Download Paediatric diabetes - Hampshire Hospitals NHS Foundation Trust

Contents
Introduction ....................................................................... 2
Winchester Paediatric Diabetes Team Information ........... 3
What is diabetes mellitus? ................................................ 5
Essential equipment .......................................................... 8
Insulin regimes ................................................................ 12
Giving an insulin injection................................................ 14
Eating for health .............................................................. 16
Clinics.............................................................................. 22
Hypoglycaemia (low blood sugar) ................................... 26
Hyperglycaemia (high blood sugar) ................................ 31
Sick day guidelines ......................................................... 33
Diabetic Ketoacidosis (DKA) ........................................... 35
School ............................................................................. 36
Diabetes Camp ............................................................... 37
Diabetes & Travel ............................................................ 38
Further reading ................................................................ 40
Discharge home from hospital – Checklist ...................... 41
This booklet is intended as an introduction to paediatric
diabetes for the family (or carer) and child with newlydiagnosed insulin dependent diabetes, looked after by the
paediatric diabetes team in Andover, Winchester and
Eastleigh/Chandlers Ford.
1
Introduction
You have just been diagnosed with Type 1 or insulin
dependent diabetes. We understand that this may have
come as a big shock to you and your family. You will
receive a lot of new information over the next few days
and will be taught how to give insulin by injection and how
to test your child’s blood sugars. You will meet the
diabetes team, the doctors, nurses and dietitians.
We are here to help and support you through this difficult
time and over the years to come.
This booklet has been produced to help you remember
some of the most important things about diabetes and to
act as a record of your child’s hospital stay. Enclosed is a
list of contact numbers which we urge you to use if you
have any questions or concerns. There is also a check list
of the things you need to know and feel confident about
before you go home. We will also give you a selection of
booklets about diabetes that have been produced by
some of the pharmaceutical companies; these provide
useful information and can be read at your leisure.
Useful websites with further information include:
http://www.diabetes.org.uk
Diabetes UK (charity)
http://www.jdrf.org
Juvenile Diabetes Research Foundation
www.runsweet.com
Runsweet (Advice about exercise)
www.a-c-d-c.org
Association of Children's Diabetes Clinicians
We also have some books that we display at each clinic
and are available for you to borrow.
2
Winchester Paediatric
Diabetes Team Information
(for children up to 19 years old)
Winchester Clinics (Royal Hampshire County Hospital,
RHCH, Northbrook Ward outpatient department)
Paediatric Clinics with Dr Williams usually take place on
the first, third and any fifth Friday of the month (morning
clinic)
Adolescent Clinics with Dr Priesemann and Dr Cleland for
young people 16 and over usually takes place on the
second Tuesday of the month (late afternoon clinic)
Andover Clinics (Andover War Memorial Hospital)
Paediatric Clinic with Dr Williams, fortnightly on a
Wednesday morning
Eastleigh/ Chandlers Ford Clinics (Velmore Centre,
Falkland Road, Chandlers Ford)
Paediatric Clinic with Dr Priesemann, on three Tuesdays a
month in the afternoon
Please contact the secretary for your consultant if you
need to change or cannot make a clinic appointment as
the appointment may be needed urgently by someone
else.
Contact Numbers
Dr Williams’ Secretary
Dr Priesemann’s Secretary
Children’s Outpatients
01962 824995
01962 825183
01962 824982
3
Paediatric Diabetes Nurses
Caroline Spence
07884 003834
[email protected]
Vicky Houghton
07887 567229
[email protected]
Jill Kelley (staff nurse) 07786 856969
Office
01962 824283
(Community Children’s Nurses)
Paediatric Diabetes Dietitians
Vicki Charlton
01256 313232
[email protected]
Felicity Beresford
01962 824731
[email protected]
My keyworker is: …………………………………………..
If you are unable to contact one of the paediatric diabetes
nurses and you are concerned because your child is
unwell and his/her diabetes control is poor (blood
glucose levels staying either too low or too high) then
please phone either:
RHCH 01962 863535, Paediatric Registrar on Bleep 305
Or
Northbrook Ward on 01962 825367 or 01962 824987
All children with diabetes have open access to Northbrook
Ward if they are unwell with their diabetes and need to be
seen urgently by a doctor. However, please phone the
numbers above beforehand and do not go to the ward
unexpectedly.
Please do not send a text message or email if you have
an urgent enquiry as messages are not picked up on days
off or annual leave. Please phone the ward directly for
advice.
4
What is diabetes mellitus?
The name comes from the ancient Greek word diabetes
meaning siphon or running through (referring to the
passing of large amounts of urine) and mellitus meaning
honey sweet (referring to the sweetness of the urine due
to excess sugar as identified by ancient physicians).
Your child has Type 1 diabetes mellitus.
This type of diabetes is most commonly seen in children
and young people. About 1 in 500 children up to 17 years
old in the UK have type 1 diabetes, roughly 2 or 3 children
in a large secondary school, so you may already know
someone with diabetes.
