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Survey of Insulin Site Rotation in Youth With Type 1 Diabetes Mellitus

Published:January 07, 2010DOI:https://doi.org/10.1016/j.pedhc.2009.11.002

      Abstract

      Objective

      Injection site rotation is an important component of insulin administration and is helpful in preventing lipodystrophy in type 1 diabetes (T1DM). We examined the number of injection/infusion sites (sites) used by youth with T1DM and their perceived barriers to using new sites for insulin.

      Methods

      Two hundred and one youth with T1DM completed a 24-item survey about site rotation practices and barriers to site rotation during a routine diabetes appointment.

      Results

      Fifteen percent of youth reported using at least four distinct sites in their rotation plan, while 22% reported using only one site. A negative correlation was found between number of sites used and the number of perceived barriers endorsed by youth on multiple daily injections. Fear of pain was the most common barrier endorsed by youth.

      Conclusion

      Many youth with T1DM may not adhere to an adequate site rotation plan. Regular assessment of insulin sites and counseling regarding adequate site rotation is needed when managing diabetes in youth. Relaxation and distraction may help to reduce youths' fear of pain when rotating to new insulin sites.

      Key Words

      Poor adherence to insulin administration is a problem for youth with type 1 diabetes mellitus (
      • Greening L.
      • Stoppelbein L.
      • Konishi C.
      • Jordan S.S.
      • Moll G.
      Child routines and youths' adherence to treatment for type 1 diabetes.
      ,
      • Patino A.M.
      • Sanchez J.
      • Eidson M.
      • Delamater A.M.
      Health beliefs and regimen adherence in minority adolescents with type 1 diabetes.
      ,
      • Stewart S.M.
      • Lee P.W.
      • Waller D.
      • Hughes C.W.
      • Low L.C.
      • Kennard B.D.
      • Huen K.F.
      A follow-up study of adherence and glycemic control among Hong Kong youths with diabetes.
      ). Survey studies suggest that as many as 50% of youth with type 1 diabetes do not administer insulin according to the recommendations of their treatment team for frequency, dosing, and timing (
      • Greening L.
      • Stoppelbein L.
      • Konishi C.
      • Jordan S.S.
      • Moll G.
      Child routines and youths' adherence to treatment for type 1 diabetes.
      ,
      • Patino A.M.
      • Sanchez J.
      • Eidson M.
      • Delamater A.M.
      Health beliefs and regimen adherence in minority adolescents with type 1 diabetes.
      ,
      • Stewart S.M.
      • Lee P.W.
      • Waller D.
      • Hughes C.W.
      • Low L.C.
      • Kennard B.D.
      • Huen K.F.
      A follow-up study of adherence and glycemic control among Hong Kong youths with diabetes.
      ). Insulin administration is a cornerstone of modern treatment in type 1 diabetes (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). Serious health complications or death can result for patients who do not administer insulin or who administer insulin incorrectly (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ).
      In modern diabetes therapy, there are three main insulin regimens for youth: conventional therapy, multiple daily injections (MDI), and continuous subcutaneous insulin infusion (CSII) (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). Youth receiving conventional therapy use fast-acting and intermediate acting insulins, which typically are injected two to three times daily. For youth receiving MDI, recommendations for insulin management call for mealtime injections of fast-acting insulin to manage blood sugars during the meal and in the post-prandial period and an injection of a long-acting insulin to manage blood glucose levels between meals. Youth on this regimen may administer at least four injections daily. Youth on a CSII regimen use an insulin pump to administer insulin through a temporary flexible catheter that is inserted into subcutaneous tissue and worn in rotating sites for 2 to 3 days (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). For all of these regimens, multiple behaviors are involved in effective dosing of insulin. Indeed, a recent review article highlights 40 specific steps involved in effective insulin administration (
      • Coffen R.D.
      • Dahlquist L.M.
      Magnitude of type 1 diabetes self-management in youth: Health care needs diabetes educators.
      ), as well as specific knowledge, including when and how much insulin to administer and whether to titrate insulin based on activity, blood glucose levels, and/or food effects (
