Treatment of children and adolescents with diabetes

Treatment of children and adolescents with diabetes A practical reference manual Dr. Birthe S Olsen, Consultant Paediatrician Dr. Henrik Mortensen, Chief Physician, Senior Paediatric Endocrinologist Department of Paediatrics, Glostrup University Hospital, Copenhagen, Denmark Childhood diabetes Practical Reference Manual Childhood diabetes Definition Childhood diabetes Practical Reference Manual • 90% Type 1 diabetes • Absolute or relative insulin deficiency • Auto-immune process • Pancreatic beta-cell destruction Aetiology Definition Childhood diabetes Practical Reference Manual • Genetic susceptibility: • HLADR3, HLADR4: risk increased • HLADR2 : risk reduced • Environmental factors: • viral factors • nutritional factors Epidemiology Definition Childhood diabetes Practical Reference Manual • Most common endocrine disease in childhood • Highest incidence in Finland and Sardinia • Highest incidence in males • Highest incidence at 10–12 years and 5–7 years • Increasing incidence in very young children (0–4 years) • Seasonality • More common in families where father has diabetes Pre-diabetes phase Definition Childhood diabetes Practical Reference Manual • Gradual destruction of beta-cells • Development of auto-antibodies: • ICA • IAA • GADA Prevention • Primary intervention: Definition • aim: reducing the prevalence of a given condition in susceptible individuals  Example: cow's milk exclusion in infancy Childhood diabetes Practical Reference Manual • Secondary intervention: • aim: early detection of a given disease and stopping or slowing further progression  Example: ENDIT study • Tertiary intervention: • aim: preventing complications associated with a disease  Example: improvement in glycaemic control, screening for complications Management – primary goals The newly diagnosed child Childhood diabetes Practical Reference Manual • To ensure that insulin is available for all children • To ensure that the child gradually takes over the responsibility for the disease (self-care) • To ensure optimum glycaemic control • To ensure freedom from diabetic complications • To ensure normal growth and development Early diagnosis The newly diagnosed child Childhood diabetes Practical Reference Manual • Symptoms and signs: • polydipsia • polyuria • night-time incontinence • loss of weight • irritability • abdominal pain • visual disturbances • frequent infections Early diagnosis • Diagnosis: The newly diagnosed child • fasting blood-glucose concentration > 7.7 mmol/l • random blood-glucose concentration > 11 mmol/l • glucosuria • ketonuria • ketoacidosis Childhood diabetes Practical Reference Manual • Differential diagnosis: • inflamed appendix • pneumonia • urinary tract infection The multi-disciplinary team The team Childhood diabetes Practical Reference Manual • The cornerstone in childhood diabetes management: • a paediatric endocrinologist • a specialised nurse • a specialised dietician • a chiropodist • a specialised social worker • a childhood psychologist • close collaboration with other relevant departments The multi-disciplinary team The team Childhood diabetes Practical Reference Manual • The team should… • have common attitudes and philosophy • meet regularly for discussion and education • develop written material dealing with dailylife and emergency issues • encourage research into childhood diabetes • attend in-service training Diabetes education 1 Diabetes education Childhood diabetes Practical Reference Manual • Initial ‘survival’ education: • the causes of diabetes • insulin management • injection technique • blood glucose measurements • acceptable blood glucose values • dietary advice • advice about hypo- and hyperglycaemic episodes Diabetes education 2 Diabetes education Childhood diabetes Practical Reference Manual Over the next months and years a more comprehensive education programme, adjusted to the age and maturity of the child: • aetiology and pathology • injection devices and methods • blood-glucose monitoring • hyperglycaemia • sick-day management • sport • diet • insulin adjustments • hypoglycaemia • insulin-treatment • alcohol • drug abuse • travelling • gynaecological issues • complications Diabetes education 3 Diabetes education Childhood diabetes Practical Reference Manual • The knowledge and skills of the child should be regularly assessed • Re-education should be performed accordingly Treatment Initial treatment Childhood diabetes Practical Reference Manual • At diagnosis • Remission phase • Long-term Non-ketotic child Initial treatment Childhood diabetes Practical Reference Manual • Insulin: • subcutaneous • multiple dose rapid-acting insulin before meals, or • combination of rapid- and intermediate-acting insulin twice daily • insulin requirements may exceed 1.5–2 IU/kg/24 hours • Potassium: • < 12 years 750 mg KCl for 3–4 days • > 12 years 1500 mg KCl for 3–4 days Non-ketoacidotic child Initial treatment • • • • • hospital stay as short as possible in paediatric setting frequent visits to out-patient clinic 24-hour hot-line service home and institution visits Childhood diabetes Practical Reference Manual • Always managed at hospital in case of: • • • • • • ketoacidosis severe dehydration very young age infection psychosocial problems language and cultural difficulties The remission phase Partial remission phase Childhood diabetes Practical Reference Manual • Duration from weeks to months • Shorter in young children • Blood glucose values between 4–8 mmol/l • Decreasing insulin requirements < 0.5 IU/kg/24 hours • One daily insulin injection is often sufficient • Insulin injections should not be abandoned Long-term management Partial remission phase Childhood diabetes Practical Reference Manual • Twice daily or multiple insulin injections • Regular blood glucose measurements • At least 4 visits to out-patient clinic every year • Instant HbA1c measurements at every visit • Height and weight measurements at every visit • Physical examination with pubertal staging every year • Regular screening for diabetes related complications Insulin Insulin Childhood diabetes Practical Reference Manual • All children with Type 1 diabetes must have insulin • Consequences of long-term insulin omission: • growth retardation • delayed puberty • poor metabolic control • microvascular complications • short life expectancy • poor quality of life Insulin types and duration of action Insulin Onset of Peak Maximal Childhood diabetes Practical Reference Manual Insulin preparation action (h or min) action (h) duration (h) • Short-acting • Intermediate-acting • Premixed insulin 10/90 30 min. 1–2 h 0.5–1 h 0.5–1 h 1–3 4–12 2–8 5–10 6–8 18–24 18–24 18–24 • Premixed insulin 20/80 • Premixed insulin 30/70 • Premixed insulin 40/60 • Premixed insulin 50/50 0.5–1 h 0.5–1 h 0.5–1 h 10–20 min. 5–9 1–3 1–3 1–3 18–24 18–24 18–24 3–5 • Rapid-acting insulin analogue Short-acting insulin Insulin Childhood diabetes Practical Reference Manual • Clear solution • Indications for use: • daily management of diabetes, alone or in combination with intermediate-acting insulin • hyperglycaemia • sick-day management • intravenous therapy Intermediate-acting insulin Insulin Childhood diabetes Practical Reference Manual • Cloudy solution (should be thoroughly mixed before use) • Indications for use: • daily management of diabetes, alone or in combination with short-acting insulin Pre-mixed insulin Insulin Childhood diabetes Practical Reference Manual • Cloudy solution (should be thoroughly mixed before use) • Indications for use: • daily management of diabetes, alone or in combination with short-acting insulin Rapid-acting insulin (Insulin Aspart) • Clinical benefits Insulin Childhood diabetes Practical Reference Manual • improved metabolic control compared with human soluble insulin • fewer hypoglycaemic episodes • no post-prandial hypoglycaemia 0 5 10 15 • rapid onset of action • short duration of action • better quality of life and improved convenience Rapid-acting insulin (Insulin Aspart) Insulin Childhood diabetes Practical Reference Manual • Patient targeting: • newly diagnosed children and adolescents with diabetes • children and adolescents currently on basal/bolus regimens 5 10 15 • children and