In Type 1 diabetes the body gradually stops making
insulin. Insulin is essential for normal sugar balance in the
body.
Insulin is a chemical made by the pancreas that transports
sugar from the bloodstream to the liver and muscle, where
it is stored and used as the body’s energy source.
Without insulin, the sugar levels in the blood stream rise
and sugar is excreted from the body in the urine.
The body no longer has stored sugar for its energy source
and so starts breaking down fat as an alternative fuel.
Ketones are produced when fat is broken down for energy
and are also excreted in the urine.
When your child was diagnosed, he/she may have had the
following symptoms:
- Increased passing of urine. This occurs when sugar
is excreted in the urine
- Increased thirst
- Weight loss due to breakdown of fat
- Tiredness
5
Insulin is produced by special cells in the pancreas called
the islet cells or Beta cells. In people with Type 1 diabetes,
the body‘s immune system, which normally protects us
against infection, starts to destroy these cells. This
process is known as an auto immune reaction.
Why this happens is not clearly understood. It seems that
genetic factors are involved: auto immune diseases tend
to be more common in some families than others. Onset of
type 1 diabetes is often diagnosed in the autumn so it is
possible that certain infections or viruses may trigger the
auto immune reaction.
Remember
You have not done anything to cause your child to
develop diabetes. Eating sugar or sweets has not
caused your child to develop diabetes. Unfortunately
your child will not grow out of this condition.
6
There are other types of Diabetes Mellitus:
Type 2 diabetes is more common in older people and
those who are very overweight. In this type the body is
making plenty of insulin but it cannot work so well. It is
treated by changing the diet to try to lose weight, tablets
and sometimes insulin injections.
Diabetes can also occur if the pancreas has been
damaged by trauma or surgery and in other conditions
such as cystic fibrosis.
7
Essential equipment
Insulin Pens
The insulin pen you have been given is specific to your
brand of insulin.
The Novopen 4 comes in two colours – silver and blue.
The ECHO can give half units and comes in two colours.
Please ensure that you have been shown how to:





Load the pen
Perform an airshot
Dial up a dose of insulin
Give an insulin injection
Take action if you have dialled up the wrong
amount
Please make sure you use a new needle for every
injection and remove the needle after use. The used
needle must be put into the ‘sharps’ bin.
It is important to have a spare pen at all times. The pen
should be on your repeat prescription.
More information about your pen can be found at
www.novonordisk.com
8
Blood Glucose Monitoring
You have been given an Aviva Blood Glucose Meter
(BGM). Please register your BGM with the company. This
meter requires a very small amount of blood to be applied
to the test strip and performs the test in 5 seconds. The
meter can read blood glucose levels between 0.633.3mmol/l. If the blood glucose is less than 0.6 the meter
will read Lo. If the reading is above 33.3 the meter will
read Hi. A control test should be performed on the meter
with every new batch of test strips or whenever you are
concerned about the results. The control solution is
obtained from Roche Diagnostics (tel. 0800 701000).
9
Using the finger pricker
Please ensure that you have been shown how to:




Use the finger pricker
Change the finger pricking lancets
Perform a blood glucose test
Record your results in a diary
The test strips and lancets should be on your repeat
prescription.
Please be aware that there are a number of BGMs
available which you will see at the chemists. We also have
a selection available at the clinic for you to view.
Computer software is available from the company for you
to download your results.
Please record your results in your diary and bring it with
you to the clinic. This will help the diabetes team to assist
you in managing your child’s diabetes.
More information about your BGM can be found at
www.accu-chek.com.
10
The medic alert bracelet
We would suggest that you buy a medic alert identity
bracelet for your child. This would help to quickly identify
your child as having diabetes in an emergency.
www.medicalert.org.uk
Telephone freephone 0800 581420
Personal Independence Payment (PIP)/ Disability
Living Allowance (DLA)
This is a tax free, non means-tested allowance for children
and adults who need help with personal care. All children
under the age of 16 years with diabetes can claim DLA.
The allowance can be used to help pay for any additional
care needed, the cost of frequent outpatients attendances
etc.
To apply for a DLA pack please telephone 08457 123456.
The diabetes nurses will be happy to help you with this
application.
Contact from Monday to Friday, 8am to 6pm:
New claims Telephone: 0800 917 2222
General information (if you already get DLA) Telephone:
08457 123 456
General information (if you don’t get DLA) Telephone:
0845 850 3322
Website: https://www.gov.uk/pip
11
Insulin regimes
There are a variety of insulin regimes that can be used to
treat diabetes. The most commonly used are described
below.
The basal bolus regime
In this regime, insulin is given four times a day.
A long acting insulin called levemir or glargine is given as
a background dose for the 24 hours. This is given once a
day, preferably before bedtime; it should be given at the
same time each day.
