Jo Summerton
Paediatric Diabetes Nurse Specialist
University Hospital Southampton NHS Trust
Solent NHS Trust
October 2015
Diabetes Mellitus
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Facts and figures
What is diabetes?
How is type 1 diabetes treated?
Factors affecting blood sugars
Low blood Sugars
High blood Sugars
The role of the school
Facts and figures
• 400,000 people in the UK with type 1 diabetes, 29,000 of
whom are children.
• The most common age for developing type 1 is between 10
and 14 but in recent years the greatest increase in incidence
has been in the under-five’s in which it is rising at a rate of
5% per year
• 97% of cases of diabetes in children are type 1 diabetes.
• In addition to the medical complications that type 1 causes,
a child diagnosed with type 1 at the age of five, faces up to
19,000 injections and 50,000 finger pricks by the time they
are 18.
What is diabetes?
In order for the glucose to enter the cell where it can be transformed into energy,
insulin is required. As the level of glucose rises in the blood, usually following a
meal, the amount of insulin that is released is increased, allowing more glucose
to be moved into the cell, maintaining the blood glucose level at a constant rate.
The Symptoms of Type 1 diabetes
Awareness Campaign
Treatment
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Type
1
Type 2
Multiple insulin
injections or
insulin pump
Blood glucose
monitoring at least
4 times a day
Carbohydrate
counting
Both
healthy
eating
frequent
clinic
follow-up
regular
exercise
Tablets or
liquid
medication
or injections
Blood glucose
monitoring
infrequently
Weight
management
Insulin Injections
MDI
• Insulin needs to be injected as it would be destroyed
by the stomach acid if it was taken by mouth;
• Most children inject with a pen device and very small
needles making it less painful and easier to do.
Injections
• Many children require injections of rapid-acting
insulin whenever they eat, so many children will
require an injection during school hours;
(Supervision or administration – safety needles)
• Many children adjust the dose of insulin needed
depending upon the current BG level and the amount
carbohydrate in the meal they are eating;
Insulin Pump Therapy
• An insulin pump is a small pager-sized device which
continually delivers insulin through a small tube sited
just under the child’s skin;
• Extra insulin can be delivered with food and/or when
the blood glucose level is high;
Insulin Pump Therapy
Blood Glucose Monitoring
A “normal” blood sugar level is 4 –
7mmols/l
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When to test:
Pre meals and
snacks
Whenever they feel
unwell
Pre exams
Before (and after) PE
Before bed
Target range for a child with type 1
diabetes
4 – 7mmols/l before a meal
4 – 8 mmols/l up to 2 hours after a
meal
Responsibilities of
Schools
• Required to be trained in diabetes incl: blood glucose
testing/insulin injections/pump management
• Perform or supervise/support blood glucose
test/injection technique/pump bolus
• Treat hypo/hyper events as directed by IHCP
• Document any care given.
• Liaise with parents and HCP’s as directed by IHCP
• Ensure IHCP is in place and reviewed annually.
Food and Diabetes
• Due to more intensive and effective diabetes
management, children and young people with
diabetes are now encouraged to follow a
normal healthy diet that is encouraged for
every CYP.
Food and Diabetes
• CYP with diabetes are able to have either a packed lunch or a
cooked school meal.
• Eating carbohydrate at mealtimes is essential.
• Many CYP who need injections at lunchtime or use insulin
pumps need to calculate the amount of carbohydrate that they
have eaten so they can inject the appropriate dose of insulin.
• Many YP can independently ‘count carbs’ but younger
children will need help doing this or will have their food
supplied by the family with the carbohydrate content already
calculated
• Some children will use a ‘smart meter’ which calculates the
insulin dose required for their lunch, depending upon the
child’s blood glucose level and carbohydrate intake.
Hypoglycaemia
4 IS THE FLOOR! A hypo is any blood sugar <4mmols/l
Why does is happen?
• Insulin is taken at the wrong time
• Too much insulin is injected
• Too little carbohydrate food is eaten
• Eating too late or missing a meal or snack
• Taking the insulin after a meal instead of before
• Not enough food taken during or after exercise
• Sometimes for unknown reasons.
