Practice Uncertainties Page

What is the best way to deliver subcutaneous insulin to infants, children, and young people with type 1 diabetes mellitus?

BMJ 2011; 343 doi: (Published 02 September 2011) Cite this as: BMJ 2011;343:d5221
  1. J C Blair, consultant endocrinologist1,
  2. M Peak, director of research 2,
  3. J W Gregory, professor in paediatric endocrinology 3
  1. 1Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
  2. 2Department of Research and Development, Alder Hey Children’s NHS Foundation Trust
  3. 3Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
  1. Correspondence to: J Blair jo.blair{at}
  • Accepted 20 July 2011

Type 1 diabetes is a common disease of childhood affecting approximately 23 000 children and young people in England.1 The daily management of type 1 diabetes is burdensome. However, over a lifetime, long term complications are likely to have the greatest adverse impact on quality of life, and pose a significant economic burden to society and the NHS. The prevalence of long term complications is lowest in those with good glycaemic control using intensive insulin regimes in the form of insulin pump therapy or multiple daily injections.2 A recent review of paediatric diabetes services in the United Kingdom reported that 94% of centres offered intensive insulin regimes, and 78% offer treatment with insulin pump therapy.3 Despite the widespread availability of insulin pump therapy, data published by the National Diabetes Information Service in 2010 reported that only 1812 people aged less than 18 years were treated with insulin pumps in England.4

The National Institute for Health and Clinical Excellence recommends insulin pump therapy as a treatment option from diagnosis of type 1 diabetes for patients aged less than 12 years and for those aged 12 years and above with inadequate glycaemic control on multiple daily injections or disabling hypoglycaemia,5 with the intention of optimising glycaemic control and quality of life. However, the authors of this guideline recognise that the evidence supporting their recommendations is poor. The additional cost of insulin pump therapy is estimated to be £1700 (€1950; $2770) per annum.6 At present there is little robust evidence that this additional investment significantly improves glycaemic control, reduces the prevalence of long term complications, or improves quality of life in the paediatric population. We consider the strengths and weaknesses of the key evidence informing national guidelines and clinical practice.

What is the evidence of the uncertainty?

We searched the Cochrane Library, the Health Technology …

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