Reducing injection pain in children and adolescents with diabetes: a review of indwelling catheters

Efficacy, Safety, and Pain Level of Subcutaneous Catheter Use for Administration of Granulocyte Colony-Stimulating Factor (G-CSF) in Children With Cancer: A Randomized Pilot Study

Background: The aim of this study was to explore the efficacy, safety, and pain level of granulocyte colony-stimulating factor (G-CSF) administration via a subcutaneous catheter compared with direct injection in children with cancer. Method: This was a pilot randomized controlled trial of standard G-CSF administration versus subcutaneous catheter administration. Children 2-15 years of age who were beginning G-CSF after their first chemotherapy cycle and anticipated to receive G-CSF following the next three cycles of chemotherapy were eligible. Efficacy, safety, and pain were as outcomes of the study. Results: Twenty-nine children with cancer (median age 12 years) were enrolled in the study (16 children in the subcutaneous catheter group and 13 children in the direct injection group). During Cycle 2, the median number of days to reach absolute neutrophil count (ANC) ≥ 500/mm3 was greater among those in the subcutaneous catheter group (12 vs. 10; p  =  .02). In Cycle 3, however, the subcutaneous catheter group received fewer doses of G-CSF (8 vs. 12; p  =  .004). No complications related to subcutaneous catheter use were observed. No differences in the visual analog scale pain score were observed between groups in Cycles 1 to 3; however, in Cycle 4, children in the subcutaneous catheter group had lower median pain scores than those in the direct subcutaneous injection group (Mdn  =  0, [IQR]  =  0-2 vs. Mdn  =  1, IQR  =  0-6; p < 0.01). Conclusion: Results demonstrated administering G-CSF via a subcutaneous catheter enables ANC to recover with no pain or complications associated with its use. Thus, oncology teams may consider this administration method to be used in children with cancer.

Effect of Hypodermic Needle Versus Safety Lancet on the Fear and Anxiety of Needle Prick Among Undergraduate Medical Students During Hematology Practical: A Cohort Study From a Resource-Limited Setting

Background

Most of the government-sponsored medical teaching institutions in India do not provide safety lancets, and hence, the students are compelled to use hypodermic needles. These needles are widely unpopular among students due to the potential hazards (pain, fear, anxiety) associated with them. This study aims to compare any difference in fear and anxiety associated with finger pricking with a hypodermic needle and a safety lancet.

Methods

This is a prospective cohort study. The current study included data from first-year undergraduate medical students for academic sessions 2021-22.

Results

A total of 121 students participated in the study. Eighty-two (67.8%) participants were male. 41/82 male participants and 20/39 female participants were allocated to the intervention cohort. 111 (91.7%) pricked their fingers by themselves. The sight of others pricking during the experiment (17 versus 5, p=0.004) and the thought of pain while pricking (36 versus 16, p<0.001) was significantly associated more with the use of a hypodermic needle compared to a safety lancet. There was no significant difference in students perceiving the smell of the hematology laboratory (4 versus 1, p=0.165) and the sight of blood (9 versus 3, p=0.064) as a factor influencing their fear and anxiety in both cohorts. There was no gender difference in the perception of these factors.

Symptoms were significantly lower in the intervention cohort compared to the control cohort (8 versus 20, odds ratio 0.302, p=0.008). The most common symptom experienced was excessive sweating (n=22, 18.18%), followed by drying of the mouth (n=12, 9.91%). There was a significant difference in pain scores between the intervention and the control cohorts. There was no significant difference in pain scores among male and female subjects.

Conclusion

A considerable difference between the two cohorts was found. The use of lancets can be proposed to medical teaching institutions for psychological advantage, pain reduction, and overall better quality of the process.

Low-molecular-weight heparin administered by subcutaneous catheter is a safe and effective anti-coagulation regimen in selected inpatient infants and children with complex congenital heart disease

BACKGROUND/HYPOTHESIS

Disadvantages of intravenous therapeutic unfractionated heparin, the first-line anti-coagulant agent in children with complex congenital heart disease, include unpredictable pharmacokinetics requiring frequent phlebotomies and the need for continuous intravenous access.

OBJECTIVE

To compare efficacy and safety of low-molecular-weight heparin administered by a subcutaneous indwelling catheter with intravenous unfractionated heparin.

MATERIALS AND METHODS

Clinical data from 31 inpatients prospectively enrolled to receive subcutaneous low-molecular-weight heparin were compared with those from a historical group of 44 inpatients receiving intravenous unfractionated heparin. Investigation of parents' satisfaction by telephone survey.