      • Coffen R.D.
      • Dahlquist L.M.
      Magnitude of type 1 diabetes self-management in youth: Health care needs diabetes educators.
      ). Each step can play an important role in glycemic control and effective insulin management (
      • Coffen R.D.
      • Dahlquist L.M.
      Magnitude of type 1 diabetes self-management in youth: Health care needs diabetes educators.
      ,
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ).
      …it is important for patients to adhere to a rotation plan for insulin administration to prevent lipodystrophy and promote better absorption.
      Past literature examining youths' adherence to insulin has generally overlooked their adherence to the process of administering insulin. However, a more detailed examination of how youth regularly administer insulin may yield data useful for patient education and intervention development. For example, one behavior that has received limited attention in the literature is youths' use of multiple site rotation for delivering insulin (
      • Becker D.
      Individualized insulin therapy in children and adolescents with type 1 diabetes.
      ). For patients with type 1 diabetes, eight areas have been identified for insulin administration. These areas include the right and left sides of patient's abdomen, arms, buttocks, and thighs (
      • Chase H.
      Understanding diabetes: A handbook for people who are living with diabetes.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). It is known that injection sites that are overused can become dystrophic, which may prevent optimal insulin absorption and lead to increased insulin requirements and/or poor metabolic control (
      • Hofman P.L.
      • Lawton S.A.
      • Peart J.M.
      • Holt J.A.
      • Jefferies C.A.
      • Robinson E.
      • Cutfied W.S.
      An angled insertion technique using 6-mm needles markedly reduces the risk of intramuscular injections in children and adolescents.
      ,
      • Johansson U.B.
      • Amsberg S.
      • Hannerz L.
      • Wredling R.
      • Adamson U.
      • Arnqvist H.J.
      • Lins P.E.
      • et al.
      Impaired absorption of insulin aspart from lipohypertrophic injection sites.
      ,
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). Thus, it is important for patients to adhere to a rotation plan for insulin administration to prevent lipodystrophy and promote better absorption.
      This study examined the number and location of injection/infusion sites (sites) reported by youth with type 1 diabetes and their perceived barriers to site rotation. We applied the Health Belief Model (HBM) as our theoretical framework for examining parents' and youths' adherence to an adequate rotation plan for insulin administration. The HBM assumes that a patient's adherence to a specific health behavior is determined by five factors: (a) perceived susceptibility to illness, (b) perceived severity of consequences, (c) perceived benefits of the health behavior, (d) perceived barriers to adherence to the behavior, and (e) perceived cues to action (
      • Glanz K.
      • Rimer B.K.
      • Marcus Lewis F.
      Health belief & health education: Theory, research, & practice.
      ,
      • Rosenstock I.M.
      Historical origins of the health belief model.
      ). In our application of the HBM, we expected that youth would be more adherent to an adequate site rotation plan if they knew that the recommendations for site rotation and the perceived benefits of regular rotation (e.g., better glycemic control and absence of lypodystrophy) outweighed the perceived costs of rotation (e.g., pain, awkwardness of using new sites). In our clinic, youth are counseled on site rotation at least annually. Therefore, it was hypothesized that at least 50% of youth in this sample would report an adequate personal rotation plan, characterized by at least four distinct sites. It also was hypothesized that there would be negative correlations between the number of sites reported by youth and the number of perceived barriers reported by youth and their average blood glucose control. Finally, to better understand youth who report an adequate site rotation plan, the number of sites reported by youth was examined based on parent and child demographic variables. In the absence of a literature base examining insulin administration behaviors in youth with type 1 diabetes, these analyses were exploratory and are proposed as a method of understanding who might benefit from a targeted intervention for site rotation.

