Diabetes in pediatrics

Diabetes Mellitus in Pediatrics

Introduction

• Definition: Diabetes mellitus is a metabolic disorder with multiple causes characterized by chronic hyperglycemia and disturbances in carbohydrate, protein, and fat metabolism due to defects in insulin secretion, insulin action, or both.
• Types of Diabetes Mellitus:
  • Type 1 Diabetes:
    • Occurs when the islets of Langerhans in the pancreas, which produce insulin, are destroyed.
    • Results in an absolute insulin deficiency.
  • Type 2 Diabetes:
    • The body produces insulin from the pancreas but either not enough or cannot use it correctly (insulin resistance).
    • Leads to a relative insulin deficiency.
• Epidemiology (2013/2014 National Paediatric Diabetes audit):
  • 26,500 children in the UK with type 1 diabetes.
  • 500 children in the UK with type 2 diabetes.

How the Body Normally Gets Energy

• Digestion: The digestive system breaks down food into glucose.
• Glucose Production: This process creates glucose, a type of sugar.
• Glucose Storage and Transport:
  • Some glucose is stored in the liver.
  • Most glucose goes into the blood and travels to cells to be used as fuel.
• Insulin's Role:
  • Insulin, a hormone made in the pancreas, allows glucose to enter cells.
  • Insulin is released into the blood when there is glucose in the blood.
• Analogy: Insulin acts like a key that attaches to the cell wall, signaling the cell to let glucose in.

Type 1 Diabetes Pathophysiology

• Beta Cells: Special cells in the pancreas called beta cells make insulin.
• Autoimmune Disease:
  • Type 1 diabetes is primarily an autoimmune disease.
  • The body's immune system harms the beta cells, reducing insulin production.
• Onset:
  • In children, this process often happens quickly.
  • In adults, it is less rapid.
• Consequences of Insulin Deficiency:
  • Without insulin, cells can't get glucose to burn for energy.
  • Patients may feel weak or tired.

Causes and Risk Factors of Type 1 Diabetes

• Unknown Precise Cause: The exact cause of islet cell destruction is unknown, but linked to:
  • Viral or Recent Infection: May initiate autoimmune destruction.
  • Genetics:
    • If a child has a first-degree relative with type 1 diabetes, the risk of developing the condition is 15 times higher than the general population.
  • Environmental Factors:
    • Growing awareness that childhood dietary and psychosocial factors (e.g., stressful life events) may contribute to the development of diabetes.

Glucose Buildup and Hyperglycemia

• Glucose Accumulation:
  • Without insulin, glucose cannot enter cells and stays in the blood.
  • The liver continues to add more glucose to the blood.
• Hyperglycemia:
  • Leads to higher blood glucose levels, called hyperglycemia.
• Health Problems:
  • High blood glucose levels can cause serious health problems over time.

Ketones and Diabetic Ketoacidosis (DKA)

• DKA Development: DKA happens when insulin signaling is very low, resulting in:
  • Glucose not entering cells for fuel.
  • The liver making a large amount of glucose.
  • Fat being broken down too rapidly.
• Ketone Production:
  • The liver breaks down fat into ketones, which are normally produced when the body breaks down fat after a long time without food.
  • Ketones are used by muscles and the heart.
• Ketoacidosis:
  • When ketones are produced too quickly, they build up in the blood and become toxic, making the blood acidic.
  • This condition is known as ketoacidosis.
• DKA as Initial Sign:
  • DKA is sometimes the first sign of type 1 diabetes in undiagnosed individuals.
  • It can also occur in diagnosed individuals.
• Triggers for DKA:
  • Infection, injury, serious illness, missing insulin doses, or the stress of surgery can lead to DKA in people with type 1 diabetes.

Clinical Presentation

• Emergency Department (ED) Encounters:
  • Nurses in EDs are often the first health professionals to encounter children with diabetes.
  • Children may present at initial diagnosis or following complications.

4Ts Campaign

• Diabetes UK Initiative: Diabetes UK launched the 4Ts campaign in 2012 to increase awareness of the main signs and symptoms of diabetes in children.

