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Diabetes and children: starting insulin therapy

Lesley Lowes
RGN RSCN RNT MSc PhD
Research Fellow/Practitioner (Paediatric Diabetes)Nursing, Health and Social Care Research Centre
University of Wales College of Medicine Cardiff
E:Lowes@cardiff.ac.uk

Type 1 (insulin-dependent) diabetes is one of the most common chronic childhood disorders,(1) and is occurring with increasing frequency.(2,3) Type 1 diabetes results from the gradual destruction of pancreatic beta- (insulin-producing) cells. A lack or relative insufficiency of insulin results in hyperglycaemia, which leads to polyuria, polydipsia, lethargy and weight loss. If that is untreated, ketoacidosis occurs, causing vomiting, coma and eventually death.(4) Children who are ketoacidotic at presentation require a period of hospitalisation for intravenous fluids and insulin to stabilise their condition. However, children often present in the early stages of the disease process and, depending upon local protocols and resources, may be managed at home from diagnosis.(5,6) The management of type 1 diabetes requires multidisciplinary input from primary and secondary care teams and involves a complex regimen of insulin injections, blood glucose monitoring, regular healthy meals and exercise.

Effect of the diagnosis on the child and family
It is an anxious and distressing time for the whole family when a child is diagnosed with diabetes.(7,8) Newly diagnosed children are frightened by the invasive procedures and, depending upon their age and stage of cognitive development, may be unable to understand the rationale for treatment and the meaning of "for life". Children who are clinically well at diagnosis may find it particularly difficult to accept the need for insulin injections when they have not felt ill. Teenagers with diabetes may worry about being "different" from their friends, as peer conformity and approval is particularly important to this age group.(9) Parents commonly experience a grieving process similar to that associated with bereavement and suffer a number of losses, such as a loss of spontaneity and a loss of confidence.(8) The thought of their child experiencing a hypoglycaemic episode (a "hypo") is extremely frightening, and parents need much reassurance that they and their child will cope when the situation arises. Siblings are often frightened and may experience feelings of jealousy when they receive less attention than their newly diagnosed sister or brother. The extended family, particularly grandparents, also find the diagnosis difficult to come to terms with. Thus input from a child psychologist is important for children and their families from diagnosis onwards.

Support and education
When a diagnosis of diabetes is suspected, most children are referred by their family doctor (GP) to their local paediatric diabetes service in secondary care, where the condition is commonly managed using a team approach with the child and family central to the team. These teams should include a paediatrician with an interest in diabetes, a paediatric dietician and a paediatric diabetes specialist nurse (PDSN).(10) The PDSN is usually the main provider of support and education to families, particularly in the early weeks after diagnosis. The education programme covers many aspects of diabetes management, but, initially, children and/or parents have to learn how to measure blood glucose levels, inject insulin and avoid, recognise and treat hypoglycaemia. For children and their families to understand the complex relationship between food intake and insulin requirements, dietary advice is required from a paediatric dietician with a special interest in diabetes.(10)

Insulin and delivery devices
Injectable insulin has been modified in various ways to allow different durations of action and longevity (under many trade names), most of which are also available in various premixed combinations (see Table 1). Insulin is available in vials, cartridges and disposable prefilled pens. Vials are used with syringes, and cartridges with a pen device.

[[NIP15_table1_42]]

Available pen devices have a range of different characteristics such as the size of cartridge and make of insulin they hold, the minimum and maximum number of units they deliver, and the mechanism for dialling up and delivering the insulin (see Table 2).

[[NIP15_table2_44]]

Children with diabetes should be offered the most appropriate insulin, delivery device and treatment regimen, taking into account their age and ability and the specific needs of the child and family. Very young children may be started on a once- or twice-daily injection of medium-/long-acting insulin. Older children may start on twice-daily premixed insulin (or self-mix short and medium-/long-acting insulin) or a three-times-a-day regimen (mixed insulin prebreakfast, short-acting insulin pre-evening meal, medium-acting insulin presupper), which can avoid the need for an injection during school hours, allow a level of flexibility and minimise the risk of nocturnal hypoglycaemia. Another option is a basal-bolus regimen (short-/rapid-acting insulin premeal and long-acting insulin presupper), which allows greater flexibility and therefore often suits the teenager's lifestyle. Sometimes a child's specific need determines the choice of pen, thus influencing the prescribed insulin. For example, younger children may need a pen with an easy delivery mechanism or one that dials up in 0.5 unit increments.
Insulin pump therapy - continuous subcutaneous insulin infusion (CSII) - is increasing in popularity for children and young people with type 1 diabetes. Via a small indwelling plastic cannula, CSII delivers a variable preprogrammable basal rate of fast-/rapid-acting insulin with bolus doses covering the intake of carbohydrate- containing foods.(12) However, CSII is not usually appropriate for newly diagnosed children.(13)

