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MANGEMENT OF DIABETIC CHILDREN IN RACH

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MANGEMENT OF DIABETIC CHILDREN IN RACH Powered By Docstoc
					 MANAGEMENT OF DIABETIC CHILDREN
            IN RACH


                                           March 2006

                                           Version 1.3




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THE NEWLY DIAGNOSED PATIENT ...................................................................4

DIAGNOSIS OF DIABETES ................................................................................................. 4
HANDLING A NEW REFERRAL ........................................................................................ 4
INITIAL MEDICAL MANAGEMENT ................................................................................ 4
INITIAL NURSING MANAGEMENT ................................................................................. 5
INSULIN .................................................................................................................................. 6
         The First Injection....................................................................................................................... 6
         Injection Sites .............................................................................................................................. 6
         Initial Insulin ............................................................................................................................... 6
         Insulin Regimes ........................................................................................................................... 7
DIET ......................................................................................................................................... 8
EDUCATION........................................................................................................................... 9
PREPARING FOR DISCHARGE ......................................................................................... 9
OTHER..................................................................................................................................... 9
NEW DIABETIC FLOW CHART ....................................................................................... 10

MANAGEMENT OF KNOWN DIABETIC CHILDREN.....................................11

INSULIN REGIMES ............................................................................................................. 11
         Twice daily injections ................................................................................................................ 11
         Three daily injections ................................................................................................................ 12
         Basal-Bolus regime .................................................................................................................... 12
FOOD ..................................................................................................................................... 13
HYPOGLYCAEMIA ............................................................................................................ 13
EXERCISE............................................................................................................................. 15
BLOOD SUGAR MONITORING ....................................................................................... 15
KETONE TESTING ............................................................................................................. 16
         Blood........................................................................................................................................... 16
         Urine ........................................................................................................................................... 17
MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA................. 18
MANAGEMENT OF DIABETIC KETOACIDOSIS ........................................................ 19
SURGERY ............................................................................................................................. 21
         Minor elective procedures ........................................................................................................ 21
         Medium/Major Elective procedures ........................................................................................ 21
         Elective procedures- afternoon list .......................................................................................... 22
         Emergency surgery ................................................................................................................... 22
OUTPATIENT SERVICES .................................................................................................. 22
         Medical clinics ........................................................................................................................... 22
         Nurse led clinics ......................................................................................................................... 22
         Podiatry ...................................................................................................................................... 23
         Psychology.................................................................................................................................. 23
ROUTINE FOLLOW UP ..................................................................................................... 23
SCI-DC ................................................................................................................................... 23
CGMS ..................................................................................................................................... 24
INSULIN PUMPS .................................................................................................................. 24
TYPE 2 DIABETES............................................................................................................... 24
COMPLICATIONS .............................................................................................................. 24

OTHER .......................................................................................................................25

OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS ................................ 25

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        Newly Diagnosed Diabetics ....................................................................................................... 25
        Out Of Hours ............................................................................................................................. 25
DIABETES TEAM CONTACT NUMBERS ...................................................................... 25

REFERENCES ...........................................................................................................26



GLOSSARY ................................................................................................................27




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THE NEWLY DIAGNOSED PATIENT

DIAGNOSIS OF DIABETES

In the majority of children and young people the diagnosis of type 1 diabetes can be made
without difficulty. The assessment of a child with possible diabetes is an emergency. The
child should be assessed by an experienced middle grade doctor immediately upon arrival.

Presenting symptoms are:

       thirst
       excessive drinking (polydipsia)
       excessive urination (polyuria) or nocturnal enuresis
       weight loss
       lethargy and tiredness
       abdominal pain

The child should be tested for:

       glycosuria
       ketonuria
       hyperglycemia


    WHO definition of diabetes:

         Fasting plasma glucose >7.0 mmol/l
         Random or 2- hours plasma glucose > 11.1 mmol/l



HANDLING A NEW REFERRAL

       Admit to Medical Ward directly. Unless arranged by the diabetes team, all newly diagnosed
        patients are managed as in-patients. The duration of the stay is in most cases 2 to 3 days.
       Inform the diabetes team as soon as the referral is taken- do not wait until the child arrives to
        the hospital- as this allows better planning of the input offered to the family. (DIABETES
        TEAM CONTACT NUMBERS p.25)

When dealing with newly diagnosed diabetics remember that families, and often children,
remember the day of diagnosis (what happened, what was said) forever.


INITIAL MEDICAL MANAGEMENT

   Exclude DKA!!
This may require blood tests (U&E, Bicarbonate, pH) but there are clinical pointers to the
diagnosis:


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       acidotic respiration,
       dehydration
       drowsiness
       abdominal pain/vomiting


          Definition of DKA:

             hyperglycaemia (BG >11 mmol/l) and
             pH <7.3 or
             Bicarbonate < 15 mmol/l


   Assess hydration and need for IVI
   If mild dehydration (5% or less) with high blood glucose and ketones consider a correction
    dose of rapid acting insulin (MANAGEMENT OF INTERCURRENT ILLNESS/
    HYPERGLYCAEMIA) and encourage oral fluids
   If the child is well start insulin when next dose would be due
   Routine bloods: thyroid function, coeliac antibodies, islet cell antibodies (these are non-
    urgent investigations and the child/family should have an explanation about the purpose of
    this tests prior to any blood being taken)
   Initial Insulin dose 0.7 U/kg/day (0.5 U/kg/day in small children)
   Insulin regime depends on the age of the child

Communicating the diagnosis to child and parents: this should be done by a senior doctor or
member of diabetes team; there is no need to give a full explanation but it is important to confirm
the certainty of the diagnosis


INITIAL NURSING MANAGEMENT

On admission :

