The American Diabetes Association's Safe at School program, in conjunction with John Hopkins Division of Pediatric Endocrinology, welcomes you this evening to our part five of our seven part series of webinars designed for school nurses. My name is Henry Rodriguez. I am a pediatric endocrinologist and clinical director of our USF Diabetes and Endocrinology Center at the University of South Florida here in Tampa. I have the privilege also of serving as co-chair of the ADA Safe at School Working Group, and I'm presenting this evening's program entitled Insulin Pumping in the School Setting. The ADA Safe at School program is devoted to protecting the legal rights of students with diabetes so these students may learn and thrive in a safe and healthy school environment and be treated fairly. School nurses play a critical role in making sure the needs of children with diabetes are met in the school setting. Our hope is tonight's program will provide school nurses with increased knowledge, skill, and the confidence to best support students with diabetes to optimize their education and enable those students to safely participate in all school sponsored activities. So the school nurse really is a student's advocate and key provider and coordinator of diabetes care in the school setting. School nurses, parents, providers, and students working together can ensure that students with diabetes are indeed safe at school. Please type your questions during this presentation in the chat box and I'll do my best to answer your questions at the end of my presentation. Soon after this program concludes, attendees will receive an email containing a link to an evaluation and post-test. Free continuing education credits will be awarded upon completion of the evaluation and the post-test. This program is also being recorded and will soon be available on ADA's professional member website. In addition, attendees will be emailed a notification enabling you to register for remaining programs in the series. The next webinar will be on March 5th at 6pm Eastern and will cover the Diabetes Medical Management Plan and I'll be speaking about that this evening, so keep an eye out for this email. Also, the registration link will be provided in the chat box at the end of my presentation So again, thanks so much for joining us this evening and again, please be sure to type your questions in the chat box. So I'm going to go ahead and get started and I should mention that the session is being recorded by the American Diabetes Association and will be made available online for public access and viewing. And while the American Diabetes Association attempts to ensure that all information is accurate and current, this general information about potential legal protections and medical best practices is not a substitute for individualized legal and other expert advice and assistance. The American Diabetes Association and staff and volunteers do not provide legal or medical advice or represent you. For detailed legal advice or representation, contact and consult an independent attorney and for health care consultation and advice, consult with your professional health care provider. So we're going to, the objectives today really are to review current insulin pump technologies in the pediatric population to identify potential benefits of insulin pump technologies, become familiar with functional similarities and differences between the available insulin pump platforms and describe proper use of insulin pump technologies in the school setting. So along with continuous glucose monitors, the most recent ADA guidelines really advocate for the use of automated insulin delivery to improve both short and long term outcomes. And with advancements in pump technology, many children with diabetes are using insulin pumps. And really, these numbers continue to increase. So if you have not encountered a student that is utilizing an insulin pump system, I suspect you probably will in the very near future. The pumps are incredibly helpful, particularly for children, because they can deliver very small doses of insulin. And so with these pumps delivering basal insulin, as I'll speak to in a moment, you can get down to 0.05 units, increments. And so that allows for more accurate insulin dosing and better blood sugar control. And as you know, children have certainly more erratic eating patterns. They frequently will snack. They've got spontaneous variable activity and their schedule varies on a day to day basis. And insulin pumps do provide the ability to customize doses, in my opinion, in a more precise manner and better meet their day to day needs. That being said, because there are many pumps available in today's market, we recognize it's really difficult to remember everything about each pump. You know, I'll try to really highlight the most important aspects of each pump and how it applies to the school setting. And so, you know, there are resources for the resources available on the ADA Safe at School website that provides more in-depth coverage of each of the devices. Before we start talking about pumps, I'd like to review some terminology that really is important and you'll hear it throughout this presentation. Basal rates refer to the amount of rapid acting insulin that's delivered by the pump every few minutes, actually, and they're generally listed as an hourly rate. Remember that these pumps utilize only rapid acting insulin. And so you can actually alter that basal delivery throughout the day. Some folks think of that basal delivery as similar to an insulin IV infusion, in this case, though, the insulin being delivered under the skin. And with few exceptions, patients that utilize insulin pump therapy do not use a long acting insulin analog like Glargine, Basaglar, Lantus, Levomir, and so forth. That pre-programmed basal rate provides that minute to minute background insulin that's required by the body. In the case of a hybrid closed loop, also referred to as automated insulin delivery, those systems allow for the pump to utilize the data coming from the continuous glucose monitor to adjust the insulin delivery based on whether the blood glucose level is rising or falling. And they utilize specific predictive algorithms in order to do that. The basal insulin should be differentiated from bolus insulin, which is the insulin we typically give at meals to cover the carbohydrate that's being consumed as well as to correct for elevated blood sugars. And the insulin on board really refers to the amount of insulin that's calculated to remain in circulation from the prior bolus that was given. And so it really avoids what we refer to as insulin stacking, and we'll speak to that in a few moments. There is also the reverse correction, which refers to the pump's ability to subtract insulin from that dose, which is recommended based on the carbohydrates to allow for the blood glucose to rise and not result in a lower blood sugar once again. And so it really helps the individual keep their blood sugar in that target range. So now that we've talked about those common terms, I'd like to discuss a traditional insulin pump. Many children are utilizing, as I mentioned, these hybrid closed loop or automated insulin delivery systems, and we're going to get into much more detail on that. But there are still many children that are using traditional insulin pumps. And so it's important to understand the features