RESULTS

The percentage of anti-factor Xa levels outside therapeutic range was lower in the subcutaneous low-molecular-weight heparin group compared with the percentage of activated partial thromboplastin times outside therapeutic range in the intravenous unfractionated heparin group (40% versus 90%, p < 0.001). Neither group had a major complication. Transient local reactions occurred in 19% of patients of the subcutaneous low-molecular-weight heparin group. The number of needle punctures and that of placement of indwelling catheters were significantly lower in the subcutaneous low-molecular-weight heparin compared with the intravenous unfractionated heparin group (p < 0.001). In total, 84.2% of parents in the subcutaneous low-molecular-weight heparin group reported a positive experience when asked about comparison with prior intravenous unfractionated heparin treatment.

CONCLUSION

Subcutaneous low-molecular-weight heparin offers a safe anti-coagulation regimen for children with complex congenital heart disease providing more efficient therapeutic anti-coagulation and a reduction in needle punctures, thus causing less pain and anxiety in this children.

Health-Related Quality of Life, Family Conflicts and Fear of Injecting: Perception Differences between Preadolescents and Adolescents with Type 1 Diabetes and Their Mothers

Good management of diabetes requires at the same time self-regulation behaviour and a balanced involvement of family components. This cross-sectional study’s aims were: understanding fear of injections and perceptions of family conflicts in preadolescents and adolescents with type 1 diabetes mellitus and their mothers, comparing their perceptions, and identifying the risk factors impacting patients’ quality of life. Eligibility criteria were: treatment for diabetes mellitus type I, currently aged 10–18 years, attending the hospital for annual hospital follow-ups. Exclusion criteria were: intellectual disabilities, inability to complete questionnaires alone and neuropsychiatric illness with active pharmacotherapy. The study design was cross-sectional. Participants were one hundred and two patients (Mean age = 14.6, SD = 2.4; age range = 10–19 years; Females = 52 and Males = 50) and their mothers (Mean age = 46.9, SD = 6.2, age range = 27–63 years), who filled in self and proxy-report questionnaires (N total= 204). The results showed that 20% of patients and 14.7% of their mothers reported clinical scores for fear of self-injection and blood testing. The mothers reported lower fear of injecting and higher family conflicts compared with the patients. Age, fear of injecting and family conflicts were significantly associated with patients’ quality of life perceptions. Clinical considerations and recommendations are given based on the empirical results.

Use of a Flexible Catheter for the Administration of Subcutaneous Insulin in Diabetic Ketoacidosis: A Feasibility Controlled Clinical Trial

BACKGROUND

Although intravenous insulin administration is the standard of care in diabetic ketoacidosis (DKA), subcutaneous insulin administration could be a suitable alternative in resource-limited settings, but pain caused by hourly insulin applications are limiting factors for using it, especially in children. We aimed to assess whether the use of a flexible subcutaneous catheter improves comfort in patients with DKA compared with the usual hourly injections' treatment. We also compared the evolution of metabolic variables in patients with DKA using both insulin administration systems.

METHODS

Randomized feasibility controlled open trial, comparing 2 ways (flexible catheter and steel needle) for the initial insulin administration in children with DKA, who were randomly selected to receive subcutaneous insulin by a flexible catheter or using standard needles. The main outcome was pain, assessed hourly and secondary outcome time to achieve ketoacidosis resolution.

RESULTS

Twenty subjects were included (10 by group). There were no differences between groups in baseline lab values (glycemia, urea, sodium, bicarbonate and pH). Pain assessment at first insulin administration was significantly lower in the intervention group (4.5 vs 0 points; P = 0.001). Similar differences between both treatment arms were observed in every pain assessment. There were no differences between groups regarding the time elapsed to achieve ketoacidosis resolution. (11.4±4.3 vs 16±8.4; P = 0.12). No adverse events or DKA complications were observed.

CONCLUSIONS

The use of a flexible catheter reduced the pain associated with subcutaneous insulin administration in nonsevere DKA. The flexible subcutaneous catheter could be a safe alternative for the treatment of uncomplicated DKA in resource-limited settings.