Novorapid (NR), a fast acting insulin, is given for the
three main meals; it is given just before the meal and thus
the timing of meals can be flexible.
Snacks containing less than 15g carbohydrate can be
eaten between meals during the first few months. An
insulin injection will be necessary for larger snacks and
with all carbohydrate snacks eventually.
Twice daily regime
Novomix 30 (NM30), is a ‘mixed’ insulin containing 30%
fast acting and 70% slower acting insulin. It is given before
breakfast and before tea at fixed times each day. Usually
about 2/3 of the total dose is required for the morning
injection. It is important that snacks are eaten between
meals when using this regime to reduce the risk of hypos.
This regime avoids the need for a lunchtime injection of
12
insulin but is less flexible than basal bolus regime. It may
be more suitable for some younger children.
Insulin Pumps
Some children and adolescents might benefit from
changing to an insulin pump at a later stage for more
intensified insulin treatment.
An insulin pump is a little device, about the size of a small
mobile phone, which holds short acting insulin in a small
syringe. The insulin is delivered from the pump into the
body through a fine plastic tube attached to a tiny cannula
which is inserted under the skin.
Pumps are quite technical and do not sort out your
diabetes on their own. It takes some time to learn how to
use them, and it is essential that you have learnt how to
give insulin by injection and are able to count
carbohydrates correctly prior to considering pump therapy.
Please contact the diabetes team for further information.
Regardless of the regime, blood sugars should be
checked before each main meal and before going to bed.
Initially we aim for your blood sugars to be in the 5-8
mmol/l range before meals and 7-12 mmol/l before bed.
The diabetes team will help you to alter your insulin doses
to achieve this.
13
Giving an insulin injection
Make sure that you are confident about giving an injection
before going home:





Remove clothing to uncover the injection site
Take a gentle ‘pinch up’ of the skin
Inject at an angle of 90 degrees to the skin
Administer the insulin
Keep the needle in place for 10 seconds after the
insulin has been given
14
Injection Sites
It is important to inject your insulin in different places as
shown in the picture below. If you inject in the same site
each time, the site may become lumpy and the insulin will
not be absorbed so well into your child’s body.
15
Eating for health
Following an appropriate diet will help children to manage
their diabetes and keep their blood glucose levels within
acceptable limits.
The diet recommended for children over five years old with
diabetes is a healthy diet, suitable for the whole family.
Children will be able to eat ordinary food but may need to
make some changes to the foods they normally choose.
It is normal for children to have a short term increase in
appetite following diagnosis and starting insulin. Let them
eat larger meals and extra suitable snacks and their
insulin will be adjusted to accommodate this increase.
If your child is under five years please request the
additional information sheet from the dietitian.
What is a healthy diet for diabetes?
In order to control blood glucose levels your child should:
 Eat regular meals. This normally means
breakfast, lunch and an evening meal. Do not
miss meals.
 Include a food containing starchy carbohydrate at
each meal.
 Limit intake of sugar and sugary foods.
 Drink plenty of sugar free fluids e.g. water or
sugar free squash.
16
Carbohydrates
Carbohydrates include both starchy and sugary foods.
Foods containing carbohydrate are broken down and
absorbed into the blood as glucose, thus raising blood
glucose levels. It is therefore useful to have some idea
about the amount and type of carbohydrate your child is
eating at each meal, to help achieve better control.
A food containing starchy carbohydrate at each meal is
recommended to help ensure that your child’s diet is
healthy and well balanced. Regular meals and snacks
containing starchy carbohydrate will help to prevent blood
glucose levels falling too low.
Good choices of starchy carbohydrate
Breakfast cereals: oat flakes, unsweetened muesli,
Special K, Shredded Wheat, Weetabix, bran flakes,
porridge.
Bread: granary, wholemeal, white, pitta bread, tortilla
wraps.
High fibre crispbread or crackers
Pasta or noodles
Rice: all varieties, including basmati, brown and white.
Potatoes: new potatoes, boiled potatoes and jacket
potatoes.
If children are active, they should have good sized
servings of starchy carbohydrate and snacks between
meals. Depending on which insulin regime they are on, we
will teach you how to count carbohydrates to allow you
and your child to adjust the insulin for each meal or snack.
This can help to improve blood sugar levels after the
‘honeymoon’ period.
17
Limiting Sugary Foods
The carbohydrate from sugary foods is absorbed into the
blood as glucose more quickly than from starchy foods,
therefore your body has to work harder to get the levels
back to normal. Cutting down on foods high in sugar will
help keep your child’s blood glucose level more stable.
The following list will help with this:
Sugary foods to change
Low sugar/sugar free
alternatives
Sugar, especially added to
drinks such as tea and
coffee.
Artificial sweeteners such as
Splenda, Saccharin, Sweetex,
Canderel, Hermasetas.
Jam, marmalade, honey.
Sugar free or low sugar jam or
marmalade.
Fizzy drinks, such as cola,
lemonade, Lucozade.