of those pumps because all of these hybrid closed loop systems, if for some reason they lose signal connection with the continuous glucose monitor, they're going to revert to what we refer to as their default settings or their traditional pump settings, and it actually functions like a traditional insulin pump. So it's important to understand these devices. The traditional insulin pumps deliver program doses, which are calculated by the medical diabetes care team, and insulin boluses are given only if the user enters a blood glucose and a carbohydrate amount. And so either of those will allow the individual to give a bolus of insulin, but the basal rates operate in the background, and those are pre-programmed into the pump. And the pump allows, it has what we refer to as a bolus calculator, it allows the individual to enter in their glucose level, enter in the amount of carbohydrates that they consume, and the pump will calculate their dose for them, and it's required that you confirm that dose before it's delivered. Part of the pump's dose calculation, again, takes into account this insulin on board, and again, that is to avoid stacking. If you've delivered a dose of insulin as a bolus within a window that's predetermined by how that pump is programmed, then it will subtract whatever insulin it believes is still functioning from that prior dose, so that we don't end up with, as we say, stacking of insulin doses and a much greater risk for low blood sugar. So as an example, if a student received their breakfast dose at home at 8 a.m. and the nurse is scheduled to give a snack bolus at 10 a.m., that's within two hours. If it's been programmed that that insulin action time is three hours, it's going to subtract a portion of the insulin that was to be given at that two-hour mark, assuming that insulin is still in action and in play from that prior dose. So if we turn to specific pumps, there are currently two types of pumps on the market, ones that have tubing and ones that are what we refer to as tubeless or patch pumps. So the Insulet Omnipod insulin pump is a completely tubeless, waterproof pump that has essentially two models. One is a traditional pump and one is this automated or hybrid closed-loop system. And so the Omnipod EROS and the DASH are Omnipod's versions of the traditional insulin pump. They're not as often prescribed currently, now that these automated systems are available. I should mention that the EROS, or sometimes referred to as the Omnipod Classic, has been discontinued as of the first of this year, but it's quite likely, I saw a patient today that still have pods and they have the operating device, which I'll speak to in a moment. And so they're operating on that traditional insulin pump. With the EROS and the DASH, insulin boluses are delivered using that personal diabetes manager, we refer to that as a PDM, and the doses that are delivered are based on program doses from their diabetes care team. It should be noted that students that utilize that system, again, they're essentially being required to transition off of that because the manufacturer is no longer providing for the pods of that system. So they're having to transition either to this other classic system or the automated system. To deliver a bolus, the user must be within five feet of the pod. These operate, in this case, by radio frequency. So they've got to be pretty close in order to administer that. If the student were to forget their PDM or leave it at home, it's important to note that as long as the pod is adhered to the skin and the cannula under the skin is delivering insulin, that basal rate will continue until that pod expires. Typically, they expire at three days. So they don't need additional basal insulin, but what they will require is an injection to be administered by a pen or syringe if they need an additional correction or additional insulin at meal or snack time. And all of those instructions should be detailed in the Diabetes Medical Management Plan. I should mention, and it's listed here, that these devices do use batteries. The dash is rechargeable with a USB-B cable. In case there's any concern, many of these devices, particularly automated devices, do allow for parents to access information regarding the pump online, but they cannot bolus. So there's not going to be a situation where a parent is going to remotely, without your knowledge, administer additional insulin. So the next pump that came to market was the Tandem T-Slim. It's a tube pump. And while the T-Slim can be programmed as a traditional pump, it also has a feature that provides for automated functionality. It has a basal IQ system that is a central augmented pump system, and it communicates with, in this case, the Dexcom Continuous Glucose Monitor, but it didn't function as a fully hybrid closed-loop system because it only addressed predicted lows and did not provide for corrections if the blood sugar were rising. And so there are still some patients that have not upgraded to the fully automated system. But you should still be aware of that. Again, this is a feature that certainly was an improvement over, in my opinion, the traditional insulin pump. When folks are utilizing this basal IQ, the pump reduces or turns off that basal insulin delivery when that Continuous Glucose Monitor predicts that their blood sugar will be less than 80 within a few days. So that's a feature that we're going to be looking at a little bit more in the future. Within the next 30 minutes. And so again, this was extremely helpful in assisting with the potential to have low blood sugars or hypoglycemia, but that was really the only feature of this algorithm. And as I mentioned, it didn't address higher blood sugars. The dosing, again, far more precise that we can deliver via pen or syringe. OK, so if we look at hybrid closed loop or automated insulin delivery systems, that really has been the latest advancement in insulin pump technology. That hybrid closed loop utilizes an algorithm that uses information from the Continuous Glucose Monitor to adjust insulin delivery outside of boluses. So it's really working on that background insulin, adjusting it either upwards or downwards, depending on the trajectory and the prediction of the insulin, sorry, the glucose levels in the future. So that helps manage low blood sugars by suspending or reducing insulin being given every five minutes or increases insulin delivery every five minutes. When the glucose levels are above the program target range. So in certainly in children, we found that these systems have been extremely helpful in improving quality of life for their for children and their families. It's resulted in improved hemoglobin A1C levels and increased time and range. And it is really impressive if you look at reports from these systems, particularly overnight when children aren't eating. These systems do a tremendous job in keeping them well within range the vast majority of the time. Each hybrid closed loop system is a little bit different. So we're going to review each of them and how they impact the school setting and diabetes management. For example, some of these devices have an activity exercise mode that allows for an increased target so that the system is not driving their blood glucose to such a lower level. And therefore, it mitigates the risk for low blood sugars. And those features should be activated approximately 60 to 90 