The Cardiff approach
In Cardiff, newly diagnosed children are usually started on twice-daily injections (before breakfast and evening meal) of premixed insulin using a pen device delivery system. We have found that this twice-daily regimen usually achieves optimal glycaemic control in the months following diagnosis, partly due to the temporary continuing production of some endogenous insulin in most children (the ­"honeymoon" period). Children and parents find the thought of injections daunting,(8) and the twice-daily regimen may minimise the impact of invasive procedures on the family at diagnosis. Changes to treatment regimens (in relation to glycaemic control) to accommodate individual needs and lifestyles are discussed at length with children and families at subsequent clinic visits.
The PDSNs encourage and support children as young as 5 or 6 years of age to do their own injections from diagnosis. With appropriate supervision, many children are willing and able to undertake the invasive procedures of diabetes management. We also encourage parents to experience what it feels like to test blood glucose and insert a needle into their skin (without actually injecting insulin!). These approaches help to dispel the initial fear experienced by children and parents, and promote subsequent self-care.
Whatever the child's age, all parents are taught how to inject their child, because, even when children are older and self-caring, parents may need to do their injections (eg, during times of illness). Insulin pens are used from diagnosis because they are believed to be more child-friendly and less frightening than syringes. As part of our education programme, parents are also taught how to draw up and administer glucagon (to treat severe hypoglycaemia), which is administered using a syringe.
It is helpful if children can learn to relax to make injections as painless as possible, and 5mm pen needles are used for all newly diagnosed children to avoid the need to "bunch up" the skin (except in very thin children), to ensure that insulin is injected into subcutaneous fat rather than muscle. The importance of not reusing needles is stressed. Strategies such as rubbing ice on injection sites to numb the skin are discouraged because this can result in the development of a "ritual" that is difficult to maintain. Some children favour one particular injection site, and this is not focused upon initially to promote compliance. However, they are subsequently encouraged to rotate injection sites to avoid the development of lipohypertrophy ("lumpy" sites) and maximise the uptake of insulin.

Conclusion
A diagnosis of childhood diabetes is a major life event for children and parents. Insulin therapy is an essential part of the complex regimen required to manage this life-threatening condition and maintain health in the short and long term. A variety of insulins, delivery devices and treatment regimens can be used to try to achieve optimal glycaemic control. Having to inject insulin at least twice a day is a daunting prospect for newly diagnosed children and their families, but injections do eventually become a part of everyday life.

References

  1. Dorman JS, O'Leary LA, Koehler AN. Epidemiology of childhood diabetes. In Kelnar CJ, editor. Childhood and adolescent diabetes. London: Chapman and Hall Medical; 1995. p. 139-59.
  2. Metcalfe MA, Baum JD. Incidence of insulin dependent diabetes in ­children aged under 15 years in the British Isles during 1988. BMJ 1991;302:443-7.
  3. Zhao HX, Stenhouse E, Soper C, et al. Incidence of childhood-onset type 1 diabetes mellitus in Devon and Cornwall, England, 1975-1996.Diabet Med 1999;16:1030-5.
  4. Brink SJ. Presentation and ­ketoacidosis. In: Kelnar CJ, editor. Childhood and adolescent diabetes. London: Chapman and Hall Medical; 1995. p. 213-40.
  5. Swift PG, Hearnshaw JR, Botha JL, et al. A decade of diabetes: keeping children out of hospital. BMJ 1993;307:96-8.
  6. Lowes L, Davis R. Ambulatory care of children with newly diagnosed diabetes. In: Glasper EA, Lowson S, editors. Innovations in paediatric ­ambulatory care. A nursing perspective. Hampshire: MacMillan Press Ltd; 1998. p. 212-27.
  7. McEvilly A. Setting standards for the home care of children with diabetes. Cascade (Action for Sick Children) 1996;December:4-5.
  8. Lowes L, Lyne P, Gregory JW. Childhood diabetes: parents' ­experience of home management and the first year following diagnosis. Diabet Med In press 2004.
  9. Taylor J, Müller D. Nursing ­adolescents: research and psychological perspectives. Oxford: Blackwell Science; 1995.
  10. Diabetes UK. What care to expect when your child has diabetes. London: Diabetes UK; 2002.
  11. Diabetes UK. Insulin pens. Available from URL: http://www.diabetes.org.uk/products/pens.htm. Last accessed 9/1/04.
  12. Torrance T, Franklin V, Greene S. Insulin pumps. Arch Dis Child 2003;88:949-53.
  13. National Institute for Clinical Excellence. Guidance on the use of continuous subcutaneous insulin ­infusion for diabetes. Technology Appraisal Guidance No 57. London: 2003.

Resources
Diabetes UK
W:www.diabetes.org.uk
Yorkshire Diabetes
W:www.yorkshirediabetes.com