Insulin Pump vs.

Insulin Self-Injection 1

Which is More Effective for the Metabolic Control of Children with Type 1 Diabetes:

Insulin Pump vs Insulin Self-Injection?

Macy Goodman, Shayna Hamilton, Cheyenne Kirkwood,

Hannah Yeager, Melissa Walko

Youngstown State University

Nursing Research 3749

25 April 2018
Insulin Pump vs. Insulin Self-Injection 2

Abstract

The purpose behind this paper was to see which was more effective for the metabolic control for

children with type 1 diabetes: insulin pump therapy or insulin self-injections. Throughout our

paper there are a plethora of academic journals sufficiently and insufficiently claiming our

question on both forms of insulin therapy. Our researched primarily focused on the kindergarten

level and factors such as HbAlc levels, hypo/hyperglycemic episodes, Diabetic Ketoacidosis

episodes, height, weight, BMI, economic factors, education and quality of life in both the United

States and across the globe. The conclusion of our statistics came out as the insulin pump having

the most increased benefits of metabolic control in type 1 diabetic children.

Insulin Pump vs. Insulin Self-Injection 3

Introduction

The topic of our paper came from one of our group members having an extensive

background in type 1 diabetes. With us wanting to further up on this by comparing insulin pump

therapy to self-injections in children in regard to which one would improve metabolic function.

All our information came from different academic journals such as, Diabetes Public Health,

JDRF, DirecNet, and International Society for Pediatric and Adolescent Diabetes with the results

having beneficial and inconclusive data. The information we received brought us to the

conclusion that insulin pump therapy had better metabolic outcomes then self-injections, but

with overall further research needing to be conducted.

Diabetes Overview

To understand the importance of this essay, one must understand what Diabetes Mellitus

is and how it affects those who suffer from it. In general Diabetes is a chronic disorder

characterized by uncontrolled blood glucose due to the body’s inability to regulate insulin. This

results in abnormally high blood glucose levels. There are two types: type one and type two.

Couch et al. (2008) states that type one diabetes occurs when one’s immune system starts to

attack itself, destroying beta cells in the pancreas until there are not any left. This means that the

body is not able to make insulin on its own, leading to glucose to build up in the blood. Type two

diabetes occurs when the body is able to produce insulin however does not use it properly

(Couch et al., 2008).

A complication of type one diabetes is hyperglycemia (high blood glucose) as well as

hypoglycemia (low blood glucose). If one’s blood glucose is too high they can go into Diabetic

Ketoacidosis (DKA). This occurs because the acute hyperglycemic state causes adipose tissue to
Insulin Pump vs. Insulin Self-Injection 4

breakdown which in turn releases ketones into the bloodstream (Couch et al., 2008). Taylor,

Mondesire, and Moran (2011) state that DKA can lead to coma and death. A study was done

looking at those who suffered from Diabetic Ketoacidosis. They found that 1 out of 4 children

went into DKA and 93% of them needed hospitalization. Hypoglycemia occurs due to insulin

therapy, which can cause low blood glucose if too much insulin is given. If it gets dangerously

low nerve damage, coma, and death can result. A study showed that severe hypoglycemia is

more likely to occur in younger children and children with low social class. The study also

showed that children with insulin pumps were less likely to have dangerously low blood glucose

levels. Uncontrolled blood glucose effects a blood test called a hemoglobin A1c. Children under

six years are recommended to have a HbA1c of 7.5-8.5% (Taylor, Mondesire, & Moran, 2011).

Chronic complications such as retinopathy, neuropathy, nephropathy as well as circulatory and

cardiovascular changes can arise if the blood glucose levels remain uncontrolled over time

(Couch et al., 2008).

In order to prevent complications proper management of blood glucose is essential. A

total of 80 studies were used to determine whether there was a specific intervention that is more

effective than the standard care that we currently use. Thirty-five out of fifty-two studies found

that there was no increase in effectiveness. The article goes on to state that the information was

too diverse to determine a more effective intervention than the standard care. The standard care

is defined as including a team (the child, their family and nurses, doctors, etc) to develop a

treatment plan that ends with the child being able to monitor their blood glucose on their own

and to achieve a near normal A1c level. They take into consideration a number of factors, such

as age, culture, family dynamics, maturity level, etc. This plan of care is more individualized

towards the child’s needs (Couch et al., 2008).