minutes before activity. So, you know, for planned PE or after school activities, I think it's very helpful for children that have more spontaneity. It can be a little bit challenging. Many of us utilize this exercise mode during the activity, also afterwards. And it should be noted that exercise can affect the blood glucose for several hours afterwards. I mean, even in some cases, overnight and the next day. But as is the case with diabetes management in general, you really need to be aware of what the patterns are for a particular student, for a particular child, and adjust based on that. So if you look at the available hybrid closed-loop systems, you have the Omnipod 5, the latest version of that tubeless or patch pump. You have the Tandem T-Slim, which utilizes the Control IQ hybrid closed-loop functionality. And then you have various iterations of the Medtronic pump. There are what are referred to as do-it-yourself or DIY looping. And the latest system is a pump that's the latest in the market. It's called the Islet. And so again, these systems all utilize a continuous glucose monitor. In the case of the Omnipod and the T-Slim, it utilizes Dexcom devices. In the case of the Medtronic pumps, they are utilizing their proprietary continuous glucose monitor. So most hybrid closed-loop algorithms have incorporated into those previous pumps. And so at this point, all the manufacturers do provide for this automated or hybrid closed-loop functionality. And so again, this is very exciting. It can really assist students in keeping their blood glucoses in their target range. And so basically, in the case of the Omnipod 5, because it's tubeless, it's waterproof, particularly for young children. I don't want to say it is the preferred pump. But again, we always try to tailor the device to the needs of a specific patient, whether it be pediatric or adults. So there is manual mode, which basically the system utilizes the pre-programmed default settings. And then there is the automated mode, which allows for adjustment of that basal insulin every five minutes based on the predicted glucose level 60 minutes in the future. And so that algorithm is utilizing that continuous glucose information to make that prediction and adjust the insulin delivery appropriately. And so the Omnipod 5 utilizes the Dexcom Generation 6, or G6. And we can change the blood sugar target in increments of 10, ranging from 110 to 150. It should be noted that boluses are still required at meals and for corrections. And you want to use the Use Sensor button that is present on the screen. That prompts the pump to use the current reading from the continuous glucose monitor. And so if need be, if there is a finger stick involved, you can enter that in as well. But you really do want to utilize at the time of meals that sensor glucose. So if a correction is necessary, it can be factored into that mealtime dose. And so as with its predecessors, the Omnipod 5 system calculates the insulin on board with each bolus and considers any insulin amounts given by the pump for blood glucoses above target, again, to avoid that stacking possibility. When it's in automated mode, you cannot give an extended bolus. We can speak to that a little bit later on. But for meals that perhaps are absorbed a little more slowly, that have more protein or fat, the traditional pump allows you to divide out that insulin. So it's given over a longer period of time. But in automated mode, that is not possible. But again, activity mode is something that we really do encourage. It really does mitigate that risk for hypoglycemia associated with activity. And again, activating that 60 to 90 minutes beforehand is the ideal. In this case, with this device, that activity mode, when it's activated, automatically sets the target at 150. And it reduces the basal rate by up to 50%. It's similar to the tandem exercise mode. And again, we want to be able to do that as early as possible. If you look at other potential considerations for these devices, so it's a little bit counterintuitive. These devices actually communicate via Bluetooth. And I think for any of us that have used earbuds or what have you, Bluetooth can operate in the next room and so forth. For this particular device, what we refer to as ideal placement is line of sight. And so the pod and the Dexcom sensor and transmitter must be on the same side of the body. For example, if the Dexcom sensor is placed on the left side of their stomach, the pod should be placed on the left leg or arm. You really want those devices to be able to communicate. Because in the absence of adequate communication between the sensor and the pump, you're going to interrupt that automated mode. So you're going to lose the benefits of that particular feature. I always indicate to our families that it becomes a little bit of a geometry issue. Because on the one hand, your continuous glucose monitor, the Dexcom device is changed every 10 days, whereas the pod is changed every three days. So you have to think ahead as to where you're going to put the next pod to make sure that it's still within, meets that requirement of line of sight. If you have something on the front of the body versus the back, they may not communicate well. And so that's one of those things that we discuss when we troubleshoot why perhaps an individual in review reports on these devices why they're not in that automated mode. I think there's also another consideration is there's a mobile bolusing app on specific phone models. Currently, they're only Android phones, but they're moving ahead with, in the future, with this specific pump, some functionality that will allow control of this system from an app, solely app on the phone. And so that's a really nice feature, particularly for adolescents that don't want to carry additional equipment if they can avoid. But again, this does not allow a parent, for instance, at home to be able to administer a bolus. They can just visualize the data. So if we look at the T-SLIM, the Tandem-C T-SLIM pump, their hybrid closed-loop system is known as the pump model is X2. It's a control IQ system. And as mentioned earlier, the T-SLIM is a two-pump. And the algorithm can change both the background insulin amount and give, well, the background insulin amount is changed every five minutes. The automatic correction can occur up to every hour. And it can give up to 60% of a recommended correction dose every hour to maintain the blood glucose that's ideally within the target range. In this case, the target of 110 cannot be altered if they're in the control IQ mode. The school nurse need not be aware of the basal rate adjustments or automatic corrections given by the pump. You really only need to look at the recorded insulin totals given with the boluses. All snacks or meals should be entered into this pump than the others. The blood sugar will be communicated by the continuous glucose monitor. Again, as with other pumps, the user needs to enter the amount of carbohydrate consumed with one exception that we'll speak to. The pump recommended dose will populate at the bottom of the pump's display for review. And then users should always use the recommended dose as it takes into account that insulin on board and guards get stacking and uses their current continuous glucose trend. And so as is true for any boluses or, quite honestly, injected insulin corrections, you don't want to correct any