MANAGEMENT OF DIABETIC CHILDREN IN RACH
March 2006
Version 1.3
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
Newly Diagnosed Diabetics 25
Out Of Hours 25
DIABETES TEAM CONTACT NUMBERS 25
REFERENCES 26
GLOSSARY 27
2
MANGEMENT OF DIABETIC CHILDREN IN RACHvmar06_final[1]
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
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:
· acidotic respiration,
· dehydration
· drowsiness
· abdominal pain/vomiting
· 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.
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.
· 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
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
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
· Insulin Novorapid® – vial
· Insulin Insulatard® – vial
(insulin prescription will vary according to regime)
· GlucoGel® (formerly Hypostop)
· GlucaGen Hypokit® 1mg / · Blood Glucose monitor
· Syringes 0.3ml with 8 mm needle
or
· Insulin Pen and needles
· Safe Clip
· Sharps Bin
· Ketostix®
· 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
NEW DIABETIC FLOW CHART
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.
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.