adolecents with poorly controlled diabetes on twice daily therapies 0 Storage of insulin Insulin Childhood diabetes Practical Reference Manual • Stable at room temperature for weeks • Should not be exposed to temperatures > 25ºC or under freezing point • Unused vials and cartridges should be stored in the refrigerator • Should never be exposed to sunlight • Should never be frozen Injection sites Insulin Childhood diabetes Practical Reference Manual • Short acting insulin: • injected subcutaneously into the abdomen at a 45° angle • Intermediate-acting and pre-mixed insulins: • injected subcutaneously in the front of the thighs or into the buttocks at a 45° angle Insulin absorption Insulin Childhood diabetes Practical Reference Manual • Factors influencing insulin absorption: • injection site • injection depth • insulin type • insulin dose • physical exercise • skin temperature Insulin requirements Insulin Childhood diabetes Practical Reference Manual • Remission period • < 0.5 IU/kg/24 hours • Pre-pubertal period • 0.6–1.0 IU/kg/24 hours • Pubertal period • 1.0–2.0 IU/kg/24 hours Insulin regimens • Insulin regimens should be: Insulin Childhood diabetes Practical Reference Manual • adjusted to age, maturity and motivation • as simple as possible • Children for multiple injection therapy should: • be selected carefully • understand the relationship between insulin, food and physical exercise • be motivated and have family support • be willing to measure blood glucose several times each day • be willing to inject insulin at school Insulin regimens Insulin Childhood diabetes Practical Reference Manual • Most widely used insulin regimens: • twice-daily injections, mixture short and intermediate, before breakfast and the evening meal • three daily injections, mixture short and intermediate before breakfast, short-acting before the evening meal and intermediateacting before bed • short-acting insulin before main meals, intermediate before bed Insulin distribution Insulin Childhood diabetes Practical Reference Manual • Twice daily injection regimen: • 2/3 of daily dose before breakfast, • 1/3 before supper • both 2/3 intermediate-acting and 1/3 short-acting insulin • Three-times daily injection regimen: • 40–50% before breakfast (2/3 intermediate- and 1/3 shortacting) • 10–15% short-acting before supper • 40% intermediate-acting before bed. • Multiple injection regimen: • 30–40 % (intermediate) before bed • the rest (short-acting) before main meals Insulin adjustments Insulin Childhood diabetes Practical Reference Manual Twice-daily injection regimen: • Blood glucose high: Dose of insulin to increase • Before breakfast or overnight • Before lunch • Before dinner intermediate-acting • Before bed • Blood glucose low: • Before breakfast or overnight acting • Before lunch • Before dinner intermediate-acting • Before bed Evening intermediate-acting Morning short-acting Morning Evening short-acting Dose of insulin to decrease Evening intermediateMorning short-acting Morning Evening short-acting Insulin adjustments Insulin Childhood diabetes Practical Reference Manual Three-times daily injection regimen: • Blood glucose high: • Before breakfast or overnight • Before lunch • Before dinner • Before bed Dose of insulin to increase Evening intermediate- acting Morning short-acting Morning intermediate-acting Evening short-acting • Blood glucose low: Dose of insulin to decrease • • • • Before Before Before Before breakfast or overnight lunch dinner bed Evening Morning Morning Evening intermediate- acting short-acting intermediate-acting short-acting Insulin adjustments Insulin Childhood diabetes Practical Reference Manual Basal-bolus (multiple injection) regimen: • Blood glucose high: • • • • Before Before Before Before breakfast or overnight lunch dinner bed Dose of insulin to increase Evening intermediate-acting Morning short-acting Lunch time short-acting Evening short-acting • Blood glucose low: Dose of insulin to decrease • • • • Before Before Before Before breakfast or overnight lunch dinner bed Evening intermediate-acting Morning short-acting Lunch time short-acting Evening