The Current Status of Clinical Research Involving Microneedles: A Systematic Review

In recent years, a number of clinical trials have been published on the efficacy and safety of drug delivery using microneedles (MNs). This review aims to systematically summarize and analyze the current evidence including the clinical effect and safety of MNs. Three electronic databases, including PubMed, were used to search the literature for randomized controlled trials (RCTs) and clinical controlled trials (CCTs) that evaluated the therapeutic efficacy of MNs from their inception to 28 June 2018. Data were extracted according to the characteristics of study subjects; disorder, types, and details of the intervention (MNs) and control groups; outcome measurements; effectiveness; and incidence of adverse events (AEs). Overall, 31 RCTs and seven CCTs met the inclusion criteria. Although MNs were commonly used in skin-related studies, evaluating the effects of MNs was difficult because many studies did not provide adequate comparison values between groups. For osteoporosis treatment, vaccine, and insulin delivery studies, MNs were comparable to or more effective than the gold standard. Regarding the safety of MNs, most AEs reported in each study were minor (grade 1 or 2). A well-designed RCT is necessary to clearly evaluate the effectiveness of MNs in the future.

Treatment satisfaction correlated with glycaemic control and burden of diabetes in Swedish adolescents with type 1 diabetes

AIM

To assess treatment satisfaction and perceived discomfort or pain from the treatment, and potential associations with glycaemic control, type of treatment, perceived burden of diabetes, sex and age, in adolescents with type 1 diabetes.

METHODS

A cross-sectional study was performed at one paediatric and at one adult diabetes clinic in Sweden, preceded by a translation of 'Diabetes Treatment Satisfaction Questionnaire (DTSQ) Teen'. Adolescents with type 1 diabetes (15-20 years) participated. The questionnaires 'DTSQ Teen' and 'Check your health' were used. Data on glycosylated haemoglobin (HbA1c), type of treatment, sex and age were collected.

RESULTS

One hundred and thirty-eight adolescents (70 females, mean age 17.3, mean HbA1c 64.0 mmol/mol) participated. Treatment satisfaction correlated inversely with HbA1c (r = -.352, P < .001) and with all types of burden of diabetes (r = -.342 to -0.467, P < .001), but did not differ with type of treatment, sex and age. Perceived pain correlated inversely with burden on physical health (r = -.265, P = .002), mental health (r = -.237, P = .006) and quality of life (r = -.246, P = .004) but not with HbA1c, age or burden on social relations. Females perceived more discomfort or pain.

CONCLUSION

In Swedish adolescents with type 1 diabetes, treatment satisfaction correlated with both glycaemic control and perceived burden of diabetes.

Formulation, characterization and evaluation of mRNA-loaded dissolvable polymeric microneedles (RNApatch)

In this paper, we report a proof of concept study on the fabrication, characterization and therapeutic evaluation of in vitro transcribed messenger RNA (mRNA) loaded in a dissolving microneedle patch (RNApatch). We show that low molecular weight polyvinylpyrrolidone (PVP) can directly be used without further purification for RNApatch fabrication with no detectable mRNA degradation. Physical and functional integrity of mRNA stored within the RNApatch are completely preserved for at least 2 weeks under ambient conditions. While the loading of mRNA into RNApatch is limited by the solubility of mRNA in concentrated PVP solution, mechanical strength of RNApatch is not compromised by the presence of mRNA. RNApatch can mediate in vivo transgene expression of mRNA encoding luciferase for up to 72 hours and transfection efficiency and kinetics mediated by RNApatch compares favorably to subcutaneous injection. Interestingly, mRNA transfection efficiency does not correlate with contact surface area but instead increases with deeper delivery depths. In an E.G7-OVA immunotherapy model, RNApatch induces slightly higher cellular and humoral immune responses compared to subcutaneous injection. In conclusion, RNApatch is a viable delivery platform for mRNA and represents an attractive option with significant translation potential for the delivery of mRNA therapeutics.

Biodegradable 3D printed polymer microneedles for transdermal drug delivery

Biodegradable polymer microneedle (MN) arrays are an emerging class of transdermal drug delivery devices that promise a painless and sanitary alternative to syringes; however, prototyping bespoke needle architectures is expensive and requires production of new master templates. Here, we present a new microfabrication technique for MNs using fused deposition modeling (FDM) 3D printing using polylactic acid, an FDA approved, renewable, biodegradable, thermoplastic material. We show how this natural degradability can be exploited to overcome a key challenge of FDM 3D printing, in particular the low resolution of these printers. We improved the feature size of the printed parts significantly by developing a post fabrication chemical etching protocol, which allowed us to access tip sizes as small as 1 μm. With 3D modeling software, various MN shapes were designed and printed rapidly with custom needle density, length, and shape. Scanning electron microscopy confirmed that our method resulted in needle tip sizes in the range of 1-55 μm, which could successfully penetrate and break off into porcine skin. We have also shown that these MNs have comparable mechanical strengths to currently fabricated MNs and we further demonstrated how the swellability of PLA can be exploited to load small molecule drugs and how its degradability in skin can release those small molecules over time.

