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Diabetes in children: improving management

Elizabeth Bragg
MB ChB
Staff Grade Paediatrician
University Hospital of Wales
Cardiff

The number of children who are being diagnosed as having diabetes is increasing, and their management is changing. Newly diagnosed children used to be admitted to hospital for days or even weeks to begin the management. It was not the control of symptoms that necessarily delayed discharge, but the whole process of introducing the child and their family to the life-changing practice of controlling a disease that can't be cured.
A multidisciplinary approach is vital. The understanding of many people is still that insulin is the mainstay of management. This is true up to the point that insulin dosage is blind without monitoring; and control by insulin is dependent upon nutrition and exercise. A person will be unable to carry out their insulin regimen without education, and may be unwilling to do so without psychosocial support. The main points of diabetes management insulin therapy are:

  • Monitoring.
  • Education.
  • Meal plan and nutrition.
  • Exercise.
  • Family and psychosocial support.
  • Monitoring for complications.

Nowadays there is a move to get well children who have just been diagnosed with diabetes out of the hospital, to start integrating their treatment and their home life together earlier. At the moment a hospital team usually oversees the management, with diabetes nurse specialists providing a much-valued lifeline. However, children with diabetes remain in the care of the primary care team and there is potential for a greater input from them in the initial management.

Treating newly diagnosed patients with diabetes
Diabetes can present in a variety of ways,(1) but the management is largely dependent upon whether or not the child is suffering from ketoacidosis at the time. If they are not, they will be started on a regimen of regularly injected insulin (subcutaneously). This is an attempt to mimic the body's normal autoregulatory response to the surge of glucose we all get after food ingestion. It is imperfect mimicry since injected insulin does not work in the same way as the natural stuff, and our dosage schedule is tinged with awareness that injection isn't the most pleasant way of receiving therapy.
There are many brands of insulin on the market, but they are mainly grouped into whether they are derived from animals (pork or rarely beef) or are human (semisynthetic). They are also categorised on their speed of action - that is into short-acting, intermediate-acting and long-acting (see Table 1). Short-acting covers this meal and the next, intermediate-acting covers the meal at the other end of the day, and long-acting is used to buffer basal insulin needs.(2)

[[NIP06_table1_27]]

Which insulin we prescribe and when largely depends upon the regimen that is chosen: in the management of children, the fewer injections the better is an attractive plan (see Table 2). However, the choice of regimen must be dependent upon the control achieved, and some patients will need more frequent injections if control is poor.

[[NIP06_table2_28]]

Standard management in children is to start at a dose of 0.5-1.0 units of insulin per kg of body weight per day as the total daily dose. This dose is divided up as two-thirds before breakfast and one-third before supper. The morning dose is usually made up of one-third short-acting insulin and two-thirds intermediate-acting insulin, while the evening dose is half and half of short- and intermediate-acting. This regimen can be modified depending upon the child's response (see Box 1).

[[NIP06_box1_28]]

Management of diabetic ketoacidosis (DKA)(4)

  • Will usually take place in hospital.
  • Any subject with hyperglycaemia and urinary ketones can be considered to be in DKA.
  • Severe DKA is a medical emergency.
  • Resuscitation may be needed - remember:A - airway, B - breathing, and C - circulation.
  • The child will be dehydrated and will need fluids (often intravenous [IV]), maintenance plus ­rehydration given over 36-48 hours.
  • Insulin is by infusion on a sliding scale (variation of the dose depending upon the blood sugar ­reading).
  • Potassium supplements will be needed unless the child is not passing urine.
  • A nasogastric tube is needed to guard against the possibility of aspiration of gastric contents.
  • Careful observation is needed to watch out for signs of cerebral oedema - which can be fatal.

Long-term management
The essence of long-term diabetic management is to achieve good control. This means keeping the blood glucose level less than 10mmol/l (180mg/dl), preferably between 4 and 7mmol/l (70-125mg/dl) before meals. The reasons are detailed in Table 3.

[[NIP06_table3_28]]

Insulin
The insulin regimen has to be continued for life. It may need to be adapted depending upon how good the control is, and it will need to be increased as the child grows.

Monitoring
There is no point in giving insulin as a therapy if its efficacy is not monitored. This needs to happen on a regular (daily) basis and involves using a small needle to prick the child's finger. A drop of blood is then put onto a monitoring (BM) stick. The reading is usually made using a small handheld machine rather than comparing the strip to a colour chart on the packet (as previously used). These monitors are very accurate if used properly, so long as the blood glucose level isn't too low. They need to be calibrated, and instructions on how much blood and where need to be followed exactly.
Monitoring of urine for ketones is also a part of diabetic management and usually involves the use of standard urine dipsticks.

