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|ROYAL FREE LONDON NHS FOUNDATION TRUST |

|CHILDREN SERVICES GUIDELINES |

|Diabetes: Management of the newly-diagnosed child not in DKA |

|(Cross site RFH & BH guideline) |

|Author(s): |Vaseem Hakeem, Consultant |

|Contact author: |Vaseem Hakeem, Consultant |

|Other contributors: |Esther Freeman, Sangeeta Chopada, Victoria Dublon, Paediatric DSN team |

|Previous authors: |N/A |

|Related guidelines or documents: |Diabetic ketoacidosis, 2016 |

|Approved by/date: |The Paediatrics Guidelines Group on behalf of the Women, Children and Imaging Services |

| |Division |

|Issue no (Version): |October 2016 (version no. 1.0) |

|File name: |Management of the newly-diagnosed child not in DKA |

|Key words: (up to 10) |Diabetes, Type 1 Diabetes, Insulin, Child, Children |

|Supercedes: |N/A |

|Significant change in practice: |New guideline |

|Stakeholders consulted |Paediatrics cross-site |

|Target clinical audience |Paediatrics |

|Implementation and launch plan: |Upload onto Freenet, and publicising through newsletters and Paediatrics team meetings |

|Audit/monitoring plan |See Appendix One |

|Service Line Lead |Paediatrics: Rahul Chodhari |

|Clinical Director |Tim Wickham |

|Director of Midwifery |Mai Buckley |

|Date for review: |October 2020 or in response to practice developments/new national guidelines. |

Contents

Introduction 3

Diagnosis 3

Investigations 3

Insulin 4

Core skills 6

Discharge planning 7

Take home advice 7

Checklist Form 7

Monitoring compliance 9

References 9

EQUALITY STATEMENT 9

APPENDIX 1: MONITORING TOOL 11

|Introduction |

In most western countries, 90% of children & teenagers with diabetes have type 1 diabetes. Pancreatic β-cell destruction results in insulin deficiency and there is usually evidence of positive serology for glutamic acid dehydrogenase (GAD), islet antigen-2 (IA2), islet cell (ICA) or insulin autoantibodies.

Obese children may have Type 2 diabetes with insulin resistance rather than insulin deficiency. This tends to occurs in the second decade of life and is more prevalent in children of African or Asian ethnicity.

Other types of diabetes are much less common. These include genetic defects of beta-cell function or insulin action, exocrine pancreatic disorders and drug-induced diabetes.

|Diagnosis |

Presenting symptoms include

• Polyuria

• Polydipsia

• Nocturnal enuresis

• Weight loss

• Abdominal pain

• Vomiting

• Blurred vision

Diagnostic criteria (WHO 2006)

1. Symptoms of polyuria & polydipsia + random plasma glucose ≥ 11.1 mmol/l

or

2. Fasting plasma glucose ≥ 7.0 mmol/l

or

3. 2 hour plasma glucose ≥ 11.1 mmol/l on standard OGTT

However, fasting glucose measurements or OGTT are seldom required in paediatric practice.

|Investigations |

• Capillary blood glucose and plasma glucose

• U & Es, creatinine

• Venous gas

• FBC

• Thyroid function

• TTG and IgA for coeliac screen

• GAD and IA2 antibodies

• Ketone measurement in urine or blood

• HbA1c

|Insulin |

Subcutaneous insulin therapy is given as a basal bolus regimen. Twice- or three-times daily insulin mixtures are no longer recommended for initiation of therapy

The first dose of insulin can be given at the next mealtime if blood ketones are < 0.6 mmol/l or urine ketones are negative, trace or small.

If blood ketones are >0.6 mmol/l or urine ketones are moderate / large, subcutaneous insulin should be given promptly as 0.1 unit/kg of rapid-acting analogue i.e. NovoRapid (insulin aspart) or Humalog (insulin lispro). The basal bolus regimen is then started when the next injection is due.

Dose

The basal, long-acting insulin and bolus doses of rapid-acting insulin given with meals comprise the total daily dose (TDD) of insulin.