   Notify Diabetes Team
       Consultant Paediatrician: Dr Amalia Mayo (Tel. 53822 – Bleep 3308) or Dr Wheldon
        Houlsby (Tel. 51727 – Bleep 3807) according to diabetes rota
       Diabetes Nurses: Isla Fairley / Edna Stewart (Tel. 52743 – Bleep 3731)
       Dietician: Elsie Carnegie (Tel. 52630 – Bleep 2464)
    Please leave a message if you cannot speak to a member of the team directly or if out of
    hours.
   Settle patient into ward
   Record: height, weight and routine observations
   Test urine and/or blood for ketones (KETONE TESTING p.16) and record on diabetic chart
   Test blood glucose (BLOOD SUGAR MONITORING p.15) – explain to the child what you
    are going to do and why you are doing it
   Medical staff should tell parents/carers and child that they have diabetes and give an outline
    of treatment. Parents often experience a feeling of shock and may not retain information
    given. It is therefore helpful if a member of the nursing staff can be present to help support
    the family later when they will ask more questions.



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You should not give any information unless you are sure that you are giving the correct
information (if in doubt it is better to give less than to cause confusion by giving wrong
information).



INSULIN

The prescription of Insulin is the responsibility of the medical staff. Nursing staff should be
aware of the different regimes and reasons for administering insulin.
As far as possible, parents/carers should be present when insulin is administered, as learning to
give injections is one of the main objectives of the new diabetic admission.


The First Injection

As the child and their family might be upset at diagnosis it is best if nursing staff do the first
injection. Giving a clear explanation of why it is required and demonstration of how to give the
injection.

This should include:
  Showing the syringe, explaining the markings on it and how to draw up the insulin to avoid
   air bubbles,
or
  Use of pen injection devices
  Injection technique – how to pinch skin


Injection Sites

Initially it is best to use the legs as the child has often lost weight and may not have much
subcutaneous tissue elsewhere. However in toddlers it may be appropriate to use buttocks, as it is
often easier for a parent/carer to hold the child.


Initial Insulin

Newly diagnosed patients will often have blood glucose readings above 10mmol/l. The body
needs time to adjust to the insulin regime therefore blood glucose may run at higher levels
initially.

Starting insulin depends on the time of day the child is admitted and whether there are ketones
present.

   If BG is >12 but ketones are negative or only trace-small, the first dose of insulin given can
    be at the time dictated by the next due dose on their regime, i.e. admitted 2 pm, BG 14
    mmol/l, Ketones trace, then give teatime dose of insulin as first dose.




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   If BG >12 and ketones moderate or large, then it is necessary to give a correction dose to
    bring sugar down and clear ketones. This would be given as 0.1 U/kg of fast acting insulin
    (Novorapid). The usual regime is then commenced when the next injection would be due.

Note: The duration of action for Novorapid is 2-4 hours. If routine dose of insulin is due in less
than 2 hours the combined effect could cause hypoglycaemia.


Insulin Regimes

Initial Insulin Dose Calculation – 0.5-0.7 U/Kg/Day

Children under 5 years should be started on 0.5 U/kg/day

A. Children in primary school (usually aged 11 or under)

Twice daily insulin regime

          Novomix® 30 (biphasic insulin aspart)- 2/3 of total daily dose before breakfast
          Novomix® 30 (biphasic insulin aspart)- 1/3 of total daily dose before evening meal

B. Children in secondary school

The choice of regime depends on the child preference and other factors such as needle phobia but
most children will be commenced on a basal-bolus regime. More dietetic input is required for this
regime and they should be seen by a dietician on the ward prior to discharge.

Basal–bolus regime

          Levemir® (insulin Detemir) or Lantus® (insulin Glargine) - 50% of total daily dose
           before evening meal
          Novorapid® (insulin Aspart) - 50% of total daily dose divided between 3 main meals
           as below:
              30% before breakfast
              30% before lunch
              40% before evening meal

Three times daily insulin regime

         Novomix® 30- 2/3 of total daily dose before breakfast
       Remaining insulin is further divided into 1/3 and 2/3, i.e.:
         Novorapid®- 1/9 of total daily dose before evening meal
         Insulatard®– 2/9 of total daily dose before bed




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Example: Twelve year old boy weighing 32 kg
Total daily dose of insulin 0.7x32=22.4 U, divided as:
   Basal-bolus regime
        Novorapid 3 U before breakfast and lunch
         (10x0.30=3), 4 U before evening meal
        Glargine 12 U before evening meal
         (22.4x0.50=11.2)
   Three daily insulin
        Novomix 30- 15 U before breakfast
         (22.4x2/3=14.9)
        Novorapid- 2.5 U before evening meal
         (22.4x1/9=2.48)
        Insulatard- 5 U before bed (22.4x2/9=4.97)



DIET

Children and young people with diabetes are often hungry after diagnosis. Encourage a good
fluid intake (water or sugar free juice). Don’t restrict food and snacks – the team will adjust
insulin according to the child’s intake.

Food in newly diagnosed diabetes-What‟s important?

1. Regular meals
Three meals and 3 snacks fairly evenly spread throughout the day. Meals and snacks should
always contain a reasonable amount (dependant on age) of starchy carbohydrate. Starchy
carbohydrate foods include – bread, plain breakfast cereals, potatoes, pasta, rice, pulses (eg baked
beans, lentil soup or broth), milk or fruit.

2. Sugar free drinks (including water)
Allow these freely. All diet coke, lemonade, Irn Bru etc are suitable. Ensure all diluting juices are
sugar free. Volvic Touch of Fruit and Ribena Light are not suitable.
Limit pure fruit juice to one small glass daily with a meal. Milk to drink should not be more than
1 pint daily spread throughout the day (for over 2‟s the milk of choice is semi skimmed)

3. Snacks away from the ward
Parents may wish to take their children to the picnic box or out of the hospital for a short while.
Remind them to have sugar free drinks (or milk). Suitable snacks would include a scone,
pancake, toast, milk, fruit or crisps. We recommend limiting crisps to once daily.

