CLINICAL GUIDELINE FOR THE MANAGEMENT OF CHILDREN AND YOUNG PEOPLE WITH NEWLY PRESENTING DIABETES 1. Aim/Purpose of this Guideline 1.1. This guideline applies to medical and nursing staff caring for children and young people presenting with newly diagnosed diabetes. 2. The Guidance 2.1 Children under the age of 16 years with newly diagnosed, or suspected diabetes, should be seen on the Paediatric Observation Unit on the same day. Those aged 16 years, and still in school year 11, can be managed initially within paediatrics, to allow education of school staff. 2.2 Diabetes is diagnosed by the presence of symptoms of diabetes (polyuria and polydipsia) and a random laboratory plasma glucose of 11.1mmol/l. (1,3,4,5) If there are no symptoms, this may be stress-induced hyperglycaemia: see section 2.7 2.3 Ward nursing staff should: perform baseline observations including BP, weight and height the child and apply topical local anaesthetic cream on arrival do capillary blood glucose and blood ketones inform a doctor immediately if: - they are concerned that the patient is unwell, - or the patient s observations meet Paediatric Early Warning Score of 3 or more, - or blood ketones are >1.5 mmol/l, - or the patient has any of the symptoms of possible DKA (section 2.4), - or the patient has a headache: this could represent cerebral oedema, even if they are not in DKA. 2.4 Consider Diabetic Ketoacidosis (DKA) in any child who is vomiting, or who has abdominal pain, is drowsy, dehydrated, or is breathing rapidly and deeply (Kussmaul respirations). If DKA is suspected then venous access should be obtained as soon as possible and bloods taken as per section 2.6. DKA is diagnosed by (2) : - ph < 7.3 and/or bicarbonate < 15 mmol/l - blood glucose >11 mmol/l - and blood ketones of 1.5 mmol/l If DKA is confirmed they should be managed by: - following the South West DKA Care Pathway (2), - informing the paediatric registrar and the consultant on call. Page 1 of 12
2.5 The majority of children presenting with diabetes will be well. In this situation: document a full medical history including: medication history (particularly steroid use) family history (particularly of diabetes and other autoimmune conditions) social history school attended document a full examination, particularly signs of dehydration do fundoscopy to check no cataracts are present (these occur in 0.7% of children presenting with diabetes secondary to metabolic disturbance). (7) plot height and weight on a growth chart. 2.6 Insert an intravenous cannula and take bloods: All of these tests (except bedside glucose and ketones) are included in the Paed New Diabetic order set on Maxims which is on the right hand side of the Paediatrics specialty order page. Blood test Adult Vacutainer * Paediatric Bottle * if you want to fill Adult Vacutainers with blood from a syringe, then remove the lid before putting blood in the bottle (do not put the needle through the lid and push the blood in otherwise the lid will pop off and spray blood everywhere). ** Fill the EDTA bottle last because EDTA contamination can affect biochemistry results. *** if any queries regarding these tests, contact immunology on ext 3040. Page 2 of 12 Form Blood gas Capillary tube (HDU or lab) Green clinical chemistry (if lab gas) Blood glucose and Bedside meter ketones N/A Laboratory glucose Grey Yellow Renal function, bicarbonate, immunoglobulins Gold Green (Li hep) Thyroid function Gold Green (Li hep) HbA1c Purple** Pink (EDTA)** FBC Purple** Pink (EDTA)** GAD and IA2 antibodies*** Coeliac screen (anti TTG)*** 1 adult Gold bottle (does not have to be completely full) is better than multiple paediatric clear bottles Green, clinical chemistry Red, haematology If possibility of infection: consider CRP, blood culture and urine MCS Special instructions Hand deliver to lab N/A N/A N/A
2.7 Other causes of hyperglycaemia: If there are no symptoms and blood ketones are <0.6 mmol/l, consider stressinduced hyperglycaemia, which is likely to be transitory. In this case, monitor capillary blood glucose and ketone levels and plan a fasting laboratory plasma glucose level with HbA1c and GAD and IA2 antibodies. Diabetes is confirmed by a fasting plasma glucose 7 mmol/l. An oral glucose tolerance test can also be considered and can be discussed with the diabetes consultants. (1,3,4,5) However if the blood ketones rise above 1.5 mmol/l at any point, then insulin should be started as per section 2.9. Consider type 2 diabetes if the child has a long duration of symptoms, is obese, has a family history of type 2 diabetes, or is of non-white ethnicity. In this case, examine the child for acanthosis nigricans, which is velvety, hyperpigmented skin in the body folds eg neck and axillae. Acanthosis is often associated with insulin resistance, although is not specific to this. However, even if type 2 diabetes is suspected, it is safer to treat initially with insulin as per section 2.9. 