Clinical Presentation: The 4Ts

• Toileting (Polyuria):
  • Increased urination.
  • Parents may report frequent urine infections.
  • Nappies may be heavier or need changing more frequently in younger children.
  • Secondary enuresis (bedwetting) is common in older children and adolescents (report due to embarrassment).
• Thirsty (Polydipsia):
  • Increased thirst and feeling unable to quench it.
  • Older children may not recall drinking more than usual.
  • Under-recognition, especially in summer.
• Tired:
  • Feeling more tired despite being rested.
  • May present as missing school or not participating in sports.
  • Disturbed sleep from waking up to urinate.
• Thinner (Weight Loss):
  • Weight loss.
  • Parents may struggle to quantify weight loss.
  • Ask about clothes sizes and if clothes appear looser.

Clinical Presentation Considerations

• Young Children: Children under two years might not present with all signs and symptoms.
• Subtle Signs: Parents might miss subtle signs such as increased drinking or urination.
• Misinterpretation: Health professionals might attribute signs to other causes like hot weather or viral illness recovery.
• Specific Enquiries: Enquire about polyuria and polydipsia in children with vaginal thrush, unexplained constipation, abdominal pain, vomiting, or weight loss without obvious cause.

DKA Symptoms in New Diagnoses

• Vague Symptoms: Symptoms often vague but may include:
  • Nausea
  • Vomiting
  • Abdominal pain
  • Fast, labored breathing
  • Ketotic (sweet-smelling & fruity) breath
  • Dehydration
  • Altered consciousness
• Masked Symptoms:
  • Symptoms can be masked by conditions like acute surgical abdomen, delaying treatment of DKA.

Important Considerations for Diagnosed Patients with Potential DKA

• Normal Blood Glucose Levels:
  • Emergency nurses must know children on insulin may present with DKA without high blood glucose.
  • Recent insulin dose at home may normalize glucose levels.
• Essential Measurements:
  • Measure blood or urinary ketone levels and obtain a blood gas to check for ketosis and acidosis.
• Cerebral Oedema:
  • Emergency practitioners should be aware that cerebral oedema can result from inappropriate fluid management in DKA due to over correction.

Cerebral Oedema Signs and Symptoms

• Headache
• Agitation
• Irritability
• Unexpected bradycardia
• Hypertension
• Reduced consciousness level
• Abnormal breathing patterns
• Inability to move eyes fully (oculomotor palsies)
• Abnormal pupil reflexes or unequal pupils

Presentations in Children with Established Diabetes

• Emergency nurses are likely to encounter children with known diabetes in four main ways:
  • 1. Hyperglycemia without Ketosis: High blood glucose levels without progression to DKA.
  • 2. Ketosis without Acidosis: High blood ketones and normal pH, with either high or low blood sugars.
  • 3. DKA:
    • Similar signs and symptoms to newly diagnosed DKA.
    • History of missing insulin doses likely.
    • Between 10% and 70% of children with uncontrolled type 1 diabetes present to emergency settings with DKA
  • 4. Hypoglycemia:
    • Defined as a blood glucose level of <4mmol/L.
    • Signs and symptoms: shaking, sweating, difficulty concentrating, irritability, agitation, quietness.
    • Precipitated by insulin overdose, reduced food intake, increased exercise, or alcohol consumption.
    • Requires urgent treatment with glucose or glucagon injection.

Nursing Assessment of a Child with Diabetes

1. History Taking:
   • S - Signs and Symptoms:
     • 4Ts (polyuria, polydipsia, tiredness, weight loss).
     • Non-specific symptoms (vaginal thrush, constipation).
     • Abdominal pain, nausea, vomiting.
     • Hypoglycemia symptoms.
   • A - Allergies: Ask about any allergies.
   • M - Medications:
     • Regular medications, especially insulin.
     • Insulin type and timing.
     • Other medications.
   • P - Previous Episodes:
     • Hyperglycemia, hypoglycemia, DKA, other complications.
     • Family history of diabetes and other chronic illnesses.
   • L - Last Oral Intake: When was the last time the patient ate or drank something?
   • E - Events Prior:
     • Factors related to hyperglycemic or hypoglycemic events.
     • Missed insulin dose, high activity, alcohol consumption, unbalanced diet, stress.
2. Physical Examination:
   • ABCDE Assessment!!!
   • Vital Signs:
     • SpO2, respiratory rate, heart rate, blood pressure, and temperature.
     • Obtain blood glucose level.
   • Height and Weight:
     • Measure and plot on growth chart.
     • BMI to evaluate for obesity.
   • Signs of Dehydration:
     • Dry mucous membranes, decreased skin turgor, altered mental status.