4. Food when blood sugar is high
When children are newly diagnosed with diabetes they are often very hungry. Even if their blood
sugar is high food should not be restricted, remembering the above advice.

5. Puddings
Families are encouraged to use less foods that are high in sugar i.e. sweets, puddings, cakes etc.
However, a small amount of sugar included as part of a meal is fine, so children can have an
average portion of pudding following their main course or soup and sandwich.

6. Bedtime


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 It is important that the children manage to maintain their blood sugar throughout the night.
 Depending on the insulin regime it is important for most children that they have a bedtime snack
 containing a reasonable amount of carbohydrate. This is often a smaller version of their breakfast
 but could be a sandwich, milk and toast or a scone.



 EDUCATION

 The Newly Diagnosed Checklists (available from the PDSNs) should be placed with the child
 kardex/ recordings and completed by the appropriate staff as education progresses. After
 discharge the checklists should be passed on to the PDSN so that the education process can be
 completed at home or on follow on visits.
 The play specialists are available in the Medical Ward to see patients as requested. Their help is
 particularly useful in children who are worried about staying in hospital or about injections or
 blood testing. Children can also be referred to the play team for education through play.



 PREPARING FOR DISCHARGE

This is an example „discharge checklist‟. The content will vary according to the patient insulin
regime, injection method and blood testing equipment. The PDSN will provide an individual list
for every new patient.


                From Pharmacy                                From Diabetes Nurses/Ward
  Insulin Novomix® 30– vial                            Blood Glucose monitor
  Insulin Novorapid® – vial                            Syringes 0.3ml with 8 mm needle
  Insulin Insulatard® – vial                            or
 (insulin prescription will vary according to           Insulin Pen and needles
 regime)                                                Safe Clip
                                                        Sharps Bin
    GlucoGel® (formerly Hypostop)                      Ketostix®
    GlucaGen Hypokit® 1mg                              Glucose testing strips
                                                        Control solution
                                                        Information pack

 Following discharge all of the items above will be prescribed by the GP


 OTHER

 See OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS p.25




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                                      NEW DIABETIC FLOW CHART


                                    Junior Dr notified of new patient
                                    Inform:
                                            Medical Ward
                                            Admissions
                                            Diabetes Team




                                  Patient arrives to Medical Ward:
                                     Rapid assessment by SpR
                                     Clerking by SHO
                                     Notify Diabetes Team
                                     Initial observations obtained (incl. Blood
                                      glucose, ketones)




            DKA                                Dehydrated with Large                    Well with up to
                                               Ketones                                  moderate ketones




        DKA protocol                           Correction dose of insulin
                                               Novorapid 0.1U/kg
                                               Encourage oral fluids
                              Deterioration/
                              DKA




     DKA corrected
     Eating and drinking                                   Start routine insulin when next injection would
                                                           be due
                                                           Total daily dose (tdd):

                                                                0.7 U/kg/day
                                                                0.5 U/kg/day (under fives)




        Age < 11 years (primary school)                                     Age >11 years (secondary school)

        Twice daily insulin                                                 Basal–bolus regime
                       ®                                                               ®          ®
            Novomix 30- 2/3 of tdd before                                     Levemir or Lantus - 50% of tdd before
             breakfast                                                          evening meal
                     ®                                                                   ®
            Novomix 30- 1/3 of tdd before                                     Novorapid - 50% of tdd divided as:
             evening meal
                                                                                   30% before breakfast
                                                                                   30% before lunch
                                                                                   40% before evening meal

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MANAGEMENT OF KNOWN DIABETIC CHILDREN

INSULIN REGIMES

The insulin regimen should be tailored to the individual child and family lifestyle. The
discussions take place between the family and the diabetes team.
The most widely used insulin regimens are:

      Two daily injections - a mixture of short- and intermediate-acting insulin before both
       breakfast and the evening meal
      Three daily injections - a mixture of short- and intermediate-acting insulin before
       breakfast, short-acting insulin before the evening meal and intermediate-acting insulin at
       bedtime
      Basal-bolus injections (also termed multiple injection therapy) - short-acting insulin
       before the main meals and long-acting insulin analogue once or twice daily

Some considerations when changing to an intensive insulin regime are:
  well-motivated with good diabetes education (or willing to accept input)
  willing to inject insulin several times a day, including at school
  willing to measure blood glucose several times a day
  capable of adjusting the insulin doses for food and physical exercise
  good family support
  no needle-phobia.

Poor metabolic control is not per se an indication for intensified insulin treatment regimens and
may even lead to poorer HbA1c values in patients who are not motivated to meet the above
requirements.


Twice daily injections

Insulin: This regime uses a biphasic insulin such as Novomix® 30 insulin, which is a mixture of
30% fast acting and 70% intermediate acting insulin and is given before breakfast and before
evening meal.

Dose adjustment: Insulin adjustments are done by reverse testing looking at trends in blood
sugars and NOT on a dose to dose basis nor on the immediate blood sugar result. So if there are
persistent HIGH results before the EVENING MEAL then the MORNING insulin is increased. If
persistent HIGH results are found before BREAKFAST then it is the BEDTIME insulin that has
to be increased. After a change in insulin dose the dose should remain the same for 3 or 4 days
before making further adjustments.

An Insulin dose change of 10% is usually required to have an effect on blood sugars.

Blood glucose testing: Minimum testing is twice daily before insulin injections. Very young
children should be tested before bed (or when the parents go to bed) to ensure blood sugar is at
least 8 mmol/l.




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Meals: Children on twice daily pre-mixed insulin should have regular meals and snacks
throughout the day and a bed time snack. The meals/snacks and insulin injections should be given
at approximately the same time every day.