more frequently than every three hours, in the case of very high blood sugars, perhaps every two hours. Similar to the Omnipod 5, the control IQ has a program called exercise mode that automatically changes that blood sugar target to maintain a level between, in this case, 140 and 160. Exercise mode, in this case, must be manually turned on and off by the user. And so there is, unfortunately, not an option to set a duration of time. So many times, folks will utilize an alarm that will remind them to exit out of exercise mode. So in the case where one would forget to come out of exercise mode, that child is going to have blood glucoses that continue to be a bit higher because it's not correcting at a lower level. And I should mention that reports are available, unfortunately, many pumps utilize their own software that you can review the reports. But you can see just what the pump is doing in terms of its insulin delivery, whether it's suspending frequently or giving additional insulin. So it's really quite remarkable. So with regards to this particular pump, the Tandem X2 T-Slim pump does allow for mobile bolusing. So the patients, if they upgrade this device, it's a little bit like the Tesla. It allows for the pump to be connected to the computer and allow for software upgrades. This particular upgrade allows students to more discreetly provide an insulin bolus utilizing the phone app without having to take the pump out. So I think that is certainly appreciated by our teenage or adolescent patients, those students that perhaps want to be a little more discreet in terms of delivering their insulin. So again, I want to emphasize the fact that even though you can do it from the app that the particular individual is using, you can't do it remotely. Another person cannot administer that bolus. You have to do it from their individual phones. And then again, if you'd like to view the T-Slim's pump interface, practice dosing, or turning on exercise mode, or other common tasks, there is a T-Simulator app that's available online. It's provided by the manufacturer. And it actually allows you to practice the button pushing. And so that's a really, really nice feature. So the Medtronic series of pumps, it was actually the 670G that came out. And it was the first automated insulin delivery system. And so FDA originally provided for very limited use for fear that there might be issues. And so that particular pump was a bit problematic. You had to calibrate their sensor at least four times a day. If the glucose reading was too much out of target, it would essentially drop them out of automated mode. And you needed to do finger sticks and so forth to get it back in. There has been greater experience with these devices. And by, honestly, comfort level with the algorithms, there has been less restrictions in terms of how long the pump can remain in automated mode. So this is the Medtronic Pumps R tube devices. They are not waterproof. It is, from a functionality standpoint, very similar to the OmniPi 5 pump. It has auto mode. It's got limited mode and manual mode. And those are displayed on the pump's screen. With this pump, the system is very, very simple. With this pump, the student will stay in automated mode unless the blood sugar is out of range for a prolonged period of time. There's also a maximum minimal basal rate. So if they're, for instance, low and it goes to halting insulin delivery on the basal side, there's a specific period of time beyond which it will basically exit out of automated mode. Essentially, these devices are designed for safety as a paramount consideration. So if the pump's not getting adequate data, if there's any question blood sugar is too high or too low, then the device will back out of that automated mode. There is this limited mode that will go into play with this particular pump for about four hours, and then it'll come completely out. Each prompt may be different based on the blood sugar value, so you want to be sure to have the student show you the prompt before they just exit out and cancel the alarm. If the prompt isn't followed within four hours, then, again, they will fall into manual mode until they activate automated mode. They'll probably need to verify a blood glucose to do that. Because a lot of these prompts are related to entering a blood sugar value, it's important for students using this device, as, in my opinion, they should for all these devices to have a backup glucometer. So we'll probably speak to this at the end, but with any of these devices, I think it's extremely important that the parents provide supplies to be able to administer injections by syringe or insulin pen, that they be able to monitor their blood glucose with finger sticks, so having meters and test strips, checking for ketones and the like. All that should be on a checklist and just regular inventory, making sure that those items are not expired. This pump also provides a temporary target for periods, for instance, of expected higher activity. And so when that feature is activated, in this particular case, that target can be provided just for a limited time. So we mentioned on the other device that you had to manually turn it on and off. In this particular case, this pump allows you to set a duration for that temporary target. So with your activity mode, again, it's raised to 150, and you could set it for however many hours you want to do that. I mentioned before that the Medtronic devices are different because they use only Medtronic's manufactured continuous glucose monitor. It's called the Guardian. There have been various iterations. The current pumps use either a Guardian 3 that requires calibration with a finger stick periodically, and then there's the Guardian 4, which is compatible with this generation 780 or 780G. So for those that use the Guardian 3, the pump requires a minimum of two finger sticks each day to keep them in auto mode. So again, that's something that should be elaborated on in the diabetes medical management plan. So again, a lot to take into account. So again, the fallback should always be utilizing that diabetes medical management plan for direction. So I'm not going to spend a lot of time on DIY looping. I think these were devices that prior to last year were not FDA approved at all. Basically, some very, I think, ingenious parents that happened to be engineers essentially hacked earlier generation pumps and essentially created their own algorithm to provide for that hybrid closed loop functionality before it became commercially available. So there is now a system that was approved by the FDA just last year. It's called Tidepool. It utilizes what's called a Reilly link. And a phone application uses the Dexcom G6 data and adjusts that insulin dose based on an open source algorithm. And so historically, I've been personally a little bit concerned. I remember one gentleman that explained that he got an old Medtronic pump on I think it was eBay or something and started using that device. But again, increasingly, there are not only commercially approved devices, which we talked about, that utilize this. But there are now there's increasing, I think, just transparency. Ultimately, we're going to hopefully reach a point where a patient or family might be able to choose a specific pump that works with a continuous glucose monitor of choice with an algorithm that they choose. As somebody who is challenged in the