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MANGEMENT OF DIABETIC CHILDREN IN RACH

MANAGEMENT OF DIABETIC CHILDREN IN RACH

March 2006

Version 1.3

4THE NEWLY DIAGNOSED PATIENT

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

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 Frui