Three daily injections

Insulin: With this regime 3 different insulins are used:
   Novomix® 30- biphasic insulin (30% fast acting, 70% intermediate acting) before breakfast.
   Novorapid® (fast acting) with evening meal.
   Insulatard® (intermediate acting) before bed.

Dose adjustment: Insulin is adjusted by reverse testing as per twice daily regime, apart from the
rapid acting insulin given with the evening meal which can be altered according to food intake
and current blood sugar result. Adjustment to insulin at evening meal can also be made to take
into account evening activities.

Blood glucose testing: Blood sugar should be tested before every insulin injection.

Meals: As per twice daily regime with some flexibility at the evening meal.


Basal-Bolus regime

Insulin: In this regime children take an injection of long acting insulin analogue Glargine
(Lantus®) or Detemir (Levemir®) once a day (in some cases twice daily). This injection is usually
given in the evening at the same time as their evening meal insulin but in a different site. The
long acting insulin should be given at the same time every day to ensure a steady background
insulin supply. Fast acting insulin (Novorapid® or Humalog®) is given with meals (and snacks
containing more than 10 g of CHO) based on how much carbohydrate they eat and the current
blood sugar result. There is no need to wait before eating once the injection has been given.

Dose adjustment: Before breakfast blood sugar will guide adjustment of the long acting
background insulin. It is important to get the background insulin dose right before starting to
adjust the bolus doses. Adjusting bolus insulin will depend on the calculated insulin/CHO ratio
for the patient. If the correct dose has been given the 2 hour post meal blood sugar will be in the
normal range. If the pre meal blood sugar is above 12 mmol/l an increased dose of insulin to
include a correction dose can be given.

Blood glucose testing: First thing in the morning and before meals.

Meals: There is no need to stick to a strict meal routine with this insulin regime. Insulin should be
given immediately prior to eating. Snacks are not compulsory and should be taken according to
natural hunger and predicted activity. Bed time snacks are recommended if blood sugar is less
than 8 mmol/l before bed.

CHO/ insulin ratios: Most children with established diabetes will be injecting 1 U of insulin per
10g of CHO eaten. This can vary between children and they should let you know which ratio they
are currently using. An insulin injection is required for meals as well as snacks including more
than 10 g CHO.

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Dose adjustment for blood sugar result: If the BG is high before a meal extra insulin can be given
to correct this. Aim to correct down to 10 mmol/l. Several formulas can be used such as the
Insulin Sensitivity Factor where 100 divided by total daily dose equals number of mmol/l of
glucose that will be reduced by 1 U of insulin.




Example: 13 years old girl on Lantus 30 U and Novorapid 1U/ 10g CHO (total daily insulin aprox.
52U). She is going to have for breakfast 60 g CHO (typical for her) and BG is 16 mmol/l.

   Insulin required to cover CHO= 60/10= 6 U
   Insulin required to bring down BG from 16 to 10 mmol/l (i.e. by 6 mmol/l) = 100/52= 1.9mmol
    reduction per 1 U insulin, so 6/1.9= 3.1U
       In total she should have 6+3= 9U insulin before breakfast




FOOD

General principles:

   Food should always be available for children with diabetes in the ward
   Insulin injections are often timed around meals
   Depending on type of insulin, the injection needs to be given either 20-30 minutes before
    food (i.e. Mixtard 30 or Actrapid) or immediately before food (Novomix 30 or Novorapid)
   Depending on insulin regime (p.7), some children must have regular snacks through the day
   Food can be used to treat hypoglycaemia



HYPOGLYCAEMIA


There is not an exact „number‟ definition of hypoglycaemia (low blood glucose or „hypo‟) but
often is considered as a blood glucose levels below 2.5-3 mmol/l. Generally, if blood glucose is
less than 4 mmol/L there should be some action instigated, i.e. treat as per „hypo‟, offer a snack
or eat meal without delay.

The symptoms and signs of hypoglycaemia vary between individuals and change with age. They
can be classified into:

       Autonomic: sweating/clammy, hunger, tremor, pallor, restlessness
       Neuroglycopenic: weakness, headache, glazed expression, mood changes/lack of
        concentration, tiredness/lethargy, visual and speech disturbances, vertigo, confusion, fits
        and unconsciousness




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A child may display some or all of the above symptoms. Some children with hypoglycaemia
unawareness might not have any symptoms. If you suspect that a child is „hypo‟ it is essential that
treatment is given as quickly as possible.
First check blood glucose level if it is over 4mmol/l they are not „hypo‟ and do not need sugary
drinks or food. They maybe hungry, so offer an appropriate snack or meal if meal is due. Giving
sugar when they are not hypo causes an unnecessary rise in blood glucose.

Symptomatic hypoglycaemia can be:

   Mild (grade 1) - the patient is able to observe and treat the episode him/herself
   Moderate (grade 2) - the patient can be treated orally, but with help from someone else
   Severe (grade 3) - the patient is unconscious or having fits and can not be treated orally

The treatment of hypoglycaemia varies with the degree of severity:

   Mild: If child is co-operative and aware of episode give 10-20 g of fast acting oral
    carbohydrate in the form of 3- 6 glucose tablets, 50ml fresh juice or lucozade, two
    teaspoons jam or honey. The fast acting sugar should raise the blood glucose level within 5 to
    10 minutes. Only if there is no improvement after 10 minutes give more sugar. You must then
    follow it up with slow-acting carbohydrate to make sure the blood glucose level does not fall
    again. For example: Digestive biscuit and glass of milk, toast or sandwich, cereal, crisps,
    piece of fruit. Additional complex long-acting carbohydrate is not required for children and
    young people using continuous subcutaneous insulin infusion (insulin pump).

   Moderate: If the child is unco-operative use GlucoGel® (formerly Hypostop gel). This is a
    fast acting sugary gel, which comes in a tube with easy twist top. The tube content is squirted
    into the side of the mouth and massaged into cheek. This is also followed with a snack.