Faster pharmacokinetics and increased patient acceptance of intradermal insulin delivery using a single hollow microneedle in children and adolescents with type 1 diabetes

OBJECTIVE

In an effort to improve compliance with insulin therapy and to accelerate insulin pharmacokinetics, we tested the hypothesis that intradermal insulin delivery using a hollow microneedle causes less pain and leads to faster onset and offset of insulin pharmacokinetics in children and adolescents with type 1 diabetes (T1DM) compared with a subcutaneous, insulin pump catheter.

RESEARCH DESIGN AND METHODS

In this repeated measures study, 16 children and adolescents with T1DM received Lispro insulin by microneedle and subcutaneous administration on separate days. Subjects rated the pain of insertion and infusion using a visual analog scale. Blood specimens were collected over 4 h to determine insulin and glucose concentrations.

RESULTS

Microneedle insertion pain was significantly lower compared with insertion of the subcutaneous catheter (p = 0.005). Insulin onset time was 22 min faster (p = 0.0004) and offset time was 34 min faster (p = 0.017) after hollow microneedle delivery compared with subcutaneous delivery.

CONCLUSIONS

In this study, intradermal insulin delivery using a single, hollow microneedle device resulted in less insertion pain and faster insulin onset and offset in children and adolescents with T1DM. A reduction in pain might improve compliance with insulin delivery. The faster onset and offset times of insulin action may enable closed-loop insulin therapy.

Why do few food-allergic adolescents treat anaphylaxis with adrenaline?--Reviewing a pressing issue

Food allergic adolescents are at higher risk of fatal anaphylaxis than other children. Both allergen avoidance and maintaining access to adrenaline auto-injectors (AAI) are key goals in effective food allergy management, for which written guidance is often supplied. However, adolescents are rarely sufficiently prepared to use adrenaline during anaphylaxis. It is likely that further didactic education would bring limited improvement in management in this population. Focused discussion of each adolescent's perspectives and current management practice may allow more effective behavioural strategies to be adopted. Key areas for appraisal include subjects' experiences after previous allergen exposure with reference to worst response, recognising specific symptoms requiring AAI administration, and appropriate priority being given to timeliness of administering adrenaline. Behavioural strategies should be discussed to increase AAI accessibility. Rigor of allergen avoidance should not be compromised by false reassurance of proximity to emergency medication or medical services. Food allergic adolescents are motivated by the psychological impact of their condition, which often makes them feel different to their peers and may result in bullying. Methods of appropriately empowering adolescents may be considered, such as involvement of close friends and lay organisations to support appropriate management. Open discussion is crucial in engaging with adolescents' reasoning for adopting their chosen management strategies. Further research is warranted to identify cognitive patterns associated with high-risk behaviour, and to design appropriate interventions for the augmentation of adolescent self-management skills.

Child's and parents' catastrophizing about pain is associated with procedural fear in children: a study in children with diabetes and their mothers

The contribution of the child's and parents' catastrophizing about pain was explored in explaining procedural pain and fear in children. Procedural fear and pain were investigated in 44 children with Type I diabetes undergoing a finger prick. The relationships between parents' catastrophizing and parents' own fear and estimates of their child's pain were also investigated. The children and their mothers completed questionnaires prior to a routine consultation with the diabetes physician. Children completed a situation-specific measure of the Pain Catastrophizing Scale for Children (PCS-C) and provided ratings of their experienced pain and fear on a 0-10 numerical rating scale (NRS). Parents completed a situation-specific measure of the Pain Catastrophizing Scale For Parents (PCS-P) d provided estimates of their child's pain and their own experienced fear on a 0-10 NRS. Analyses indicated that higher catastrophizing by children was associated with more fear and pain during the finger prick. Scores for parents' catastrophzing about their children's pain were positively related to parents' scores for their own fear, estimates of their children's pain, and child-reported fear, but not the amount of pain reported by the child. The findings attest to the importance of assessing for and targeting child and parents' catastrophizing about pain. Addressing catastrophizing and related fears and concerns of both parents and children may be necessary to assure appropriate self-management. Further investigation of the mechanisms relating catastrophizing to deleterious outcomes is warranted.

