Diabetes and the Pied Piper of Hamelin

"Into the street the Piper stept

            As if he knew what magic slept

Then, like a musical adept

            Out came the children running-

When, lo, as they reached the mountain side,

            A wondrous portal opened wide-

And the piper advanced and the children followed...

The Pied Piper of Hamelin

Robert Browning, 1842

Little do my readers know that I actually enjoy literature other than diabetes journals. I have always loved British literature, as the themes keep intertwining with both my personal and professional life. So, why, today do I quote Robert Browning? The "Pied Piper of Hamelin" has arrived in the 20th and 21st centuries with the latest in diabetes regimens. There has always been a controversy over the correct insulin therapy: the most flexible, most physiologic, most convenient, most portable, least expensive, safest, etc. I am aware that many blogs and chat rooms discuss the best way to treat insulin dependant diabetes. Even at professional conferences (American Diabetes Association, 2008 in San Francisco, California, for example) there was a debate on the benefits of basal/bolus therapy vs. conventional insulin therapy with NPH and Regular or analog insulin. At the February 2009 Post-Graduate Diabetes Update Course in New York City, one of the presenters referred to the "Pied Piper" as we discussed the various insulin regimes.

My own Diabetes team at Children's National Medical Center continues to have multiple discussions about the use of conventional insulin therapy with 2 or 3 injections/day versus basal/bolus therapy via syringe or pen injection or insulin pumps. We are working on a tool to determine what families at diagnosis would do best on conventional insulin therapy or a form of basal/bolus therapy in which we use basal insulin (Lantus once daily, or Levemir twice daily) and fixed doses of rapid acting analog at meals without snacks ("modified" basal/bolus therapy). The best form of insulin therapy depends on multiple factors. Simply deciding which regimen to start should be based on many factors especially in a heterogeneous urban community. What are some of these factors?

The decision to start basal/bolus therapy in a newly diagnosed patient must ensure that important considerations are in place. Firstly, the age of a child is extremely significant. In young children, basal/bolus therapy might be appropriate due to erratic eating patterns (as well as different insulin action profiles) to avoid hypoglycemia. However, a caregiver must be available to give all injections via syringe or insulin pen. Diabetes education is essential. In school-aged children, we have a different dilemma. Who is going to give the insulin at lunch? The child? The nurse? Another trained adult? Will the school allow insulin syringes in the school, or do they require pens only? Will the school enable the child to give insulin in the cafeteria or does he have to report to the nurse? Knowing the answers to these questions are essential before the decision is made to start basal/bolus therapy.