University Nursing Report: Insulin Therapy for Pediatric Diabetes

This nursing report presents a systematic review comparing the efficacy of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) in children with type 1 diabetes. The review analyzed several research articles, including studies by Batajoo et al. (2012), Burckhardt et al. (2018), Benkhadra et al. (2017), Blair et al. (2018), Hasselmann et al. (2012), Fendler et al. (2012), and Karges et al. (2017). The findings indicated mixed results, with some studies showing no significant difference in glycemic control between the two therapies, while others favored CSII in terms of better metabolic control, reduced HbA1c levels, and decreased hospital stays. The report highlights the complexities in drawing definitive conclusions due to variations in study methodologies, sample sizes, and follow-up durations. The review also discusses the impact of each therapy on the quality of life for children with type 1 diabetes, emphasizing the need for further research to establish evidence-based practice guidelines.

Running head: NURSING
Nursing
Name of the Student
Name of University
Author’s note

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Introduction
The following assessment task aimed to conduct a literature review by the use of
systematic review approach. The main research question that will be covered in this systematic
review include In Children in the age of 0 Yr to 18 yrs with Type 1 diabetes, will continuous
subcutaneous insulin infusion be more effective in maintaining good diabetic control with few
adverse events (etc) than multiple daily injections?. The review will initiate search strategy that
was used for the selection of the articles for the review. The search strategy will be illustrated in
a table format. This will be followed second table highlighting literature summary. At the end the
key findings will be illustrated in the paragraph format in order to conclude the PICO question of
the review.
Search Strategy
Keywords
Keyword 1: Diabetes Mellitus OR Glycated Haemoglobin OR Haemoglobin A1c OR Type
1 Diabetes Mellitus
AND
Keyword 2: insulin pump OR diabetic control OR continuous subcutaneous insulin
infection (CSII)
AND
Keyword 3: Multiple daily injections OR Insulin delivery system
AND
Keyword 4: Paediatric diabetes

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Inclusion and Exclusion Criteria for the Selection of Papers
Inclusion Criteria Exclusion Criteria
Year of publication: 2012 to 2019 Year of publication: Before 2012
Type of article: Primary and secondary
research article
Article type: Frey literatures and case studies
Type: Peer reviewed Type: Non-peer reviewed
Language: English Other than English
Databases used for article search
1. CINHAL
2. PubMed
3. MedLine
4. PsycInfo
5. Crochane

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PRISMA (Table 1)
Articles reviewed from the database search
(n = 342)
Final set of articles title scrutiny (n =188)
Redundant articles removed (n
= 152)
Number of articles for abstract
analysis (n = 76)
Number of articles removed (n =
112)
Number of articles for Full-text
analysis (n = 18)
Number of articles removed (n =
58)
Articles removed after JBI analysis ( n
=3)
Total number of articles for critical
analysis of the methodology (n
=10)
Number of articles not meeting the inclusion
criteria
Conducted with oral insulin (n =8)
Final set of articles for the review = 7

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Table 2
Author Yea
r
Countr
y
Methodolo
gy
Participants Key findings
Batajoo, R. J.,
Messina, C. R., &
Wilson, T. A
2012 New
York
Retrospective
observational
study
131 patients suffering from typ2 1 diabetes
mellitus (T1DM) and were treated with
insulin pump from multiple daily insulin
injections during the tenure of 1999 to 2009
Mean HbA1c before the initiation of the continuous insulin infusion
pump therapy (CSII) was high (8.0 +0.9 %, 7.7 +1.0 % at 6 months) and
7.8+1.2 % after 1 yr after the initiation of CSII. However, at around 30
months after the initiation of the treatment there occurred only a
transient improvement in the HbA1c concentration in blood serum
among the children who are below 11 years of age. Thus the study
showed that there was no significant different in the overall glycemic
control among the patients who are udder the CSII in comparison to the
MDI (multiple daily insulin)
Burckhardt, M.
A., Smith, G. J.,
Cooper, M. N.,
Jones, T. W., &
Davis, E. A
2018 Western
Australia
, Perth,
Australia
A
retrospective
matched-
cohort study
Patients using insulin pump therapy during
the tenure of 1999 to 2016 were compared
to the patients who are on the insulin
therapy depending on several parameters
like the age, the actual date of T1DM
diagnosis and the level of HbA1c during the
initiation of the insulin pump therapy
The key findings of the study showed that a total 513 pump-injection
were identified and the cohort of the pump is significantly lower in
comparison to the mean HbA1c concentration that was tabulated during
the first 6 months of the follow-up. The difference in the concentration
of the HbA1c was noted post 6 months of follow-up and a greater
difference was sustained during the follow-up of 6 years. The final
results concluded that the patients who are using the insulin pump
therapy have a greater glycaemic control in comparison to the matched
injection therapy
Benkhadra, K.,
Alahdab, F.,
2017 Mayo
Clinic,
Systematic
review and
The review was conducted over the
randomised control trial study (RCT) that
The meta-analysis showed that there is a significant reduction in the
concentration of the glycosylated haemoglobin in the blood of the