Insulin Pump vs. Insulin Self-Injection 5

Taking into consideration the resources available to treat the child is extremely important.

Diabetes is a growing problem around the world, two thirds of those with diabetes will be in

developing countries by 2025. Other countries do not have the resources that we have here in the

United States needed to prevent complications and death. The incidence of diabetes worldwide is

increasing so quickly, along with fatal consequences, that it is making its way to becoming the

largest epidemic the world has faced. The biggest problem worldwide is lack of insulin

availability, monitoring equipment, educators and funding, causing many children with Type 1

diabetes to die at a very young age. In Mozambique, Africa, the life expectancy is only 7 months

old. Other studies in Africa show a varying life expectancy of 1.5 years to 3.8 years and one

study showed a survival rate of up to 6 years old (Taylor, Mondesire, & Moran, 2011).

Insulin Pump Advantages and Disadvantages

With our day and age wildly growing on technology there are many advantages and

disadvantages of these findings. A community well rounded in technological advances are type 1

diabetics, with the introduction of a continuous subcutaneous insulin infusion (CSII), also known

as an insulin pump. A pump is a small computerized device used to deliver insulin while

improving glycemic control and management in diabetic children. Advantages with the insulin

pump are extremely high due to the functions it provides. An insulin pump is programed with the

ability to obtain blood glucose readings from a glucometer and convert the results with its

equipped algorithm to adequately administer bolus and basal insulin doses by automatically

factoring the math of the self-inserted carbohydrates by the children or parent, also referred to by

many as a bolus advisor. This feature alone is improving the glycemic control in children who

have frequent hypo and hyperglycemic episodes. That’s why another tool in the pump is a “low

glucose suspend” feature, that stops the administration of the basal rate, a small continuous
Insulin Pump vs. Insulin Self-Injection 6

amount of insulin constantly running throughout a diabetic’s system. The low glucose suspend is

activated whenever low blood sugars are detected to stop the basal rate for 2 hours. (Heinemann,

Fleming, Petrie, Holl, Bergernstal, & Peters, 2015).

With the insulin being beneficial it also comes with a few disadvantages. The main one

being the cost, due to only a small amount of health care insurance companies approving it.

Another factor playing a disadvantaged is human error, causing either insulin infusion blockage

and/or lipohypertrophy that could cause either hyperglycemia and/or diabetic ketoacidosis. These

disadvantages are frightening factors that can be avoided with proper researching that does show

insurance companies reimbursing patients with health benefits and proper teaching. With the

analysis of a MAUDE database constructing adequate teaching measures, guidelines, and

choosing the proper children to advance with an insulin pump to have the least side effects as

possible. The advantages of this article alone show how beneficial an insulin pump is for

children’s metabolic health and how their health improves due to the features it provides

(Heinemann, Fleming, Petrie, Holl, Bergernstal, & Peters, 2015).

Improving of health of children using an insulin pump

Research is continually being conducted justifying the claims and features the insulin

pump has on improving the metabolic well-being in type 1 diabetic children. An insulin pump

alone comes with outstanding features but it also opens doors for additional attachments. One

feature being implemented with insulin pump therapy is a real-time continuous glucose

monitoring sensor (RT-CGM), called sensor-augmented pump (SAP) therapy. The goal of SAP

therapy is to allow improvement of glycemic control, reduction rates of hypoglycemic episodes,

and glycemic variability, that allow a diabetic child and/or parent to adequately adjust insulin

infusion and carbohydrate intake to prevent a hypo or hyperglycemic episode. Many clinical
Insulin Pump vs. Insulin Self-Injection 7

trials have been performed showing the improvement of a diabetics metabolic control, patient

satisfaction, and health-related quality of life, with the production of a real-time continuous

glucose monitoring sensor (Tumminia, Sciacca, Frittitta, Squatrito, Vigneri, Le Moli, and

Tomaselli, 2015).

A study using SAP therapy verses daily self-injections was led viewing the metabolic

function of diabetic children’s glycated hemoglobin (A1c) levels. With the results showing an

approximate decrease ranging from 0.8% to 1.2% and without increases in hypoglycemic

episodes. An important aspect that affects a diabetics metabolic control is their quality of life and

how they adequately control their diabetes. This is especially true with diabetic children, and

their parents having a huge role in their disease. During a trial conducted by the JDRF, they

studied the quality of life with SAP therapy showing high satisfaction using the insulin pump

with the sensor 6 or more days per week. In the study by DirecNet 41% children used their

sensor 6 or more days a week with parents scoring high levels on the “self-management survey”.