Low calorie sugar free or diet fizzy
drinks, e.g. diet cola or slim line
lemonade.
Fruit squash, fruit juice
drinks e.g. J2O, large
amounts of unsweetened
fruit juice.
Sugar free or no added sugar
squash. Plain or fizzy water. Sugar
free flavoured water.
Sweets, chocolate.
Fresh or dried fruit, sugar free
chewing gum.
Cakes, sweet biscuits.
Plain biscuits, eg, rich tea,
digestive, Garibaldi, oatcakes,
cream crackers, Hobnobs.
Fruit in syrup, sweet
puddings, ice cream,
instant whip.
Fresh fruit, tinned fruit in natural
juice. Yoghurts with less than 14g
of sugar per pot (check “of which
sugars” on packaging). Sugar free
instant whips and jelly.
Sugar coated breakfast
Porridge, bran flakes, Weetabix,
cereals, e.g. Frosties, Coco Shredded Wheat, Special K, corn
Pops, Crunchy Nut, Cookie flakes, Rice Krispies.
Crisp
18
It is not necessary to avoid savoury foods containing
sugar, e.g. baked beans. The total amount of sugar in
savoury foods is small, and its absorption is slowed down
by the fibre in the food.
Fruit and vegetables
Fruit and vegetables are good for your health. Aim to have
five servings every day. Try to have some vegetables or
salad at lunch and supper.
All fresh fruit is suitable for children with diabetes. It is low
in calories and makes a healthy pudding or snack. There
is however some natural sugar in all fruit so it is best to
limit fruit to three or four portions a day. Have one portion
at a time and spread your fruit intake over the whole day.
Examples of 1 portion of fruit: 1 apple, 1 orange, 1
peach, 1 small banana, 2 plums, 1 small bowl of
strawberries.
A word about puddings………………
Although it is best to include low sugar puddings on a day
to day basis, having the occasional high sugar pudding
will not affect your child’s diabetes in the long term. If your
child wants a treat such as vanilla ice cream, then having
it straight after a main meal, rather than in between meals,
will reduce the effect it has on the blood glucose levels.
19
Diabetic products and low fat foods
There are some special foods produced for people with
diabetes which you may see in the chemists or
confectioners. These are not recommended as they are
expensive, high in calories and there is no health benefit
in using them.
There are also many low fat foods on the market to help
people on low fat diets. Be careful with these products as
some of them, such as low fat puddings and low fat
biscuits, are high in sugar and not suitable for people with
diabetes. Suitable products are low in fat and low in sugar.
Snacks (less than 15g carbohydrate)
These are some examples of snacks that are suitable
initially between meals if your child is on the basal bolus
regime.
Bread & cereals:
1 medium
slice
½a
1
1 biscuit
Wholemeal, granary, white hi-fibre or fruit
loaf
Bap, bread roll, finger roll, English muffin,
hot cross bun, fruit scone, or currant bun
Waffle (45g) or scotch pancake
Weetabix or Shredded Wheat
Biscuits & crackers (wholemeal preferably):
3
2
1
Rich tea, cream crackers
Rye crispbread, rice cakes
Digestive biscuit
Fruit:
1
2
Apple, orange, peach, small banana
Plums, satsumas
20
Further information on diet and diabetes
The information above has been designed to give general
dietary guidelines for children with diabetes.
Individual dietary advice is recommended, so please make
sure you have seen the dietitian before you are
discharged home. If you do not manage to see the
dietitian during your admission, for example at the
weekend, we will see you at your first clinic appointment.
Please feel free to contact us if you have any questions.
If you would like information on any of the following topics
ask your dietitian:





Meal suggestions and advice on eating out.
Sport and PE lessons.
Advice on fussy eaters.
Further information on healthy eating.
Further information on sweeteners and
appropriate amounts of sugar.
 Understanding food labels.
 Information on appropriate types and amounts of
carbohydrate.
 Other queries on diet and diabetes.
Further information on managing diabetes
Speak to your doctor, diabetes nurse or dietitian.
21
Clinics
Diabetes clinics take place at Royal Hampshire County
Hospital, Winchester, at Andover war Memorial Hospital,
Andover and in Eastleigh/Chandlers Ford. You will be
seen quite frequently in clinic to begin with for support until
you have gained confidence in managing your child’s
diabetes. Eventually you will be seen every three months
and in between times only if you are experiencing
difficulties. All members of the diabetes team are available
in clinic for advice.
Routine appointments
At each routine clinic appointment height and weight will
be measured and a blood test called the HbA1C taken.
HbA1C
This is a blood test taken by a finger prick in the same way
that you do for your child. It gives us information about
how well your child’s diabetes has been controlled over
the past two or three months. You should be aiming for an
HbA1C of below 7.5% (below 58 mmol/l). The measurement
is different from your regular blood glucose finger prick
test so the values should not be compared.