   Severe: Do not attempt to give anything orally. In hospital and when IV access is available
    give an intravenous glucose bolus (5ml/kg of 10% glucose solution over 3 minutes),
    followed by intravenous infusion of 5% glucose solution at 12ml/kg/h. If IV access is not
    immediately available give glucagon (GlucaGen Hypokit®) by injection (i.m.):

    - Children < 8 years or body weight less than 25 kg: 0.5 mg (half of the emergency kit)
    - Children > 8 years or body weight more than 25 kg: 1 mg (the whole emergency kit)

    NB: Glucagon can cause vomiting afterwards.

After severe hypoglycaemia, blood glucose should be measured after 4-5 minutes and frequently
during the next hours. The blood glucose values should stay in the range of 10-15 mmol/l and
after waking, the child should be offered simple carbohydrates in the form of white bread or
similar. If the child is still unconscious half an hour after normalising the blood glucose level,
cerebral oedema should be considered and treated accordingly.

After a severe hypoglycaemic episode the cause of the event should be sought and corrected.
Hypoglycemia is the result of a mismatch between insulin, food and exercise. Points to be
considered are:

   Altered routine (missed or erratic meals, changes in physical activity, alterations or errors in
    insulin dosage or absorption)
   Younger age (<6 years)
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   Lower HbA1c
   Total deficiency of endogenous insulin
   Antecedent hypoglycemic episodes
   Hypoglycemic unawareness
   Defective glucagon and catecholamine counter-regulation (longer duration of diabetes)
   Alcohol ingestion

All patients admitted with hypoglycaemic seizures should be seen by the PDSN prior to discharge
(at the weekend leave a message in their maibox ext. 52734). Patients should be discussed with
the consultant for consideration of CGMS (CGMS).



EXERCISE

Exercise has a number of effects on blood glucose levels:
  Increased absorption of insulin from injection site
  Increased consumption of glucose without the need for extra insulin
  The glycogen stores in the liver are used up and have to be replenished sometimes hours after
   exercise
These can cause hypoglycaemia immediately and many hours after exercise

  Cells can not take up glucose if there is lack of insulin
  During competitive strenuous sport counteregulatory hormones are released
These can cause the blood glucose to go up

Children should not be allowed to exercise if the blood glucose is high (>15 mmol/L) AND
there are ketones present as this can precipitate DKA

Prevention of hypoglycaemia during exercise:

   For light or brief exercise (up to 30 min) a small intake (10 g) of rapidly absorbed
    carbohydrate is usually recommended prior to exercise if blood glucose is < 6 mmol/L
   For intensive, strenuous or prolonged exercise
       Careful monitoring of BG levels
       Reduction of insulin should be considered
       For every 30 min of heavy exercise 10- 15g of carbohydrate are required (a mixture of
        slow and quick acting), for example 100 ml of fruit juice.
       Extra slowly absorbed complex carbohydrate will be necessary at bedtime. A bedtime
        snack containing fat and protein may help to prevent nocturnal hypoglycemia
       Exercise should take place in the presence of a companion familiar with the recognition
        and treatment of hypoglycemia



BLOOD SUGAR MONITORING

Self-monitoring of blood glucose (SMBG) is an essential tool in the management of childhood
and adolescent diabetes:


                                               15
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   Helps to monitor immediate and daily levels of control
   Detects hypoglycemia
   Assists in the safe management of hyperglycemia
   Has educational value in assessing BG responses to insulin, food and exercise

Equipment

The following equipment is required:
  Blood glucose meter
  Test strips
  Finger pricking equipment

Equipment maintenance: The meter should be calibrated for every new pack of test strips and
also monthly with the control solutions.

Technique

   Wash hands
   Prepare device by loading strip, ensuring that meter has been calibrated
   Prick finger – using the side, by the nail. Try not to use the pad of the finger as there are more
    nerve endings there and it is more painful
   Place drop of blood on strip
   Wait for meter to count down and record blood glucose reading on chart.

Timing of SMBG

The number and regularity of SMBG should be individualised depending on acceptance by the
young person and the type of insulin regimen. Frequent, accurate SMBG is the only method by
which optimal glycaemic control can be achieved by intensified management regimens.

Suggested timing of SMBG would be:

   Before insulin injections
   At different times in the day to assess BG response to insulin, food intake and exercise. In this
    way, changes may be made in management to improve BG profiles
   To confirm hypoglycaemia and to monitor recovery
   During intercurrent illness to prevent hyperglycaemic crises
   In association with vigorous sport or exercise



KETONE TESTING

Ketones should be checked whenever the blood sugar is high (>15 mmol/L) or if there is concern
regarding the development of ketoacidosis. They can be checked either in blood or urine.

Blood

Blood ketones are measured by monitoring blood ß-hydroxybutyrate (ß-OHB). Near-patient
blood ketone testing is available with the Medisense Optium or Optium Xceed meters.

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This is the preferred method of monitoring ketones during an episode of DKA.

Technique: Wash your hands put a B-ketone strip into the meter and put a drop of blood on the
end of the strip.

Interpretation of results:

   Between 0.1 and 1.0: These are acceptable blood ketone levels. Continue to test blood
    glucose as usual

   Between 1.1 and 3.0: This is too high. A correction dose of insulin should be administered
    (MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA). Blood glucose
    and ketones should be rechecked in 1 to 2 hours.

   Over 3.0: This is too high and might indicate ketoacidosis. If blood sugar is also high a
    correction dose of insulin should be given or the DKA protocol initiated as appropriate.


Urine

Ketone Reagent Strips are used to check for the presence of acetoacetate in the urine.