Education
This begins at diagnosis and needs to carry on throughout life. Diabetes management can be perceived as complex, so it is important that parents and children feel that they can ask for further clarification about any part of the management at any time. The main points that they need to be educated about include:

  • What diabetes is.
  • Why insulin therapy is necessary.
  • How to give insulin injections (which includes use of the pen injector to dial up the correct dose, if this is used). Parents will have to do this for younger children; then there will be a point when children start to want to do it for themselves. The age at which this happens varies depending upon the child, but it's usually at about eight years old.
  • That they need to vary injection sites. This is because subcutaneous fat changes occur with repeated needle insertions, which makes the insulin absorption erratic and unreliable. Unfortunately it also makes the injections less painful, so children would much rather stick to the same site.
  • How to do a fingerprick test and how to use the blood glucose monitor. Also, why it is important to do the test and what the results mean.
  • What they can eat and when they need to eat.
  • What they need to do when the child is acutely unwell (sick-day rules).

Meal plan and nutrition
Previously a complicated system of carbohydrate exchange with no sugar and special diabetic foods was recommended. Nowadays the only dietary stipulation is healthy food with regular meals and snacks in between the meals and at bedtime. Meals should be based on starchy foods and should include small amounts of fat, particularly saturated fats from red meat and dairy products (it is particularly difficult for a patient with diabetes to practise strict vegetarianism). Very young children might need more fat in their diet for growth. Five portions of fruit and vegetables should be consumed a day. Diabetes no longer means no sugar: it means low sugar. Children are allowed sweets once it has been worked out how to vary their insulin to cope with that.

Exercise
Active subjects have better control of their diabetes than sedentary ones.(2) Children with diabetes should be encouraged to be active as there is really no restriction on activities. If they are unwell they should refrain from exercise as part of the sick-day rules, but they are unlikely to feel like being active at that time anyhow.
Children with diabetes will need to have an extra snack, carbohydrate or sugar, before they participate in any sport. This is to counteract the possibility of developing hypoglycaemia. They should always carry some form of instant sugar with them (such as glucose tablets) to use should they overexert themselves or feel as if they are developing hypoglycaemic symptoms.

Family and psychosocial support

  • The whole family will need support at diagnosis.
  • The child needs to adjust to having a lifelong ­condition.
  • Adolescence often proves to be a difficult time - a diabetic child has additional adjustments to make.
  • There may be a grieving process for the perceived loss of good health.
  • Good communication between healthcare ­practitioners and the family can facilitate ­understanding, which reduces fears and ­misconceptions.
  • Communication should be facilitated between family members.
  • Practical help is sometimes needed.
  • Put people in touch with information sources and self-help groups.

Monitoring for complications
Apart from the above self-monitoring, all subjects with diabetes will need to be seen regularly by medical ­personnel for various tests. These include:

  • Measurement of blood pressure.
  • Blood tests - including HbA1c (also known as ­glycosylated haemoglobin). This gives a good idea of how well control has been maintained over the last 2-3 months. Nondiabetic people have an HbA1c level of less than 6%; we aim for less than 7% in diabetic children. A level consistently above 8% puts the child at great risk of long-term ­complications of diabetes.(5)
  • Eye checks - should be done by an ­ophthalmologist once a year in all teenagers.

Conclusion
Management of diabetes in children may seem complicated, but it follows a few simple rules. So long as insulin is always taken, its effect is always monitored and adjustments are made as a result of that monitoring, the therapy should be effective. Otherwise there is a need for the patient to follow a healthy lifestyle and  the practitioner has a duty of care to educate the ­family and fulfil any psychosocial needs.

References

  1. Bragg L. Recognising diabetes in children: a vital skill. Nursing in Practice 2002;(5):35-6.
  2. Rudolph AM, Hoffman JIE, Rudolph CD. Rudolph Paediatrics. 20th ed. New York: Appleton and Lange; 1995.
  3. British National Formulary 41. London: BMA and RPSGB;March 2001.
  4. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, editors. Advanced paediatric life support. London:?BMJ Books; 2001.
  5. Available from URL: http://www.surgerydoor.co.uk

Resources
Diabetes UK
W:www.diabetes.org.uk
British Dietetic Association
W:www.bda.org.uk
Diabetes News
W:www.diabetesnews.com