Initial management of a child presenting with diabetes:
The newly diagnosed child with Type 1 diabetes:
Initial investigations
The following bloods need to be checked at diagnosis:
- Lab Glucose – one yellow Fluoride Oxalate tube
- Coeliac antibodies, anti-GAD, IA2, ZnT8 antibodies – 2 white clotted/serum tubes
- Thyroid function tests – one paediatric white tube (or adult brown tube)
- HbA1c – one red EDTA tube
Initial management
If the child is well and not in DKA at presentation, start them on basal bolus therapy with FIASP and LANTUS. Do not wait for laboratory glucose to come back before starting treatment. If the child presents out with meal times, they should have a correction dose of FIASP.
Starting doses 0.6u/kg/day if ketones ≤ 1.0 at presentation
0.8u/kg/day if ketones >1.0 at presentation
Prescribe 50% as the basal insulin LANTUS. Please prescribe it for 9pm. Prescribe this on the basal or long acting insulin page on the front of the prescription.
Prescribe the remaining 50% as FIASP, approximately split into 3 equal doses before breakfast, lunch and tea. If breakfast is usually minimal or missed, the amount of insulin for that meal should be adjusted accordingly. Prescribe this in the rapid acting insulin section on the 2nd page under ‘fixed doses’. Older children of secondary age should be prescribed a dose of FIASP for their evening snack at 9pm (to coincide with correction dose before bedtime). If so please prescribe FIASP insulin at one third of the evening meal dose for 9pm.
Remember to complete the whole prescription, which includes calculating both the standard correction dose and the ketone correction dose. These are calculated based on the total daily dose of insulin. This is on the bottom of page 2 of the prescription chart. From this the initial correction dose can be given.
Adjusting Doses
Blood sugars should be checked before main meals and before the bed time snack.
The starting doses above will most likely need to be changed during the admission.
If for example the child is high before breakfast, increase the evening Lantus dose by 10%. If high before lunch, increase the morning FIASP dose by 10% etc.
Similarly, if the child is hypo, or less than 5 on wakening, reduce the Lantus dose by 10%.
The diabetes team will do this on weekdays, but please review during the weekend ward rounds and make adjustments as necessary.
Dietary management
Diet is an essential part of diabetes treatment. A well balanced diet will help control blood sugars and maintain a healthy weight. The dietitian will see patients at diagnosis to provide individual advice.
Meals
Although individual dietary advice can depend on insulin regime, it is important to have starchy carbohydrates at each meal such as potatoes or wholemeal versions of bread/pasta/rice/noodles plus some protein and fruit or vegetables. Sugary drinks and snacks should be avoided.
Snacks
Children on basal bolus therapy do not need to snack between meals, but if they wish could have a small carbohydrate snack between meals.
A piece of fruit is the ideal snack between meals. Other options include a pancake, plain biscuit, crackers, natural yoghurt, toast or bread. Sugary drinks and snacks should be avoided.
Initial education
The family should be provided at admission with their own copy of the locally prepared folder “Your Guide to Diabetes” (on the intranet under the title “introduction to diabetes”). The pages on “introduction to diabetes” and “life with diabetes” are printed in duplicate in the booklet to allow family members to share, and are likely to be particularly useful in setting realistic expectations from the outset.
Aims of the admission
The aim of the admission is not stability. Even if the blood sugars were perfect on going home, the change in routine would require early adjustment of insulin doses. The target is that the child should have blood ketone levels less than 1 mmol/L, and that the parents should be confident in giving injections, blood glucose testing, recording sugars, recognising and treating hypoglycaemia and knowing to call for advice as necessary. The diabetes team will maintain close telephone contact in the first few weeks to help with dose adjustment.
Diabetic ketoacidosis (DKA): Paediatric DKA integrated care pathway:
- All children admitted with DKA should be admitted to paediatric HDU and the on-call consultant informed.
- Please print out and follow: BSPED DKA Guidelines | BSPED
- In addition to investigations outlined in the DKA protocol, the following bloods also need to be checked at diagnosis: (1 yellow, 3 white, 1 red paediatric tubes)
- Lab glucose. one yellow fluoride oxalate tube
- Coeliac antibodies and anti-GAD/IA2/ZnT8 antibodies, 2 white clotted/serum tubes
- Thyroid function tests, one white tube or adult brown tube
- HbA1c, one red EDTA tube
TAM (Treatments and Medicines) NHS Highland