      Research Design and Methods

      Population and Sample

      Participants were parents or youth with type 1 diabetes who attended a pediatric diabetes clinic within a large academic medical center in the Midwestern United States. The hospital's pediatric diabetes clinic serves approximately 600 youth with type 1 diabetes. Inclusion criteria were: (a) a confirmed diagnosis of type 1 diabetes, (b) age of the child between 2 and 17 years, (c) time since diagnosis of at least 12 months (to allow for adjustment to diabetes), and (d) the presence of at least one primary caregiver (e.g., parent/guardian) at the recruitment appointment. Families were excluded from the study if they were non–English speaking, the child was developmentally delayed, or the parent or child had a diagnosis of severe psychopathology resulting in a psychiatric hospital admission within the past 12 months.
      Two hundred and five families were approached for this study. Of these, 201 agreed to participate, for a response rate of 98%. The average age of youth was 11.8 ± 3.4 years, and their mean time since diagnosis was 5.9±3.4 years (range, 1.0-15.9 years). Youth were nearly evenly divided based on gender (45% male) and insulin regimen (52% MDI; 48% CSII). The majority of youth described themselves as White (86%). Youth had a mean hemoglobin A1c (HbA1c) level of 8.7±1.8% (range, 5.5 - >14.0). There was a significant difference in HbA1c levels reported by youth using MDI versus CSII regimens (P < .01), with youth using an MDI regimen reporting a higher mean HbA1c level (9.0±2.1%) than those using a CSII regimen (8.3 ±1.2%). Table 1 provides a summary of demographic characteristics for this sample.
      Table 1Sample characteristics
      VariableMSDFrequency%
      Age (y)11.83.4
      Time since diagnosis with type 1 diabetes (y)5.93.4
      Gender
       Male9145
       Female11055
      Race
       White17386
       Non-white2814
      Insulin regimen
       Multiple daily injection10552
       Continuous subcutaneous insulin pump9648
      Father's education
       Less than college11155
       College or greater9045
      Mother's education
       Less than college10351
       College or greater9849
      Marital status
       Married12763
       Not married7437
      M, mean; SD, standard deviation.

      Procedure

      This study was approved by the Institutional Review Board with a waiver of documentation of written informed consent. Families who met inclusion criteria were recruited during a routine diabetes appointment to complete a survey. Demographic information, but no identifying information, was requested. As part of their clinical care, all patients had their HbA1c level checked during the study appointment. Participants were asked to provide a report of the youth's HbA1c level for the study appointment directly on the survey. Families who completed the survey were compensated with a $5 gift card to a popular retail store.

      Survey Data

      A survey was designed for this study to assess participants' use of multiple sites for insulin administration. The survey contained 24 items that asked participants about their diabetes history, current diabetes regimen for insulin administration, and common barriers to and perceptions regarding the use of multiple sites for insulin administration. Barrier items were developed based on the clinical experience of the investigators and research specific to the management of type 1 diabetes mellitus in children (
      • Wysocki T.
      • Greco P.
      • Buckloh L.
      Childhood diabetes in psychological context.
      ). The items were judged to be face valid based on the review of three certified diabetes educators (one not affiliated with the research project) and a parent of an adolescent with type 1 diabetes mellitus. The final survey included nine barrier items specific to insulin administration and site rotation. Youth responded true or false to the barrier items based on how true the item was for them. Barrier items were scored to yield a total barrier score (total possible score=9), with positively phrased items reverse scored so that higher scores reflected more barriers to site rotation. In addition, the survey included a body drawing on which youth marked all of the sites they currently use for insulin administration. The survey was designed to take approximately 10 minutes to complete. Parents of children ages 2 to 11 years were asked to complete the survey for their child, while participants ages 12 to 17 years were given the option to complete the survey on their own or to have a caregiver assist them. The decision to have parents complete the survey for children 2 to 11 years was based on the current recommendations for diabetes self-management in children and adolescents, which suggests that parents and children share daily diabetes self-care management until children are at least 12 years old (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ).

      Statistical Analyses

      All data were analyzed using SPSS statistical software (version 16, Chicago, IL, 2008). To examine sample characteristics, means, standard deviations, and frequencies were calculated for variables. To examine hypothesis 1, the frequency of youth reporting use of at least four insulin sites was calculated and compared with the benchmark of 50% proposed in the hypothesis. Data also were examined according to the mean number of sites reported by youth on an MDI regimen and youth on a CSII regimen. These means were compared using an independent sample t test. To examine hypothesis 2, a series of Pearson product-moment correlations were used to examine the association between the number of sites reported by a youth and the number of perceived barriers to site rotation and the youth's HbA1c level. Additional analyses compared the percentage of youth on MDI and CSII regimens who endorsed each barrier using χ2 analyses. Finally, exploratory analyses were conducted to examine the number of sites reported by youth based on specific demographic variables. These analyses were conducted separately for youth on an MDI regimen and youth on a CSII regimen. To examine the association between number of sites and child age or time since diagnosis, Pearson product-moment correlations were used. For this study, parents' marital status (married or not married) and education (less than college or college and greater) were coded as dichotomous variables. Therefore, differences were examined using a series of independent sample t tests. For all study analyses, an a priori α level was set at 0.05.

