See also: 

Diabetic Ketoacidosis (DKA) 

Diabetes insipidus

Diabetic Mellitus and Endoscopy  

Diabetes Mellitus and Surgery

Diabetes phone calls (Management of Diabetes phone calls)

Background 

All patients presenting with a blood glucose level (BGL) ≥11.1 mmol/L should have blood ketones tested on a capillary sample using a bedside Optium^TM meter.

• If this test is positive (>0.6 mmol/L), assess for acidosis to determine further management, see Diabetic Ketoacidosis (DKA). Urinalysis can be used for initial assessment if blood ketone testing is not available
• If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (subcut) insulin

New presentation diabetes, mildly ill

Assessment

<3% dehydration, no acidosis and not vomiting

Investigations for all children newly diagnosed with diabetes

• Check blood ketones (bedside test) on all patients presenting with BGL ≥11.1 mmol/L.

  • If ketones positive (>0.6), assess for acidosis with a venous blood gas; if pH <7.30, proceed as per Diabetic Ketoacidosis (DKA).
  • Ketones may be present without acidosis; if this is the case, continue to monitor ketones with each BGL to ensure they are clearing with insulin therapy (monitor until 2 consecutive levels are <0.6 and again if any BGL is >15.0 mmol/L).
•  GAD antibodies, insulin antibodies, coeliac screen, thyroid function tests

Additional tests to consider

• For children / adolescents who are overweight or have clinical evidence of acanthosis nigricans:     

  • C-peptide and insulin levels (may help to distinguish Type 2 diabetes, although T1DM still more likely in this scenario)
  • lipid profile  
  • LFTs

Management

The decision about the individual insulin regimen will be made by the paediatric diabetes team in discussion with the family and child. The regimens outlined below are a guide only and individual clinicians may recommend an alternative approach.

Initial Treatment

• 0.25 units/kg of quick-acting insulin subcut stat.

  • If within 2 hr prior to a meal defer and give meal-time dose only.
  • Halve dose if ≤4 yr old. Dose may be lower if not ketotic.

Ongoing Treatment

Standard insulin regimens in newly diagnosed patients may comprise either of the two regimens below:

1. Twice daily injections of a mixture of short and intermediate-acting insulins:

Usually commence with total daily dose (TDD) of 1 unit/kg/day but this may need modification (eg less in younger child aged <5 years).

This is given as 2/3 of TDD in morning, 1/3 of TDD at night. 2/3 of each dose as intermediate-acting insulin, 1/3 as short-acting insulin.

Note: In children who will be starting twice daily injections but who present after 2200 hrs, it may be too late to start with a mixture of intermediate and short acting insulins. In this instance, give 0.25 U/kg short-acting insulin, which may need to be repeated after 4-6 hours, with a snack (depending on BGL, ketones and interval to breakfast).

2. Multiple daily injections (MDI) of insulin using a long-acting insulin analogue at night and pre-meal injections of rapid-acting insulin analogue

Also start with TDD of ~1.0 U/kg/day.

• Give 0.4U/kg as basal insulin (long-acting insulin analogue eg insulin glargine) at ~2000- 2100 hrs.
• Give the remainder as rapid-acting insulin in 3 equal doses before meals (ie ~0.2 U/kg before each main meal).
• If children who will start MDI regimens present during the day, slightly higher pre-meal doses may be necessary (eg 0.25 U/kg) until basal insulin is given that evening.

In general, multiple daily injection regimens offer greater lifestyle flexibility (around mealtimes, sport etc); however the child must be old enough to learn how to administer insulin using a pen device without parental supervision (eg at school). This is usually possible with children aged >10 years. Twice daily mixed injections are usually commenced in children <10 years.

When to admit/consult local paediatric team:

• All new presentations of diabetes. In many places these children need to be admitted for commencement of insulin and diabetic education.

When to consider transfer to tertiary centre:

• Children requiring care above the level of comfort of the local hospital.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Information specific to MMC Diabetes Ambulatory Care Service (DACS) allows for many newly diagnosed children with diabetes to not require hospitalization. Please see relevant paediatric diabetes protocol on MMC intranet policies and procedures site. Information Specific to RCH AnGel cream can be used for initial doses of insulin in a newly diagnosed child Ambulatory care program at diagnosis Children who are well at diagnosis (not acidotic, well hydrated and tolerating oral intake) may be eligible to have their diabetes education and initial stabilisation as an ambulatory care patient. Additional eligibility criteria include age >3 years, English speaking family, living within the HITH catchment area, contactable by telephone and absence of any familial / psychosocial impediment to safe care in the community. Prior to linking into this program, children need to have met with the diabetes team (medical team, social worker and diabetes educator) to be assessed for suitability and also to have an initial education session around blood glucose testing and management of hypoglycemia. Hospital in the Home nurses also need to be available to attend the family home to support injections. These requirements generally mean that children who present after lunchtime will not be discharged to HITH until the following day. Direct access to ambulatory care on day of diagnosis is also not possible for children whose initial presentation is on Friday, Saturday or Sunday. Please let the diabetes team know of any new patients in ED as soon as possible, so that every effort to enrol eligible patients in ambulatory care can be made.

Hyperglycaemic, ketotic mildly ill patients with established diabetes

Patients with established T1DM who present with hyperglycaemia and ketosis but normal pH, will need additional subcut insulin to clear their ketones.

(i) Patients on intermittent daily injections of insulin (bd or MDI)

Give 10% of the patient's total daily insulin dose as a sub-cut injection of rapid-acting insulin (this is in addition to usual insulin regimen). Monitor BGL and ketones 1-2 hourly. This dose of rapid-acting insulin can be repeated after 2-4 hours if blood ketones are not <1.0 mmol/L.

(ii) Patients on insulin pump therapy

Need to assume line failure / blockage has interrupted insulin delivery. Give 20% of the patient's total daily insulin dose as a s.c. injection of rapid-acting insulin (higher dose relative to above patient group is because there is no longer acting insulin 'on board' in pump patients). Once subcut insulin has been given, ask the patient or family to resite the pump cannula and commence delivery at usual settings. Monitor BGL and ketones 1-2 hourly. For patients on pump therapy, ketones should clear to <0.6 mmol/L.

Notify local paediatric team or paediatric endocrinologist if there are any management issues that you want to discuss. If discharged home, the family should be advised to check BGLs and ketones regularly and to follow up with their diabetes nurse educator the following day.

Consider transfer when:

• Children requiring care above the level of comfort of the local hospital.

Information Specific to RCH Diabetic educators and the endocrinology team are available for help with management.