ABCDE Assessment Details

• A - Airway:
  • Assessment:
    • Check if clear and patent.
    • Look for obstruction signs (stridor, choking, inability to talk).
    • Assess for foreign bodies, swelling, or trauma.
  • Interventions:
    • If compromised, provide appropriate interventions.
    • Position patient to optimize airway patency (head tilt, chin lift). (In infants, keep head neutral).
    • Administer supplemental oxygen as needed.
    • Consider advanced airway management if necessary.
• B - Breathing:
  • Assessment:
    • Respiratory Rate and Effort: Count rate; assess for shallow, deep, or labored breathing; look for nasal flaring or use of accessory muscles.
    • Auscultation: Listen for breath sounds; abnormal sounds can indicate respiratory distress or infection.
  • Interventions:
    • Oxygen Therapy: Administer supplemental oxygen as needed.
    • Bronchodilators: Administer via nebulizer or MDI for conditions like asthma.
• C - Circulation:
  • Assessment:
    • Heart Rate and Rhythm: Assess pulse quality, rate, and rhythm; check for bradycardia or tachycardia.
    • Blood Pressure: Consider age-specific normal ranges; observe for shock signs (cool, clammy skin, prolonged capillary refill time).
  • Interventions:
    • IV Access: Establish peripheral IV access for fluid resuscitation and medication administration.
    • Fluid Resuscitation: Administer isotonic fluids for dehydration or shock.
    • Medications: Prepare to administer medications like epinephrine if indicated for anaphylaxis.
• D - Disability:
  • Assessment:
    • Level of Consciousness: Use the AVPU scale (Alert, Voice, Pain, Unresponsive) to assess responsiveness.
    • Pupil Assessment: Check for size, equality, and reactivity to light; note any abnormal findings.
  • Interventions:
    • Blood Glucose: Check blood glucose levels if altered consciousness or history of diabetes.
    • Neurological Monitoring: Observe for seizures or signs of increased intracranial pressure. Use pediatric GCS.
    • Pain assessment
• E - Exposure:
  • Assessment:
    • Full Examination: Undress to examine for hidden injuries or rashes, ensuring warmth and dignity.
    • Skin Assessment: Look for infection, allergic reactions, or dehydration signs.
  • Interventions:
    • Temperature Regulation: Cover with warm blanket to prevent hypothermia.
    • Documentation: Record findings thoroughly for care planning.

AVPU Scale

• A - Alert: Person is fully awake, oriented to person, place, and time, and responds to questions.
• C - Confusion: Person is awake but acute confusion is noted (new onset, acute, or worsening confusion).
• V - Voice: Person responds to voice.
• P - Pain: Person responds to pain or when appropriate painful stimuli is used.
• U - Unresponsive: Person does not respond to communication or react to stimuli (e.g., pain, voice).

Pediatric Glasgow Coma Scale

• Eye Opening:
  • Spontaneous: 4
  • To speech: 3
  • To pain: 2
  • No response: 1
• Verbal Response:
  • Oriented/Coos: 5
  • Confused/Irritable: 4
  • Words inappropriate/Cries: 3
  • Sounds incomprehensible/Moans: 2
  • No response: 1
• Motor Response:
  • Obeys/Moves spontaneously: 6
  • Localizes/Withdraws to touch: 5
  • Withdraws from pain: 4
  • Decorticate to pain: 3
  • Decerebrate to pain: 2
  • No response: 1