      Results

      Depending on the child's age, surveys were completed by either a parent/caregiver and/or the child. Forty-one percent of surveys were completed by youth independently, while 59% were completed by youth with assistance from a parent. No difference was found in the number of sites reported when surveys were completed by a parent versus the youth alone (t[194] =–1.13, P=.26); therefore, data were collapsed for analysis.
      With respect to insulin administration, the average number of sites used by youth was 2.34±1.0. Thirty-six percent of youth reported using two sites, followed by three sites (25%), one site (22%), and four sites (15%). Thus, our hypothesis, which predicted at least 50% of youth would report using four or more sites, was not supported. A significant difference was found in the mean number of sites reported by youth on CSII versus MDI regimens (t[197]=8.19, P=.001). Specifically, youth on an MDI regimen reported more sites in their rotation plan (2.81±0.90) than did youth on a CSII regimen (1.81±0.82). More than 94% of youth on an MDI regimen reported two or more different sites in their rotation plan. In contrast, 81% of youth on a CSII regimen reported using only one or two sites. Consistent with existing research, there was a positive correlation between a child's age and his or her HbA1c level, suggesting a tendency for older youth in this study to report higher HbA1c levels (r=0.39, P=.001). However, contrary to our hypothesis, there was no correlation between HbA1c level and the number of sites reported by youth (r=0.13, P=.08).

      Demographic Characteristics of Number of Sites

      Exploratory analyses were conducted next to examine the number of sites reported by youth based on specific demographic variables. Because a significant difference existed in the number of sites reported by youth on MDI versus CSII regimens, analyses were conducted separately for youth based on insulin regimen. No correlations were found between the number of sites and the child's age (MDI: r=0.04, P=0.70; CSII: r=–0.01, P=.99) or time since diagnosis (MDI: r=–0.09, P=.37; CSII: r=0.07, P=.49) for youth on MDI or CSII regimens. Similarly, when controlling for regimen type, no differences were found between number of sites and parental marital status (MDI: P=.26; CSII: P=.89) or highest grade level completed by fathers (MDI: P=.75; CSII: P=.06) or mothers (MDI: P=.88; CSII: P=.79).

      Self-reported Barriers to Multiple Sites

      Table 2 lists the percentage of youth who endorsed barriers to trying new sites along with χ2 analyses that examined differences in the percentage of youth endorsing each barrier. Forty-nine percent of youth on an MDI regimen reported fear that new insulin sites would be painful compared with 64% of youth on a CSII regimen. Interestingly, 76% of youth on an MDI regimen and 61% of youth on a CSII regimen reported believing that rotating sites would improve overall diabetes control. However, 54% of youth on an MDI regimen and 67% of youth on a CSII regimen also endorsed comfort with their existing routine as a barrier to adopting new sites. There was no difference in the number of barriers endorsed by youth on an MDI regimen and youth on a CSII regimen (2.0 ± 1.3 and 1.7±1.4, respectively). A negative correlation existed between the number of perceived barriers to site rotation and the number of sites reported (r=–0.28, P=.01) for youth on an MDI regimen. Interestingly, a negative correlation also existed between the number of perceived barriers to site rotation and HbA1c level (r=–0.21, P=.05) for youth on an MDI regimen. It is possible that youth on an MDI regimen with a lower HbA1c level have fewer sites in their rotation and thus may perceive more barriers to site rotation because they have less experience trying new sites. No correlations were found between the number of perceived barriers to site rotation and the number of sites (r=–0.21, P=.06) or HbA1c level reported by youth on a CSII regimen (r=0.07, P=.56).
      Table 2Perceived barriers to insulin sites reported by youth on MDI or CSII regimens
      Perceived barrierMDI (% “true”)
      Percent “true” is the percentage of youth reporting that the particular barrier was true for them.
      CSII (% “true”)
      Percent “true” is the percentage of youth reporting that the particular barrier was true for them.
      χ2P
      Afraid new insulin sites will be more painful49645.78.02
      Tried a new insulin site and it hurt more than current sites43370.73.46
      New sites are more awkward and conspicuous44551.92.19
      Received instruction for new sites from my diabetes team86820.87.43
      Comfortable with the current routine and do not want to try new sites54673.30.08
      Have had problems with new sites (e.g., leaking insulin, infusion site problems)16190.34.57
      It is hard to get to new sites to do an injection/place infusion site24331.72.19
      Have been told by the diabetes team only to use current insulin sites932.70.14
      Using new sites for insulin can improve diabetes control76614.91.04
      Percent “true” is the percentage of youth reporting that the particular barrier was true for them.

