Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

Overview

Journal Diabetes Ther

Specialty Cardiology & Vascular Diseases

Date 2018 Sep 23

PMID 30242612

Citations 4

Authors

Sanjay Kalra

Laurence J Hirsch

Anders Frid

Asma Deeb

Kenneth W Strauss

Affiliations

Soon will be listed here.

Abstract

Introduction: The 2015 Insulin Injection Technique Questionnaire survey involving 13,289 patients included 898 (6.8%) patients in the pediatric age range (≤ 18 years).

Methods: The younger patients included in the questionnaire survey were grouped according to age: Group 1 (G1), 0-6 years, n = 85; Group 2(G2), 7-13, n = 423; Group 3 (G3), 14-18, n = 390. The injection technique was evaluated by means of a questionnaire and nurse assessment.

Results: Nurses found lipohypertrophy at injection sites in 41.3, 45.2, and 47.3% of patients in G1, G2, and G3, respectively. Unexpected hypoglycemia was common, ranging from 23.8 to 48.1% of patients, and glucose variability was even more common (61.0% in G1, 45.9% in G2, and 52.5% in G3); both conditions were associated with lipohypertrophy. While increasing numbers of patients were using the recommended 4-mm needles, large percentages still used longer ones (33.3% in G1, 45.9% in G2, and 61.5% in G3). The reuse of needles was also common, ranging from 21.1 to 32.5% in the three age groups. Excessive reuse, defined as using a single needle more than five times, was reported by 9.4-21.8% of patients in the three age group. The percentages of patients who had not received any injection training in the last 12 months ranged from 21.2 to 26.8% in the three groups.

Conclusion: Implications of our study are as follows: (1) pediatric patients should use 4-mm pen needles or 6-mm syringes (inserted at a 45° angle); (2) patients aged ≤ 6 years should always inject into a raised skin fold regardless of which device is used; (3) all patients should rotate sites and use needles only once to avoid lipohypertrophy.

Funding: Becton-Dickinson (BD) diabetes care.

Citing Articles

Insulin-induced lipodystrophy and predisposing factors in children and adolescents with type 1 diabetes mellitus (T1DM) in a tertiary care Egyptian center.

Elsayed S, Soliman A, De Sanctis V, Fawzy D, Ahmed S, Alaaraj N Acta Biomed. 2023; 94(3):e2023078.

PMID: 37326270 PMC: 10308467. DOI: 10.23750/abm.v94i3.14117.

Checklists for Assessing Skills of Children With Type 1 Diabetes on Insulin Injection Technique.

La Banca R, Rebustini F, Alvarenga W, de Carvalho E, Lopes M, Milaszewski K J Diabetes Sci Technol. 2021; 16(3):742-750.

PMID: 33423543 PMC: 9294572. DOI: 10.1177/1932296820984771.

Access to insulin delivery devices and glycated haemoglobin in lower-income countries.

Klatman E, Ogle G World J Diabetes. 2020; 11(8):358-369.

PMID: 32864048 PMC: 7438184. DOI: 10.4239/wjd.v11.i8.358.

Impact of Insulin Injection and Infusion Routines on Lipohypertrophy and Glycemic Control in Children and Adults with Diabetes.

Deeb A, Abdelrahman L, Tomy M, Suliman S, Akle M, Smith M Diabetes Ther. 2019; 10(1):259-267.

PMID: 30617932 PMC: 6349294. DOI: 10.1007/s13300-018-0561-7.

References

Hofman P, Lawton S, Peart J, Holt J, Jefferies C, Robinson E . An angled insertion technique using 6-mm needles markedly reduces the risk of intramuscular injections in children and adolescents. Diabet Med. 2007; 24(12):1400-5. DOI: 10.1111/j.1464-5491.2007.02272.x. View

Miller K, Foster N, Beck R, Bergenstal R, DuBose S, DiMeglio L . Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D Exchange clinic registry. Diabetes Care. 2015; 38(6):971-8. DOI: 10.2337/dc15-0078. View

Smith C, Sargent M, Wilson B, Price D . Subcutaneous or intramuscular insulin injections. Arch Dis Child. 1991; 66(7):879-82. PMC: 1793246. DOI: 10.1136/adc.66.7.879. View

Frid A, Kreugel G, Grassi G, Halimi S, Hicks D, Hirsch L . New Insulin Delivery Recommendations. Mayo Clin Proc. 2016; 91(9):1231-55. DOI: 10.1016/j.mayocp.2016.06.010. View