These findings show justification of sensor and insulin therapy for both children and parents

because it makes for more tedious time spent on diabetic care to help improve quality of life and

maintain proper metabolic levels (Tumminia, Sciacca, Frittitta, Squatrito, Vigneri, Le Moli, and

Tomaselli, 2015).

Quality of life is properly defined by the Oxford Dictionary as “the standard of health,

comfort, and happiness experienced by an individual or group”. In the medical world today, it is

important to create and use both procedures and technology that will better improve the quality

of life of its consumers. The diabetic population is just one of many in the world that need these

kinds of procedures and technologies to better improve all around quality of life. The question as

to whether an insulin pump brings about more freedom in a diabetic’s life, especially for
Insulin Pump vs. Insulin Self-Injection 8

children, than regular self-injections of insulin is an important one. Another question surrounding

freedom and quality of life is if self-injection users spend more time caring for themselves than

those that use an insulin pump.

A group of researchers at the University of Southampton in Southampton, England did

extensive literature reviews to determine the quality of life associated with insulin pump use in

type 1 diabetes. Barnard, Lloyd, and Skinner (2007) dug deep into several search engines such as

MEDLINE and Cinahl journals from the Diabetes UK website, and requested information from

the American Diabetes Association to find information that would answer their question. The

goal was to find articles that fit in a specific frame of time and that provided information on

quality of life. Out of 84 articles that the group found during their research, 17 filled the criteria

and were used in the study. Conflicting evidence as to whether insulin pump use brings users a

better quality of life was recorded. Of the studies used, five of them were randomized controlled

trials. The results of these trials proved different evidence about quality of life – three reported

mixed results, one reported quality of life benefits, and one reported that there was no evidence

of quality of life benefits. One of the main issues the researchers found when analyzing articles is

that the definition of quality of life and the way that quality of life is measured was not the same

for each of the trials. If each researcher uses a different definition to define quality of life or the

way it can be measured, data will not correlate. It is not the matter of whether insulin pumps

provide quality of life benefits or not, but the fact that quality of life benefits are not often

reported and offered for research (Barnard, Lloyd, & Skinner, 2007).

Comparisons of Insulin Injections vs Insulin Pump Improving Metabolic Function

The main goal of conducting research on insulin pumps versus self-inserted insulin

injections is to determine which provides better metabolic control for children. Different types of
Insulin Pump vs. Insulin Self-Injection 9

metabolic control that is often considered in children that are type 1 diabetics include glycemic

control, hemoglobin A1C levels, incidences of diabetic ketoacidosis, and severe hypoglycemic or

hyperglycemic episodes. Other factors that are also considered are height, weight, and BMI. It is

vital to keep blood glucose levels regulated and to monitor them frequently to ensure that no

complications will occur. It is also important to remember that children are unlike adults in many

ways. They have different metabolic systems, a higher level of activity in daily life, different

behaviors of eating, and smaller body mass to account for.

In 2001, there was about 1.54 cases for every one thousand children in the United States

with type 1 diabetes (Taylor, Mondesire, & Moran, 2011). Although this fact is outdated, the

number has significantly increased upon our youth. An important factor that remains is

monitoring glycemic control and safety in children. With an insulin pump previously being

stated to having many advantages, as justified by the article by Heinemann, Fleming, Petrie,

Holl, Bergernstal, & Peters (2015). This statement, brought further articles to surface claiming

this research. The validation by authors Litton, Rice, Friedman, Oden, Lee, & Freemark (2002),

showed how the use of a continuous insulin infusion via by an insulin pump was beneficial

controlling glycemic control and safety among type 1 diabetic children. In this study, they tested

the effectiveness of daily insulin injections vs. a continuous insulin infusion through an insulin

pump (Litton, Rice, Friedman, Oden, Lee, & Freemark, 2002).