area of technology, I'm not gonna go any further than that, but it is exciting as to what potentially we might be able to do moving forward. I mentioned that the latest insulin pump is the islet, and I think there are some important things that you need to appreciate about this particular pump. So it was just FDA approved in May of 2023. It has what's referred to as an adaptive close-up algorithm that's based on the person's weight only. So for the first two weeks of wear, essentially they need to have their continuous glucose monitor on at all times. It happens to fall off and they don't have a replacement. Believe it or not, it's required that they check their blood glucoses at least every hour. And to provide that information. So the really innovative feature of this pump is that it no longer requires the user to count carbohydrates. They enter their boluses based on a relative amount of carbohydrate consumed. So within those first two weeks, they're basically informing the pump what their typical meal is. If it is a smaller than typical meal, that means that it's about 50% of their usual. And if it's a larger, it's at least 50% greater. And so the pump then adapts. And so I think from one perspective, it's actually quite exciting. Carbohydrate counting has been challenging from day one. I think all of us appreciate that it's not the most precise measure at times, but I think one thing I should mention that if the continuous glucose monitor comes off, this individual will have to resort to injections. So there isn't this manual mode or anything of that nature. If the system isn't entirely communicating and working, really the individual will have to resort to insulin injections until they get the system up and running again. The other thing that you should be aware of is that not all sections of the DMMP may be applicable because it doesn't have an exercise mode. It doesn't have carbohydrate doses or correction factors. I believe that information should be provided in the DMMP so that you are aware if you do need to resort to injections. And so I think they're like all things related to care of children with diabetes in the school, it's really important that the school staff communicate with the family and with the diabetes care team, the medical team to really review expectations. So you'll likely be seeing these devices in the not too distant future if you haven't already. So just in general, you should appreciate that insulin pump settings are pre-programmed by the family and the diabetes care team. The school nurse can check program doses in the pump. In general, students are gonna come in with their pumps and they're programmed. While the nurse doesn't have any responsibility for programming or changing insulin doses in the pump, it's reasonable for them to double check the insulin doses that are programmed. Certainly at the start of the school year and if they're aware, the diabetes care team should be communicating changes if they're made throughout the year. Remember that our patients are generally seen every three months, sometimes more frequently. And at those three month intervals at a minimum, it provides us the opportunity to review their data and perhaps make changes in their insulin doses. And so those should be communicated to you at school so that again, if you're having to intervene, you know what their insulin dosage should be if they require injections. So additional considerations, you really should not be overriding those recommended doses because that pump again is utilizing that background information. If there is an automated device it's using the continuous glucose monitor, it's utilizing, it's basically memory of the most recent insulin dose that was administered and adjusting appropriately. So again, there's always, when you're talking about boluses given at meals or snacks or for corrections, it's always gonna ask for a confirmation but in general, we recommend that you use that dose. Certainly if a parent requests that you do something beyond that, you wanna consult the DMMP and then on that final page, page six of the ADA DMMP is an indicator as to whether their clinical care team would like to be contacted in the event that those adjustments are being proposed. So if again, as mentioned when discussing each individual pump, exercise activity mode or temp targets can be extremely helpful to a student who has a pattern of exercise induced hypoglycemia. It really mitigates that risk by providing that higher target. If the student that you're working with will be using this feature during the school day, again, it's important to have that discussion with the family, how did they typically utilize it? When should it be turned on? Again, ideally 30, sorry, 60 to 90 minutes beforehand and how long it should be maintained. And then if you have an individual that's utilizing a traditional pump with temporary basal rates, you're gonna want to and it's really listed in the DMMP, what parameters you utilize that temporary basal rate, how much you reduce that for activity for instance. You may wanna ask the family if there are other times during the day when they wanna use this feature to avoid low blood glucoses. If the student is old enough and quite honestly developmentally appropriate, it'd be reasonable to ask them as well. They can certainly, we encourage that transfer of responsibility to the student when they're deemed to be, it's deemed to be appropriate by the family and the diabetes care team. We'd like our students to become more and more independent so that if you imagine they're, when they graduate high school, they're going off on their own, they should be able to manage these devices and their diabetes in general independently. Again, we very much want the student with diabetes to be able to manage their diabetes without necessarily again, depending on their competence in doing these things, to be able to do it without having to travel to the school nurse all the time and disrupting their school day. But also listed on the diabetes medical management plan is whether the student should be independent, what they might require assistance with if they're totally dependent, for instance, a very young child or a child that's recently diagnosed may require that the school nurse and staff assist with virtually all of their diabetes care. So again, important to know. You know, I've mentioned the activity or exercise mode, the Omnipod 5 can be set for a duration of time up to 24 hours. The T-Slim with Control IQ has to be manually turned on and off. The Medtronic allows for the 660G and the 670G can be set for a duration of time as well, up to 24 hours. So that's a really nice feature. You always wanna confirm low blood glucoses with a finger stick. With, you know, for years, we were adamant that, you know, utilize that 15-15 rule, right? Hypoglycemia, low blood sugar, you give 15 grams, you wait 15 minutes and check again. Well, you really need to be aware that that may not, it's all in all likelihood is not gonna be applicable with these hybrid closed loop systems. The reason being that, remember, these systems are predicting where that blood glucose is headed. And so before that student actually gets to be low, that pump will have reduced their basal insulin and even turned it off, hoping that the insulin's gonna come back, sorry, the blood glucose is gonna rise again. So there's less background