Technique:

   Check the strips are not out of date or have been open for more than 6 months
   Remove the strip from the box and put the lid back on the box
   Dip the strip into fresh urine, remove strip, shake to remove excess urine
   At exactly 15 seconds (use a watch with seconds hand) check the strip against the colour key
    on the side of the container

Interpretation:

   Small to moderate – This level is acceptable. Continue routine monitoring or as indicated.

   Moderate to large – This is too high. A correction dose of fast acting insulin should be given
    and blood sugar and urine ketones rechecked in 1 to 2 hours.




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         MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA


                                           Blood Glucose >15 mmol/l
                                              Vomiting or unwell


                                           Check ketones:
                                            Blood (B-ketone strip),
                                             or
                                            Urine (Ketostix)



        Ketones:                                               Ketones:
          Urine: moderate/ large                                Urine: negative/ trace/ small
          Blood: > 1.0                                          Blood: <1.0




       Calculate the insulin correction dose =                 Continue usual insulin doses at
       ‘total daily dose’ /6                                   usual times.
                                                               Check blood glucose 2-3 hrly
       and give NOW as an extra injection of
       fast acting insulin (eg Novorapid)



                                                                 Blood Glucose <15 mmol/l
             Check BG and ketones after 1                        Ketones:
             or 2 hours                                            Urine: negative/ trace/ small
                                                                   Blood: <1.0


           Blood Glucose >15 mmol/l
           Ketones:
             Urine: moderate/ large
             Blood: > 1.0




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MANAGEMENT OF DIABETIC KETOACIDOSIS

The management of Diabetic Ketoacidosis (DKA) includes not only the acute management but
also understanding the reasons why DKA developed in the first instance. The acute management
of DKA is everybody‟s responsibility and the DKA protocol below should be followed. The
underlying cause for the development of DKA is often straight forward and should be elucidated
by good history taking. The diabetes team will usually deal with the further management such as
psychology referral and increased educational input.
The full and most up to date DKA guideline is available at the following link:

www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf

or

www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf (see appendix D)




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     Algorithm for the Management of Diabetic
     Ketoacidosis
    Clinical History                                       Clinical Signs                              Biochemical Signs
  - polyuria                                                                                    - ketones in urine or blood
                                            - assess dehydration
  - polydipsia                                                                                  - elevated blood glucose (>11mmol/l)
                                            - deep sighing respiration (Kussmaul)
  - weight loss                                                                                 - acidaemia (pH<7.3)
                                            - smell of ketones
  - abdominal pain                                                                              - take blood also for electrolytes,
                                            - lethargy, drowsiness
  - weakness                                                                                      urea
  - vomiting                                                                                    - perform other investigations if
  - confusion                                                                                     indicated



                                                        Confirm Diagnosis
                                                       Diabetic Ketoacidosis
                                                        Call Senior Staff
Shock
Reduced peripheral pulse volume                         Dehydration > 5%                               Dehydration < 5%
Reduced conscious level                                 Clinically acidotic                            Clinically well
Coma                                                    Vomiting                                       Tolerating fluid orally


        Resuscitation                                    Intravenous therapy
                                                - calculate fluid requirements                                Therapy
    - Airway + N/G tube                                                                                - start with s.c insulin
    - Breathing (100% 02)                       - correct over 48 hours
                                                - 0.9% saline                                          - give oral fluids
    - Circulation (10ml/kg
    of 0.9% saline repeated                     - add KCL 20 mmol every 500 ml
    until circulation restored,                 - insulin (Novorapid) 0.1U/kg/hour by
    max 3 doses)                                infusion


                                                                                                           No improvement

                                                             Observations
                                            - hourly blood glucose
                                            - neurological status at least hourly
                                            - hourly fluid input:output                               Neurological deterioration
      No improvement                        - electrolytes 2 hours after start of IV-therapy,
                                                                                                      Warning signs :
                                            then 4-hourly                                             headache, irritability, slowing
                                                                                                      heart rate, reduced conscious
                                                                                                      level, specific signs raised intra-
                                                                                                      cranial pressure
          Re-evaluate
  - fluid balance + IV-therapy
  - if continued acidosis, may
  require further resuscitation        ?                    blood glucose
                                                                                                                 exclude
  fluid                                                     < 15 mmol\L
                                                                                                              hypoglycaemia
  - check insulin dose correct
                                                                                                                 is it
  - consider sepsis
                                                                                                          cerebral oedema ?


                                                         Intravenous therapy
                                            -     change to 0.45% saline + glucose 5%
                                            -     continue monitoring as above
                                            -     consider reducing insulin 0.05/kg/hour,
                                                but only when pH>7.3                                   Management
                                                                                                         - give mannitol 1.0 g/kg
                                                                                                         - call senior staff
                                                                                                         - restrict I.V. fluids by 2/3
                 Insulin                                        Improvement                              - move to ITU
   start subcutaneous insulin then                                                                       - CT Scan when stabilised
                                      -     - clinically well, drinking well, tolerating food
   stop intravenous insulin 1 hour    -     - urine ketones may still be positive
   later                                                    20
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SURGERY

The ISPAD consensus guideline makes recommendations regarding children and young people
with type 1 diabetes who require surgery or fasting.
Children and young people with type 1 diabetes who require surgery:
• should be admitted to hospital for general anaesthesia
• require insulin, even if they are fasting, to avoid ketoacidosis
• should receive glucose infusion when fasting before an anaesthetic to prevent hypoglycaemia
(unless having a minor procedure).


The Medical Team is responsible and available for advising on the management of diabetic
children.
As a general rule, for children on basal-bolus regimes (Basal-Bolus regime), the basal
insulin is given as usual and the bolus insulin is omitted until they start eating again. Children
should have IV access to manage possible hypoglycaemia.