2.8 If the diagnosis of diabetes is confirmed: A doctor should explain to the child and parents: - that the purpose of the admission is to confirm the diagnosis, initiate treatment and to start to educate them in how to manage diabetes. - a brief explanation of diabetes. They should be given the Diabetes UK magazine and the Journey of a Lifetime DVD to watch: these should both be available in the diabetes box in the cupboards in the Paediatric Observation Treatment Room or Fistral Storeroom. Initial management must be discussed with: - the paediatric registrar - and the Paediatric Diabetes Specialist Nurses (PDSN): available between 08.00 and 20.00 hours Monday to Sunday (see contact details page 5) If the child is in DKA: - Treat as per DKA Care Pathway and inform consultant on call. If the child is not in DKA: - The consultant on call can be informed the following day (weekday or weekend). The PDSN will inform the relevant diabetes consultant of the child s admission. 2.9 Subcutaneous Insulin Regime All children, even those with suspected type 2 diabetes, should start on a Multiple Daily Injection (MDI) insulin regime, which should be prescribed as follows using the instructions on the PAPER Paediatric Insulin Prescription Sheet: A. Lantus Insulin (long-acting) For all ages prescribe Lantus Insulin 3ml cartridges via JuniorStar pen. If less than 2 years old: - 0.2 Units/kg/dose once daily at breakfast time (round down to nearest half unit) Page 3 of 12
- If admitted after breakfast, but within 6 hours after their usual bedtime, then give the Lantus at the time of admission and then bring forward subsequent doses by 2-6 hours a day towards breakfast time. - If admitted more than 6 hours after their usual bedtime, then the first dose of Lantus will not be given until breakfast time and Novorapid can be given as detailed below. If 2 years old and over: - Lantus should be given at bedtime. - between 2 years old and 10 years old: 0.2 units/kg/dose once daily at bedtime (round down to nearest half unit - If 10 years old and over: 0.3 units/kg/dose once daily at bedtime (round down to nearest half unit) - If admitted at night after their usual bedtime and before breakfast: If it is within 6 hours of their normal bedtime, then the Lantus dose can still be given. If it is more than 6 hours after their usual bedtime, then the first dose of Lantus will not be given until the next bedtime and Novorapid can be given as detailed below. B. NovoRapid insulin (Rapid-Acting) With Main Meals: - If less than 10 years: 0.1 units/kg/dose with main meals 3 times a day. - If 10 years or over: 0.15units/kg/dose with main meals 3 times a day (round down to nearest half unit) - This is usually given immediately before eating, but if their appetite is unpredictable eg toddlers, then it may be given immediately after eating. With Snacks: - Prescribe quarter the main meal dose to cover all snacks (rounded down to nearest half unit if works out to less than 0.5 units then do not give any Novorapid to cover snacks) Novorapid Correction dose: - should be prescribed to be given if: it is more than 2 hours since the last dose of Novorapid AND - blood ketones 1.5 mmol/l and blood glucose 15mmol/l at ANY TIME - OR if Blood glucose >20 mmol/l during the day and at bedtime - calculated as 0.05 units/kg (rounded down to nearest 0.5 unit). - repeat blood glucose and ketones levels 2 hours later. 2.10 Ongoing Management in Hospital The aim of the hospital admission is to provide support and education (1,5) and to turn off any ketone production and to start aiming for optimal diabetes control. This will be achieved over the next few weeks. The child and/or carer should be encouraged to perform blood glucose testing and insulin injections as early as possible. Page 4 of 12
a) Capillary blood glucose should be performed pre-meals, 2 hours after meals/before snacks, pre-bed, and at 2-3 am and should be recorded on the Paediatric Insulin Prescription Sheet (Section F on page 4 or on the continuation sheets). Blood glucose levels will need to be done more often, 2 hourly, if: the blood glucose falls to 5 mmol/l or blood glucose rises to 15 mmol/l OR blood ketones are rising or 1.5 mmol/l. 2 hours after a Novorapid Correction dose. b) Blood ketones should be done: if the blood glucose is 15 mmol/l. 2 hourly if the previous ketone level was 0.6 mmol/l or above. c) The diabetes team will see the child and family daily during admission and they will decide when the child and family are ready for discharge. We are aiming to avoid hypoglycaemia in hospital and when the child goes home and starts exercising. To know that the child is safe from developing DKA (ie has a reasonable insulin level to turn off ketone production), the child needs to have blood ketones < 0.6 mmol/l before discharge and tolerate their blood glucose between 4 and 20mmol/l. d) The Paediatric Diabetes Dietitian should be informed of the admission: see contact details below. - The child and their family will be seen by the Paediatric Diabetes Dietitian within 2 working days of admission. - The family should be seen by the Dietitian twice within the first week of diagnosis. If the family are discharged before their second review they will need to return to the Paediatric Observation Unit to continue dietetic education. Please ensure this appointment is arranged before discharge. e) The PDSN should inform the Paediatric Research Nurses of the admission so that they can ask the family if they would like to take part in a research study called Address 2: see contact details below. f) Discharge prescription for pharmacy: E-discharge JACS: use the Insulin Treatment protocols as follows: i. PAEDIATRIC LANTUS & NOVORAPID INSULIN REGIMEN ii. And the PAEDIATRIC DIABETIC ACCESSORIES. This excepts Novofine Needles which are not a pharmacy line and are provided by the PDSN. Need to remember to change Glucagon dose according to weight (see below). If JACS is not working and you need to do a handwritten TTO, they should be prescribed the following: - Lantus (Glargine) Insulin 3ml cartridges x 1 box of 5 - Novorapid 3ml Penfill cartridges x 1 box of 5 - Glucagon 1mg/ml x 1 GlucaGen HypoKit (second to be prescribed by GP): Body weight less than 25kg give 0.5mg PRN Body weight of 25kg or more give 1mg PRN - Glucose 40% oral gel x 1 box of 3 tubes (second to be prescribed by GP) - Glucose 4g tablets x 1 box Page 5 of 12
