Section: 9.4 Diabetes - Insulin Strategy for Newly Diagnosed Children

Paediatric Clinical Guideline Section: 9.4 Diabetes - Insulin Strategy for Newly Diagnosed Children

Short Title: Diabetes - Insulin Strategy for Newly Diagnosed Children

Full Title: Guideline for the insulin strategy in children and young people with newly diagnosed diabetes Date of production: Sept 2004 Last revision: November 2008

Explicit definition of patient group This guideline applies to all children and young people under the age of 19 to which it applies: years under the care of the paediatric team.

Name of contact author DrTabitha Randell, Consultant in Paediatric Endocrinology and Diabetes Dr Stephanie Smith, Consultant Paediatrician Ext: 64042 Revision Date April 2010

This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Diabetes - Insulin Strategy for Newly Diagnosed Children

It is hoped that most children presenting with diabetes will fall in the ‘walking wounded’ category. All newly diagnosed children require the following blood tests:

Baseline investigations for newly diagnosed children

(see also Diabetic Ketoacidosis guideline)

 Blood glucose (fluoride)  Urinary ketones (ward dipstick)  U&E (lithium hep)  Osmolality (lithium hep)  Bicarbonate/ venous blood gas (lithium hep/heparinised capillary tube)  coeliac and thyroid antibodies (clotted)  islet cell antibodies (clotted)  HbA1c (EDTA to biochemistry)  Thyroid function (lithium hep)  FBC (EDTA to haematology)  IgA (clotted or lithium hep)

If pH is <7.3, then follow the Diabetic Ketoacidosis protocol

Subcutaneous insulin regimens are started after confirmation of Type 1 diabetes and correction of ketoacidosis. The child should be able to tolerate a normal or near normal diet. There are two main insulin manufacturers – Lilly and NovoNordisk. There is no difference between the types of insulin made by either company, so we have decided to adopt a rotational prescribing approach depending on which month of the year the diagnosis is made – see appendix 1.

Dr Tabitha Randell Page 1 of 4 November 2008 Paediatric Clinical Guideline Section: 9.4 Diabetes - Insulin Strategy for Newly Diagnosed Children

Basal bolus regimen

Injection device

Under 5 yrs old NovoNordisk Junior pen or Humapen Luxura HD (Lilly) (for quick acting, allows for 0.5u dose adjustment) and Lantus Solostar Disposable pen (for basal insulin)

5 yrs and over NovoNordisk Novopen 3 (or 4) or Humapen Luxura (Lilly) (for quick acting, 1 unit dose increments) and Lantus Solostar Disposable pen (for basal insulin).

Insulin NovoRapid (NovoNordisk)/ Humalog (Lilly) (quick acting) and Glargine (basal insulin).

Frequency NovoRapid/ Humalog before meals, Glargine before bed.

Dose 0.5u/kg body weight /day with adjustment as indicated below.

Dose distribution 40% as Glargine before bed, 20% as NovoRapid/ Humalog given before each meal (i.e. breakfast, lunch and tea)

Factors that may increase early insulin requirement to 0.8 to 1.0u/kg/day;

1. Severe metabolic decompensation (ketoacidosis) at presentation 2. Substantial weight loss at presentation and therefore predicted catch-up phase with increased appetite 3. Coincidental illness

Factors that may reduce early insulin requirement to 0.3-0.4u/kg/day;

1. Early diagnosis with mild metabolic decompensation 2. Little weight loss at presentation 3. Continued normal activity 4. Extra caution with children aged less than 2 years

Insulin strategy

 Children requiring initial diabetic ketoacidosis treatment may be converted to subcutaneous insulin injections when they are able to tolerate regular food and pH >7.3. Glargine is normally given at night so if the insulin infusion is stopped at breakfast or lunch, half calculated dose of Glargine should be given at the same time as the quick acting to prevent DKA recurring. The insulin infusion should be continued for 10 minutes after NovoRapid/ Humalog given.

 Children admitted without clinically significant ketoacidosis can start sub-cutaneous insulin straight away, using the regimens described above. If a child’s first meal is lunch, administer NovoRapid/ Humalog as calculated above. Glargine should be given at bed as per the regimen above – an additional dose should not be needed before then.

 If a child comes in after the evening meal, give a stat dose of NovoRapid or Humalog based on 10% of child’s weight (e.g. 3units for a 30 kg child), then give Glargine at bed as per the regimen above.

 Select initial dosage of insulin but be prepared to alter regimen frequently in the first few days. The adjustments will be guided by Specialist Nurse after discharge.

 Scheme for calculating additional Human NovoRapid/ Humalog dose:

o If blood glucose > 15 units, and moderate (or more) ketones, give 20% of total daily dose (TDD) of insulin as extra ultra-quick acting insulin (e.g. if on 4 units with meals and 8 units at bed, TDD = 20 units, so give 4 units extra as NovoRapid/ Humalog).

When first starting on insulin, nearly all children will have high blood sugar levels. If the Paediatric Diabetes Specialist Nurses or nursing staff on Short Stay Unit are happy for the child to be discharged, then high blood sugars alone are not a reason for the child to remain in hospital. If the child has moderate or less ketones on urine testing and the nursing staff are happy the parents have appropriate ‘survival skills’, then they can go home, even if their blood sugar levels are still high.

Starter kit

This should be prescribed at admission so that child and family become familiar with their own equipment.

o Write ‘Diabetes Starter Kit’ on discharge prescription – comes complete from pharmacy o Initial supply of 5mm fine hypodermic needles for use with pen device (may be altered to 8mm needles for older or obese children). o Needle clipping device e.g. B-D Safe-Clip.

Insulin

As per regimen above

Blood glucose meter

Provided by the Diabetes nurses. If child presents at the weekend, the key to the Diabetes Nurses’ Room is held on CSSU (QMC)

Ketones detection

Urine Ketostix

Hypoglycaemia treatment

GlucaGen kit – 500 micrograms by IM injection if child weighs <25kg, 1 mg by IM injection if >25kg if hypoglycaemic and drowsy or unconscious.

Insulin preparation (3ml pen cartridges or prefilled onset- peak- duration-hrs disposable pens) hrs hrs Insulin Aspart (NovoRapid) or Lispro (Humalog) 0.1 0.5-1.0 4 Insulin Glargine (Lantus) constant No peak 22-24 Figures approximate

Appendix 1: insulin of the month

January Novo February Lilly March Novo April Lilly May Novo June Lilly July Novo August Lilly September Novo October Lilly November Novo December Lilly

Consultation Process

Dr Louise Denvir Dr Josie Drew PDSNs – Vreni Verhoeven, Karen Cuttell, Glyn Feerick Paediatric clinical guidelines committee

References

1. Type 1 Diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. NICE guidelines, July 2004

2. ISPAD Consensus Guidelines 2000

Dr Tabitha Randell Page 4 of 4 November 2008