insulin. And if you give that student excess carbohydrate, it's gonna raise their blood sugar and it's gonna prompt the pump to give additional insulin. So again, you need to be aware of that. I should also mention that checking a finger stick is really important. There may be at times where the continuous glucose monitor produces a low alert. Remember that your CGM is really relying on the glucose level in the skin. If the blood glucose is changing rapidly, then for instance, you just treated a low, then you wanna make sure that you're using that finger stick to guide management because the CGM may lag by as much as 15 minutes. Again, all of these things should be directed to in the DMMP and certainly, we always encourage school staff to communicate with families and the medical team to see if they have questions. Green meal bolusing or split meal bolusing. Okay, so it's incredibly important to bolus prior to eating whenever possible for any student that are using these automated insulin systems. You wanna announce to the pump that the student is gonna be eating and therefore, even with the islet that requires no carbohydrate counting, you wanna be able to bolus beforehand. Remember that that background adjustment prediction is always gonna lag a bit behind. So for instance, I saw a patient earlier this week that is on this automated system but their blood glucoses are chronically elevated. Why? Because they haven't been bolusing for the meal and so after the rise has occurred, then the pump is working on bringing it down and it's not gonna be nearly aggressive enough to bring the blood sugar down in a reasonable amount of time. So that patient's gonna have this blood glucose, elevated blood glucose for an extended period of time. If pre-meal bolusing is not an option because they're unreliable in what they eat or there are other factors affecting their ability to eat a full meal, you can use with manual pumps, a split meal bolus. You can essentially dose for what you're certain they're gonna consume and then dose again afterwards. It does take some more follow-up. You know, with injections, certainly that's a second injection. With pumps, that's not really the issue. It's just remembering to bolus for that additional amount that they may have consumed beyond what you initially bolus for. So if a student has a lunch that has a total of 40 grams of carbohydrate, you're not sure that they're gonna eat very much of it at all. You can dose for the 10 grams that you're certain that they're gonna eat. And if they refuse to eat anything more or refuse to eat at all, remember that you can always substitute juice if need be. It's not the ideal, but we do really encourage pre-meal bolusing. If they ate the entire lunch provided and you only dose for 10 grams, you would give coverage for the remaining 30 grams that they consumed. And therefore provide for much better blood glucose control in relation to that meal. So another big consideration, how can I put this? Many students and families are familiar with tactics to prevent low blood sugars during the day. So I will use the example of a young lady that I cared for years ago that was very, very active in soccer. And so on a traditional pump, she was accustomed to basically carb loading prior to the activity. So she'd eat an additional snack prior to the activity so she wouldn't go low. With these hybrid closed-loop or automated pump systems, that's not a great idea because if you do that, the pump is gonna see that rise in glucose and it's going to try to correct for it. So it's best to enter all the carbs that are being consumed. The pump is going to adjust depending on the glucose trend. Better than doing a carb load initially is again to utilize the exercise or activity mode so that the pump will have a higher target and they will be at less risk for having a low blood sugar. It is best to use that Dexcom blood glucose reading. And depending on the pump, you have to select that at the time of a meal rather than a manual entry. Again, it's gonna make it, not only is it gonna make it easier, but it's going to allow for the pump to take all of that into account. I don't know if any of you have heard of the term sugar surfing. Essentially, in a traditional pump or even with injections, folks many times, particularly adults, that really wanted to have tight control of their blood sugars would test blood sugars more frequently and dose insulin more frequently. It's not something that we generally will promote. Reason being is A, it's an awful lot of work. B, these hybrid closed loop systems essentially eliminate the need for that. And so it's also disruptive quite honestly in the school situation. So certainly we don't want students to do that. There is a greater risk, depending on how they're doing this, for stacking insulin doses, if they're giving manual boluses and overriding. So again, these are all things that if you review the pump memory, you can see if that's occurring. And if it does, certainly you wanna make the parents and the diabetes care team, you wanna make them aware. Insulin pump failure. I alluded to this earlier. These devices are phenomenal, but they are not foolproof. As I frequently share when I'm discussing insulin pump therapy with patients and families, the single weakest link in the pump system is that little cannula that's replaced typically every three days. Medtronic has a one week wear infusion set, but that little cannula, particularly with kids that are moving around a lot, particularly if they're not cognizant of this with their site selection, that cannula can pull out a little bit, it could kink. So we want to make sure that we're monitoring their glucose levels closely. And so particularly with very young children is a concern. Why? Because for instance, a blockage in that cannula, it requires the pump to recognize that there's increased pressure being built up in that cannula. In the case of a tube pump, it'll be in the tubing. In the case of the Omnipod, it'll be in that short segment. But if you have a very young child that's utilizing very small insulin doses or maybe a basal rate that's very, very small, it's gonna take a while for that pressure to build up in that pump to realize that. So again, monitoring blood glucoses is really, really important. The pump can be programmed and if let's say the cannula slipped out a little bit, you may, those of you that have had students with diabetes that you can smell the insulin, but it may not be obvious. And so you wanna make sure that you're keeping an eye on those blood glucoses levels. I always tell folks that if the blood glucose rises without a good reason, you wanna check for ketones. Basically, if they have positive ketones, you wanna assume that they're not getting insulin. You wanna make sure they hydrate as you know, you wanna make sure that you give an injection if there is the ability to replace that infusion site and it's been agreed upon with the family and it's in the DMMP, you can go ahead and do that. But keep in mind that a child, even if they arrive at school and their site comes out, it doesn't necessarily require that that child be picked up by their parent. You can manage that child with injected insulin. Again, this is why having those supplies on hand and making sure that they're not expired is incredibly important. If the CGM comes out, you're going to go to manual mode if they have a