Managing Reduced Consciousness Level

1. Conscious Level:
   • Institute hourly neurological observations using Glasgow Coma Scale.
   • If reduced level, seek urgent anaesthetic review if airway cannot be protected.
     • Discuss with senior paediatrician.
     • Discuss with paediatric critical care specialist to decide appropriate care setting.
   • Conscious level is related to degree of acidosis; signs of raised intracranial pressure suggest cerebral oedema.
     • If cerebral oedema is suspected, refer to urgent management protocols.
2. Full Examination: Looking for evidence of
   • cerebral oedema: headache, irritability, slowing pulse, rising blood pressure, reducing conscious level (papilloedema is a late sign)
   • infection
   • ileus (common in DKA)

Normal Blood Sugar Levels by Age

• Reference table for fasting, 1-2 hours after eating, and bedtime blood sugar levels with and without diabetes across different age groups.
• HbA1c ranges for patients with and without diabetes across different age groups.

Investigations for New Diagnoses

• Require admission to paediatric ward for initiation of treatment with subcutaneous insulin and diabetes education for family.
• Diabetes specialist teams to see the child and family early for management and education.

Detailed Investigations

• Plasma glucose levels:
  • To diagnose and quantify hyperglycaemia.
• Plasma/urine ketone levels:
  • To differentiate between DKA and hyperosmolar hyperglycaemia state.
• Blood gas:
  • To measure pH and bicarbonate level (to identify acidosis).
• Full blood count and C-reactive protein:
  • To rule out infection, but isolated leucocytosis is common in DKA and does not indicate sepsis.
• Urea and electrolytes:
  • To assess the level of dehydration.
• Serum osmolarity:
  • To differentiate between DKA and hyperosmolar hyperglycaemia state.
• Liver function tests:
  • To record patients’ baseline levels.
• Thyroid function tests and coeliac screening:
  • To investigate for other autoimmune conditions.
• C-peptide or diabetes-specific autoantibody titres:
  • May be measured later if specialists consider appropriate.
• Consider septic screen:
  • Includes chest X-ray, blood and urine culture, and throat swab if there is fever, hypothermia, hypotension, refractory or lactic acidosis.

DKA Diagnostic Critera

• Urgent Paediatric Review:
  • If children are unwell and DKA is suspected, request urgent paediatric review.
  • Very unwell children in DKA will need to be managed by the ABCDE approach to resuscitation.
• Diagnostic Criteria (NICE 2015a):
  • Acidosis: pH < 7.3 or bicarbonate <18mmol/L
  • Ketonaemia: blood β-hydroxybutyrate >3mmol/L (normal under 0.6mmol/L) or ketonuria (++ or above on a standard strip marking scale).
  • Blood investigations will need to be done as highlighted in the previous section.

DKA Management Guidelines

1. General Resuscitation: A, B, C.
   • Airway:
     • Ensure patent; if comatose, insert airway.
     • If reduced consciousness or vomiting, consider N/G tube.
     • Seek urgent anaesthetic review and discuss with paediatric critical care specialist if reduced consciousness level and unable to protect airway.
   • Breathing:
     • Give 100% oxygen by face-mask.
   • Circulation:
     • Insert IV cannula and take blood samples.
     • Cardiac monitor for T waves (peaked in hyperkalaemia).
     • Measure blood pressure and heart rate.
     • Shocked patients require adequate fluid volume resuscitation (a fluid bolus of 10ml/kg should be given if shocked, in line with recent UK Resuscitation Council guidance).
2. Initial fluid bolus:
   • All children and young people with mild, moderate or severe DKA who are not shocked and are felt to require IV fluids should receive a 10 ml/kg 0.9% sodium chloride bolus over 30 minutes.
   • SHOCKED patients should receive a 10 ml/kg bolus over 15 minutes. Shock is defined by the APLS definition of tachycardia, prolonged central capillary refill, poor peripheral pulses and hypotension (though this is a late sign of shock)
   • Following the initial 10 ml/kg bolus shocked patients should be reassessed and further boluses of 10 ml/kg may be given if required to restore adequate circulation up to a total of 40 ml/kg at which stage inotropes should be considered.
   • Whilst excessive fluid should be avoided because of the risk of cerebral oedema it is important to ensure that the circulation is adequate and fluid should be given to support this.
3. Initial Investigations:
   • Blood glucose
   • FBC, Urea and electrolytes
   • Blood gases
   • Ketones - Near patient blood ketones (beta-hydroxybutyrate) testing should be used.
   • If able to obtain sufficient blood, send new diagnosis investigations (HbA1c, TFT, Coeliac screen)

Fluid Management

• It is essential that all fluids given are documented carefully, particularly the fluid which is given in the accident and emergency department and on the way to the ward, as this is where most mistakes occur.