To start out, type 1 diabetic children were doing about 3 to 4 daily insulin injections,

while paired with 4 to 10 times a day of blood sugar checks by their parents. After an average of

13.7 months of daily insulin injections, the children were put on a continuous insulin pump for

an average of 12.7 months. While their parents continued to monitor blood sugars throughout the

day. During both types of insulin administrations, the patients had to get their children’s HbA1c
Insulin Pump vs. Insulin Self-Injection 10

checked every 3 months; their heights and weights obtained every 3 months; and parents had to

call the doctor if their child ever had a hypoglycemic episode or a ketoacidosis episode. Before

beginning continuous pump therapy, the HbA1c levels averaged to 9.5% +(-) 0.4%. During

continuous pump therapy, HbA1c levels declined to an average of 7.9% +(-) 0.3%. There was

not a big change between the initial height and weight of the patient compared to their height and

weight after beginning continuous pump therapy. During daily injection therapy, the patients had

an average of 0.52% +(-) 0.10% episodes of hypoglycemia per month. However, after beginning

continuous pump therapy, this average declined to an average of 0.09% +(-) 0.02% episodes of

hypoglycemia per month. The average visit to the emergency room for a patient that experienced

a ketoacidosis episode was unchanged during both injection therapy and continuous pump

therapy at an average of 0.06% +(-) 0.03% visits a month. Overall, this study proved that

administrating insulin via pump therapy has a significant impact on lowering HbA1c levels and

hypoglycemic episodes in children with type 1 diabetes (Litton, Rice, Friedman, Oden, Lee, &

Freemark, 2002).

Multiple factors come into play with diabetics, such as glycemic control, BMI, and

neurocognitive outcomes. Nabhan et al. (2009) wrote about a randomized study with type 1

diabetic children. It was conducted by placing them into two separate groups for six months.

Group one was put on insulin injection therapy, and group two was put on a continuous insulin

infusion therapy. After those six months, group one was switched over to continuous insulin

infusions, while group two continued using continuous insulin infusion therapy. The purpose of

this study was to see if the continuous infusion therapy showed better control of the children’s

glycemic index, body mass index, and neurocognitive function compared to using injection

therapy. Every three months, the children had visits to get their HbA1c, weight, height, and
Insulin Pump vs. Insulin Self-Injection 11

BMIs checked and documented. Neurocognitive function was tested before initiating therapy, at

six months, and again at twelve months. After just three months of therapy, regardless of when

continuous infusion therapy was started, HbA1c decreased by 0.4%. However, this improvement

lessoned over time, although it was still an overall improvement. At the end of the study, there

were no drastic changes between HbA1c levels from the beginning measurements. There were

also no drastic differences between both groups’ BMI percentile or their neurocognitive

functioning (Nabhan et al., 2009).

A large group of researchers from the International Society for Pediatric and Adolescent

Diabetes set out to compare injection use to pump use in children younger than six years old with

type 1 diabetes to determine which group had better metabolic control. The children studied were

part of the type 1 diabetes exchange clinic registry. The studied reported that higher parental

education, household income, and provider preferences influenced whether the child used a

pump over self-injection, but race and ethnicity did not. Hemoglobin A1c (HbA1c), instances of

severe hypoglycemia, and parent reported episodes of diabetic ketoacidosis (DKA) were

observed. HbA1c was proven to be lower and better controlled in those that used the pump

compared to those that self-injected (7.9% as compared to 8.9%). Insulin pumps and insulin

injections were tied in the frequency of severe incidences of hypoglycemia. As for parent

reported episodes of DKA in the previous year, insulin pump users had poorer outcomes than

those who utilized self- injections. It was more common for pump users at 10% to be associated

with DKA than the users of self-injections at 8%. The data reported and presented in this study

supports the use of insulin pumps as opposed to the use of insulin injections for the metabolic

control in children (Blackman et al., 2014).

Insulin Pump vs. Insulin Self-Injection 12

Advantages and Disadvantages of Self-Injections

For children with type 1 diabetes self-injections have many consequences that can be

both beneficial and harmful. The article by Sharef, Ullah, Al-Shidhani, Al-Farsi, & Al-Yaarubi

(2015) explains that the use of multiple daily injections, or MDI, using rapid acting insulin or

once daily injections of long acting insulin can be used to treat type 1 diabetes. Multiple daily

injections, or MDI, are a very common and effective choice in children. The article assessed

patients that switched from twice a day (BID) injections to MDI and alone MDI patients to

evaluate and compare the effectiveness. The results showed that there was better glucose control

in diabetic children that switched from BID to MDI. They studied 146 children, 12 (8%) were

using insulin pump, 23 (16%) were on BID insulin, and 109 (76%) were on MDI. Among the