short-acting Diet • Nutritional advice should take into consideration: Diet • individual requirements • local customs • family dietary habits Childhood diabetes Practical Reference Manual • General recommendations: • • • • • eat a broad variety of food eat plenty of bread, cereals, vegetables and fruit eat only small amounts of sugar in young children fat intake should not be restricted older children and adolescents should eat a low fat diet • choose food with small amounts of salt • encourage breast-feeding at least until six months of age Diet: principles • Number of meals: • 3 main meals • 3 snacks • adapted to age, physical activity and insulin regimen Diet Childhood diabetes Practical Reference Manual • Energy intake: • 1000 calories (4180 Kj) + 100 calories/year of age • 50–55% of energy from carbohydrates • 30% of energy from fat • 15–20% of energy from protein Carbohydrates Diet Childhood diabetes Practical Reference Manual • Glycaemic index (GI): • carbohydrate ranking system • based on post-prandial blood glucose response • low GI = slow, sustained blood glucose response (e.g. rice, pasta) • high GI = rapid and high blood-glucose response (e.g. white bread, candy/sweets, cornflakes, honey, sugar) Carbohydrates Diet Childhood diabetes Practical Reference Manual • Carbohydrate exchange system: • based on the carbohydrate content and not the weight of the food • makes it easy to exchange carbohydrate containing food elements (e.g. 15 g carbohydrates in candy for 15 g carbohydrates in fruit) • one exchange usually contains 10–15 g carbohydrate Effects of exercise Exercise Childhood diabetes Practical Reference Manual • Increases insulin sensitivity • Improves the physical state • Reduces the risk of cardiac diseases • Reduces the risk of hypertension • Does not improve metabolic control • Increases the risk of hypoglycaemia Food adjustments Exercise Type of activity Blood glucose (mmol/L) Before exercise Mild exercise (walking, slow speed cycling) Moderate exercise (tennis, jogging, golf, cycling) below 7 above 7 below 7 7-10 10-15 Childhood diabetes Practical Reference Manual Carbohydrate intake Before 0-15g nothing 25-50 g 10-15 g nothing During exercise from 2nd hour 10-15 g/h 15-25 g/h 15-25 g/h from 2nd hour 15-25 g/h 25-50 g/h 25-50 g/h from 2nd hour 25-50 g/h After if necessary 10 g 50 g within the first hour carb rich meal after 2 hrs 50 g within the 1st hour carb rich meal after 2 hrs Strenuous exercise (football, basketball, running, swimming, aerobics) below 7 7-10 10-15 50 g 25-50 g 10-15 g Guidelines Exercise Childhood diabetes Practical Reference Manual • Measure blood glucose before, during and after physical exercise • Increased risk of hypoglycaemia 12–40 hours after strenuous physical exercise • Reduce short-acting insulin accordingly • Blood glucose before bedtime should be > 10–12 mmol/l Definition and causes • Blood glucose < 3 mmol/l Hypoglycaemia • Mild (Grade 1): recognised and treated orally by the patient • Moderate (Grade 2): treated orally, with help from someone else • Severe (Grade 3): unconscious or having fits – nothing by mouth Childhood diabetes Practical Reference Manual • Causes: • strenuous exercise • missed meals • injection errors Symptoms Hypoglycaemia Childhood diabetes Practical Reference Manual • Neurogenic: • sweating • hunger • tremor • pallor • restlessness • Neuroglycopenic: • weakness • headache • change in behaviour • tiredness • visual and speech disturbances • vertigo • lethargy • confusion • fits and unconsciousness Treatment Hypoglycaemia Childhood diabetes Practical Reference Manual Mild hypoglycaemia (Grade 1): Severe hypoglycaemia (Grade 3): • 10–20 g glucose tablets, • Outside hospital: juice or sweet drinks • 1–2 slices of bread • children < 10 years: 0.5 mg glucagon i.m. • children > 10 years: 1.0 mg glucagon i.m. Moderate hypoglycaemia (Grade 2): • 10–20 g glucose tablets • 1–2 slices of bread • In hospital: • bolus glucose (20%) 1 ml/kg over 3 min followed by • glucose (10%), 0.2 ml/kg/min Definition and aetiology • Severity degree: • Mild ketoacidosis Childhood diabetes Practical Reference Manual