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Reducing injection pain in children and adolescents with type 1 diabetes: Studies on indwelling catheters and injection needles
Linköping University, Department of Molecular and Clinical Medicine, Pediatrics. Linköping University, Faculty of Health Sciences.
2001 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Insulin injections can be painful for many children, especially when using multiple daily injections. To reduce this procedural pain we in 1985 designed ao indwelling catheter for subcutaneous use when injecting insulin. This catheter has been well accepted by our patients. The aims of the present studies have been to further investigate the problems of pain associated with insulin injections in children and adolescents and to study side effects, metabolic control, and insulin absorption when using indwelling catheters (Insuflon®, Maersk Medical, Lynge, Denmark). Side effects and indwelling times were studied at home using questionnaires.Injection pain and needle phobia were studied using 10 cm VAS scales. Metabolic control was studied in a 10-week crossover study and insulin absorption with the help of an uncollimated gamma camera and 125I-insulin.

The mean indwelling time was 4.8 ± 2.2 (range 0.5-17) days. Fixation problems and local redness at the insertion site were the most frequent side effects. No major infections requiring surgical or antibiotic treatment occurred. In the questionnaire of recalled pain, the VAS score of injections (median and quartiles) with syringes was 1.9 (1.1,3.5) cm, with pens 0.4 (0.2,1.3) cm, with indwelling catheters 0.4 (0.2, I. 7) cm, when taking a pump bolus dose 0.0 cm (0.0, 0.0), and when talcing a blood glucose test 0.7 (0.1, 2.4) cm. The injection pain and needle phobia declined with increasing age but some, both yOlmg children and teenagers, regarded the injection pain as almost unbearable. In the crossover study we found no significant difference between the arms with and without Insuflon in HbA1c, 24 hour profiles of blood glucose or serum free insulin. In the absorption study the patients used the same indwelling catheter for injections of short-acting insulin for 4 days. We found no significant difference in residual activity of 125 I-insulin after 60 min. or time to 50% remaining activity between injections day 1, 3 and 5, nor between catheter and ordinary injections on day 1, 3 and 5, respectively. HbA1c correlated significantly both to T-50% and residual activity of 125 I-insulin after 60 min. In the randomized multicenter study using Insuflon from the onset of diabetes, injection pain and parental pre-injection anxiety decreased from day 1-15 in both groups (in average 4.1 injections/day). Pain (median 1.7 cm vs. 2.7 cm, p=0.002) and parental pre-injection anxiety (1.2 cm vs. 2.9 cm, p=0.016) was lower for Insuflon users vs. ordinary injections. Talcing injections (including insertiug Insuflon) was found less problematic in the Insuflon group (1.6 cm vs. 3.3 cm, p=0.009). During the 6 month follow-up injection pain and injection problems were significantly lower in the Insuflon group. When comparing pen injector needles, the median VAS score ranged from 0. 7 cm to 1.2 cm in the first study where 27G and 28G needles were compared (n.s. ). In the following study, 280; 29G and 30G needles scored from 1.5 cm to 2.8 cm (n.s.). Placebo injections scored 0.1 cm (p=0.0001). Leakage of insulin was found in 14% of abdominal and 25% of thigh injections (p=0.0001) with no difference between the needles. VAS scores were higher in the later study which may be explained by the adding of faces to VAS, increasing the range of scores.

In summary, most patients find the pain when injecting insulin quite small but for some it is almost unbearable. Needle diameter is of less importance for the expedenced injection pain. When using indwelling catheters from the onset of diabetes injection pain and pre-injection anxiety can be decreased significantly. The average indwelling time is 4-5 days and the frequency of side effects is low. Using indwelling catheters for up to 4 days does not affect the absorption of shmt-acting insulin when the catheter is inserted in an area free from lipohypertrophies and the long- and short-term metabolic control is not altered. We conclude that indwelling catheters can safely be used from the onset of diabetes to lessen injection pain in children and adolescents.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2001. , 94 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 700
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-28576Local ID: 13730ISBN: 91-7373-138-2 (print)OAI: oai:DiVA.org:liu-28576DiVA: diva2:249387
Public defence
2001-11-23, Berzeliussalen, Universitetssjukhuset, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-08-23Bibliographically approved
List of papers
1. Side effects and indwelling times of subcutaneous catheters for insulin injections: a new device for injecting insulin with a minimum of pain in the treatment of insulin-dependent diabetes mellitus
Open this publication in new window or tab >>Side effects and indwelling times of subcutaneous catheters for insulin injections: a new device for injecting insulin with a minimum of pain in the treatment of insulin-dependent diabetes mellitus
1990 (English)In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 10, no 1, 73-83 p.Article in journal (Refereed) Published
Abstract [en]