Insulin delivery by injection in children and adolescents with diabetes

Type 1 diabetes is treated with insulin, which has traditionally been delivered by vial and syringe. However, for many patients, dosing inaccuracy, pain, anxiety, inconvenience, and social acceptability present barriers to this method of administration (1-5). This has contributed to the increased popularity of alternative insulin delivery systems, including pen delivery devices (4, 6). Evidence suggests that discreet devices, such as insulin pens, facilitate adherence to intensive insulin therapy regimens, help improve lifestyle flexibility, and reduce injection pain compared with the conventional syringe-based regimens, as shown in studies in adults and adolescents (7). In addition, compared with the vial and syringe method of insulin administration, pens may provide more accurate dosing - which is particularly important in children - thereby improving short-term blood glucose control and potentially improving long-term outcomes (5, 8). Children, in particular, may benefit from insulin pens that are simple to use as adherence issues may be more evident in this patient group (9). Pens for insulin delivery in children with type 1 diabetes have been used for a long time in Europe, and have recently gained in popularity in many other places around the world (4, 10). Furthermore, the conventional vial and syringe method of insulin delivery is beginning to be considered as obsolete (11). Moreover, there is a continued drive to improve insulin pen technology, to refine and enhance the functionality and usability of these pens. However, despite recent advances in pen design and function, the selection of pens available especially for children is limited.

Infusion pressure and pain during microneedle injection into skin of human subjects

Infusion into skin using hollow microneedles offers an attractive alternative to hypodermic needle injections. However, the fluid mechanics and pain associated with injection into skin using a microneedle have not been studied in detail before. Here, we report on the effect of microneedle insertion depth into skin, partial needle retraction, fluid infusion flow rate and the co-administration of hyaluronidase on infusion pressure during microneedle-based saline infusion, as well as on associated pain in human subjects. Infusion of up to a few hundred microliters of fluid required pressures of a few hundred mmHg, caused little to no pain, and showed weak dependence on infusion parameters. Infusion of larger volumes up to 1 mL required pressures up to a few thousand mmHg, but still usually caused little pain. In general, injection of larger volumes of fluid required larger pressures and application of larger pressures caused more pain, although other experimental parameters also played a significant role. Among the intradermal microneedle groups, microneedle length had little effect; microneedle retraction lowered infusion pressure but increased pain; lower flow rate reduced infusion pressure and kept pain low; and use of hyaluronidase also lowered infusion pressure and kept pain low. We conclude that microneedles offer a simple method to infuse fluid into the skin that can be carried out with little to no pain.

Delivery devices for the administration of paediatric formulations: overview of current practice, challenges and recent developments

The European Paediatric Formulation Initiative (EuPFI), a group consisting of paediatric formulation experts from industry, academia and clinical pharmacy was founded with the aim of raising awareness of paediatric formulation issues. It is imperative that paediatric medicines can be administered accurately to ensure the correct dose is provided and that the administration device is easy to use and acceptable from the patient's and carer's perspectives. This reflection paper provides an overview of currently available paediatric administration devices and highlights some of the challenges associated with, recommendations and recent developments in delivery devices for the oral, inhaled, parenteral, nasal and ocular administration of paediatric formulations, on behalf of the EuPFI.

Rapid pharmacokinetics of intradermal insulin administered using microneedles in type 1 diabetes subjects

BACKGROUND

This study compared the pharmacokinetics, postprandial glycemic response, and pain associated with intradermal lispro insulin delivery using a microneedle with that of a conventional catheter.

SUBJECTS AND METHODS

Five subjects with type 1 diabetes were administered a bolus infusion of lispro insulin using a 9-mm-long subcutaneous catheter (control treatment) and a 0.9-mm-long microneedle (study treatment), followed by consumption of a standardized meal. Blood samples were periodically assayed for plasma glucose and free insulin levels.

RESULTS

Intradermal insulin infusion using microneedles reached peak insulin concentrations in approximately half the time and led to greater reduction in plasma glucose levels than subcutaneous catheters. Microneedles were also significantly less painful than the catheters.

CONCLUSION

The rapid pharmacokinetics and minimally invasive nature of intradermal insulin infusion using microneedles provide significant potential for improved diabetes management.

Dissolving microneedle patch for transdermal delivery of human growth hormone

The clinical impact of biotechnology has been constrained by the limitations of traditional hypodermic injection of biopharmaceuticals. Microneedle patches have been proposed as a minimally invasive alternative. In this study, the translation of a dissolving microneedle patch designed for simple, painless self-administration of biopharmacetucials that generates no sharp biohazardous waste is assessed. To study the pharmacokinetics and safety of this approach, human growth hormone (hGH) was encapsulated in 600 μm-long dissolving microneedles composed of carboxymethylcellulose and trehalose using an aqueous, moderate-temperature process that maintained complete hGH activity after encapsulation and retained most activity after storage for up to 15 months at room temperature and humidity. After manual insertion into the skin of hairless rats, hGH pharmacokinetics were similar to conventional subcutaneous injection. After patch removal, the microneedles had almost completely dissolved, leaving behind only blunt stubs. The dissolving microneedle patch was well tolerated, causing only slight, transient erythema. This study suggests that a dissolving microneedle patch can deliver hGH and other biopharmaceuticals in a manner suitable for self-administration without sharp biohazardous waste.