HbA1C
in % (old)
Mean blood
glucose
in mmol/l
Interpretation
4–6
Non - diabetic range
4–5
in mmol/mol
(new)
20 – 31
6–7
42 – 53
6.7 – 8.3
Target HbA1C
8–9
64 – 75
10 – 11.6
10 – 14
86 – 130
13.9 – 20.0
Improvement
needed
Poor control
URGENT action
22
Annual review or the ‘MOT assessment’
Once a year you will have a more comprehensive review
in clinic. This is called the MOT assessment. At this
appointment, as well as looking at your child’s diabetes
control, your child will be examined and have a urine test
to screen for complications that can occur in the long term
with diabetes and a blood test to screen for conditions that
are associated with diabetes. You will also be seen by one
of the paediatric dietitians for an annual review of your
child’s diet.
Examination will include:
 Eye examination (fundoscopy)
 Blood pressure check
 Assessment of feet.
Urine test
The urine sample is taken to look at levels of a protein
called microalbumin. This will tell us if your child’s kidneys
are functioning normally.
It is recommended that patients under 12 years of age
should have fundoscopy and a urine test for microalbumin
after they have had their diabetes for five years and yearly
after this.
23
Patients over 12 years should have these screening tests
after they have had their diabetes for two years. Most
general practices offer retinal camera screening; remind
your GP to book your child in for this.
Blood test
The blood tests screen for conditions that are associated
with diabetes:
Type 1 diabetes is an autoimmune disease where the
body’s immune system has damaged the insulin producing
cells (islet cells). Coeliac and thyroid problems belong to a
similar group of diseases and are associated with type 1
diabetes. Approximately 1 in 20 people with type 1
diabetes develop either coeliac or thyroid disease.
Thyroid disease
This involves under or overactive production of thyroid
hormone. Thyroid hormone (thyroxine) controls the body’s
metabolic rate. This affects only a small percentage of
children with diabetes. An overactive thyroid gland is much
less common than an underactive thyroid gland.
Treatment of these conditions is normally managed by
taking tablets each day.
Coeliac disease
This is a condition which leads to poor absorption of food.
It often has no signs or symptoms, but can cause
diarrhoea, abdominal pain, weight loss and unexpected
hypoglycaemia (low blood sugars). The condition is
treated by removing gluten (predominantly in wheat) from
the diet.
24
Cholesterol levels
Tested routinely in children over 11 years and earlier if
there is a family history of high cholesterol or early onset
heart disease
Regular examination and screening aims to
reduce and prevent complications associated
with diabetes and ensures normal growth and
development through childhood and
adolescence.
Structured Education
During the first few days and weeks after diagnosis we
would encourage you to keep in very close telephone
contact to enable us to support you with managing your
child’s diabetes.
We will meet you frequently to start with including visits to
home and school.
Education for the whole family is a fundamental part of
diabetes management. We provide regular structured
education sessions covering a variety of topics which are
important for you to attend.
25
Hypoglycaemia (low blood sugar)
It is important that you know what a ‘hypo’ or low blood
sugar is and how to treat it before you leave hospital.
A hypo is a blood glucose level of 4 mmol/l or
less. You and your child will soon learn to
recognise the symptoms and signs of a hypo.
These may include:
 Paleness
 Shakiness
 Headache
 Sweating
 Feeling hungry
 Heart pounding
 Irritability‚ change in
mood
 Lack of concentration
 Confusion‚ vagueness
 Crying
 Weakness
In severe hypos the blood glucose is very low. The child
may become very drowsy‚ disorientated‚ unconscious or
may have a brief fit or convulsion.
It is important to recognise what can cause a low blood
sugar, how best to prevent this from happening and how
to treat a hypo.
The main causes of ‘hypos’ are listed below:
 Exercise‚ without eating extra carbohydrate or
without decreasing the insulin
 Missed or delayed meals‚ or eating too little
carbohydrate at meals
 Having too much insulin (dose needs adjusting‚
or a mistake had been made)
 Alcohol intake without eating
Night time ‘hypos’ are always a major worry for parents.
They are more likely to occur after a lot of exercise during
the day or if the child has eaten poorly or is unwell.
26
Sometimes, children wake with hypos at night‚ but often
they can sleep through and may wake up the next
morning with a headache or seem confused and
disorientated. Recurring night hypos can contribute to
memory and concentration problems.
To prevent or minimise night time hypos we recommend
regularly checking the blood glucose level at the child’s
bed time or in the late evening‚ aiming for a level of 7 to
12 mmol/l. This is particularly important if the child has
exercised a lot that day or evening‚ has eaten poorly or is
unwell.
If the blood sugar is less than 7 mmol/l‚ some extra slow–
acting carbohydrate should be given.
If less than 4 mmol/l‚ treat as a hypo with fast–acting then
slow–acting carbohydrate.
If low during the evening‚ it is wise to re–check the blood
sugar at 2–3 am.
Some children find it necessary to reduce evening insulin
doses after sport or exercise to prevent delayed night time
hypos.
