Why does insulin have to be given by injection or pump? Why can’t it be given in tablets?

Current insulin preparations cannot be given by mouth because the insulin is destroyed by the acid in the stomach. Researchers are working to develop insulin-like medications that can be taken by mouth. The tablets that some older people with type 2 diabetes take are not insulin tablets and do not work in children with type 1 diabetes. Other ways of giving insulin are actively being researched.

Should we have our other children tested for risk of diabetes?

Many people worry about the increase in risk of other children in the family getting diabetes. This is completely normal. Blood testing is available to look for diabetes antibodies and higher risk genes and this is an active area of research. One problem at present is that if a high risk of diabetes is found in another child, there are no proven ways to prevent it. There are continuing studies on possible preventions. Your doctor and other diabetes team members will be able to give you the latest information on diabetes screening and prevention trials.

I know my pancreas isn’t making insulin anymore, do I still need it?

Yes! The pancreas has many jobs and making insulin is just one of them. Type 1 diabetes only affects the ability to make insulin and this is only about 3% of what pancreas does overall.

Will my child be able to come off insulin later in life?

No. Type 1 diabetes requires life-long insulin therapy. Not until a cure is found will it be possible for people with type 1 diabetes to stop insulin treatment.    

When do your diabetes medical clinics run?

Our diabetes clinics run on a Tuesday and Wednesday afternoon from 2–5pm. Unfortunately you cannot make an appointment to see your diabetes doctor outside of these times.

How often do I need to see my diabetes doctor>?

Appointments to see your diabetes doctor will be made for every three to four months. 

I need to change my appointment with my diabetes doctor, who do I contact?

You can contact RCH Specialist clinics on 9345 6180 to reschedule your appointment. Please keep in mind that as our appointment slots are filled up three to four months in advance, you may not be able to get another doctor’s appointment for a significant period of time.

Can we see our family doctor for follow-up of our child’s diabetes?

Your family doctor is very important in your child’s overall health care; however you must also have regular visits to your diabetes team. International recommendations and best practice are that children with diabetes should be seen at least three or four times each year by a team with specialised knowledge and experience in children’s diabetes. The diabetes team keeps in touch with your family doctor so that he or she is fully informed about the diabetes. Your family doctor’s role in diabetes management is to manage vaccinations, medication prescriptions, minor illnesses, travel needs etc. As well as your regular visits to your diabetes team, you should see your family doctor regularly about the diabetes care plan. If you don’t see your family doctor regularly it is difficult for them to help you when you need them.

We were surprised when we were asked to see the social worker at the hospital because we didn’t think we had those types of problems. Why was this?

Diabetes has a major impact on the child and the family and it is important to talk with someone about this. The social worker in the diabetes team meets with all families and their children to help them explore the social impacts on the family system and find ways to deal with these.

My wife and I have not had a night out with just the two of us since our daughter developed diabetes. What should we do?

It is important to have some support from close family and friends where possible. Often a relative or close friend will be happy to have some diabetes education so they can look after your daughter sometimes. Resources such as this will help, and education sessions can be arranged through your diabetes educator if needed. Some time-out from diabetes is important for parents.

Since our two-year-old developed diabetes, we have been worried about the effect on the behaviour of our five-year-old. What can we do?

The two-year-old will need a lot of attention, but it is also important to find time to do things as a family, and special time for one or both parents to have with your other children. Brothers and sisters can sometimes worry a lot about things such as the possibility that their brother or sister may die, they themselves may get diabetes or that they caused the diabetes. Reassurance is needed, and the social worker or psychologist can help with these common concerns.

My 10 year old is very capable and independent. When can I let her do all her diabetes cares by herself?

Even once children and teenagers are capable in many aspects of diabetes self-care, evidence shows that it is very important for parents or caregivers to remain closely and actively involved in supervising and assisting with the daily care. While the level of assistance will be different than for younger children, your continued involvement shows your support and guidance and allows you to know that the diabetes is being appropriately managed. Try to be actively involved rather than being seen to 'check-up on' or 'nag' about routines. The consequences of poor diabetes control are so serious that this role is an important responsibility of parents      

Why are different children on different insulin types?

