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Although insulin pump or continuous subcutaneous insulin infusion (CSII) treatment was first introduced more than 25 yr ago, very few children and adolescents with type 1 diabetes mellitus (T1DM) utilized this therapy until recently. In this paper, we review many of the early triumphs, as well as a number of unexpected obstacles that were encountered in applying CSII in the treatment of T1DM. Nevertheless, the greater urgency to obtain optimal control of diabetes following the Diabetes Control and Complications Trial (DCCT), the introduction of rapid-acting insulin analogs and improvements in pump technology have led to a sharp increase in the use of this therapy in youth with T1DM and, generally, favorable outcomes. Moreover, the recent introduction of continuous glucose monitoring systems (CGMSs) offers the prospect of finally realizing the full potential of insulin pump therapy to normalize hemoglobin A1c (HbAlc) levels with minimal risk of hypoglycemia.