Minor elective procedures

The child should always be placed first on the morning list. For grommets or other very short,
relatively painless procedures, at the discretion of the Consultant Anaesthetist the child can be
fasted, not given morning Insulin and then given normal Insulin plus breakfast on return to the
Ward at 9 to 9.30 am. A cannula is not required prior to going to theatre.

Medium/Major Elective procedures

   Admit to hospital the afternoon prior to surgery. The usual evening or bedtime insulin(s) and
    a bedtime snack should be given.
   Earlier admission might be necessary if glycaemic control is poor.
   The child must be first on the morning list and have intravenous access in situ.
   For procedures where a child may not be eating or drinking later in the day an Insulin
    infusion and intravenous fluids should be started.
It is often most convenient to arrange this by putting in a heparinised cannula the evening before and writing up
an Insulin infusion and maintenance fluids according to the instructions on the paediatric Insulin infusion sheet
for the Nurses to start at 7 am.
   No solid food from midnight.
   Clear fluids may be allowed up to 4 hours pre-operatively (this should be checked with the
    anaesthetist).
   Omit usual morning insulin dose.
   Start intravenous fluid and insulin infusion at 6.00–7.00 a.m.
   Hourly blood glucose monitoring pre-operatively, then half-hourly during operation and until
    woken from anaesthetic.
   Hourly blood glucose monitoring 4 hours post-operatively
   Aim to maintain blood glucose between 5 and 12 mmol/l.
   Continue intravenous infusion until the child or young person tolerates oral fluids and snacks
    (this may not be until 24–48 hours after major surgery). The infusion can then be stopped
    whenever the child is ready to drink and eat.
   Change to usual subcutaneous insulin regimen or short-acting insulin/rapid-acting insulin
    analogue before the first meal is taken.

                                                         21
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This could be at lunchtime on the day of the operation giving half the morning dose of Insulin as Novorapid or at
teatime giving the normal teatime dose of Insulin or breakfast time the next morning giving the normal morning dose
of Insulin.

   Stop insulin infusion 60 minutes after subcutaneous insulin is given.

Elective procedures- afternoon list

Whenever possible the afternoon list should be avoided unless the clinical need is such that the
procedure should go ahead. For children on twice or three time a day insulin regimes:

   Give one-third of the usual morning insulin dose as short-acting insulin if the operation is
    after midday.
   Allow a light breakfast.
   Clear fluids may be allowed up to 4 hours preoperatively.
   Start intravenous fluids at midday at the latest. There is no need for IV insulin infusion for
    minor procedures such as a jejunal biopsy.
   Then as for morning operations (see above).
   The child should have his usual tea time insulin and meal.


Emergency surgery

• Diabetic ketoacidosis may present as „acute abdomen‟.
• Acute illness may precipitate diabetic ketoacidosis (with severe abdominal pain).
• Nil by mouth.
• Secure intravenous access.
• Check weight, electrolytes, glucose, blood gases and ketones pre-operatively.
• If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery until
circulating volume and electrolyte deficits are corrected.
• If there is no ketoacidosis, start intravenous fluid and insulin infusion as for elective surgery.



OUTPATIENT SERVICES


Medical clinics

   RACH Clinic: Friday morning weekly from 9 am
   Fraserburgh Clinic: all day clinic alternate months
   Orkney Clinic: twice a year June and December one day only
   Shetland Clinic: twice a year April and October two days clinic
   Woolmanhill Young Persons Clinic: Tuesday morning, last of month



Nurse led clinics



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   Routine review clinic: Second Thursday of the month 2-4pm – Patients whose diabetes is well
    controlled and do not require to see a doctor every visit can come to this clinic and have
    HbA1C, height, weight checks and discuss their progress with the specialist nurse (medical
    advice will be available should it be required).
   Diabetes education clinic: Fourth Thursday of the month 2-4pm - Education clinic for newly
    diagnosed patients, adolescents pre-transfer to adult service and any other educational issues.
    Patients/families have a 20minute slot with specialist nurse.


Podiatry

A podiatrist is in attendance at the clinic on the 2nd Friday of the month but occasionally dates
may changes so please check before asking a patient to attend a specific clinic.


Psychology

Dr Andrew Keen is available on the last Friday of each month at the Diabetic outpatient clinic.
Referral should be made through the PDSNs Isla Fairley and Edna Stewart.


ROUTINE FOLLOW UP

The following checks and discussions should take place at every routine clinic visit:

   Height and weight- plot in chart
   HbA1c
   Check current insulin therapy
   Review of blood sugar home monitoring
   Review of hypoglycaemia
   Injection sites
   School issues
   Family issues (holidays, special dates, new situation)
   Other problems
   Has the child had an annual review in the last year?

In addition, at the time of the annual review, the following take place:

   BP
   Urine for microalbumin (over 10 years old)
   Blood test for thyroid function and coeliac antibodies
   Check retinal screening in place
   Check Podiatrist screening done
   DSN review
   Dietetic review


SCI-DC




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Details of all children are available in the SCI-DC database which is accessed from the main
computers in all wards. A password is required to access the system.

CGMS

Some patients might benefit from a period of Continuous Glucose Monitoring. This is available
as an outpatient procedure. CGMS should only be organised after full discussion with the
Consultant. A separate protocol is available for this procedure.
All patients admitted with hypoglycaemic seizures should be discussed with the consultant for
consideration of CGMS.


INSULIN PUMPS

Children using insulin pumps are highly competent in their use and they will guide you on their
use and their insulin requirements.
Never disconnect a pump for more than 30 min (for showering, etc) as there is no reserve of
insulin in the body and the child might become unwell very quickly.
Contact a member of the diabetes team if you are unsure about anything.