pump. You're going to use finger sticks. Again, there should not be a crisis if these devices go offline. We always want to make sure that there's a plan B. I think, again, it's an issue of determining. It's troubleshooting and determining if the blood sugar is high because they perhaps ate an additional snack. Well, it shouldn't be high for any more than about three hours. Certainly, if the student appears ill, you want to check for ketones. Certainly, if they have nausea and whatnot. If their blood sugar is high, without a good reason, you want to check the pot or the infusion site. Maybe they were out at recess and it got ripped off. So I think it does require a certain level of troubleshooting. And that should be, again, you should refer to the diabetes medical management plan. Again, unfortunately, if you don't have those backup supplies, then certainly you need to contact the family. And either they're going to bring in insulin or they're going to take the student home. Again, it's important to discuss all of these things and review that medical management plan so that you know what the plan B is. And so, again, working with the student, if they're of age and competent, and working with the family is incredibly important. As mentioned before, the expectation is not that school staff, unless they're very experienced with these devices, are going to replace sensors, are going to replace infusion sets. We can always resort to finger sticks and injected insulin. And I should mention that if a sensor comes off or the infusion site, we don't want to discard any of that. We want to make sure that you put them in, for instance, a baggie and send that home with the student. Again, specifically with regards to these hybrid closed-loop or automated devices, troubleshooting, the hybrid closed-loop system is not going to operate unless that pump is receiving information from the continuous glucose monitor. And this is happening via Bluetooth, as mentioned. That line of sight, particularly with the pods, is incredibly important, despite the fact it's Bluetooth. And so each pump has also their own alerts and alarms. You should try to follow the prompts on the screen if possible. Again, in the case of a system that's utilizing a Dexam continuous glucose monitor, you want to make sure that there's connection and that information is being transmitted to the pump. If it's an Omnipod 5, again, this issue of line of sight is really, really important. In the case of a loss of continuous glucose monitor, again, these devices will resort to that backup settings. And so, again, the goal, ideally, is to replace that continuous glucose monitor and get them back into automated mode. It's going to help with higher blood sugars. It's going to assist in preventing lows. So we want to keep them in automated delivery as much as possible. So that's all that I have for insulin pumps today. I hope the information was helpful. We are going to start with the question and answer period. And so we have those in the chat. So I think Crystal is going to assist me with that. Yes. Thank you, Dr. Rodriguez. We do have some questions, some great questions. Super. I am a school nurse and have a fourth grade student that went from finger sticks and insulin pen to Omnipod and sensor. He is highly allergic to the adhesive from the equipment and removes the devices at will and does not understand the ramifications of that. There is a question of autism. What would be best for the student during school hours? Let's see. He is very comfortable with the finger sticks and insulin pen. Yeah. So it actually raises a couple of issues. The first is with regards to adhesives. These devices only work if they stay on. So I think we've all encountered students and, quite honestly, children that have particularly sensitive skin. I think it's important to contact their diabetes medical care team. There are products that provide barriers so that you can essentially protect the skin from that adhesive. They run the range from a solution that you can apply that provides that microscopic barrier. There are actually surgical dressings that you can put on there. I should mention that outside of irritation from the adhesive, sometimes devices, particularly here in Florida, if they're perspiring profusely during the summer months, definitely happens here. There are products to assist in adhesion. It's also important to note that skin care is extremely important. Remember, they're rotating sites. They should be. But they're going back to those same sites. We want to make sure they're taking care of their skin. We don't want to tear these devices off. It's going to traumatize the skin. There are, as much as there are products that help them adhere better, there are products that allow you to peel them off and really minimize the trauma to the skin. With regards to this particular child, and I've had children that are developmentally belayed where they find it uncomfortable, assuming that they're not having major skin irritation and they want to take it off, I think it really is a discussion with the family and the medical care team. I remember that when we first started putting very young children on insulin pumps, they all seemed to end up wearing overalls because we would place it in their back and they couldn't get to it. I think it is really a conversation to have. If, quite honestly, if there isn't a manner to keep the devices on, then again, for at least that particular scenario, it may be appropriate for them to go back on multiple daily injections. And the devices may not be the best choice at the current time. OK. I have a student who has a tandem pump. He is very active. When he goes to recess or has PE, he puts the pump on exercise mode. His blood sugar at the time prior to the activity would range from 120 to 140-ish. He will eat a snack prior to going out. When he is done with recess or PE, his blood sugar goes down, 40 to 70. Any advice as to how to work with this issue? So I tried to address this a little bit. And again, like everything else, we kind of have our standard approach and then it really depends on the individual child. It is quite possible if this child is using a tandem pump that is utilizing that control IQ feature by eating that snack and probably not administering an insulin bullish for that. What the pump is seeing is that their blood glucose is rising. And despite his best intentions of eating a snack not to go low, the pump is actually responding by giving additional insulin. So again, that exercise mode should help with minimizing that risk for low blood sugar during activity. If there is additional carbohydrate that's needed, we recommend very small amounts. The other option potentially, and you don't want to do this for an extended period of time, with these hybrid closed loop systems, we try not to do this, but you can suspend or disconnect. But again, our general recommendation is to try to utilize the functionality of that system. OK. If a pump isn't working or the site is leaking and extra equipment for the pump is not available at school, how soon should blood sugar be covered with an insulin pen or syringe? So that's going to depend on the blood glucose level. So we try not to administer insulin any more frequently than every two to three hours, two at the least. And so if the blood sugar is elevated, the first thing that I would recommend is monitoring for