For 2 months we observed side-effects and indwelling times when using a subcutaneous catheter (Insuflon, Viggo AB, Sweden) for insulin injections. This method is used by approximately 600 children and adolescents with IDDM in Sweden today. 22 children and adolescents aged 4–19 years with a diabetes duration of 4.0 ± 3.0 (mean ± SD) years participated. Their HbA1c was 5.8 ± 1.0%. All used 4–6 dosages of insulin per day. The catheter was placed subcutaneously in the abdominal wall, and replaced by parents when home tests showed increased blood or urine glucose, when the child experienced pain or when skin changes were observed. The 22 patients used 239 catheters with a mean time between changing catheters of 4.8 ± 2.2 (range 0.5 – 17) days (= 1147 catheter days). Noted side effects were (% of catheter days): fixation problems, 5.6%; minor infection/irritation (= redness > 1 mm), 5.6%; pain, 2.8%; sore skin from plastic wings, 2.4%; itching/dry skin, 2.0%; eczema from band-aid, 1.7%; blocked catheter/injection needle, 1.6%; leakage of insulin, 1.3%, transient lipohypertrophies, 1.1%; hematoma/blood in catheter, 0.8%, and moist skin, 0.3%. No major infections requiring surgical or antibiotic treatment occurred. In conclusion, the use of indwelling insulin catheters seems to be a safe method to lessen the pain of insulin injections with a low frequency of side effects. The long-term metabolic control was not altered in this group of well-controlled children. We therefore find that we can recommend the use of indwelling catheters to children and adolescents who have difficulties with injections because of needle phobia or pain, particularly when using MIT.

Keyword
Insulin therapy, Indwelling catheter, Multiple injection therapy, Insuflon, Injection pain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-80246 (URN)10.1016/0168-8227(90)90084-7 (DOI)
Available from: 2012-08-23 Created: 2012-08-23 Last updated: 2017-12-07Bibliographically approved
2. Experience of pain from insulin injections and needle-phobia in young patients with IDDM
Open this publication in new window or tab >>Experience of pain from insulin injections and needle-phobia in young patients with IDDM
1997 (English)In: Practical Diabetes International, ISSN 1357-8170, E-ISSN 1528-252X, Vol. 14, no 4, 95-99 p.Article in journal (Refereed) Published
Abstract [en]

We studied attitudes towards insulin injections, needle-phobia and the experience of pain when using syringes, pens, insulin pumps and in-dwelling subcutaneous catheters (Insuflon®, Maersk Medical, Lynge, Denmark).

185 children and adolescents with IDDM aged 14.2±4.1 years with a HbA1c of 6.4±1.4% answered a questionnaire using 10 cm VAS scores (0 cm = hardly noticeable pain/not scared of needles at all, 10 cm=unbearable pain, very scared of needles).

The VAS score of injections (median and quartiles) with syringes was 1.9 (1.1, 3.5) cm, with pens 0.4 (0.0, 1.3) cm, with in-dwelling catheters 0.4 (0.2, 1.7) cm, when taking a bolus dose with insulin pump 0.0 (0.0, 0.0) cm and when taking a blood glucose test 0.7 (0.1, 2.4) cm. The injection pain declined with increasing age but still several teenagers regarded the injection pain as almost unbearable. Injection pain correlated to HbA1c (p=0.033), age (p=0.0003), their own (p<0.0001) and their mother's (p=0.032) needle-phobia (but not father's) but not to diabetes duration or if parents had tried injections or blood glucose testing. Median needle-phobia score was 0.4 (0.1, 1.4) cm. Overall, 8.3% of the patients, 16.8% of the mothers and 17.7% of the fathers defined themselves as having pronounced needle-phobia (⩾5 cm). Those using in-dwelling catheters reported a higher needle-phobia but their injection pain was in the same low range as for other individuals.

We conclude that, for most patients, the pain when injecting insulin is quite small irrespective of injection mode, but for some it is almost unbearable. Parents' attitudes are important for children's acceptance of injections. Injections through an in-dwelling injection aid enables children and adolescents to reduce the pain to levels comparable to those who are less needle-phobic.

Keyword
insulin-dependent diabetes mellitus, children, injection pain, pain measurement, analogue pain scale, needle-phobia, in-dwelling catheters
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-80253 (URN)10.1002/pdi.1960140404 (DOI)
Available from: 2012-08-23 Created: 2012-08-23 Last updated: 2017-12-07Bibliographically approved
3. Metabolic Control Is Not Altered When Using Indwelling Catheters for Insulin Inactions
Open this publication in new window or tab >>Metabolic Control Is Not Altered When Using Indwelling Catheters for Insulin Inactions
1994 (English)In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 17, no 7, 716-718 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE To determine if the use of indwelling catheters for insulin injections affects the long- and short-term metabolic control of insulin-dependent diabetes mellitus (IDDM).