Fluid Requirement Calculation

• Requirement = Deficit + Maintenance
• Fluid Deficit
  • It is not possible to accurately clinically assess the degree of dehydration to work out the deficit. Clinical methods are unreliable. Estimation of the fluid deficit should be based on the initial blood pH.
• The fluid deficit should be replaced over 48 hours alongside maintenance fluids.
  • Assume a 5% fluid deficit in children and young people in mild DKA (indicated by a blood pH 7.2-7.29 &/or bicarbonate <15)
  • Assume a 5% fluid deficit in children and young people in moderate DKA (indicated by a blood pH of 7.1-7.19 &/or bicarbonate <10)
  • Assume a 10% fluid deficit in children and young people in severe DKA (indicated by a blood pH <7.1 &/or bicarbonate <5)

Maintenance Fluid Calculation

• Maintenance fluid volumes should be calculated using the Holliday - Segar formula - 100 ml/kg/day for the first 10 kg body weight, plus 50 ml/kg/day for 10 to 20 kg and 20 ml/kg/day for each additional kilogram above 20 kg.
• 100 ml/kg/day for the first 10 kg of body weight.
• 50 ml/kg/day for the next 10 to 20 kg.
• 20 ml/kg/day for each additional kilogram above 20 kg.
• Calculate the fluid deficit (either 5% or 10% dehydration depending on whether the patient has mild, moderate or severe DKA), subtract the initial 10ml/kg bolus (unless given for Shock) then divide this over 48 hours and add to the hourly rate of maintenance fluid volume, giving the total volume evenly over the next 48 hours. i.e.
• Hourly rate = (\frac{Deficit - initial bolus}{48hr}) + Maintenance per hour

Fluid Examples:

• Example 1:

  • A 20 kg 6 year old boy who has a pH of 7.15 (Moderate DKA => 5% Dehydrated) will receive a 10ml/kg bolus (200mls fluid) over 30 minutes as part of his initial management. His ongoing fluids will comprise:

    • Deficit = 5 % x 20 kg = 1000 ml

    • Subtract initial bolus = 1000-200 bolus = 800ml to be replaced over 48 hours = 17 ml/hr

    • Maintenance:

      • 10 \times 100 = 1000 ml per day for 1st 10 kg
      • 10 \times 50 = 500ml per day for next 10 kg (weighs 20kg)
      • 1500 ml per day total (over 24 hours) = 62 ml/hour

    • Total fluid = 17ml/hour (Deficit of 5% (minus bolus) over 48 hours) + 62 ml/hr (Maintenance fluids)

    • = 79 ml/hour

• Example 2:

  • A 60 kg 15 year old girl with a pH of 6.9 who was shocked at presentation has received 30ml/kg of 0.9% Saline for resuscitation. These boluses are not subtracted from ongoing maintenance fluids. Her ongoing fluids will comprise:

    • Deficit = 10 % x 60 kg = 6000 ml to be replaced over 48 hours = 125 ml/hr

    • Maintenance:

      • 10 \times 100 = 1000 ml per day for 1st 10 kg

      • 10 \times 50 = 500ml per day for next 10 kg (10-20kg)

      • 40 \times 20 = 800ml per day for next 40kg

      • 2300 ml per day total (over 24 hours) = 96 ml/hour

    • Total fluid

      • = 125 ml/hour (Deficit of 10 % over 48 hours) + 96 ml/hr (Maintenance fluids)

    • = 221 ml/hour

Type of fluid:

• Use 0.9% sodium chloride with 20 mmol potassium chloride in 500 ml (40 mmol per litre) until blood glucose levels are less than 14 mmol/l.