Always discuss any concerns with your diabetes team
What to do for a mild or moderate hypo:
Step 1
Give some fast–acting carbohydrate to raise the blood
glucose level quickly. This should be something that can
be eaten or drunk quickly and easily.
Examples:
 3 glucose tablets
 50 ml Lucozade (not Lucozade Sport)
 100 ml of full sugar soft drink e.g. carton of
Ribena (not a diet drink)
27
If your child seems confused and is refusing to eat or
drink it may be necessary to give dextrogel. This is a
concentrated sugar gel. It is given by mouth and
massaged into the inside of the cheek. Once given the
blood glucose will increase quickly and your child will feel
better. It is important that you then move on to step 2.
Step 2
Give a slow–acting carbohydrate to help maintain the
blood glucose level‚ or, if a meal is due soon‚ have that
earlier.
Examples of slow–acting carbohydrate include:
 One slice of bread
 Two plain sweet biscuits
 One apple or one banana
 250 ml (1 cup) milk
After a hypo your child will usually be feeling better within
5 to 10 minutes; however‚ it may take a little longer to see
a measurable rise in blood glucose levels (10–20
minutes). Always keep a close eye on your child after a
hypo. If the child is not improving after 5 to 10 minutes‚
recheck the blood glucose level‚ and repeat the hypo
treatment if necessary.
Avoid the tendency to over–treat mild hypos‚ as this
causes large blood glucose peaks that will affect overall
control.
What to do for a severe hypo:
The symptoms of a severe hypo are:
 Extremely drowsy or disorientated
 Unconscious‚ or
 Having a fit or convulsion
28
If your child is unable to swallow or is unconscious a
glucagon injection is necessary.
 Call for help if anyone is around.
 Place the child in the recovery position. Do not
attempt to place anything in the mouth.
 Give glucagon injection.
 Call an ambulance and come straight to Northbrook
Ward.
 Always contact your diabetes team for advice
following a severe hypo
Giving a glucagon injection with the GlucaGen hypokit
(Novo Nordisk)
The GlucaGen Hypokit contains a synthetic form of
glucagon in a powder form that needs to be dissolved in
the sterile water provided in the kit before it can be used.
Remember to check the expiry date of your glucagon
periodically and obtain a new supply from your GP just
before the old one expires. It is worth practising making up
the glucagon with your time expired glucagon kit before
throwing it away, so that you remember how to do it.
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A glucagon injection is given as follows: Remove the orange cap from the bottle.
 Remove the grey needle guard.
 Inject all the sterile water from the syringe into the
bottle containing the powder (the glucagon).
Leave the syringe in the bottle.
 Swirl (don’t shake) the bottle with the syringe in it
until the glucagon has dissolved (leave your
finger on the plunger to stop it coming back).
 Draw up all the glucagon (1 ml) if over 8 years of
age‚ or half the glucagon (0.5 ml) if under 8 years
of age.
 Inject into the front of the thigh or buttock (upper‚
outer part of buttock) just as you would an insulin
injection.
 Do a blood glucose level.
Ask a member of the diabetes team for a demonstration
before you go home.
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Hyperglycaemia (high blood sugar)
To achieve good diabetes control it is important to try to
keep your child’s blood sugars within the recommended
ranges.
When you leave hospital the blood sugar levels will be
higher than these ranges because your child has been
less active than normal in hospital. Over the next few
weeks the blood sugars will fall into the recommended
ranges. The diabetes team will guide you with adjusting
insulin doses to achieve this.
Recommended target ranges for blood sugars:
Babies, infants and children
less than 6 years old
Children 6 - 12 years
Adolescents and adults
Before
meals
5 – 12
mmol/l
4 – 10
mmol/l
4–8
mmol/l
Bed
time
7 – 12
mmol/l
7 – 12
mmol/l
7 – 12
mmol/l
There will always be times when the blood sugar rises
higher than the recommended ranges, for example just
after eating, but these times should be short and blood
sugars should soon fall into the normal range again
without any action needed.
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Causes of high blood sugars:
 The insulin may not be enough for the amount of
carbohydrates eaten.
 Less exercise than usual.
 Sometimes temporarily during or just after
vigorous exercise (stress effect).
 Measuring the blood glucose too soon after a
meal – usually wait two hours after eating.
 The insulin dose may be too low, or may have
forgotten.
 Your child’s insulin pen may be leaking – check
the cartridge.
 Emotion, such as excitement or stress.
 Infection or other illness.
 Glucose on the fingers will give a falsely high
reading. If this is suspected wash the hands and
recheck the blood glucose level.
Ketones:
If the levels stay high (above 15 mmol/l) for a number of
hours, you should test the urine for Ketones.
 If children’s blood sugar has only been high for a
short time and they are well and there are no
ketones in their urine, no action is necessary.
Just check their blood sugar later (1- 2 hours) to
make sure that it is falling.
