How is it treated and managed?
The important indicator in terms of care needs in diabetes is whether treatment with insulin is required. Type 1 diabetes will always need insulin treatment. Type 2 diabetes will sometimes require this treatment.
Insulin is a hormone given by injection that reduces blood sugar. Regular injections with insulin will be required to control blood sugar through the day. Monitoring blood sugar, calculating the carbohydrate content of food to calculate insulin dose required, administering insulin by injection or using an insulin pump is the treatment required. Insulin treatment may be managed in two ways by -:
- Regular insulin injections through the day.
- Use of an insulin pump. An insulin pump is the size of a mobile telephone and is worn around the waist under clothes. The pump is attached via a tube to a plastic cannula under the skin and gives a background dose of insulin to control blood sugar. Booster doses can be programmed into the machine at mealtimes based on carbohydrates to be eaten and most recent blood sugar level.
Both methods require regular monitoring of blood sugars through the day and knowledge of carbohydrate content of foods to calculate dose of insulin required. The aim of treatment is to keep blood sugar readings within normal limits, as if the body was producing its own insulin to control blood sugar. Good control of blood sugar reduces long term complications of diabetes and short term problems with control namely symptoms of hyperglycaemia and hypoglycaemia. There are different types of insulin available which have short, medium and long durations of action.
Insulin Injection Regimes
Examples include -:
- Twice daily injections – 12 hours apart – rigid eating pattern required – not often used
- Three times daily injections – rigid eating pattern required
- Multiple injection regime – will usually consist of short acting insulin at mealtimes and a longer acting insulin for overnight. 4 insulin injections per day on average. Multiple blood sugar measurements are required to calculate insulin dose required (between 4 and 10 blood glucose measurements per day). This regime involves more monitoring and injections but allows flexibility in terms of meal times. It is commonly used. Children are likely to use a pen size device for administering insulin.
Children will be able to do injections themselves from diagnosis but will need prompting and supervision.
Insulin Pump
The insulin pump has tended to be used in children whose diabetes has been hard to control on an injection regime but is now being offered to all children under 12 who are suitable. The pump is worn 24 hours a day and the injection site is moved around to avoid skin complications. Managing diabetes with an insulin pump is more complex than using an injection regime. Children may be able to do this themselves from diagnosis but will need prompting and supervision.
Blood glucose monitoring
Blood glucose levels vary substantially during the day. Children should be aiming for levels of 4-7mmol/L before meals and below 9mmmol/L after meals. Staying within these limits may not always be possible. Children will be trained to look for peaks and troughs of blood sugar and to avoid these by adjusting insulin dose or carbohydrate intake. Blood glucose monitoring involves pricking a fingertip to obtain a drop of blood. Glucose level in the drop of blood is measured using a simple palm sized device. Children will be able to do this themselves from diagnosis but will need prompting and supervision. They will need guidance to interpret results and calculate next insulin dose.
Management of hyperglycaemia, hypoglycaemia & difficult to control / brittle diabetes
Hyperglycaemia
If blood sugar is too high it can be reduced by increasing insulin dose. If blood sugar is getting out of control children may need medical help and advice or admission to hospital to correct it. Insulin requirements increase during infections for example and learning how to manage this independently takes time and experience.
Hypoglycaemia
Blood sugar levels may fall too far and cause symptoms of nausea, dizziness, blurred vision and unconsciousness. Children may carry dextrose tablets or ‘Glucogel’ or other source of glucose to take if this occurs. Some children do not develop warning signs of hypoglycaemia and this is a hazard as unconsciousness will be the first sign of it. Such children may carry an emergency injection kit containing a hormone called glucagons, which raises blood sugar. This can be injected by a trained non-medical person if unconsciousness occurs. Warning signs of hypoglycaemia can be restored by improving diabetes control and minimising episodes of hypoglycaemia.
The child will need to eat a more sustaining source of carbohydrate after the initial hypoglycaemia has resolved e.g. a sandwich.
Difficult to control diabetes / brittle diabetes
Blood sugar levels may be erratic or not clearly related to food intake or insulin dose despite the best endeavours of the child. This may be related to other conditions the child has and is particularly common in children who take drugs that affect blood sugar levels such as steroids. Such children are likely to try an insulin pump. However they are managed, they are likely to check their blood sugar more frequently than other children with diabetes and there may be a need for parents to check blood sugar for them during the night. There will be written evidence of such care if it is required.
