insulin to take well before you even know what or where your next meal might be. You are then obligated to eat an amount to match the insulin you took.”
Now, new, longer lasting insulins are available, and through a protocol called basal bolus, patients can take one 24-hour dose, and inject a very rapid acting booster just before eating. “You buy a lot of flexibility with this method,” says Repaske. “Kids can sleep in on Saturday mornings.”
CCHMC’s Pursuing Perfection team debated which protocol to offer, says Repaske. “We began to wonder why we couldn’t offer both. We called other academic medical pediatric centers around the country, and didn’t find anyone who was giving a choice. We decided to try it. ”
The patients have split about evenly between the two choices, says Repaske. An unanticipated benefit, he says, is that patients on the basal bolus therapy have gained a measure of independence because they are less in need of daily guidance about dosage. “Dosing traditional insulin is an art,” says Repaske, which is why most patients on conventional therapy call in daily to discuss their doses. “We’re getting far fewer phone calls from parents of the second group,” says Repaske.