Parent report and direct observation of injection-related coping behaviors in youth with type 1 diabetes

OBJECTIVE

This study evaluated insulin injection coping by parental report and video observation in children 3 to <11 years old with diabetes.

METHODS

Caregivers of 61 youth with type 1 diabetes completed the Diabetes Injection Distress-Parent Report Form (DID-PRF); a subsample (n = 19; 30%) submitted video recordings of their children's insulin injections.

RESULTS

The DID-PRF demonstrated acceptable internal consistency and moderately correlated with video recordings. Half of parents (n = 31; 51%) reported their child's history of insulin injection distress; 30% reportedly experienced distress ≥1 year after diagnosis. Current distress was reported for about half (n = 28) of children. More parent and child coping/distress behaviors was associated with younger child age. Children displayed more injection distress in their first month after diagnosis versus the most recent month.

CONCLUSIONS

Diabetes-related injection distress and associated coping behaviors should be further explored; longitudinal data and additional measurement development is warranted.

Dose sparing enabled by skin immunization with influenza virus-like particle vaccine using microneedles

To address the limitations of conventional influenza vaccine manufacturing and delivery, this study investigated administration of virus-like particle (VLP) influenza vaccine using a microneedle patch. The goal was to determine if skin immunization with influenza VLP vaccine using microneedles enables dose sparing. We found that low-dose influenza (A/PR/8/34 H1N1) VLP vaccination using microneedles was more immunogenic than low-dose intramuscular (IM) vaccination and similarly immunogenic as high-dose IM vaccination in a mouse model. With a 1μg dose of vaccine, both routes showed similar immune responses and protective efficacy, with microneedle vaccination being more effective in inducing recall antibody responses in lungs and antibody secreting cells in bone marrow. With a low dose of vaccine (0.3μg), microneedle vaccination induced significantly superior protective immunity, which included binding and functional antibodies as well as complete protection against a high dose lethal infection with A/PR/8/34 virus, whereas IM immunization provided only partial (40%) protection. Therefore, this study demonstrates that microneedle vaccination in the skin confers more effective protective immunity at a lower dose, thus providing vaccine dose-sparing effects.

Minimally invasive insulin delivery in subjects with type 1 diabetes using hollow microneedles

BACKGROUND

Microneedles have previously been used to deliver insulin to animal models, but not in human subjects. This study tested the hypothesis that hollow microneedles can deliver insulin to modulate blood glucose levels in subjects with type 1 diabetes in a minimally invasive manner.

METHODS

This study was carried out in two adults with type 1 diabetes and evaluated bolus delivery of lispro insulin using a hollow microneedle compared to a catheter infusion set (9 mm). The study first determined the minimum insulin delivery depth by administering insulin from microneedles inserted 1, 3.5, and 5 mm into the skin of fasting subjects and then assessed the efficacy of insulin delivery from microneedles inserted 1 mm into the skin to reduce postprandial glucose levels. Blood samples were periodically assayed for plasma free insulin and plasma glucose levels for up to 3.5 h.

RESULTS

The first phase of the study indicated that microneedles inserted at the shallowest depth of 1 mm within the skin led to rapid insulin absorption and reduction in glucose levels. Bolus insulin delivery followed by consumption of a standardized meal in the second phase revealed that microneedles were effective in reducing postprandial glucose levels. Subjects reported no pain from microneedle treatments, and there were no adverse events.

CONCLUSIONS

This study provides the first proof of concept that hollow microneedles can effectively deliver bolus insulin to type 1 diabetes subjects in a minimally invasive manner.

Effect of microneedle design on pain in human volunteers

OBJECTIVES

To design microneedles that minimize pain, this study tested the hypothesis that microneedles cause significantly less pain than a 26-gauge hypodermic needle, and that decreasing microneedle length and the number of microneedles reduces pain in normal human volunteers.

METHODS

Single microneedles with lengths ranging from 480 to 1450 microm, widths from 160 to 465 microm, thicknesses from 30 to 100 microm, and tip angles from 20 to 90 degrees; and arrays containing 5 or 50 microneedles were inserted into the volar forearms of 10 healthy, human volunteers in a double-blinded, randomized study. Visual analog scale pain scores were recorded and compared with each other and to the pain from a 26-gauge hypodermic needle.

