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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. 29 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. 30 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. 31 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. 32 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 33 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. 35 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 36 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. 37 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. 39 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 40 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 41 □ 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. 42 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 43