Instead of calculating the total daily dose of insulin as we previously used to do, we now prescribe how much basal (long-acting) insulin to give and advise that mealtime bolus doses of rapid-acting insulin should be calculated according to the carbohydrate content of the food & drink. This requires an understanding of carbohydrate content and the carbohydrate ratio appropriate for that child (see below)

Basal insulin:

Basal insulin is given as Lantus (insulin glargine) or Levemir (insulin detemir) and calculated as 0.25 unit/kg/day for prepubertal children and 0.4 unit/kg/day for pubertal children.

Glargine can be given at any time but morning administration reduces the likelihood of nocturnal hypoglycaemia, which may be a concern in young children.

Levemir can be given once daily but twice-daily administration is recommended ie half the calculated basal dose given in the morning and the other half in the evening.

Examples:

For a 45 kg teenager: 0.4 unit/kg/day = 18 units

so give 18 units of glargine o.d. or 9 units of Levemir b.d.

For a 16 kg child: 0.25 unit/kg/day = 4 units

So give 4 units of glargine o.d. or 2 units of Levemir b.d.

Meal-time / bolus insulin

Rapid-acting analogues such as NovoRapid or Humalog are given with meals. Bolus insulin should be given before food but in young children with unpredictable eating patterns, it can also be given just after eating.

The dose of rapid-acting insulin is calculated using an insulin-to- carbohydrate ratio (ICR). This will vary from one person to another, but the following guide can be used to initiate therapy. The ICR can be adjusted by the diabetes team over the next few days and weeks, as needed.

Age ICR

Over 12 years: 1 unit to 10g carbohydrate

8 - 12 years: 1 unit to 15g carbohydrate

5 - 8 years: 1 unit to 20g carbohydrate

3 - 5 years: 1 unit to 30g carbohydrate

Less than 3 years: 1 unit to 50 g carbohydrate

Correction doses

Correction doses can be given with mealtime insulin if the BG is above the target range.

The correction dose is calculated by using the formula: 100 ÷ TDD

It may not be possible to calculate the correction dose until the child has been on insulin for a couple of days and their average TDD becomes clear.

Until the effect of the correction dose is reliably known, correct down to a target BG of 10mmol/l.

Eg for a child on a TDD of insulin of 25 units, their correction dose = 100 ÷ 25 = 4

This means that 1 extra unit of rapid-acting insulin would lower their BG by 4 mmol/l

So if their pre-meal BG was 18 mmol/l, you could give an extra 2 units in addition to the dose calculated for the carbohydrate content of their meal (and check ketones, of course!)

Sites

Insulin can be injected into the legs (upper outer aspects of thigh), upper arms, abdomen or buttocks (upper outer quadrant). Inject at a 90 degree angle, using a 4 mm needle

[pic]

|Core skills |

Ensure the family and child has the key core skills before discharge. These include basic understanding of diabetes and the need for insulin, injection technique and blood glucose monitoring. They should be taught about hypoglycaemia symptoms & treatment and shown how to use glucagon. They must be given information about the effects of illness on their child’s diabetes and taught about ketone testing.

The attached checklist summarises information given to the family at initial presentation and can be kept as evidence for Best Practice Tariff purposes.

|Discharge planning |

• On admission the Family should be given a folder with information about the diabetes team and educational materials.

• Provide the family with 1 box each of needles and lancets from the ward supply.

• Order insulin and Glucogel and Glucagon from pharmacy.

• Fax details to GP to ensure prompt provision of repeat prescriptions, particularly of test strips.

• Provide the family with a sharps box and local information about sharps disposal.

• Arrange first appointment at diabetes clinic, within 4-6 weeks of discharge.

• Check they have contact details for the team.

• Explain how to access advice out-of-hours and provide written details.

|Take home advice |

• Family are instructed to test blood glucose pre-meals and before the child goes to bed. Blood glucose testing 2 hours after a meal will provide information about the adequacy of the pre-meal insulin dose. Target ranges: Pre-meal = 4-7 mmol/l; post meal 5-9mmol/l

• If the blood glucose is less than 7 mmol/l at bedtime, a snack of 10-15g of starchy carbohydrate should be given, without insulin

• Advise the family to check blood glucose during the night, for 1 or 2 nights following discharge.