Diabetic ketoacidosis • Moderate ketoacidosis • Severe ketoacidosis bicarbonate > 16 and < 22 mmol/l bicarbonate > 10 and < 16 mmol/l bicarbonate < 10 mmol/l • Characterised by: • absolute insulin deficiency • increased level of counter regulatory hormones • Aetiology: • newly diagnosed • infections • insulin omission Symptoms and signs Diabetic ketoacidosis Childhood diabetes Practical Reference Manual • Dehydration • Vomiting • Loss of weight • Kussmaul respirations • Acetone smell • Impaired sensorium • Shock Diagnosis Diabetic ketoacidosis Childhood diabetes Practical Reference Manual • Clinical appearance • Hyperglycaemia • Ketonuria • Ketonaemia • Plasma bicarbonate < 22 mmol/l Treatment: fluid Diabetic ketoacidosis Childhood diabetes Practical Reference Manual • Due to the risk for overhydration: • fluid volume in the first 24 hours should not exceed 4 l/m2 • rehydration over 24–36 hours • Initiate treatment with isotonic 0.9 % saline: • 1st hour: 20 ml/kg body weight (previous) • 2nd hour: 10 ml/kg body weight • 3rd hour onwards: 5 ml/kg body weight • When blood glucose levels are below 12 mmol/l: • 5–10 % glucose solution Treatment: insulin • Low-dose insulin regimen: Diabetic ketoacidosis • short-acting insulin • intravenously Childhood diabetes Practical Reference Manual • bolus or continuous infusion • 0.1 IU/kg/hour • Ideal blood-glucose reduction: • maximal 4–5 mmol/l • Until acidosis is corrected: • adjust insulin and fluid to blood glucose level between 5–15 mmol/l Treatment: potassium Diabetic ketoacidosis Childhood diabetes Practical Reference Manual • DKA is always accompanied by severe potassium deficiency • Treatment: • initially add 20 mmol KCl to 500 ml fluid • adjust potassium replacements to plasma potassium level: plasma potassium (mmol/l) < 3 3–4 4–5 5–6 > 6 potassium chloride (mmol/kg/h) 0.5 0.4 0.3 0.2 nothing Treatment • Sodium: Diabetic ketoacidosis • • • • measured level low due to dilution only correction if values are below 120 mmol/l if values are above 160 mmol/l (hypernatriaemic state) rehydrate over 48–72 hours Childhood diabetes Practical Reference Manual • Bicarbonate: • only in very sick children with severe ketoacidosis (pH < 7.0) • recommended dose 1–2 mmol/kg • ½ of the dose over 30 minutes and ½ over 1–2 hours • Hazards of bicarbonate treatment: • precipitation of hypokalaemia • paradoxical exacerbation of CNS acidosis • cerebral oedema Cerebral oedema • Aetiology: Diabetic ketoacidosis Childhood diabetes Practical Reference Manual • rapid fluid correction • hyperglycaemia • bicarbonate treatment • Treatment: • fluid restriction • hyperventilation • mannitol infusion 1–2 g/kg over 20–30 minutes • Prognosis: • very poor Sick-day management Sick-day management Childhood diabetes Practical Reference Manual • Basis for sick-day management at home: • • • • insulin should never be omitted frequent blood glucose measurements frequent urine testing for ketone bodies close contact with the diabetes team • Situations where admittance to hospital is indicated: • • • • • • • persistant vomiting increasing ketone bodies in the urine increasingly sick child abdominal pain non-compliance and psycho-social problems language and cultural difficulties very young age (< 2 years) Sick-day management Sick-day management Childhood diabetes Practical Reference Manual • Situations with high fever, high blood-glucose and ketonuria: • most often caused by bacterial infections • seek and treat the infection focus • give frequent subcutaneous injections of short-acting insulin • continue treatment until ketone bodies have disappeared • give glucose containing food or drinks to maintain acceptable blood glucose values • encourage the child to drink plenty of fluids Sick-day management Sick-day management Childhood diabetes Practical Reference Manual • Situations with low-grade fever, low bloodglucose and ketonuria • most often caused by viral infections • associated with anorexia, vomiting and diarrhoea • reduce short- and intermediate- acting insulin according to blood glucose values • give glucose containing food or drinks to maintain acceptable