Hypoglycaemia
Hypo treatment
Always test BS. If < 4, eat something from list A followed by
something from List B. Pump patients just list A
List A
List B
Glucose tablets 2 to 3
Slice of toast or bread
Lucozade (original not Sport)
Sandwich
50ml
Coca cola/Sprite/Pepsi (not diet)
2 Plain biscuits
100ml
Honey
Jam
Cereal Bar
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2 teaspoons
Sugar
Fruit Juice 100mls
Glucogel – 1 tube
Bowl of cereal
Hypo Treatment
Glucogel may be used to treat a
hypo when/if the CYP is
uncooperative or too shaky to hold
their usual treatment or as directed
by the IHCP.
Glucogel must never be given if the
CYP is drowsy/sleepy or
unconscious.
Severe hypo
treatment - Glucagon
• Glucagon is an emergency injection to
correct a severe hypo.
• Very few schools are trained to use it.
• Some schools are happy to store it, in
case of emergency, for use by
parents/paramedics
Hyperglycaemia
Blood glucose level >14mmols
• Why does it happen?
• Not enough insulin
• Too much food
• Less exercise than usual
• Just after a meal
• Infection or illness
• Anxiety and stress
Hyperglycaemia
Treatment of
Hyperglycaemia
Try to think why the blood sugar may be high?
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Did they wash their hands properly?
Have they eaten something different?
Have they missed an injections?
Did they inject into a lumpy area?
Are they feeling poorly?
Encourage plenty of sugar free fluids and avoid vigorous or
prolonged exercise. Follow IHCP
Treatment
of Hyperglycaemia
When blood sugar is >14mmols/l:
• Check for blood ketones
• If under 0.6mmols/l, give correction dose of insulin (as
directed by parents/IHCP/PDT) and then recheck BG level in
1 hour
• If over 0.6mmols/l, ring parents or PDT.
• If vomiting, drowsy ring 999.
• if hyperglycaemia is left untreated for a prolonged period
of time it can deteriorate into a potentially fatal condition
called diabetic ketoacidosis or DKA.
GUIDELINES FOR HYPOGLYCAEMIA
AND HYPERGLYCAEMIA FOR CYP ON
INSULIN PUMP THERAPY
Blood Sugar of Less than 4.0mmols (Hypoglycaemia)
IF blood glucose is less than 4 mmols and child is able to eat/ drink
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Give 10 – 20 grams of dextrose (e.g. 100 mls of pure fruit juice or coke)
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Repeat blood glucose test after 15 minutes
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If blood glucose still below 4 mmols, give a further 10- 20 grams of dextrose
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Repeat blood glucose test after 15 minutes
If blood glucose remains under 4mmols, give a further 10-20 grams of dextrose
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If still low ‘suspend’ the pump (or disconnect at the site) until blood glucose naturally rises
If the child is about to have a meal, treat the hypo as above, re-measure blood sugar after 10
minutes and then give normal dose of insulin for the meal.
If the Child is UNCONSCIOUS, suspend the pump or cut the tubing immediately to stop the
flow of insulin and follow the original Hypoglycaemia protocol
Blood Sugar of more than 14 mmols (Hyperglycaemia)
If the blood glucose level is above the target range of 14 mmols,
Assess
Is the pump running?
Is there insulin in the pump?
Is the infusion line leaking or damaged?
Is the needle/ cannula OK?
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Bolus
Check for ketones using Optium Exceed Blood Ketone Meter
If ketones less than 0.6mmols/l give a correction bolus via the pump
SEE EACH INDIVIDUAL CAREPLAN FOR INFORMATION ABOUT HOW TO
ADMINISTER THIS BOLUS
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IF ketones present at this point telephone parents or Urgent Call Service (0870 626
0364) and give a correction dose via the insulin pen (cannula and set will also need to
be changed)
If ketones are not present, follow instructions below
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Check blood glucose level 1 hour after this bolus has been given
If blood glucose level is lower than the previous value, no further action is required
Change
If blood glucose level is equal to or higher than the previous value, contact parents and check
blood ketones level again.
