insulin pumps

Kids and Infusion Sets

Insulin pump therapy is the gold standard in pediatric type 1 diabetes management. The pump is well accepted and has specific benefits over MDI in this population adding to it’s increasing popularity amongst families of children with diabetes. There are also more choices for infusion sets than ever before adding to the convenience of the therapy. This article aims to assist the pediatric educator in choosing the best infusion set for their client and troubleshoot common set problems.

Each type of infusion set has it’s own specific benefits and considerations. Assisting your client to choose the one that suits them the best can eliminate untoward events or unnecessary frustration. The following are some general suggestions when choosing an infusion set.

Teach more than one type of infusion set

Preparing to start insulin pump therapy is the “teachable moment” for learning new things. Training the child and parent more than one type of infusion in the beginning can help them later on if they have problems with the initial set or get caught in a situation where they have to use an infusion set they are less familiar with.

Age and infusion set considerations

Young children under the age of 5 or 6 are best with an angled set such as the Sillouhette™ placed in the tissue of the upper outer buttock. There are several reasons for this including the “out of sight out of mind” factor, the added subcutaneous tissue in this area and the fact that these kids often “lead with their bellies” making that area more prone to being bumped. Parents should be taught to put the infusion set in manually as opposed to using an insertion device. Topical anesthetics, ice or the back of a cold spoon can be used to desensitize the area prior to insertion. Practice makes perfect in selecting the best insertion angle from 15–35 degrees.

In school aged children the preference for using the buttocks is less common. Increasing independence with set changes and being away from home for sleep over, camp etc. means that these children can learn to place their own infusion sets. Lean children should use shorter length cannulas such as the Quick set™ 6mm or a manually placed Sillouhette.

Teenage girls often prefer the low profile placement of the Sillouhette infusion set as it can be inserted in front of the hip bone on the lower part of the abdomen out of sight and in keeping with today’s’ popular fashions. Instruct them to pinch their skin up high when they place this infusion set aiming the needle at the highest point of the pinch.

Any school aged child or teen who can pinch an inch may find that a short cannula leads to frequent bouts of dislodgement or poor absorption. A 9mm cannula or angled infusion set is preferred.

Troubleshooting

The following are some suggestions when troubleshooting infusion set problems:

1.	An infusion set should last 3 days, though in some children, rising blood sugars on day three can indicate the need to change more frequently if it occurs consistently. This may be due to the combination of a low infusion rate and rapid healing often seen in children.
2.	If your client is struggling with dislodgement or site problems, it is important to evaluate their technique in placing their infusion set including the use of an insertion device.
3.	A kink in the tip of the cannula may indicate an infusion set resting against a muscle. Use a shorter length cannula, or angled infusion set to a lesser degree upon insertion. Kinks at the top of the set close to the hub are due to “set migration” caused from added pulling on the tubing. Either secure the site using the “sandwich technique” or use another piece of tape to secure a loop of tubing close to the body.
4.	Skin irritation under the infusion set is not un-common. This can occur when the set is left in too long, gets wet and or there is a sensitivity to the adhesive, skin prep product or cannula itself. Rule out product sensitivities by using only soap and water. Sandwiching the set is the next step at isolating the cause of the sensitivity. If it truly is a cannula sensitivity and your client is using the Quick set or Sillouhette, suggest they try a sof set as the cannula is made of a different material.
5.	Site allergy is more serious and may require systemic medications to prevent an allergic reaction. Localized site allergy may be temporarily offset by the use of a topical antihistamine such as Benedryl stick or lotion. Talk to the physician about prescribing Atrovent for topical use. One dose on the skin prior to infusion set placement has been known to prophylactically prevent a skin reaction.
6.	Removing adhesives can appear as a local site irritation the same way a raised red area commonly occurs when removing a band aid. Use baby oil or lotion to remove an infusion set if this is the case. Use lip balm on the site to remove the grey “gunk” left from the adhesive. If removing an IV 3000 dressing remove by stretching the dressing progressively until it peels off easily.
7.	Long-term pump users may experience “site fatigue” from using the same areas over a long period of time. This scarring and decreasing or variable absorption is preventable to a point. There is no one type of infusion set that is better than another one at preventing site fatigue. A more important factor is good skin care. Explain to the client that leaving their infusion set in too long, surface skin infections after the set is removed or lack of rotation of infusion areas are causes of site fatigue. Each nursing visit should include an assessment of the infusion sites and review site rotation and good skin care techniques.

Sandwiching the Sillouhette and IV 3000 (Smith & Nephew)

IV 3000 is an occlusive dressing, which can be placed over a cleansed skin area to provide added security to the Sillouhette infusion set. This is useful in the following cases:

• Infusion set does not stay in for 3 days.
• Child who has baths daily.
• Anyone who swims.
• People who sweat.

The procedure, also known as the “sandwiching technique” is as follows:

1.	Cleanse skin using the above-suggested products.
2.	Allow to “dry to tacky”.
3.	Peel off first backing of the IV 3000.
4.	Place IV 3000 onto the infusion site area. Peel off the second backing to reveal the thin layer of the clear dressing.
5.	Pinch and place Sillouhette by inserting manually through the occlusive dressing. Note, this will not result in coring of the barrier.
6.	The backing of the infusion set has an affinity for the IV 3000 dressing and will hold very well.

Jill Milliken RN CDE
Diabetes Nurse Specialist - Canada

insulin pumps > kids and infusion sets