- Optium ceed beta ketone blood test strips x 1 box of 10 - Accu-Chek Aviva blood glucose test strips x 2 boxes of 50 - Accu-Chek Fastclix Drums x 1 box - Novofine needles 4mm, 1 box of 100 and sharps bin (given by nurses as non-pharmacy items. g) The PDSN will arrange an outpatient appointment with the appropriate diabetes consultant within the next 6 weeks. Contact details Paediatric Diabetes Specialist Nurses: 08.00 20.00, daily Monday to Sunday, by pager via switch for initial diagnosis. Office ext 4567. Paediatric Diabetes Consultants - Dr Katie Mallam: ext 2637 or mobile via switch - Dr Simon Robertson: ext 2716 or mobile via switch Paediatric Dietitians: ext 2409 messages can be left Play Specialists for procedure therapy: Bleep 2948 Paediatric Research Nurses: ext 5138/5139 or contact via Groupwise Page 6 of 12
3 Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Compliance with guidance Diabetes team (Dr Katie Mallam) Audit If any problems identified, or minimum 3 yearly Diabetes team and Directorate Audit and Guidelines meeting Audit lead and diabetes team Required changes to practice will be identified and actioned within a specified time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4 Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 12
Appendix 1. Governance Information Document Title Date Issued/Approved: July 2015 Clinical guideline for the management of children and young people with newly presenting diabetes. Date Valid From: July 2015 Date Valid To: July 2018 Directorate / Department responsible (author/owner): Katie Mallam paediatric consultant Contact details: 01872 252637 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Guideline for standardised care of children and young people with newly presenting diabetes. Diabetes Children Diagnosis New RCHT PCH CFT KCCG Clinical guideline for the management of children and young people with newly presenting diabetes. Version 3 Nov 2014 Paediatric Diabetes team Paediatric consultants Directorate audit and guidelines Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Not Required Internet & Intranet Paediatrics Intranet Only Page 8 of 12
Links to key external standards Related Documents: (1) NICE Clinical Guideline 15. Type 1 Diabetes: diagnosis, and management of type 1 diabetes in children, young people and adults. July 2004 (2) BSPED (British Society of Paediatric Endocrinology and Diabetes) Recommended DKA Guidelines 2009 (minor review 2013), http://www.bsped.org.uk/clinical/docs/dk AGuideline.pdf, or the Southwest Diabetes Regional Network Integrated Care Pathway for Children with Diabetic Ketoacidosis. (3) Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia. Report of WHO/IDF Consultation 2006. (4) ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Ragnar Hanas, Kim C. Donaghue, Georgeanna Klingensmith, Peter G.F. Swift; Pediatric Diabetes 2009: 10(Suppl. 12). (5) Care of the well child newly diagnosed with Type 1 Diabetes Mellitus, Clinical Guideline, Association of Children s Diabetes Clinicians, December 2012. Training Need Identified? No Version Control Table Date March 2012 October 2013 November 2014 Versio n No V1.0 Initial Issue V2.0 V3.0 Update Summary of Changes Review and Update Re format in current template Changes Made by (Name and Job Title) Dr. Mallam, Dr. Robertson, Anita England, Trish Shaw, Michelle Skews, Pip Ali- Diabetes Team. Dr. Mallam- Paediatric consultant Tabitha Fergus- Deputy ward manager Dr Mallam and Paediatric Diabetes Team Page 9 of 12
May 2015 V4.0 Update (main changes: reduced Novorapid snack dose and changed PDSN on call hours) Dr Mallam and Paediatric Diabetes Team All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 10 of 12
Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): clinical guideline for the management of children and young people with newly presenting diabetes. Directorate and service area: child health Is this a new or existing Policy? Existing Name of individual completing assessment: T.Fergus 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Telephone: 01872 252000 To provide clear standardised care for children and young people with newly presenting diabetes. 2. Policy Objectives* Clear standardised care for children and young people with newly presenting diabetes. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Standardised care for children and young people with newly presenting diabetes. audit Children, young people and families no b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Page 11 of 12
Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No x 9. If you are not recommending a Full Impact assessment please explain why. Not required Signature of policy developer / lead manager / director T. Fergus Date of completion and submission July 2015 Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed T. Fergus Date Page 12 of 12