 If ketones are present, follow the sick day
guidelines.
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Sick day guidelines
All children with diabetes have open access to
Northbrook ward for diabetes related problems. Call
01962 824987/5367.
1. Check blood sugars more frequently, at least every 2
hours to begin with. Illness can cause your child’s
blood sugars to go up or down.
Usually at times of illness your child’s body needs
more insulin even if he/she is not eating. This is
because the stress hormones that the body produces
when your child is unwell make your child’s body
more resistant to insulin, so he/she needs more
insulin to have the same effect and you may
therefore need to give your child more insulin during
this time.
.
Some children, especially younger children, may
have a fall in blood sugar when they are unwell and
may require a reduction in their insulin dose. Please
call for advice about this.
2. Never stop giving insulin to your child.
3. Give you child plenty of sugar free drinks to prevent
dehydration.
4. Replace meals (if necessary) with sugary drinks.
Children should try to eat their usual diet if possible.
If this is not possible, they should try to eat ‘light’
foods that contain carbohydrate. These foods can be
spread throughout the day as snacks, rather than
eaten at set meal times.
During illness, it is
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acceptable for some of this carbohydrate to be
sugary rather than starchy.
Examples of light foods include:
Soup and bread
Beans on toast
Cereal and milk
Ordinary yoghurt/ fromage frais
Jelly/ mousse
Tinned rice pudding
Ice cream
If children are feeling sick and unable to eat, then
carbohydrate may be taken as drinks. Fizzy drinks
may be better tolerated if allowed to go ‘flat’ whilst
you are feeling sick. As an approximate guide, one of
the following should be given hourly and sipped
slowly:
50mls
100mls
100mls
200mls
20mls
full sugar Lucozade (not Lucozade Sport)
full sugar fizzy drinks
unsweetened pure fruit juice
milk
undiluted full sugar Ribena plus added
water to taste
100mls carton of full sugar Ribena
5. Children should avoid vigorous exercise; this will not
bring down their blood sugar levels and may make
them feel more unwell.
6. Children’s urine should be tested for ketones.
Call the diabetes team if urgently (any of below):
• You are unsure what to do
• Vomiting persists
• You are unable to keep your child’s blood
glucose level above 4 mmol/l
• You are unable to get your child’s blood
glucose level below 34
15 mmol/l with extra insulin
doses, or unable to clear ketones
• Your child is becoming more unwell
• You are worried or exhausted or don’t know
Diabetic Ketoacidosis (DKA)
This occurs if the blood sugars remain high without
treatment.
Your child will feel unwell; have high blood sugars and
ketones in the urine.
In this situation they will need to be seen in hospital and
may need fluids and insulin through a drip. Children can
become very ill quite quickly especially if they are vomiting
so it is important that you contact the diabetes team early
on in any illness.
Always call the diabetes team early on if your child is
becoming unwell or you are unsure.
Children and adolescents with well-controlled diabetes are
not at greater risk of getting sick with infections or other
illnesses than children without diabetes.
When children with diabetes do get sick their sugar
balance can be upset and their exercise levels and eating
and drinking are affected.
Much greater care and attention is required in the
management of their diabetes during these times.
If the principles of sick day management are understood
and followed and early advice sought, most sick days can
be easily managed at home.
Flu vaccine once a year is recommended for patients
with diabetes.
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School
Many parents worry about their child returning to school;
please be reassured that your child will be supported with
their medical needs.
Pre-school/Nursery/Primary Schools:
A paediatric diabetes nurse will visit the school to discuss
diabetes and the impact this will have on the school day.
You are very welcome to attend this meeting.
Secondary/Sixth Form College:
We will telephone the school to inform them that your child
has diabetes and try to arrange a meeting with the First
Aider/Tutor. We occasionally hold ‘drop in’ clinics at
secondary schools. This does not replace your hospital
clinic appointment but is an opportunity for us to help
support your teenager either on a one to one or group
basis. You will be informed if this is going to happen.
With your help we will write a care plan to help the school
staff care for your child with diabetes.
It is essential that parents provide an ‘emergency box’ at
school. This should be kept in the office/medical room and
in primary schools it is very helpful to also have one in the
classroom.
What to put in the emergency box:
Dextrose tablets
Sugary drink i.e. lucozade, full sugar ribena, full sugar
coke
Small packet of plain biscuits
1 tube of dextrogel
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Please take this box home every half term to ensure it is
stocked and in date.
Secondary school/college; your son or daughter should
always carry ‘emergency’ items with them e.g. dextrose
tablets.
Diabetes Camp
The paediatric diabetes team at Winchester and
Basingstoke hold a ‘camp’ at Fairthorne Manor, Botley,
every year for children aged 7 - 11years (School Years 26).
This experience gives children an opportunity to learn
about their diabetes in a fun environment. If you would like
to know more about this camp then please speak to one of
the team.
The camp is supported by our local Young Diabetics
Group (www.bydg.org.uk/index.php).