ketones. If they have ketones, you know that they haven't been getting insulin for quite some time. And so in that case, you want to administer a correction dose with, we typically recommend, and this where you want to consult the diabetes care team, we typically recommend additional insulin or supplemental dose if they have moderate or large ketones. Because that student's response to insulin is going to be blunted. They're more insulin resistant if they already have ketones and they've not had blood sugar, I'm sorry, not have an insulin for quite some time. So it is going to depend. The challenge is that child that perhaps administered a bolus prior to lunch, and they ate their lunch, but then their site came out. Well, did they get the full bolus or not? And that's where these continuous glucose monitors are really, really helpful because you can look at the trend and you can see if they're going up excessively. The short answer to that question is you really don't, you want to try to avoid giving insulin any more, as a bolus, any more frequently than every two hours. I have a kindergartner, newly diagnosed in May 2023, who has a sustained blood sugar of over 200 two to three hours in the AM. Then in the afternoon, her blood sugar falls down to the 90s to 100s. Is there a reason why she has a sustained blood sugar in the AM and falls in the PM? We have bolused her prior to lunch and give her the rest if she eats her entire lunch. So again, if the higher, if I'm understanding correctly, the blood sugar is higher in the morning, correct? Right. The blood sugar sounds like it's 200 two to three hours, and then it falls. Yeah, so it may vary. And I don't know if this child is on a pump or injections, but if they're high in the morning, generally, we think back to what's going on with their breakfast dosing. Are they getting a sufficient amount of insulin to cover their breakfast? And if they're not, then that's certainly going to cause your blood sugars to be high. And then at lunch, you're correcting that, and then they're coming down into range. So again, I think communication is key to all of this because as school personnel, you can only address what you know. And so if they're having breakfast at home, or let's say if we take an ultimate example, they forget their dose at home. They've eaten breakfast. Now their blood sugar is very, very high. You want to check for ketones. If they don't have ketones, you can give them a correction. Best to communicate with the parent to determine if perhaps they were aware that they missed their dose. Any suggestions on how to get middle school students to want to try to take care of their carbs and insulin? And sometimes it's not middle school. Sometimes it's high school and older. The challenge that we always face is how best to motivate an individual, whether it be a child or an adult, to manage their blood glucoses. In the developing child, I think trying to find out what really motivates them. For instance, if you have a child that is very much into sports, perhaps appealing to their desire to perform well and to really explain to them that their blood glucoses are going to affect that. If their blood sugars are too high or too low, if they're too low, they're not going to be able to participate in the activity. If they're too high, they're going to be somewhat sluggish and so forth. So finding that which motivates them is extremely important. And just trying to work with them on that. OK. Let's see. I have a student who doesn't change his pump every week as ordered because he's trying to circumvent insurance to have extra available. He always has false lobes, and I cannot get him to change. He's a 12th grader. Any thoughts on that? So it's not clear whether the question is, is it his infusion site? Is it his sensor? I mean, the sensor is depending on certainly the Dexcom. That needs to be changed out every 10 days. There are ways that you can trick the system. We very much discourage people from doing that. I think having a conversation potentially with his medical team, hopefully that medical team will have access to, ideally, part of the team. A clinical social worker. They are a tremendous resource in terms of identifying resources in the community. Maybe working with their insurance. Sometimes a prior authorization that is required by the insurance company that says this individual requires more frequent site changes. And hopefully, they get coverage. Also, I think when these issues come up, we shouldn't overlook the behavioral and mental health concerns that may arise. And so making sure that parents are aware. Again, contacting the medical team to see if there's a mental therapist or a psychologist, depending on what issues may come into play. Just a couple more. What did you say earlier about the placement of the CGM and the pump? Something about being on the same side. Yeah. So particularly with this newer Omnipod system, despite the fact that this continuous glucose monitor and the pump do communicate via Bluetooth, it's recommended by the manufacturer that we refer to as line of sight. So if you have, and it doesn't just have to be on the same side of the body. I mean, if you have the sensor on their abdomen and you have the pod directly across from it, that should be fine. But what you don't want to do is have a pod, for instance, on the buttock and their sensor on the front of their abdomen on the opposite side. I've seen where it works well. But again, these are one of these things that you need to troubleshoot. If you're not getting good communication between the pod and the sensor, you're not going to be able to stay in automated mode. And it's going to keep falling out. And so typically, there are error messages that clue you into it being a connection issue. And one last question. Which has less problems, tube or tubeless? It depends. And this is really one take-home message is all of this has to be really adapted to the individual student or patient. There are those that, as we mentioned, have rather severe reactions to the adhesive. And sometimes, despite our best efforts, having a pod that's this big, as opposed with a tubeless Omnipod system, the adhesive is going to be that entire area. Whereas an infusion site for a tube device may be only the size of a quarter. So all of those things have to be taken into account. Most providers, quite honestly, are what I've referred to as device agnostic. At our own center, what we refer to as our exploring pumps and CGM class. So we really do try to provide the pros and cons of all the devices and help the family and the patient decide on which device they think best meets their needs. That's it for the questions. I send it back to you, Dr. Rodriguez, to close us out. Well, again, I very much appreciate all of you attending tonight's presentation and very much appreciate your support of students with diabetes. I would remind you to keep an eye out for that email from the ADA directing you to the evaluation and post-test. You'll need to complete both of those in order to qualify for the continuing education credit. And so I thank you all for attending, and I hope you enjoy the rest of your evening.

American Diabetes Association

Safe at School program

insulin pumping

school setting

diabetes management

school nurses

insulin pumping technologies

blood sugar control

insulin dosing

troubleshooting techniques

student motivation