      Discussion

      Regular rotation of insulin sites is a standard recommendation for diabetes self-care (
      • Deeb L.
      • Grey M.
      • Anderson B.
      • Holzmeister L.
      • Clark N.
      the American Diabetes Association
      Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association.
      ,
      • Sperling M.
      Diabetes mellitus.
      ). We designed this study to collect survey data from youth with type 1 diabetes and their parents to assess the youths' current plan for site rotation and their perceptions of barriers to using multiple insulin sites. The theoretical framework used to guide this study was the HBM, which predicts that a patient will adhere to a specific self-care behavior based on how the patient perceives its importance and likelihood to benefit his or her overall health along with the cost of adherence (
      • Glanz K.
      • Rimer B.K.
      • Marcus Lewis F.
      Health belief & health education: Theory, research, & practice.
      ,
      • Rosenstock I.M.
      Historical origins of the health belief model.
      ). In this study, more than 80% of youth reported receiving instructions for using multiple sites as part of their diabetes management. However, our findings also suggest that youth with type 1 diabetes and their families may not be following an adequate plan for site rotation. Our clinic teaches families to consider all eight approved areas for insulin administration in their rotation plan regardless of their insulin regimen (
      • Walsh J.
      • Roberts R.
      Pumping insulin: Everything you need for success with an insulin pump.
      ). Thus, when considering the possibility of eight distinct insulin sites, our data suggest that youth on an MDI regimen are using only about one third of available sites as part of their rotation plan and youth on a CSII regimen are using approximately one quarter of available sites. If the upper thighs are removed from a rotation plan, a recommendation that is sometimes made to patients on a CSII regimen because of concerns related to the rate of insulin uptake in the tissue, our data suggest youth on a CSII regimen are similarly using only one third of available sites as part of their rotation plan, a number that still may not offer youth adequate opportunity to rotate to novel sites and avoid the development of lipodystrophy.
      …because of increased insulin resistance at the site, some patients with lipodystrophy may require higher total doses of insulin to achieve optimal glycemic control.
      Lipodystrophy is the most common adverse consequence associated with inadequate insulin site rotation (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ,
      • Johansson U.B.
      • Amsberg S.
      • Hannerz L.
      • Wredling R.
      • Adamson U.
      • Arnqvist H.J.
      • Lins P.E.
      • et al.
      Impaired absorption of insulin aspart from lipohypertrophic injection sites.
      ,
      • Vardar B.
      • Kizilci S.
      Incidence of lipohypertrophy in diabetic patients and a study of influencing factors.
      ). Lipodystrophy is a degenerative disorder of subcutaneous tissue that can cause thickening of the tissue and sometimes lumps or dents in affected areas (
      • Kordonouri O.
      • Lauterborn R.
      • Deiss D.
      Lipohypertrophy in young patients with type 1 diabetes.
      ). Lipodystrophy is not dangerous in itself. However, research suggests that it can reduce the absorption of insulin at the site by as much as 25%, which in turn can lead to poorer blood glucose control (
      • Johansson U.B.
      • Amsberg S.
      • Hannerz L.
      • Wredling R.
      • Adamson U.
      • Arnqvist H.J.
      • Lins P.E.
      • et al.
      Impaired absorption of insulin aspart from lipohypertrophic injection sites.
      ). Also, because of increased insulin resistance at the site, some patients with lipodystrophy may require higher total doses of insulin to achieve optimal glycemic control. In cases of mild lipodystrophy, early detection and time off from administering insulin at the site may provide an opportunity for the affected tissue to heal and reverse many of the effects of dystrophy. However, in some patients and/or more severe cases, the dystrophic tissue may never heal completely, making these sites suboptimal for insulin administration (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ,
      • Johansson U.B.
      • Amsberg S.
      • Hannerz L.
      • Wredling R.
      • Adamson U.
      • Arnqvist H.J.
      • Lins P.E.
      • et al.
      Impaired absorption of insulin aspart from lipohypertrophic injection sites.