Diabetes camps are also run by Diabetes UK.
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Diabetes & Travel
Check list for planning a holiday:
1. Review by the diabetes team
We will assess your child’s diabetes control and give you
instructions on how to adjust the insulin to cope with time
zone changes. We will provide you with an official letter
explaining that your child has diabetes. Other issues such
as insulin adjustments for activity changes and overseas
medical facilities can also be discussed.
2. Travel insurance
Obtain travel insurance well in advance. The insurer may
require information from your doctor so sufficient time
needs to be allowed for this process.
Diabetes UK has a travel insurance quote line on
freephone
0800
7317431
or
visit
www.diabetes.org.uk/travel for details. However, Diabetes
UK policies cannot be guaranteed to be the cheapest in
every case.
For further advice:
Diabetes UK Careline (Tel: 08451202960, Email:
[email protected]) can supply up-to-date guides to
most countries in the world, including translations of
phrases
to
use
in
an
emergency
http://www.diabetes.org.uk/
Diabetes Travel Information: www.diabetes-travel.co.uk
38
3. Contact the airline
Advise the airline that your child has diabetes. Find out
approximate meal times and whether extra snacks are
available. Do not ask for a “diabetic diet” as this is often
low in carbohydrate. Ask for a children’s meal or normal
meal. Always bring some of your own supplies just in
case.
4. Immunisations
Ensure your child has any special immunisations required
for travel to particular countries.
5. Diabetes kit
Make sure your child is wearing a diabetes ID necklace
or bracelet.
Make sure you have enough supplies of:
- Insulin pens, spare insulin cartridges
- Hypoglycaemia kit – to include dextrogel, glucagon.
- Blood glucose meter and spare batteries, blood and
urine test strips.
The insulin‚ glucagon and blood glucose meter need to be
protected from extremes of temperature; if these are likely
to occur on the trip use an insulated container or packing.
Carry the essential diabetes equipment divided between
two separate hand luggage bags‚ in case one is lost.
Supplies should not be packed in your luggage in the
cargo hold as they may be exposed to extreme
temperatures or get lost at the airport.
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Further reading
Type 1 diabetes in children, adolescents and young
adults
Dr Ragnar Hanas - Class Health publishing (UK edition)
This is a well written, easy to navigate book covering all
aspects of having type 1 diabetes
Diabetes UK
National Charity for people with diabetes – the website
has loads of information about all types of diabetes, as
well as special sections for children and young people.
www.diabetes.org.uk
Runsweet.com
Website designed for diabetics who do lots of sport, with
lots of tips on how to adjust your insulin and diet to control
your sugar and maximise your performance.
www.runsweet.com
Juvenile Diabetes Research Foundation
Loads of info about Diabetes in young people, and news
on the latest research.
www.jdrf.org.uk
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Discharge home from
hospital – Checklist
Before leaving hospital it is important that you have been
seen by the doctor, diabetes specialist nurse and dietitian
and feel confident to take your child home.
The following are essential requirements prior to
discharge:
1. You have a written list of emergency contact numbers
2. You are competent in the following practical skills:
□ Finger prick blood sugar testing
□ Giving an insulin injection
□ Recording blood sugar readings in the diary
provided
□ Have been shown how to make up and give a
glucagon injection
3. You should have a basic understanding of Type 1
diabetes and in particular
□ Understand what hypoglycaemia is and the
symptoms to look out for
□ Know how to prevent hypoglycaemia
□ Understand how to treat mild hypoglycaemia
□ Understand how to treat more severe
hypoglycaemia
□ Understand what a high blood sugar level is
□ Understand what ketoacidosis is
□ Know that you must never miss your insulin
especially when you are unwell even if you are
not eating or vomiting
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□ Know that it is important to call for advice early on
in an illness or if you are unsure □ Have a basic
knowledge of the diet including regular
carbohydrate-based meals and limited sugar
4. You have been given a follow up appointment
5. You have been provided with the following:
□ Insulin or basal bolus regime: Novorapid 3ml
penfill cartridges; Levemir 3ml penfill cartridges
□ Insulin for twice daily regime:
Novomix30 3ml penfill cartridges; Novorapid 3ml
penfill cartridges
□ BD Microfine Pen needles 4mm
□ Blood Testing Equipment
□ Accu-chek Aviva (Roche) reagent strips
□ Accu-chek Fastclix (Roche) lancet drums
□ Ketostix urine test strips
□ GlucoGel Triple Pack
□ Glucagen HypoKit 1mg
□ Novopen 4 or Novopen Echo
□ 1 litre sharps bin
We will write to your doctor to inform him/her of your
admission and request that the above items are put onto a
repeat prescription.
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Authored by Dr Eleri Williams, Consultant Paediatrician, Royal Hampshire County Hospital
February 2009, updated June 2013
Archive/patient information/paediatric diabetes booklet. indd
© Winchester and Eastleigh Healthcare NHS Trust 2009
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