RESEARCH DESIGN AND METHODS Sixteen children and adolescents 9–20 years of age were included in a randomized 10-week crossover study using indwelling catheters (Insuflon, Pharma-Plast, Lynge, Denmark; CHRONIMED, Minnetonka, Minnesota) for insulin injections. Their diabetes duration was 7.5 ± 3.3 years (range 2–14), and they used multiple injection therapy with 4–5 doses/day. C-peptide was <0.15 nM fasting and ≤0.30 nM postprandial.

RESULTS We found no significant difference between those with and without Insuflon in degree of metabolic control reflected by HbA1c (with Insuflon, 7.3 ± 2.6%; without, 7.1 ± 2.2%), 24-h profiles of blood glucose and free insulin, 24-h samples of glucosuria, or ketonuria. Weight, insulin doses per kilogram per 24 h, and insulin antibodies were all the same in the two groups.

CONCLUSIONS The long- and short-term metabolic control of IDDM was not altered by the use of indwelling catheters for insulin injections. Insuflon can be offered as an alternative to patients with IDDM who find regular injections uncomfortable.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-80254 (URN)10.2337/diacare.17.7.716 (DOI)
Available from: 2012-08-23 Created: 2012-08-23 Last updated: 2017-12-07Bibliographically approved
4. Diagnosis of the cause of malfunction of indwelling catheters for insulin injections by the use of digital fluoroscopy
Open this publication in new window or tab >>Diagnosis of the cause of malfunction of indwelling catheters for insulin injections by the use of digital fluoroscopy
2000 (English)In: Pediatric Radiology, ISSN 0301-0449, E-ISSN 1432-1998, Vol. 30, no 10, 674-676 p.Article in journal (Refereed) Published
Abstract [en]

Background. Subcutaneous indwelling catheters are used for reducing pain when injecting insulin and other drugs.

Objective. To use digital fluoroscopy for the diagnosis of catheter malfunction.

Material and methods. Seven children (aged 5–11 years) with diabetes mellitus were studied. They used indwelling catheters (Insuflon) for insulin injections. Contrast medium was injected into the problem catheter.

Results. The subcutaneous position of the catheter was correct in all cases, but we found two cases of delayed absorption caused by lipohypertrophy and one case of leakage.

Conclusions. Digital fluoroscopy is a useful method for determining potential problems with indwelling catheters.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25949 (URN)10.1007/s002470000248 (DOI)10396 (Local ID)10396 (Archive number)10396 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
5. Unchanged Insulin Absorption After 4 Days' Use of Subcutaneous Indwelling Catheters for Insulin Injections
Open this publication in new window or tab >>Unchanged Insulin Absorption After 4 Days' Use of Subcutaneous Indwelling Catheters for Insulin Injections
1997 (English)In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 20, no 4, 487-490 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE Since 1985, we have used indwelling catheters (Insuflon, Maersk Medical, Lynge, Denmark; Chronimed, Minnetonka, MN) to lessen pain when injecting insulin. However, some patients experience a rise in blood glucose after using indwelling catheters for a few days. We therefore studied the absorption of 125I-labeled insulin when using indwelling catheters.

RESEARCH DESIGN AND METHODS Five men and five women participated (age 18–25 years, C-peptide negative, HbA1c 9.0 ± 1.0% [mean ± SD, DCA-2000 method], diabetes duration 5–21 [median 9.5] years). After thyroid blockage with potassium iodide, we injected 5IU of 125I-labeled short-acting insulin subcutaneously in the abdomen (“ordinary injection”) and 5 IU on the contralateral side through an indwelling catheter (“catheter injection”). The injection/insertion area was free of lipohyper- and lipohypotrophies. Disappearance rate was measured for 180 min with a gamma camera. The patients injected all premeal injections of short-acting insulin through the same indwelling catheter in the following 4 days. The investigation procedure was repeated day 3 and 5.

RESULTS We found no statistically or clinically (95% CI) significant difference in residual activity of 125I-insulin after 60 min or in time for 50% of the injected depot to disappear (T-50%) among catheter injections on day 1, 3, and 5; ordinary injections on days 1, 3, and 5; or catheter and ordinary injections on days 1, 3, and 5, respectively. HbA1c correlated both to T-50% (r = 0.73, P = 0.016) and residual activity of 125I-insulin after 60 min (r = 0.69, P = 0.028), indicating that patients with a slower absorption will have a less ideal metabolic control when using premeal bolus injections.