• Explain that it will take approximately 3 days for the long-acting insulin to achieve a steady level. Dose changes should be made at intervals of 3 – 4 days, with advice from the diabetes team.

• Ask the young person to complete a food diary

• Manage hypoglycaemia using the “15 Rule”

|Checklist Form |

The checklist begins on the next page.

This form is to be retained in the patient’s notes

DIABETES SUPPORT SERVICES

Primary (Level 1) education

Notes: the best practice tariff states;

Each provider unit should provide evidence that each patient has received a structured education programme, tailored to the child or young person’s and their family’s needs, both at the time of initial diagnosis and ongoing updates throughout the child or young person’s attendance at the paediatric diabetes clinic.

|Issues to be covered with the patient and / or parents of carers at first diagnosis |Date |Initials of MDT |

| | |member |

|Explanation of how the diagnosis has been made and reasons for symptoms | | |

|Simple explanation of the uncertain cause of diabetes. Explaining no cause for blame | | |

|The need for immediate insulin and how it will work | | |

|What is glucose, normal blood glucose levels and blood glucose targets | | |

|Practical skills, including insulin injections ,blood and / or urine testing and reasons for | | |

|monitoring | | |

|Basic dietetic advice | | |

|Including regular starchy CHO with all meals, care with the size of the snacks ( under 5’s | | |

|tending to need more snacks), sugar free drinks, | | |

|Start to discuss what CHO is, how it effects BG levels, the 4 main food groups that contain | | |

|CHO, the concepts of how to CHO count (food labels, packaging, apps, books, food tables,etc), | | |

|CHO counting snacks | | |

|Simple explanation of hypoglycaemia | | |

|Diabetes during an illness, including advice not to omit insulin and | | |

|prevention of DKA (diabetic ketoacidosis) | | |

|Diabetes at home or at school including the effects of exercise | | |

|Identity cards, necklets, bracelets and other equipment | | |

|Membership of a Diabetes Association and other available support services | | |

|Psychological adjustment to the diagnosis | | |

|Details of emergency telephone contacts | | |

|Signature of patient / parent or guardian |Date |

| | |

| | |

| | |

|Monitoring compliance |

The regimen for monitoring compliance with the guideline is as described in the monitoring table in Appendix 1.

|References |

• NICE Guideline 2015 NG18

▪ ISPAD Clinical Consensus Guidelines 2009

▪ Type 1 Diabetes in Children, Adolescents and Young Adults

Ragnar Hanas 2007

▪ Yorkhill Diabetes Service guidelines

January 2010

▪ Starting subcutaneous insulin doses in a paediatric population with newly diagnosed Type 1 diabetes mellitus

▪ Lisa Lemieux et al

Pediatric Child Health 2010 15 (6) 357-362

▪ World Health Organisation: Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications: Report of a WHO Consultation. 2006

▪ Local guidelines from

o University College Hospital

o The Whittington Hospital

o The Royal Free Hospital

o Barnet & Chase Farm Hospitals

|EQUALITY STATEMENT |

The Royal Free London NHS Foundation Trust is committed to creating a positive culture of respect for all individuals, including job applicants, employees, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability (including HIV status), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. It is also intended to use the Human Rights Act 1998 to treat fairly and value equality of opportunity regardless of socio-economic status, domestic circumstances, employment status, political affiliation or trade union membership, and to promote positive practice and value the diversity of all individuals and communities.

|APPENDIX 1: MONITORING TOOL |

Element to be monitored |Lead |Tool |Frequency |Reporting arrangements |Acting on recommendations and Lead(s) |Change in practice and lessons to be shared | |Appropriate Starting doses of subcutaneous insulin |Vaseem Hakeem |Notes review |Annual |Routine data capture |Vaseem Hakeem | | |Initiation and use of carbohydrate counting from diagnosis on ward |Vaseem Hakeem |Notes review |Annual |Routine data capture |Vaseem Hakkem | | |

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NB

Ensure that the child is not in diabetic ketoacidosis, defined as a

blood glucose > 11.1 mmol/l,

• pH < 7.30 or Bicarbonate < 18 mmol/l

• Ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre)

with > 5% dehydration

If the child is in DKA, follow the DKA protocol

Affix patient label here

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