Title: Author: Speciality / Division: Directorate: CLINICAL GUIDELINES ID TAG Management of Children with newly diagnosed type 1 diabetes (up until their 18th Birthday) Dr Teresa Mulroe and Dr Sarinda Millar Acute Paediatrics CYPS Date Uploaded: 16/10/15 Review Date 20/1/2018 Clinical Guideline ID CG0185
Children & Young People s Directorate Paediatric-Neonatal Guidelines Checklist & Version Control Sheet 1 Name of Guideline / Policy/ Procedure 2 Purpose of Procedure/ Guidelines/ Protocol: 3 Replaces: Replaces existing guideline 4 Professionals consulted during development Management of children with newly diagnosed type 1 diabetes (up until their 18 th birthday) To assist staff in the management of children and adolescents diagnosed with type 1 diabetes Developed by SHSCT Paediatric and adolescent diabetes team 5 Applicable to which staff: Medical & Nursing Staff 6 Name & Title of Author: Dr Teresa Mulroe and Dr Sarinda Millar 7 Proposals for dissemination: CYPD SHSST 8 Proposals for implementation: To be utilised in the management of children and adolescents with newly diagnosed type 1 diabetes 9 Training Implications: Teaching on guideline for medical and nursing staff 10 Date Procedure/Guideline/ Protocol submitted to Procedures Committee: 11 Outcome: Approved Approved/Minor amendments Not approved Deferred 22/01/2015 12 Date of CYP SMT approval Comments: 13 Date of approval by Trust SMT (if required): 14 Date for further review (3 year default) 15 Date added to repository: Note: Guideline author to complete parts 1-10
Management of children with newly diagnosed type 1 Diabetes (not for use in patients with DKA until IV fluids & IV Insulin have been stopped) Introduction: Most well newly diagnosed patients with diabetes can be managed on an outpatient/ambulatory basis, provided they have access to 24 hourly telephone support from a member of the diabetes team. Children with DKA or who are vomiting or systemically unwell or hypoglycaemic or those where there are social concerns or marked parental anxiety should be managed as an in-patient Children with newly diagnosed diabetes do not automatically need intravenous fluids and intravenous insulin; provided they are drinking well, not dehydrated or acidotic. Most children with newly diagnosed diabetes will have up to 4+ ketones & 4 + glucose in their urine with blood ketones generally <3mmol/l. Please inform Diabetes Consultant, Diabetes Specialist Nurse (DSN) and Dietitian of all children newly diagnosed with diabetes to enable them to make arrangements to see the child and family at the earliest opportunity. Diagnosis of Type 1 diabetes: Diagnosis of type 1 diabetes may be confirmed in a child presenting with osmotic symptoms (polyuria, polydypsia +/- weight loss) with glucose +/- ketones in urine and a random glucose 11.1mmol/L, if there are no osmotic symptoms, but high plasma glucose level, confirm high plasma glucose level on subsequent day after discussion with a senior colleague or the diabetes team. Fasting Plasma glucose < 5.6 mmol/l = normal 5.6-6.9 mmol/l =Impaired Fasting Glucose (IFG) 7 mmol/l =provisional diagnosis of diabetes 2 hour Oral Glucose Tolerance test (1.75g/kg of anhydrous glucose dissolved in water to a maximum of 75g) <7.8mmol/L= normal 7.8-11.1mmol/L=Impaired Glucose Tolerance (IGT) >11.1mmol/L=provisional diagnosis of diabetes Consider non Type 1 causes of diabetes if any of the following are present 1.A strong family history of Autosomal Dominant type of diabetes inheritance 2 Diagnosis before the age of 1 year old 3 Obesity 4 Black or Asian origin 5 Evidence of insulin resistance or metabolic syndrome(acanthosis nigricans, hypertension, hyperlipidaemia, polycystic ovarian syndrome etc) 6 Co morbidities eg eye or renal disease,deafness or another systemic illness/syndrome.