CONCLUSIONS We conclude that using indwelling subcutaneous catheters for insulin injections for up to 4 days does not affect the absorption of short-acting insulin.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-80255 (URN)10.2337/diacare.20.4.487 (DOI)
Available from: 2012-08-23 Created: 2012-08-23 Last updated: 2017-12-07Bibliographically approved
6. Indwelling catheters used from the onset of diabetes decrease injection pain and pre-injection anxiety
Open this publication in new window or tab >>Indwelling catheters used from the onset of diabetes decrease injection pain and pre-injection anxiety
Show others...
2002 (English)In: Journal of Pediatrics, ISSN 0022-3476, E-ISSN 1097-6833, Vol. 140, no 3, 315-320 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: To investigate the use of indwelling catheters as injection aids at diabetes onset to reduce injection pain and pre-injection anxiety.

Study design: Forty-one patients aged 8.1 ± 3.7 years (range, 1-15) participated in this open, controlled randomized study. A 10-cm VAS with faces was used for scoring. A local anesthetic cream was used before all insertions. The control group used insulin pens with standard needles. After one week, the indwelling catheter group could choose regular injections but were included in the “intention to treat” analysis.

Results: Injection pain and anxiety decreased from day 1 to 15 in both groups (average, 4.1 injections/day). Pain was significantly lower for indwelling catheter injections when scored by parents (median, 1.2 cm vs 2.7 cm; P = .002), children/teenagers (0.8 cm vs 1.5 cm; P = .006), and nurses (1.4 cm vs 3.0 cm; P = .002). Parental pre-injection anxiety was also lower (1.2 cm vs 2.9 cm; P = .016). Taking injections, including inserting catheters, was found to be less problematic with an indwelling catheter (1.6 cm vs 3.3 cm;P = .009). During the 6-month follow-up, injection pain and injection problems were significantly lower in the catheter group. Mean catheter indwelling time was 3.7 days. Median pain for catheter insertion was 2.1 cm and for glucose testing was 0.9 cm. Sixteen of 20 patients continued to use indwelling catheters after 2 weeks, and 9 of 20 after 6 months.

Conclusions: We found an evident relief of pre-injection anxiety and injection pain when using indwelling catheters for introducing insulin injections at the onset of diabetes. (J Pediatr 2002;140:315-20)

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26528 (URN)10.1067/mpd.2002.122470 (DOI)11088 (Local ID)11088 (Archive number)11088 (OAI)
Note
On the day of the defence day the status of this article was submitted.Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
7. Thinner needles do not influence injection pain, insulin leakage or bleeding in children and adolescents with type 1 diabetes
Open this publication in new window or tab >>Thinner needles do not influence injection pain, insulin leakage or bleeding in children and adolescents with type 1 diabetes
2000 (English)In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 1, no 3, 142-149 p.Article in journal (Refereed) Published
Abstract [en]

Aims: To investigate pain, leakage and bleeding when injecting insulin with different diameters of needles.

Methods: Sixty children and adolescents aged 9–21 yrs participated in study A and 40 aged 8–20 yrs in study B. Both were double-blind and randomized. In study A, we evaluated the pain when injecting with three needles [Novo 27G/13 mm (N27), B-D MicroFine IV 28G/13 mm (B28), NovoFine 28G/12 mm (N28)] and in study B, with three needles [NovoFine 28G/12 mm (N28), B-D MicroFine+ 29G/13 mm (B29), NovoFine 30G/8 mm (N30)] and one placebo injection (no needle mounted). Abdominal and thigh injections were given in a 45° angle with a lifted two-finger skinfold on two different visits, scoring pain on a 10-cm visual analog scale (VAS), and in study B faces were added to the scale.

Results: The median VAS scores in study A were 1.2 cm (N27), 1.2 cm (B28) and 1.0 cm (N28) for abdominal injections, and 1.2 cm (N27), 0.7 cm (B28) and 1.1 cm (N28) (n.s.) for thigh injections. The median VAS scores in study B were 2.5 cm (N28), 2.3 cm (B29) and 2.8 cm (N30) (n.s.) for abdominal injections, and 2.0 cm (N28), 1.5 cm (B29) and 1.9 cm (N30) (n.s.) for thigh injections. The overall median score of placebo injections was 0.1 cm (p=0.0001). Bleedings were less common with the B29 needle (35.5%) than with the N28 needle (48.1%) (p=0.028) but with no difference compared to the N30 needle (39.2%). Leakage of insulin was found in 14% of abdominal and 25% of thigh injections (p=0.0001) with no difference between the needles. VAS scores were higher in study B which may be explained by the facial VAS scale increasing the range of answers.

Conclusions: We found no difference in injection pain, preference, bleeding or insulin leakage between the needles. Decreasing the needle diameter from 0.4 to 0.3 mm (27–30G) does not seem to decrease pain perception in this age group.

Keyword
childhood diabetes, injection pain, pain measurement, pen needles, VAS
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25950 (URN)10.1034/j.1399-5448.2000.010305.x (DOI)10397 (Local ID)10397 (Archive number)10397 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved

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