Oral Fluids:

• Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA until ketosis is resolving and there is no nausea or vomiting.
• A nasogastric tube may be necessary in the case of gastric paresis.
• If oral fluids are given before the 48hr rehydration period is completed, the IV infusion needs to be reduced to take account of the oral intake.

Potassium Management

• Ensure fluids (except initial boluses) contain 40 mmol/l potassium chloride, unless renal failure is evident.
• Hypokalaemia can occur up to 48 hours after starting DKA treatment.
• Potassium is mainly an intracellular ion, and there is always depletion of total body potassium although initial plasma levels may be low, normal or even high. Levels in the blood will fall once insulin is commenced.
• Therefore ensure that every 500 ml bag of fluid contains 20 mmol potassium chloride (40 mmol per litre).
• If Potassium is low at presentation (<3.0mmol/l), this may require high concentrations of intravenous Potassium in fluids which would require a central line. MONITOR ECG!

Importance of Monitoring ECG with Potassium Imbalance

• Monitoring ECG in pediatric patients with abnormal potassium levels is crucial because potassium plays a vital role in cardiac electrical activity. Both hyperkalemia (high potassium) and hypokalemia (low potassium) can lead to significant changes in heart function, potentially resulting in arrhythmias or other cardiac complications.

Insulin Administration

• Do not give bolus doses of intravenous insulin.
• Therefore start an intravenous insulin infusion 1-2 hours after beginning intravenous fluid therapy.
• Use pre-filled syringes containing 50 Units of soluble insulin in 50 ml 0.9% sodium chloride where available. If pre-filled syringes are not available, add 50 units of soluble insulin (e.g. Actrapid) to 49.5ml 0.9% sodium chloride.
• Insulin rates of 0.05 Units/kg/hr and 0.1 Units/kg/hr are typically suggested. Use a soluble insulin infusion at a dosage between 0.05 and 0.1 units/kg/hour.

Nursing Observations for DKA Patient

• Strict fluid balance including oral fluids and urine output, using fluid balance charts (urinary catheterisation may be required in young/sick children)
• Hourly capillary blood glucose measurements (these may be inaccurate with severe dehydration/acidosis but are useful in documenting the trends. Do not rely on any sudden changes but check with a venous laboratory glucose measurement)
• Capillary blood ketone levels every 1-2 hours
• Hourly BP and basic observations
• Hourly level of consciousness initially, using the modified Glasgow coma score
• Half-hourly neurological observations, including level of consciousness (using the modified Glasgow coma score) and heart rate, in children under the age of 2, or in children and young people with a pH less than 7.1, because they are at increased risk of cerebral oedema
• Reporting immediately to the medical staff, even at night, symptoms of headache, or slowing of pulse rate, or any change in either conscious level or behaviour
• Reporting any changes in the ECG trace, especially signs of hypokalaemia, including ST-segment depression and prominent U- waves
• Twice daily weight; can be helpful in assessing fluid balance

Continuous Management

• Continue with 0.9% sodium chloride containing 20 mmol potassium chloride in 500ml until blood glucose levels have fallen to 14 mmol/l.
• If the blood glucose rises out of control, or the pH level is not improving after 4-6 hours consult senior medical staff and re-evaluate (possible sepsis, insulin dosage errors, blocked or leaking lines, excessive urine loss, fluid calculation error or other conditions), and consider starting the whole protocol again.
• If the blood ketone level is not falling within 6–8 hours then get senior help and advice and consider increasing the insulin dosage to 0.1 units/kg/hour or greater.
• Change the fluid to contain 5% glucose; use 500 ml bags of 0.9% sodium chloride with 5% glucose and 20 mmol potassium chloride in 500ml which are available from Pharmacy (or see Appendix 2)
• Reduce insulin infusion rate to 0.05 units/kg/hr from 0.1 Units/kg/hour (or maintain at that rate if patient initiated on 0.05 units/kg/hr)
• If local policy is to maintain 0.1 units/kg/hour insulin infusion or if a higher dose of insulin is thought necessary then change the fluid to contain 10% glucose rather than 5% glucose, in order to prevent hypoglycaemia when the higher dose of insulin is continued (use 500 ml bags of 0.9% sodium chloride with 10% glucose and 20 mmol potassium chloride in 500mol)
• Once ketones are < 1.0 mmol/l, consider switching from intravenous to subcutaneous insulin
• DO NOT stop the insulin infusion while glucose is being infused, as insulin is required to switch off ketone production.
• If the blood glucose falls below 6 mmol/l -
  • increase the glucose concentration of the intravenous fluid infusion, and
  • if there is persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/hour
• If the blood glucose falls below 4 mmol/l, give a bolus of 2 ml/kg of 10% glucose and increase the glucose concentration of the infusion. Insulin can temporarily be reduced for 1 hour.