109 on MDI, 53 (49%) were initially on BID then switched to MDI, and the other 56 (51%) were

started on the regimen or on MDI for less than 6 months. After three months of switching from

BID to MDI, the mean HbA1c values were 10.0+/-1.6 and 9.5+/-1.6. For calculated percentage

of improvement in HbA1c at three months follow up was 4.4+/-14. Overall, they discussed some

definite improvements of glycemic control with MDIs. There were also fewer hypoglycemic

attacks with the use of MDIs. Results showed that 23% of patients reported episodes of

hypoglycemia while on BID, and 11% of patients reported episodes after switching to MDI. This

type of regimen is encouraging with the effects it gives. However, there are disadvantages of

self-injections as well, especially in pediatric patients (Sharef, Ullah, Al-Shidhani, Al-Farsi, &

Al-Yaarubi, 2015).

As the article by Wu, Graves, Roberts, & Mitchell (2010) states, it causes more stress on

the parents, as they need to constantly monitor their children’s state of health. If they are not able

to do the self-injections themselves then they have the responsibility on making sure that: the
Insulin Pump vs. Insulin Self-Injection 13

insulin is given at the right time; that they have food available; that they know what the onset,

the duration and the peak is; and so on so forth. Another disadvantage is that children,

themselves, don’t have much flexibility with self-injections as compared to insulin pumps. Other

disadvantages that are proven include insulin pumps having better effectiveness in metabolic

control rather than self-injections, such as MDIs, therefore more patients will turn to the insulin

pump. In this article, statistics found that with parental stress, there was a connection between the

quality of life and HgA1c. Ultimately, parenting stress is a significant factor in dealing with

pediatric patients and self-injections and this is proven to be a huge disadvantage (Wu, Graves,

Roberts, & Mitchell, 2010).

Conclusion

In conclusion, as we already know, diabetes is an extraordinarily complicated disease.

This disease does not discriminate, meaning that it affects millions of people of all ages and

races around the world, with type 1 diabetes being particularly abundant in children. The results

from our research were conflicting. Some studies showed that insulin pump use had an increased

beneficial outcome of metabolic control (HgA1C, DKA, and hypo/hyperglycemia) over self-

injection. On the other hand, some studies found that there was no significant evidence to

support insulin pump use over insulin self-injection for metabolic control. Although there is

sufficient evidence to support the idea that pump use has more advantages compared to self-

injection, it is determined that more research should be conducted on the topic of metabolic

control with a larger population being studied. Continuing education and research on the pump

alone and its attachments (sensor) should be made to continue to improve the metabolic control

of type 1 diabetic children. Quality of life will better improve with accurate metabolic control
Insulin Pump vs. Insulin Self-Injection 14

after education of the insulin pump is provided. There is a need for more diabetic prevention and

control, not only in the United States, but around the world.

References

Barnard, D. K., Lloyd, E. C., & Skinner, C. T. (2007). Systematic literature review: quality of
life associated with insulin pump use in Type 1 diabetes. DIABETICMedicine, 24, 607-
617. doi: 10.1111/j.1464-5491.2007.02120.x. Retrieved from
https://journals.ohiolink.edu/pg_99?201790973729815::NO::P99_ENTITY_ID,P99_EN
TITY_TYPE:15135048,MAIN_FILE&cs=3MgP2k1X1jtJ_cdCcKfN_yLy7MQv2xGmM
KMLFqAQ_wVajolk8BDI7Dsgu2VmpWspzxl4HVyo9L6KyBOec7pZhzw
Blackman, M. S., Raghinaru, D., Adi, S., Simmons, H. J., Ebner-Lyen, L., Chase, P. H., . . .
DiMeglio, A. L. (2014). Insulin pump use in young children in the T1D exchange clinic
registry is associated with lower hemoglobin A1c levels than injection therapy. Pediatric
Diabetes, 15, 564-572, doi: 10.1111/pedi.12121. Retrieved from
https://journals.ohiolink.edu/pg_99?210626930403092::NO::P99_ENTITY_ID,P99_EN
TITY_TYPE:35489643,MAIN_FILE&cs=39vTkmBbZQarzmI6yVNwoF2bgs2c1o1s8F2
ysncTBm7OrMDkhl9taxU7N3z39MsTicGwfVYCgFxSIhyu02UeePQ
Couch, R., Jetha, M., Dryden, D. M., Hooton, N., Liang, Y., Durec, T., . . . Klassen, T. P. (2008,
April). Diabetes Education for Children With Type 1 Diabetes Mellitus and Their
Families. Retrieved March 17, 2018, from
https://permanent.access.gpo.gov/lps93804/diabetesed.pdf
Heinemann, L., Flemin, A.G., Petrie, R. J., Holl, W. R., Bergenstal, M. R., & Peters, L.A.
(2015). Insulin pump risks and benefits: A clinical appraisal of pump safety standards,
adverse event reporting, and research needs a joint statement of the European association
for the study of diabetes and the American diabetes association diabetes technology
working group. Diabetes Care, 38, 716-722. doi: 10.2337/dc15-0168. Retrieved from
http://eps.cc.ysu.edu:2085/ehost/detail/detail?vid=2&sid=bf77d827-7302-41f4-9b59-
bc8a52ce903c%40sessionmgr102&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVo
b3N0LWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=101709451&db=a9h