RESULTS

All microneedles investigated were significantly less painful than the hypodermic needle with microneedle pain scores varying from 5% to 40% of the hypodermic needle. Microneedle length had the strongest effect on pain, where a 3-fold increase in length increased the pain score by 7-fold. The number of microneedles also affected the pain score, where a 10-fold increase in the number of microneedles increased pain just over 2-fold. Microneedle tip angle, thickness, and width did not significantly influence pain.

DISCUSSION

Microneedles are significantly less painful than a 26-gauge hypodermic needle over the range of dimensions investigated. Decreasing microneedle length and number of microneedles reduces pain.

Intensive insulin therapy in preschool-aged diabetic children: from multiple daily injections to continuous subcutaneous insulin infusion through indwelling catheters

In this study, glycemic control, diabetes care indices and quality of life (QoL) were assessed in 2 groups of newly diagnosed Type 1 diabetic subjects <6 yr old who were randomized to multiple daily injections with (Group A) or without (Group B) an indwelling catheter. Group A [12 males (M)/8 females (F), mean age 3.2+/-1.4 yr] and Group B (9M/11F, mean age 3.9+/-1.8 yr) were evaluated at baseline and after 6 and 12 months of treatment. No significant difference was observed in metabolic control (glycosylated hemoglobin) or in the number of hypoglycemic events between the groups. Patients in Group A had a greater number of daily insulin injections, monitored blood glucose more frequently and had a lower total daily insulin dose per kg (p<0.05). QoL was better in group A. At the end of the study 30% of group A patients progressed to continuous sc insulin infusion (CSII), while no child in Group B switched to a different insulin regimen. Based on these findings, indwelling catheter therapy may be helpful for selected CSII candidates.

Paediatric diabetes: achieving practical, effective insulin therapy in type 1 and type 2 diabetes

Both type 1 and type 2 diabetes can occur in children and adolescents. Type 1 diabetes is the most common chronic disease in children in the developed countries and the number of adolescents with type 2 diabetes is rising as a consequence of the obesity epidemic. As they grow, children and adolescents with diabetes have special and changing needs; these must be recognized and addressed as there are major physiological, medical, psychological, social and emotional differences in adults with diabetes. Glycaemic control is important to prevent or delay long-term complications also in the paediatric age group. This goal is often achieved using insulin. However, practical issues associated with insulin use in paediatric patients include attainment of target glycaemic levels without increased risk of hypoglycaemia, hormone-driven fluctuations in insulin requirements, and the psychological and social impacts of weight gain and puberty. This article reviews the advances that are helping to overcome these issues and enable paediatric patients to achieve their treatment goals.

CONCLUSION

Advanced insulin formulations, particularly insulin analogues, tailored insulin regimens and delivery systems combined with age-appropriate education, patient/carer involvement and ongoing support from the wider diabetes team will assist in the effective management of diabetes among children and adolescents.

The role of new technologies in treating children and adolescents with type 1 diabetes mellitus

Given the physiological and psychological impact of type 1 diabetes in children and adolescents, these patients present special challenges to pediatric health care providers. The goals of intensive management of diabetes have been clearly established since the publication of the Diabetes Control and Complication Trial (DCCT) in 1993, which demonstrated that tight metabolic control achieved with intensive insulin therapy is superior to conventional treatment in reducing the risk of long-term microvascular complications. Thus, current recommendations mandate that youth with type 1 diabetes should aim to achieve metabolic control as close to normal as possible. However, strict glycemic control is hard to achieve requiring frequent blood glucose measurements and several insulin injections per day, and in addition is associated with an increased risk of severe hypoglycemia. Recurrent episodes of hypoglycemia, especially at young ages, may cause adverse effects on neurocognitive function, may lead to hypoglycemia unawareness, and may be associated with significant emotional morbidity for the child and parents. Since the discovery of insulin in 1921 there has been constant progress in the way patients with type 1 diabetes are treated. The introduction of recombinant insulin and insulin analogs as well as new insulin delivery systems and glucose monitoring devices enhanced the ability of both patients and medical teams to better define the therapeutic goals and to develop more effective therapeutic strategies. Recent advances in devices for insulin administration and glucose monitoring and the introduction of telemedicine are having a profound effect on the lives of youth with type 1 diabetes. This review focuses on the new technologies which have been developed for treating children and adolescents with type 1 diabetes.