Investigations for Diagnosing Non type 1 Diabetes Fasting plasma glucose, serum insulin (insulin <15mmol/L=normal, serum insulin >20mmol/L =likely insulin resistance), C-peptide (a measurable C-peptide when the blood glucose is high (>8mmol/L) shows insulin secretion is still occurring. Pancreatic auto antibodies (GAD65, Islet cell, IA-2& Insulin auto antibodies) are usually present in type 1 diabetes and negative in type 2 diabetes. Consider genetic testing for Maturity Onset Diabetes of the Young (MODY) if there is mild glucose intolerance, with other family members affected in autosomal dominant inheritance pattern, not obese with negative auto antibodies. Infants < 1 year old should have genetic bloods sent to Exeter after discussion with the diabetes team (they may have a genetic mutation involving the ATP sensitive potassium channel which may respond to oral sulphonyurea treatment) Borderline hyperglycaemia A well child may present with mildly raised random or fasting plasma glucose, which may represent IFG or IGT, with a 30% risk of progression to diabetes. Arrange for the child to have a fasting blood sugar level tested and glucose tolerance test if required. An unwell child may be found to have a transiently raised plasma glucose e.g.lower respiratory chest infection or asthmatic on steroids. This may be due to counter regulatory stress hormones. Discuss management with a senior colleague. Medical Management: Investigations: Do all investigations at one time Label sample Paediatric Diabetes OPC (to ensure results go directly to the TWINKLE system) Investigations Investigation Date Sent Urine Ketones & glucose Blood Ketones & Glucose HbA1c Venous blood gas U&E & osmolality Lipids FBC & dwcc TFTs and Thyroid Auto antibodies Coeliac screen & Immunoglobulins Anti Islet cell & anti GAD antibodies Consider other investigations as required : MSSU, Blood Culture, throat Swab,
CXR, LP (Fever is not part of diabetes) Hyponatraemia may be due to raised glucose. Formula to calculate the corrected Sodium is : Corrected Sodium= Sodium + 0.4x ([glucose] -5.5) (link from DKA guideline) DKA is diagnosed when Plasma Glucose is > 11.1mmol/L, ph< 7.3, Bicarbonate <15mmol/L and ketones are raised/ketonuria. If DKA is diagnosed follow the BSPED DKA guideline. Education: Education and explanation of diabetes & diabetes management should start immediately and include blood glucose (BG) testing and insulin administration. Ensure the child and family are given a copy of the information file for children with newly diagnosed diabetes and talk them through this information. (excluding carbohydrate counting which will be discussed at a later date) Give the family contact telephone number for their local DSN. Insulin Guidelines: Once DKA has been excluded, Start subcutaneous (SC) insulin therapy The initial aim is to stabilise the BG, whilst avoiding hypoglycaemia. If the child is well, not vomiting, not in DKA and the family are able to cope, they may be able to go home for management as a day case. If the child and family go home, they should be given a glucometer and shown how to check BG levels 4 hourly overnight (only required in early stages after diagnosis). If the child and family go home they should be given a telephone contact number of the DSN or advised how and when to contact the on call doctor for advice. If the admission occurs late in the evening, start basal insulin. The child and family may then go home and return to the ward the following morning before breakfast. If the admission occurs over a weekend, the child could be managed as a day case, to cover meal time BGs and injections on the children s ward and overnight home leave. They should then meet the diabetes team on Monday or the next normal working day. Families should know how to treat hypoglycaemia before going home protocol on intranet or on front of orange hypoglycaemia box in ward. Insulin Doses Start total daily dose of insulin at 0.5 units per kilogram per day (U/kg/day) for >5 year old with 50% as basal insulin (Lantus or Levemir ) and 50 % as bolus insulin (eg Novorapid, Apidra or Humalog) divided equally initially between breakfast, lunch and dinner. Give bolus insulin just before meals and basal insulin either pre tea or pre bed. Basal insulin must be given at the same time each day. Those <5 years old should be started on a total daily dose of insulin of 0.3U/kg/day divided as above. (Start total of 0.25 U/Kg/day if child has a very short history with little weight
loss) Patients < 3years old should be started on a ½ unit pen and prescribed ½ units cartridge to go with this Hyperglycaemia correction: Try to avoid extra doses of insulin between meals Be careful if giving extra insulin doses to children with newly diagnosed diabetes (as they may have marked insulin sensitivity) to avoid hypoglycaemia especially at home. As an inpatient, if BG>20mmol/L and 3+ ketones in urine between 22.00 and 0500, and no rapid acting insulin given in previous 3 hours, then you could give extra rapid acting insulin 0.1U/kg/dose SC 4hrly if needed Also, if BG is raised before meals, add an extra 0.05U/kg/dose to pre meal time injection, to avoid the need for extra Insulin between meals. Points to Note: Insulin should be prescribed in once only Column Prescribe as Units not U or IU Doses will be adjusted gradually and regularly with DSN until BGs in the 4-8 mmol/l range Pens are for single patient use and should be labelled with patient ID Test BM every 4 hours, before meals and 4hrly overnight The family should be given a glucometer to take home and shown how to use this and how to record BGs in a diary Morning BG levels are mostly influenced by basal insulin. (i.e. If morning BG is raised, consider increasing basal insulin dose) Dr T Mulroe/Dr S Millar January 2015