Gentile S, Strollo F, Della Corte T, Marino G, Guarino G . Insulin related lipodystrophic lesions and hypoglycemia: Double standards?. Diabetes Metab Syndr. 2018; 12(5):813-818. DOI: 10.1016/j.dsx.2018.04.023. View

Blanco M, Hernandez M, Strauss K, Amaya M . Prevalence and risk factors of lipohypertrophy in insulin-injecting patients with diabetes. Diabetes Metab. 2013; 39(5):445-53. DOI: 10.1016/j.diabet.2013.05.006. View

Home P . Pharmacokinetics and Pharmacodynamics of Biosimilar Insulins: Is Clamp Technology Fit for Purpose?. Diabetes Care. 2015; 38(12):2234-6. DOI: 10.2337/dc15-1046. View

Frid A, Hirsch L, Menchior A, Morel D, Strauss K . Worldwide Injection Technique Questionnaire Study: Injecting Complications and the Role of the Professional. Mayo Clin Proc. 2016; 91(9):1224-30. DOI: 10.1016/j.mayocp.2016.06.012. View

Hirsch L, Gibney M, Albanese J, Qu S, Kassler-Taub K, Klaff L . Comparative glycemic control, safety and patient ratings for a new 4 mm x 32G insulin pen needle in adults with diabetes. Curr Med Res Opin. 2010; 26(6):1531-41. DOI: 10.1185/03007995.2010.482499. View

10.

Famulla S, Hovelmann U, Fischer A, Coester H, Hermanski L, Kaltheuner M . Insulin Injection Into Lipohypertrophic Tissue: Blunted and More Variable Insulin Absorption and Action and Impaired Postprandial Glucose Control. Diabetes Care. 2016; 39(9):1486-92. DOI: 10.2337/dc16-0610. View

11.

Vaag A, Pedersen K, Lauritzen M, Hildebrandt P, Beck-Nielsen H . Intramuscular versus subcutaneous injection of unmodified insulin: consequences for blood glucose control in patients with type 1 diabetes mellitus. Diabet Med. 1990; 7(4):335-42. DOI: 10.1111/j.1464-5491.1990.tb01401.x. View

12.

Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J . New injection recommendations for patients with diabetes. Diabetes Metab. 2010; 36 Suppl 2:S3-18. DOI: 10.1016/S1262-3636(10)70002-1. View

13.

Hofman P, Derraik J, Pinto T, Tregurtha S, Faherty A, Peart J . Defining the ideal injection techniques when using 5-mm needles in children and adults. Diabetes Care. 2010; 33(9):1940-4. PMC: 2928337. DOI: 10.2337/dc10-0871. View

14.

Tandon N, Kalra S, Balhara Y, Baruah M, Chadha M, Chandalia H . Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017. Indian J Endocrinol Metab. 2017; 21(4):600-617. PMC: 5477451. DOI: 10.4103/ijem.IJEM_97_17. View

15.

Polak M, Beregszaszi M, Belarbi N, Benali K, Hassan M, Czernichow P . Subcutaneous or intramuscular injections of insulin in children. Are we injecting where we think we are?. Diabetes Care. 1996; 19(12):1434-6. DOI: 10.2337/diacare.19.12.1434. View

16.

Vaag A, Handberg A, Lauritzen M, Henriksen J, Pedersen K, Beck-Nielsen H . Variation in absorption of NPH insulin due to intramuscular injection. Diabetes Care. 1990; 13(1):74-6. DOI: 10.2337/diacare.13.1.74. View

17.

Ji L, Sun Z, Li Q, Qin G, Wei Z, Liu J . Lipohypertrophy in China: Prevalence, Risk Factors, Insulin Consumption, and Clinical Impact. Diabetes Technol Ther. 2017; 19(1):61-67. DOI: 10.1089/dia.2016.0334. View

18.

Susman E, Houts R, Steinberg L, Belsky J, Cauffman E, DeHart G . Longitudinal development of secondary sexual characteristics in girls and boys between ages 91/2 and 151/2 years. Arch Pediatr Adolesc Med. 2010; 164(2):166-73. PMC: 2863107. DOI: 10.1001/archpediatrics.2009.261. View

19.

Kalra S, Mithal A, Sahay R, John M, Unnikrishnan A, Saboo B . Indian Injection Technique Study: Population Characteristics and Injection Practices. Diabetes Ther. 2017; 8(3):637-657. PMC: 5446372. DOI: 10.1007/s13300-017-0243-x. View

20.

Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J . A 4-mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care. 2008; 31(9):e65. DOI: 10.2337/dc08-0977. View