TYPE 2 DIABETES

Children with type 2 diabetes may be asymptomatic, or may have symptoms of thirst and
polyuria
plus ketonuria. There is usually a family history of type 2 diabetes, and there may be evidence of
insulin resistance (acanthosis nigricans). These children are usually overweight (=85th centile
according to the new BMI charts of Cole) or obese (=95th centile on the BMI charts). The
differential diagnosis is usually between type 1 diabetes (children may have more weight loss and
symptoms) or Maturity Onset Diabetes of the Young (MODY) (white UK children who are
usually thin, asymptomatic, and family history of diabetes in 3 generations), or diabetes
secondary to another condition (such as Prader Willi , cystic fibrosis). It cannot be stressed
enough that a child should be treated as type 1 diabetes and commenced on insulin if there is
any doubt about the diagnosis, or the child presents with significant symptoms, or with
ketonuria. The diagnosis can always be revised at a later stage, and the child taken off insulin, if
appropriate.
A separate protocol on the management of children with Type 2 Diabetes is available from the
diabetes team.


COMPLICATIONS


For advise on the diagnosis and management of diabetes complications please see the Grampian
Guidelines for Management of Diabetes Mellitus, Feb 2004, available in the intranet
(http://193.195.78.72/nhsgrampian/files/Guidelines2004).




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OTHER

OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS

Newly Diagnosed Diabetics

If a child is admitted on Friday evening/Saturday please contact a member of the diabetic team
and if available we might be able to come and see them. Contact numbers are available through
the Medical Ward at RACH.
Contact: Isla Fairley /Edna Stewart and Elsie Carnegie.


Out Of Hours

Patients are referred to the Medical Ward RACH ext. 50380 for out of hours urgent advise-
please record details of the call and advice given and pass on to Diabetes Team. If the staff
member answering the call is unable to give suitable advice then the call should be passed on to
middle-grade doctor on call for Medical Unit on bleep 2678.
For non-urgent enquiries patients and staff are advised to leave a message on voicemail ext.
52734



DIABETES TEAM CONTACT NUMBERS


Name               Role                bleep   phone              e-mail address
Dr Amalia          Consultant          3308    Xt 53822           a.mayo@arh.grampian.scot.nhs.uk
Mayo               (RACH)                      Xt 50125 (Sec)
Dr Wheldon         Consultant          3807    Xt 51727           wheldon.houlsby@nhs.net
Houlsby            (RACH)
Dr Willem van      Consultant                                     vanijperen@nhs.net
Ijperen            (Elgin)
Lisa Wallis        Secretary                   Xt 50125           lisa.wallis@arh.grampian.scot.nhs.uk
                                               Fax: 01224
                                               550704
Isla Fairley       PDSN                3731    Xt 52734           Islafairley@nhs.net
Edna Stewart       PDSN                3731    Xt 52734           edna.stewart@nhs.net
Irene Hill         DSN                         Xt 55527           Irene.hill@nhs.net
                   (Woolmanhill)
Sheena Duffus      DSN                         01346 585244       sheena.duffus@nhs.net
                   (Fraserburgh)
Caroline Page      DSN (Orkney)                01856 888218       caroline.page@nhs.net
                                               mobile
                                               07884114517
                                               page
                                               07623978203

                                               25
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Kirsty             Community                  01595 743362       community.paediatric.nurse@lerwick.
Anderson           Paediatric Nurse                              shetland.scot.nhs.uk
                   (Shetland)
Elsie Carnegie     Paediatric          2464   Xt 52630           Elsie.carnegie@nhs.net
                   Dietitian
Shona Milne        Dietitian                  Xt 56305           shona.milne@nhs.net
                   (Fraserburgh)
Shelly Watt/       Podiatrist                 Xt 55273           shelly.watt@arh.grampian.scot.nhs.uk
Lynda Sime
Dr Andrew          Health                     Xt 52234           Andrew.keen@arh.grampian.scot.nhs.
Keen               Psychologist                                  uk


Postal address:

Diabetes Service
Department of Medical Paediatrics
Royal Aberdeen Children‟s Hospital
Westburn Road
Aberdeen
AB25 2ZG



REFERENCES

1. ISPAD and International Diabetes Federation (European Region). Laron Z (ed). Consensus
   guidelines for the management of insulin-dependent (Type 1) diabetes mellitus (IDDM) in
   childhood and adolescence. Tel Aviv: Freund Publishing House Ltd, 1995.

2. The Diabetes and Complications Trial Research Group. The effect of intensive treatment of
   diabetes on the development and progression of long-term complications in insulin-dependent
   diabetes mellitus. The Diabetes Control and Complications Trial Research Group. New
   England Journal of Medicine, 1993, 329:977-986.

3. SIGN 55 “Children and Young People” Management of Diabetes. November 2001: ISBN
   1899893 82 2

4. NICE. Type 1 Diabetes (Childhood) - Full Guideline,September 2004
   www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf

5. Grampian Guidelines for Management of Diabetes Mellitus, Feb 2004
   http://193.195.78.72/nhsgrampian/files/Guidelines2004

6. BSPED Recommended DKA Guidelines, Feb 2004
   http://www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf




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GLOSSARY

BG                Blood Glucose
BMI               Body Mass Index. Weight (kg) divided by square height (m2)
CGMS              Continuous Glucose Monitoring System
CHO               Carbohydrate
DKA               Diabetic Ketoacidosis
HbA1c             A fraction of the total Haemoglobin content of the blood with glucose stuck
                  to it. This measurement is used to monitor diabetes control
ISPAD             International Society for Pediatric and Adolescent Diabetes. See
                  ‘References’ for their consensus document
IVI               Intravenous Infusion
PDSN              Paediatric Diabetes Specialist Nurse
RACH              Royal Aberdeen Children’s Hospital
SCI-DC            Scottish Care Information- Diabetes Collaboration. This diabetes database
                  is used for clinical management at the children’s services
SMBG              Self Monitoring of Blood Glucose (with a near-patient blood glucose meter)
tdd               Total daily dose (of insulin)
WHO               World Health Organisation




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