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Tamhane, S. U.,
McCoy, R. G.,
Prokop, L. J., &
Murad, M. H
Rocheste
r, MN,
USA
meta-analysis was conducted over children suffering from
T1DM and are published during the tenure
of 2008 to 2015. The main databases used
for the search of the articles: MEDLINE,
EMBASE, Cochrane Central Register of
Controlled Trials and Database of
Systematic Reviews, and Scopus. A total of
25 RCTs with moderate level of bias were
included in the review
children with T1DM who are treated with the continuous subcutaneous
insulin infusion in comparison to the multiple daily injections of insulin
(the mean difference is 0.37 with a confidence interval of 95%)
Blair, J., McKay,
A., Ridyard, C.,
Thornborough,
K., Bedson, E.,
Peak, M., ... &
Gamble, C
2018 NHS
Foundati
on Trust,
Liverpoo
l, UK
Randomised
control trial
Children aged from 7 months to 15 years
were recruited in the study and patients
having previous complications with T1DM
or other allergy to insulin or psychological
complications were excluded from the
study. The sample size was 143 and the trial
stated within 14 days of T1DM detection.
12 months of follow-up study
The analysis of the RCT result showed that The concentration of the
HbA1c did not differ in between the treatment arms during the 12
months follow up. No significant difference was found in the BMI. The
insulin requirement was found higher among the CSII participants in
comparison to the MDI. CSII also requires more hospital visits and
inpatient status and thus increasing the cost of care
Hasselmann, C.,
Bonnemaison, E.,
Faure, N.,
Mercat, I.,
Bouillo, M. P. D.,
Magontier, N., ...
& Labarthe, F.
2012 France Randomised
control trial
Thirty-eight T1D children were participated
in the trial and were recruited to the CSII
group and the results were compared to 38
children who are treated with MDI
There were no differences found in between the 2 groups as highlighted
in the baseline data. As per the 3 years of follow-up session, CSII
treated children required lower dosage of insulin and have significantly
lower level of the HbA1c. The people who are treated with the CSII
have better metabolic control than MDI patients and also have
decreased level of acute complications associated with T1DM.
Fendler, W.,
Baranowska, A.
I., Mianowska,
2012 Universit
y of
Lodz,
Cross-
sectional
observational
Data was included for the children who are
hospitalised with T1DM during the tenure
of 2002 to 2010.
The group who are treated with the CSII have lower dosage of HbA1c.
However, the rate of hospitalization was similar in both the group MDI
and CSII. However, the duration of the hospitalization was lower in the

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B., Szadkowska,
A., & Mlynarski,
W
Poland study CSII and have reduce rate of acute complications.
Karges, B.,
Schwandt, A.,
Heidtmann, B.,
Kordonouri, O.,
Binder, E.,
Schierloh, U., ...
& Holl, R. W
2017 Germany Population-
based cohort
study
The participants were recruited who are
admitted in the hospitals during the tenure
of January 2011 and December 2015. A
total of 446 diabetes centres took part in the
study of the Diabetes Prospective Follow-up
in the Germany, Austria and in the
Luxembourg. The children have T1DM and
were younger than20 years and are
suffering from diabetes for 1 year
Insulin pump therapy is associated with the lower risk of diabetes and
lower risk of severe hypo-glycaemia and diabetic ketoacidosis in
comparison to the insulin injection therapy. The study also showed
lower rate of diabetic complication in comparison to the insulin
injection

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Summary of the key findings
Analysis of the seven literacy articles failed to come to a definite conclusion for derive a
strong opinion about the CSII pump therapy and multiple insulin injection therapy over the
children who are below 18 years of age and are suffering from type 1 diabetes mellitus. The
study conducted by Batajoo, Messina and Wilson (2012) failed to highlight any significant
difference in the overall glycemic control among the patients with CSII therapy in comparison to
the children who are under the MDI therapy. However, Burckhardt et al. (2018) are of the
opinion that T1DM is also associated with numerous complications like decrease in the quality
of life, increased rate of stay at the hospital and high healthcare costs. However, Batajoo,
Messina and Wilson (2012) failed to study thee other aspects of the T1DM among the paediatric
population and only focused in the long-term significant in the long-term follow up that was gain
associated with the decrease in the sample size in the follow-up sessions. Thus the overall
interpretation is biased. Burckhardt et al. (2018) highlighted in their study that the patients who
are using the CSII have better glycemic control in comparison to the MDI or multiple injection
therapy. This result showed a significant contradiction with the study results reported by Batajoo,
Messina and Wilson (2012). Moreover, Burckhardt et al. (2018) also used long-term follow-up
sessions (15 years) and thus ruling out the results elucidated by Batajoo, Messina and Wilson
(2012). Benkhadra et al. (2017) showed significant reduction in the level of glycosylated
hemoglobin the in patients with CSII in comparison to the patients with multiple daily injections
(MDI). The results had a confidence interval of 85% and thus showing a significant statistical
significance and are also going in favor of the results reported by Burckhardt et al. (2018).
Moreover, the study conducted by Benkhadra et al. (2017) falls under the level 1 of the hieracchy
of evidence as they used systematic review and meta-analysis of RCT but they have included