Enoxaparin Use in the Neonatal Intensive Care Unit: Experience Over 8 Years

STUDY OBJECTIVE

To evaluate the effectiveness and safety of enoxaparin therapy in a neonatal intensive care unit (NICU).

DESIGN

Retrospective chart review.

SETTING

Level III NICU in a Canadian academic center.

PATIENTS

All neonates treated with enoxaparin while in the NICU between January 1, 1998, and June 1, 2006.

MEASUREMENTS AND MAIN RESULTS

Data abstracted included patient demographics, diagnosis of thrombosis and its progression, enoxaparin dosages with corresponding antifactor Xa levels, and adverse events. Sixteen neonates (four term, 12 preterm) were treated with enoxaparin at a mean +/- SD initial subcutaneous dose of 1.41 +/- 0.15 mg/kg every 12 hours. The target therapeutic range (antifactor Xa level 0.5-1.0 U/ml) was achieved by 12 infants at a mean +/- SD dose of 1.92 +/- 0.43 mg/kg every 12 hours, after a mean of 5.6 days (range 1-15 days). Preterm infants required a higher dose (per kilogram) compared with term infants to maintain therapeutic antifactor Xa levels (mean +/- SD 1.94 +/- 0.39 vs 1.65 +/- 0.14 mg/kg every 12 hrs, p<0.001). Enoxaparin doses were more strongly correlated to antifactor Xa levels in term infants (r(2)=0.51, p<0.001) compared with preterm infants (r(2)=0.20, p<0.001). Ten (71%) of 14 thromboembolic events resolved, either partially or completely, at a mean of 39 days (range 8-61 days) of enoxaparin therapy. Nine infants (56%) experienced minor local adverse effects at the site of the indwelling subcutaneous catheter (induration, bruises, hematomas, or leakage). Systemic adverse events that were possibly related to enoxaparin therapy included osteopenia (one infant), scleral hemorrhage (one), and minor gastrointestinal tract bleeding (three) found in gastric feeding tubes. No adverse effects were associated with antifactor Xa levels greater than 1.0 U/ml.

CONCLUSION

Enoxaparin may be effective in the treatment of neonatal thrombosis. An initial dosage of 1.5 mg/kg every 12 hours is likely inadequate to obtain therapeutic antifactor Xa levels rapidly and differs for term and preterm neonates. Therapeutic levels in preterm infants may be more variable, and the pharmacokinetics of this drug in preterm infants requires further evaluation. Future studies in neonates should prospectively evaluate a higher starting dose of enoxaparin to document effectiveness, acceptance, compliance with treatment guidelines, and adverse effects.

Does needle size matter?

Hypodermic needles are in widespread use, but patients are unhappy with the pain, anxiety, and difficulty of using them. To increase patient acceptance, smaller needle diameters and lower insertion forces have been shown to reduce the frequency of painful injections. Guided by these observations, fine needles and microneedles have been developed to minimize pain and have found the greatest utility for delivery of vaccines and biopharmaceuticals such as insulin. However, pain reduction must be balanced against limitations of injection depth, volume, and formulations introduced by reduced needle dimensions. In some cases, needle-free delivery methods provide useful alternatives.

Treatment with CSII in two infants with neonatal diabetes mellitus

This article reports the case studies of two children with neonatal onset of diabetes who were treated with continuous subcutaneous insulin infusion (CSII) from within 4 d to 3 wk of the diagnosis. The aim was to describe diabetes-related and insulin-pump-specific data in relation to growth and various feeding patterns when using CSII in infants with diabetes during their first year of life. The two children's medical records were scrutinized. The results showed that both children had good metabolic control [median hemoglobin A1c (HbA1c) 5.3 and 5.7%, high performance liquid chromatography (HPLC) method, reference: 3.4-5.0%. Compared with the Diabetes Control and Complications Trial (DCCT) HbA1c units, Swedish units give approximately 1% point lower results]. No episodes of severe hypoglycemia or diabetic ketoacidosis have been demonstrated. The children had normal growth patterns, as they followed a normal feeding regime for their age. The meal doses of insulin were given over 12 min to 3 h. The children had diluted Humalog((R)) insulin 10 U/mL (Eli Lilly & Co, Indianapolis, IN, USA) in their pumps. Different types of insulin pumps were used, namely, the Minimed 507C and 508 (Medtronic, Minneapolis, MN, USA), and a Disetronic H-tron V100 (Roche Diagnostics, Basel, Switzerland). The children used different types of infusion sets. Neither family reported any technical problems with their pump system. CSII was an effective and safe treatment for the two children suffering from neonatal diabetes. This offers an alternative for other infants with a similar diagnosis.