Litton, J., RN, CDE, Rice, A., MD, Friedman, N., MD, Oden, J., MD, Lee, M. M., MD, &
Freemark, M., MD. (2002, October). Insulin pump therapy in toddlers and preschool
children with type 1 diabetes mellitus. Retrieved March 17, 2018, from
file:///C:/Users/organ/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bb
we/TempState/Downloads/Diabetes%20Journal%20.pdf

Nabhan, M. Z., Kreher, C. N., Greene, M. D., Eugster, A. E., Kronenberger, W., & DiMeglio,
A.L. (2009). A randomized prospective study of insulin pump vs. insulin injection
therapy in very young children with type 1 diabetes: 12-month glycemic, BMI, and
neurocognitive outcomes. Pediatric Diabetes, 10, 202-208. doi: 10.1111/1399-
Insulin Pump vs. Insulin Self-Injection 15

5448.2008.00494.x. Retrieved from

file:///C:/Users/organ/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bb
we/TempState/Downloads/nursing%20research%20journal%20_3%20(2).pdf

Sharef, S. W., Ullah, I., Al-Shidhani, A., Al-Farsi, T., & Al-Yaarubi, S (2015). Switching to
Multiple Daily Insulin Injections in Children and Adolescents with Type 1 Diabetes:
Revisiting Benefits from Oman. Oman Medical Journal, 30(2), 83-89. Doi:
10.5001/omj.2015.19. Retrieved from
http://eps.cc.ysu.edu:2063/ehost/detail/detail?vid=3&sid=9e6f7cb9-
05c9440f9fbf664dc315e617%40sessionmgr4006&bdata=JkF1dGhUeXBlPWlwLHVpZ
CZzaXRlPWVob3N0LWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=103067498&db=a9
h

Taylor, P. L., Mondesire, J., & Moran, S. (2011). Diabetes Public Health (K. M. Venkat
Narayan, D. Williams, E. W. Gregg, & C. C. Cowie, Eds.). Retrieved March 17, 2018,
from
http://ebooks.ohiolink.edu/xtfebc/view?docId=tei/ox/9780195317060/9780195317060.x
ml;chunk.id=acprof-9780195317060-miscMatter-2;toc.depth=1;toc.id=;brand=default

Tumminia, A., Sciacca, L., Frittitta, L., Squatrito, S., Vigneri, R., Le Moli, R., & Tomaselli, L.
(2015). Integrated insulin therapy with continuous glucose monitoring for improved
adherence: technology update. Patient Preference & Adherence, 9, 1263-1270. doi:
10.2147/PPA.S69482. Retrieved from
http://eps.cc.ysu.edu:2085/ehost/detail/detail?vid=4&sid=bf77d827-7302-41f4-9b59-
bc8a52ce903c%40sessionmgr102&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVo
b3N0LWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=110257658&db=a9h

Wu, Y., Graves, M., Roberts, M., & Mitchell, A. (2010). Is insulin pump therapy better than
injection for adolescents with diabetes?. Diabetes Research and Clinical Practice, 89(2),
121-125. doi:10.1016/J.DIABRES.2010.04.010. Retrieved from
https://journals.ohiolink.edu/pg_200?108340798879485::NO:200:P200_ARTICLEID:33
2387906