Management of Hypoglycaemia

• Mild to moderate hypoglycaemia can be managed with oral fast-acting glucose, for example a drink of Lucozade, followed by an oral long-acting carbohydrate once normoglycaemia is attained.
• In more severe cases where consciousness is impaired, intramuscular glucagon injection or intravenous glucose bolus will be required.
• When brought to an ED in an unconscious state, these children will need to be managed by the ABCDE approach to resuscitation, particularly if they are having hypoglycaemic seizures.
• Children with recurrent episodes of hypoglycaemia should be followed up by the paediatric diabetes team, who will review their insulin regime, offer diabetes education, and try to identify what may have triggered the events, and determine how to avoid and manage them in the future.

Types of Insulin

• Bolus (prandial) Insulins
• Basal Insulins

Other Nursing Management Considerations

Dietary Management

• Collaborate with a dietician to create a personalized meal plan.
• Educate on carbohydrate counting, glycemic index, and the importance of balanced meals.
• Encourage regular meal times and healthy snack options.

Physical Activity

• Encourage regular physical activity, emphasizing safety and proper monitoring of blood glucose before and after exercise.
• Discuss adjustments to insulin and dietary intake related to activity levels.

Education and Support

• Provide age-appropriate education on diabetes self-management.
• Involve the family in education to ensure a supportive home environment.

Parental and Child Education on Blood Glucose Testing

1. Wash your child’s hands.
2. Prick the side of your child’s finger rather than the tip, as this keeps pain to a minimum. Don’t prick too near the nail and don’t prick the index finger or thumb.
3. Devices are now available that allow you to take blood from different parts of the body, such as the base of the thumb or the arm. Talk to your diabetes team about the suitability of alternative site meters.
4. Insert a test strip into the blood glucose meter – this will turn on most meters automatically.
5. Apply a drop of blood to the test strip, and the meter will automatically read the test results. All meters and strips are tested to ensure they’re accurate, but be aware that extreme temperatures can affect meter readings.
6. Make a note of all the test results – this will help you and your diabetes team to establish your child’s pattern of blood sugar levels.
7. Depending on the type of meter, you may need to calibrate it when you first use a new packet of test strips. Talk to your diabetes team about how to do this.
8. You may also need to quality-check your meter from time to time. Again, talk to your diabetes team about this.

When to Do a Blood Glucose Test

• before a main meal
• before bed
• if they feel unwell
• before and after physical activity
• if they feel any hypo warning signs
• any time you or your child feels their blood sugar levels are too high or too low.
• Your diabetes team may also ask you to test at other times as well or instead (eg during the night), in order to get an overall view of your child’s diabetes control. If your child has recently been diagnosed, it’s particularly important to test often to get a good idea of what’s happening with their blood sugar levels.

Testing your Baby’s Blood Sugar vs Toddler

Testing your baby’s blood sugar

• With babies, you need to prick their heels, instead of their fingers. Show mother how to do this.
• Because your baby can’t tell you how they feel (other than by crying), you’ll probably need to check their levels frequently. Again, your diabetes team will guide you on this.

Testing your toddler’s blood sugar

• Getting blood from a toddler can be difficult. Try to get them to cooperate as much as possible: explain what you’re going to do and reassure them that even though it may hurt, it’ll be over quickly. Try pricking teddy’s finger or encourage your child to help if they want to. If you’re finding it difficult, ask your diabetes team for advice

Selecting the site for capillary blood sampling