Case Study: Experience in Insulin Pump Therapy During the Neonatal Period

T.C., a 4-day-old baby girl born at 36 weeks, was brought to the emergency department with a history of poor feeding and lethargy. She was small for gestational age, with a birth weight of 4.6 lb. The pregnancy was complicated with oligohydroamnios.On examination, she appeared emaciated and dehydrated, with sunken eyes and depressed anterior fontanele. Her capillary refill was 4 seconds, and she weighed 4 lb. Her laboratory tests results were significant for elevated blood glucose at 765 mg/dl , and she was diagnosed with neonatal diabetes.T.C. was admitted to the pediatric intensive care unit for the initial management of diabetes with intravenous (IV) insulin infusion (0.01-0.05 units/kg of body weight/hour). After 6 days on IV insulin, she was switched to subcutaneous (SC) insulin injection therapy with NPH and aspart insulin, 2-3 times a day. The insulin doses were titrated frequently to control blood glucose levels (0.5-1 units/kg/day). Because of wide excursions of blood glucose levels with one episode of severe hypoglycemia, her NPH was changed to ultralente insulin. T.C.’s blood glucose remained difficult to manage with SC insulin injections. She required IV insulin infusion again to stabilize her glucose levels.1. What is the best way to optimize diabetes management for an infant with difficult-to-control neonatal diabetes?2. What considerations are necessary to develop a safe discharge plan for such a patient? Initiating CSIITo better control her blood glucose levels, physicians treating T.C. considered initiating insulin pump therapy. After parental consent was obtained and diabetes education was provided, continuous subcutaneous insulin infusion (CSII) therapy was started via an insulin pump (Medtronic 512) on day 27 of T.C.’s life. She was started with an initial basal infusion rate of 0.05 units/hour using lispro insulin in 10x dilution (Humalog U10/ml, Eli Lilly and Co.). For a consistent feeding regimen (every 2-3 hours), …