      ). In all cases, detection is key to preventing further skin damage, and/or adjusting insulin recommendations for patients (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ). To detect lipodystrophy, a physical examination with finger palpation of insulin sites should be conducted because lipodystrophy often can be hard to detect with a visual inspection alone (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ). To palpate the site, providers should use their fingers to firmly rub injection sites back and forth in a sweeping motion, seeking areas where the tissue feels changed from normal (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ). As stated previously, dystrophy can feel like areas of hardened tissue (e.g., tissue may feel muscular in nature and lumpy), or in some cases, it may feel very soft to the touch, and visual inspection may show a protuberance in the affected area. In addition, areas of lipodystrophy may show red marks, suggesting repeated insulin injections. Nurses and primary care providers can play an important role in helping to detect dystrophy and can make recommendations for site rotation. Similarly, as an additional prevention tool, it may be helpful to educate parents and youth about the signs of dystrophy and encourage parents and youth to monitor insulin sites and schedule an appointment with their health care provider if they are concerned that a site may be becoming dystrophic.
      In addition to providing patient education specific to the causes and effects of lipodystrophy, our findings highlight a need for nurses and diabetes educators to work directly with youth and parents to help to address perceived barriers to adequate site rotation. Consistent with the HBM, if patients perceive that barriers to site rotation are significant, these barriers may prevent them from adopting new sites, even in cases where youth and parents understand the benefits of having multiple sites available for insulin (
      • Glanz K.
      • Rimer B.K.
      • Marcus Lewis F.
      Health belief & health education: Theory, research, & practice.
      ). In this study, common barriers to using new insulin sites were fear that sites would hurt, problems reaching sites or concern that sites would be awkward, and comfort with the existing routine. For youth and parents who are concerned about reaching unfamiliar sites, scheduling an education appointment to practice using these new sites with guidance from a nurse or diabetes educator may be a necessary strategy to overcome this barrier and build confidence. It also may be helpful for the nurse or diabetes educator to assist families in identifying someone else to administer injections at new sites. For example, for youth attending schools with a nurse or aide, it may be possible to work out a plan for the school nurse or aide to use only new sites for injections at school and save existing sites for home management. For youth and parents who are concerned that using unfamiliar sites will be painful, teaching coping strategies may be helpful. For example, for young children, it may effective to teach parents how to use distraction to help their child to cope with their fear while they become more familiar with new injection sites. Common distraction techniques that parents could try with their young children include singing, use of interactive toys or puzzles, making believe they are blowing out candles, or reading books. For older children and adolescents, brief cognitive behavioral techniques may be needed, such as relaxation training, cognitive distraction, cognitive re-appraisal, comforting self-talk, and reducing any behavior or thoughts that may cue children to be fearful of new sites (e.g., saying to the child at the time of the injection, “I promise this won't hurt”). Alternatively, behavioral strategies, including use of an incentive plan for adequate site rotation, could help youth to try new sites and maintain adequate site rotation over time. In tracking goals related to site rotation, older youth or parents may find it helpful to use a modified log book where they can record injection sites across the day. In our clinic, when counseling families, we typically do not recommend that youth and parents introduce a new site through use of a topical analgesic or by applying an ice cube to the site before injection. While these strategies can be very effective in managing pain for behaviors performed infrequently (e.g., annual venous blood draws or placing a continuous glucose sensor to complete a glucose profile), we do not find them to be practical for daily insulin injections because of the extra planning and time they require. Similarly, we caution families about using these strategies when placing infusion sites, because they increase the length of time needed to place the site and actually may contribute to greater anticipatory anxiety as youth wait for the infusion site to be placed. Finally, for youth and parents who seem ambivalent about changing their personal rotation plan or report comfort with their current routine, it may be helpful to use components of motivational interviewing to help them recognize the connection between proper site rotation and the realization of their own diabetes care goals, such as greater independence in diabetes self-care, improved glycemic control, and/or improved physical well-being, in order to create the behavior change (