blood glucose values • encourage the child to drink plenty of fluids Minor surgery (duration < 3h) Surgery Childhood diabetes Practical Reference Manual • Insulin: • in the morning intermediate-acting insulin, 1/2 to 2/3 of total daily dose • if blood glucose is above 20 mmol/l supply with a small dose short-acting insulin • in the evening give intermediate-acting insulin, 1/3 of daily dose • Fluid: • glucose 5% intravenously, volume according to age • Blood glucose monitoring: • every 1–2 hours • values between 10–14 mmol/l Major surgery (duration > 3h) Surgery Childhood diabetes Practical Reference Manual • Insulin and fluid: • infusion solution containing 5% glucose and 20 mmol/l sodium chloride (maintenance volume) • 50 IU short-acting insulin in 500 ml 0.9 % saline by separate drip infusion 0.5 ml = 0.05 IU/kg/hour • Blood glucose monitoring: • every 1–2 hours • values between 6–14 mmol/l • if < 5 mmol/l reduce infusion rate • continue infusion therapy until food intake is reestablished Tests • HbA1c: Glycaemic control • average blood glucose over last 4–6 weeks • should be measured and available at every out-patient clinic visit • • • • • • • ideally before breakfast, lunch, evening meal and bedtime before, during and after physical exercise during intercurrent illnesses if hypo- or hyperglycaemia is suspected following hypoglycaemia after changing insulin dose frequency of HBG should be adjusted to age, insulin regimen and acceptance of the child Childhood diabetes Practical Reference Manual • Home blood glucose (HBG) measurement: • Urine testing: • ketone testing in case of fever and high blood glucose Goals Glycaemic control Childhood diabetes Practical Reference Manual • Well-adjusted children/adolescents with normal growth and development • HbA1c between 7–9% • Less than 10–20 severe hypoglycaemia episodes and ketoacidosis per 100 patient years • Post-prandial blood glucose values below 10–12 mmol/l • Pre-prandial blood glucose values between 4–8 mmol/l • Glycaemic goals less strict for very young children • Goals realistic and individualised in puberty Microvascular complications Complications Childhood diabetes Practical Reference Manual • Microvascular complications in kidneys, eyes and nerves: • closely related to poor long-term metabolic control • occur from puberty • preceded by subclinical changes • can be delayed or prevented by good metabolic control Diabetic nephropathy Complications Childhood diabetes Practical Reference Manual • Leading cause of increased morbidity and mortality in Type 1 diabetes • Preceded by microalbuminuria (albumin excretion rate > 20 µg/min) • Prevalence in adolescence 5–20% • Correlated with long-term metabolic control • Long diabetes duration • Elevated arterial blood pressure • Genetic susceptibility Diabetic nephropathy Annual screening: Complications • after 5 years’ diabetes duration in pre-pubertal children Childhood diabetes Practical Reference Manual • after 2 years’ diabetes duration in adolescents • Screening method: • albumin excretion rate calculated from night-time urine collections • Microalbuminuria treatment: • improved long-term metabolic control • normalising arterial blood pressure • smoking discouraged • ACE-inhibition Diabetic retinopathy Complications • Leading cause of visual loss and blindness in working-age population • Prevalence in adolescence: 10–80% • Correlated with long-term metabolic control • Long diabetes duration • Elevated arterial blood-pressure • Genetic susceptibility Childhood diabetes Practical Reference Manual • Background retinopathy: • not vision threatening • Proliferative retinopathy: • vision-threatening • new vessels • retinal retraction • stable for many years Diabetic retinopathy Complications Childhood diabetes Practical Reference Manual • Annual screening: • after 5 years’ diabetes duration in pre-pubertal children • after 2 years’ diabetes duration in adolescents • Screening method: • ophthalmoscopy • fundus photography • fluorescein angiography • Retinopathy treatment: • improved long-term metabolic control • normalising arterial blood pressure • laser therapy