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RCTS with moderate level of bias and thus questioning overall significance of the elucidated
results. Benkhadra et al. (2017) also reported that there was no significant difference in the
chances of developing hypoglycemia (nocturnal) and thus failed to show the importance of the
therapy in improving the quality of life T1DM population. Blair et al (2018) failed to report any
significant difference between the two therapies both the domain of the clinical efficacy and in
the domain of the cost effectiveness. Thus the results go in favour of the study of Batajoo,
Messina and Wilson (2012). Hasselmann et al. (2012) showed that CSSI help in attaining better
metabolic control in comparison to the MDI without increasing the accurate complications of the
T1DM among the children. Better metabolic control help in improving the glycaemic control of
the body and thereby helping to improving the overall scope of the disease management. Thus,
CSII helps in improving the quality of life of the children with T1DM. Thus what Burckhardt et
al. (2018) failed to do, Hasselmann et al. (2012) were successful in showing how CSII helped in
improving the quality of life of children. Fendler et al. (2012) showed that CSII help to reduce
the duration or the length of stay at the hospital of the children with T1DM. however, failed to
highlight any significant difference in the acute complications that increase the need of
hospitalization. Thus the study conducted by Fendler et al. (2012) helped in identifying only
aspect of improved quality of life of the children with T1DM. However, though the sample size
was large, the follow-up tenure is low and thus might lead to the generation of biased result.
Karges et al. (2017) helped in understanding few more importance of CSII like reduce risk of
hypoglycaemic, diabetic keto-acidosis and better glycaemic control. However, it was a single
study to highlight such promising benefits of the CSSI, the results cannot be used for the
generation of the Evidence-based practice in nursing.

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Conclusion
Thus from the above discussion, it can be concluded that more randomised control trials
with longer years of follow-up must be undertaken in order to understand the effectiveness of the
CSII in T1DM management among the children who are below 18 years of age in order to rule
out the importance of the multiple insulin injection pump therapy. The RCTs along with
systematic reveries of the RCTs will help in the establishment of the evidence-based practice
guidelines for understanding the comparative importance of the CSII and MDI among the
paediatric population and thereby helping in the establishment of the evidence-based practice.

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References
Batajoo, R. J., Messina, C. R., & Wilson, T. A. (2012). Long-term efficacy of insulin pump
therapy in children with type 1 diabetes mellitus. Journal of clinical research in pediatric
endocrinology, 4(3), 127.
Benkhadra, K., Alahdab, F., Tamhane, S. U., McCoy, R. G., Prokop, L. J., & Murad, M. H.
(2017). Continuous subcutaneous insulin infusion versus multiple daily injections in
individuals with type 1 diabetes: a systematic review and meta-analysis.
Blair, J., McKay, A., Ridyard, C., Thornborough, K., Bedson, E., Peak, M., ... & Gamble, C.
(2018). Continuous subcutaneous insulin infusion versus multiple daily injections in
children and young people at diagnosis of type 1 diabetes: the SCIPI RCT.
Burckhardt, M. A., Smith, G. J., Cooper, M. N., Jones, T. W., & Davis, E. A. (2018). Real‐world
outcomes of insulin pump compared to injection therapy in a population‐based sample of
children with type 1 diabetes. Pediatric diabetes, 19(8), 1459-1466.
Fendler, W., Baranowska, A. I., Mianowska, B., Szadkowska, A., & Mlynarski, W. (2012).
Three-year comparison of subcutaneous insulin pump treatment with multi-daily
injections on HbA1c, its variability and hospital burden of children with type 1
diabetes. Acta diabetologica, 49(5), 363-370.
Hasselmann, C., Bonnemaison, E., Faure, N., Mercat, I., Bouillo, M. P. D., Magontier, N., ... &
Labarthe, F. (2012). Benefits of continuous subcutaneous insulin infusion in children
with type 1 diabetes mellitus. Archives de pediatrie: organe officiel de la Societe
francaise de pediatrie, 19(6), 593-598.

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Karges, B., Schwandt, A., Heidtmann, B., Kordonouri, O., Binder, E., Schierloh, U., ... & Holl,
R. W. (2017). Association of insulin pump therapy vs insulin injection therapy with
severe hypoglycemia, ketoacidosis, and glycemic control among children, adolescents,
and young adults with type 1 diabetes. Jama, 318(14), 1358-1366.

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