      • Channon S.J.
      • Huws-Thomas M.V.
      • Rollnick S.
      • Hood K.
      • Cannings-John R.L.
      • Rogers C.
      • Gregory J.W.
      A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes.
      ,
      • Rollnick S.M.
      • Miller W.R.
      • Butler C.C.
      Motivational interviewing in health care: Helping patients change behavior.
      ).
      The current study has some limitations. First, this study used survey data obtained directly from youth and families. While all participants were instructed that their data would be kept confidential, self-report data are vulnerable to a social desirability bias. Thus, it is possible that these data may over-report the actual number of insulin sites used by youth with type 1 diabetes. Second, this study used a convenience sample of youth with type 1 diabetes recruited at one of their regularly scheduled diabetes appointment. This study did not make attempts to recruit youth with type 1 diabetes who were not coming to their diabetes appointments as recommended or youth who came only annually to the pediatric diabetes clinic. Thus, it is possible that the results may not generalize to all youth with type 1 diabetes, especially youth who only seek care intermittently from a tertiary pediatric diabetes clinic. Finally, this study did not collect data from practitioners to compare with the youths' self-report. Therefore, no data can be reported specifically quantifying patients' adherence to their rotation plan as defined by their diabetes practitioner. Future research may want to include physician/nurse responses to quantify youths' adherence to site rotations as a component of their insulin management.
      Nurses and primary care providers can play an important role in recognizing the signs of dystrophy and counseling youth and families on adequate site rotation in between youths' quarterly diabetes clinic appointments.
      The results of this study have implications for clinical practice. First, these findings suggest that many youth with type 1 diabetes may not be adhering to an adequate site rotation plan. Thus, regular assessment of insulin administration sites and follow-up on recommendations to rotate sites is important for detecting lipodystrophy in youth with type 1 diabetes. As mentioned earlier, areas that are dystrophic may appear as a lump, a dent, or as red and swollen tissue that is hard to the touch. In most cases, it is easier to detect lipodystrophy using finger palpation versus visual inspection, and early detection and time off from using the site may help preserve the site for future insulin use (
      • de Villiers F.P.
      Lipohypertrophy—a complication of insulin injections.
      ,
      • Johansson U.B.
      • Amsberg S.
      • Hannerz L.
      • Wredling R.
      • Adamson U.
      • Arnqvist H.J.
      • Lins P.E.
      • et al.
      Impaired absorption of insulin aspart from lipohypertrophic injection sites.
      ,
      • Kordonouri O.
      • Lauterborn R.
      • Deiss D.
      Lipohypertrophy in young patients with type 1 diabetes.
      ). Nurses and primary care providers can play an important role in recognizing the signs of dystrophy and counseling youth and families on adequate site rotation in between youths' quarterly diabetes clinic appointments.
      Second, this study suggests that information on site rotation alone is not sufficient to lead most families of youth with type 1 diabetes to try new sites in their rotation plan. Therefore, to help families overcome perceived barriers to use of multiple insulin sites, medical providers may need to become creative and use a combination of education and behavioral techniques to help families implement adequate site rotation.
      We thank the following persons who assisted with subject recruitment: Drs. My Lien, Ram Menon, Ming Chen, Josephine Kasa-Vubu, Delia Vazquez, and Joyce Lee; Jane Burton, MSW; Donna Doyle, RN, CDE; and Mary Hodge, RD, CDE. We thank Drs. Jessica Kichler, Emily Fredericks, Dawn Dore-Stites, and Matt Myrvik for their review of the manuscript. Finally, we thank the families who participated.

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      Biography

      Susana R. Patton, Assistant Professor of Pediatrics, Division of Child Behavioral Health, C.S. Mott Children's Hospital; and the University of Michigan Medical School, Department of Pediatrics, Ann Arbor, MI.
      Sally Eder, Research Technician Associate, Division of Child Behavioral Health, C.S. Mott Children's Hospital; and the University of Michigan Medical School, Department of Pediatrics, Ann Arbor, MI.
      Jennifer Schwab, Pediatric Diabetes Nurse, Division of Endocrinology, C.S. Mott Children's Hospital; and the University of Michigan Medical School, Department of Pediatrics, Ann Arbor, MI.
      Christine M. Sisson, Pediatric Nurse Practitioner, Division of Endocrinology, C.S. Mott Children's Hospital; and the University of Michigan Medical School, Department of Pediatrics, Ann Arbor, MI.