Physical Activity
• CYP should be encouraged to test their BG level
before taking part in PE and activity.
• The child’s IHCP may indicate an ideal blood
glucose target range in which the CYP can
safely take part in the activity.
• All CYP should have swift access to hypo
treatment no matter where the activity is taking
place. For young children, the teacher or support
staff should be responsible for ensuring this.
Physical Activity
• CYP using an insulin pump may need to disconnect the
device during the activity and reconnect once finished.
The pump should be stored in a secure place if
disconnected. This may need to be checked by a
member of staff and should be documented in their IHCP.
• The IHCP will document CYP will require additional
carbohydrate via food or drink..
• Some children will need an adjustment to their lunchtime
insulin dose depending on when the activity session is –
this will be documented in their IHCP.
School Trips
and Residentials
• Diabetes should not prevent a child from going on
school or residential trips. Full participation and
opportunities in all academic, social and sporting
activities should be encouraged as development of
self-esteem and confidence in such activities can have
positive effects on the management of diabetes.
(ISPAD, 2000).
Important points to remember
… for day trips:
• Provide a plan for the day for the parents / carers. This should
include times of arrival and departure, and the likely activities
during the day.
• Ensure a risk assessment is carried out by the school and
appropriate action taken;
• Identify at least 1 keyworker that the child / young person and
their parents / carers can liaise with both before and during the
trip.
• Provide an emergency contact number for the parents / carers
for the day.
• Ensure a copy of the IHCP is reviewed and taken on the trip.
Important points to remember…
for residential visits:
• Provide a plan for the trip, including itinerary, meal plans etc.
• Ensure a risk assessment is carried out by the school and
appropriate action taken;
• Identify at least 2 keyworkers that the child / young person and
their parents / carers can liaise with both before and during the
trip.
• Additional training may be required for the overnight care of a
child / young person with diabetes. Ensure that these training
needs are identified and discussed to allow plenty of time to
ensure an adequate number of staff are trained and supported.
Residential Trips
• For younger children it may be advisable for
contact to be made with the parents / carers
each evening to review the day and highlight
areas of concern.
• Ensure a copy of the IHCP is reviewed and
adapted to include evening and overnight care
and taken on the trip.
England – legal duties on schools
Children and Families Act 2014
The Children and Families Act 2014 includes a duty on
schools to support children with medical conditions.
This is inclusive of children with diabetes. Schools
must make arrangements for supporting pupils at
schools with medical conditions and in meeting that
duty they must have regard to the statutory guidance
issued by the Secretary of State.
The statutory guidance, Supporting pupils at school
with medical conditions, is available to read on the
Government website, Gov.uk.
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Specialist Team
Solent PDNS Team – Southampton (UHS) 08706260364
• Jo Summerton
• Gill Crouch
• John Whiteside
New Milton
Lymington
Waterside
Totton
Romsey
Eastleigh
Hedge End
West End
Hamble
Netley
Southampton
(Warsash, Locks Heath, Sarisbury, Fareham)
We visit each school at least once annually.
Local Resources
Southampton Paediatric Diabetes Team
Diabetes Education and Care plans for Nurseries, Pre schools and Schools
Individual Health Care Plan for
Date of Birth:
Name:
Address:
School:
Medical Diagnosis: Type 1 Diabetes
Summary of care required within school setting (delete if not required)
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Supervise and record blood glucose test before meal and as necessary
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Perform and record blood glucose test before meal and as necessary
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Supervise insulin dose calculation
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Calculate insulin dose
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Supervise meal time bolus via pump
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Administer meal time bolus via pump
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Treat low blood glucose levels (hypoglycaemia)
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Treat high blood glucose levels (hyperglycaemia)
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Maintain
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Ensure staff are aware of
Safety at all times
condition and care
Parent/Carer Contact Details:
Name:
Telephone:
Paediatric Diabetes Nursing Team
For Urgent advice
02380796893
0870 626 0364
Individual Health Care Plan written by:
Date:
Review Date: Annually
Any questions?