in case of proliferative retinopathy Diabetic neuropathy Complications Childhood diabetes Practical Reference Manual • Peripheral and autonomic • Rare in childhood and adolescence • Preceded by subclinical abnormalities • Correlated with • • • • • poor long-term metabolic control long diabetes duration older age higher Tanner stage male sex Diabetic neuropathy Complications Childhood diabetes Practical Reference Manual • Annual screening: • from puberty • Screening method: • ankle reflexes • sensation (temperature discrimination) • non-invasive test of nerve function (biothesiometry) • Neuropathy treatment: • improved long-term metabolic control Adolescence Adolescence Childhood diabetes Practical Reference Manual • Insulin insensitivity • Poor metabolic control • Insulin omission • Overweight • Eating disorders • Psychosocial problems • Microvascular complications Treatment strategies Adolescence Childhood diabetes Practical Reference Manual • Non-threatening open-minded atmosphere • Patience • Respect • Flexible appointment times • Opportunity to meet other adolescents with diabetes • Planned transition to adult setting • Parental involvement Risk-taking behaviour • Alcohol: Adolescence Childhood diabetes Practical Reference Manual • impairs gluconeogenesis • associated with severe hypoglycaemia • Advice: • drink in moderation • eat complex carbohydrates while drinking alcohol • if HBG is not measured always eat extra food before bedtime • make sure that your friends are aware of your diabetes • always wear your diabetes amulet when going to parties • measure HBG before going to bed • measure blood glucose (HBG) regularly Risk-taking behaviour Adolescence Childhood diabetes Practical Reference Manual • Smoking: • harmful to the health of all people • associated with increased risk of microvascular complications • is expensive • is addictive • Drug abuse: • should be considered in connection with other risk-taking behaviour Gynaecological issues Adolescence Childhood diabetes Practical Reference Manual • Menstruation: • may be irregular due to poor metabolic control • may be accompanied by high blood glucose levels • Oral contraceptives with low-dose oestrogen: • safe for most adolescents with diabetes • may be accompanied by insulin resistance • not to be used in cases of arterial hypertension • Condoms: • safe contraceptive method • protect against sexually transmitted diseases School Camps, school and travel Childhood diabetes Practical Reference Manual • All children should be attending school • Academic expectations should be the same • Teachers and school nurse should be informed about general rules and emergency situations • Written material about diabetes should be handed out to school staff • A close communication should exist between home and school Travelling Camps, school and travel Childhood diabetes Practical Reference Manual • Appointment in the out-patient clinic 4–6 weeks before travel • Improve metabolic control, if necessary • Make sure that the family is capable of treating hypo- and hyperglycaemic episodes • Make sure that the family is informed about sickday management • Make sure that travel health insurance is valid Travelling Camps, school and travel Childhood diabetes Practical Reference Manual • Bring: • introduction letter • sufficient insulin, needles, blood glucose testing material and glucagon • blood glucose meters and extra batteries • extra food and drink • Long flights: • stick to the ‘home-time’ and normal routines • 6-hourly injections of short-acting insulin Psychosocial problems • Psychosocial problems in childhood diabetes: Psychosocial problems • imposes major demands on child and family • pre-existing problems may interfere with patients compliance • different psychological problems may emerge in different agegroups Childhood diabetes Practical Reference Manual • Parents: • in shock at diagnosis • Young children: • needle-phobia and eating problems • Adolescents: • poor compliance, insulin omission, eating disorders • The team should: • look for these problems from diagnosis • take care that early counselling is initiated