Insulin treatment has to be tailored for the individual child. Different insulin types suit different children, and this may depend on the age, how long they have had diabetes, their eating and activity pattern and other factors. Sometimes your child may need to change insulin types. Your diabetes team will work out what suits your child best at any time.

My child’s insulin doses keep having to be put up. Does this mean his diabetes is getting worse?

No. Doses have to increase as children grow and this is normal. They also increase when the honeymoon period is over, and increase quite a lot during the teenage years.

How does the diabetes team decide how many injections per day my child needs?

This is an individual decision for your child and may change with age and duration of diabetes. There is increasing use of multiple daily injection plans or insulin pumps, since these are recognized to have advantages for long-term diabetes control, reduction of complications and lifestyle flexibility. Your diabetes team will discuss these issues with you and your child.

Are insulin pens better than syringes?

Both pens and syringes give a dose of insulin just as well, but pens tend to be quicker and more convenient.  

My child has fatty lumps at the injection sites — is this a problem?

Yes. This is called liporhypertrophy, and is caused by giving too many injections in the one place or putting pump sets in the same area repeatedly. It does not look good and also causes unreliable absorption of insulin. It goes away if these sites are rested. It is prevented by changing the point of injection or pump set as often as possible.

Should I move to a completely different injection site every day?

Insulin is absorbed differently from different areas of the body. The abdomen (tummy) is the best injection site and many use this for all injections, but some children prefer to use other areas. It is recommended that the injection site be changed each time, moving 2-3cms away from the previous site. 

My 13-year-old daughter wants to give her injection through her clothes when she goes out so as not to be embarrassed by lifting up her clothing. Will this cause problems?

Although this is not the best practice and cannot be generally recommended, it is better to have the injection through the clothes than to avoid it because of embarrassment. A number of studies have shown no harm from injecting insulin through thin clean clothing.   

How accurate do I need to be with the amount of carbohydrate foods?

Modern insulin plans (injection or pump) work best when there is accurate matching of carbohydrate intake to insulin doses. Thus, it is worth working on this and doing the best you can. Sometimes it is not easy, e.g. unfamiliar foods or restaurant meals, but at home you can more easily estimate accurately by using scales and reading food labels as needed.

What should I do if my child’s blood glucose level is high at meal or snack time?

The approach varies according to the circumstances and whether the child is treated with injections or a pump. 

Injections: The meal or snack should be given as usual. Not giving food when a child is hungry just because the blood glucose is high is not recommended and may be interpreted as punishment. If insulin is due at the time, our general advice is not to give extra rapid/short-acting insulin to ‘correct’ the elevated BG.

If the blood glucose remains high and there are ketones present, refer to the section on sick days. If this is happening regularly, then it is more appropriate to review overall insulin doses.

Pump: a correction can easily be given with the pump, either with a meal or snack, or in-between. The pump wizard or calculator guides this.

What happens if my child eats too much carbohydrate at a meal or snack?

This will happen sometimes as appetite varies. If it is significantly more than the usual, blood glucose levels may be elevated, but usually only for a few hours afterwards. If your child is more active and eating more, then it usually balances out well, since extra carbohydrate is needed when more active. If your child is on a pump, the extra carbohydrate can be bolused for or a correction dose given later if needed.

If on injections and insulin is not due but your child is very hungry and intends to eat more than usual, then give an extra rapid or short-acting insulin injection so the BGL does not become high later on.

What if my child does not want to eat?

Your child may be feeling unwell or just not hungry. On some insulin regimens, e.g. pump or multiple daily injections, the meal can often be delayed until the child feels ready to eat provided that the BGL level is fine. Work at establishing consistent eating patterns and avoid feeding young children too often, since this may reduce appetite at routine meal and snack times. Sometimes it is reasonable to offer substitutions of food, but this should not be for 'junk foods' and be careful of setting up a pattern where you become a slave in the kitchen, trying to cater for all whims. Offer a limited number of healthy choices e.g. would you like yoghurt or banana instead?

Just after diagnosis my child was very hungry and eating a lot, but is now less hungry. Why is this?

At first, the body has to make up for the weight loss before the diabetes diagnosed. After a while the appetite usually decreases back to normal. Your diabetes dietitian and nurse educator will advise and also guide you with any insulin adjustments that may be needed at the time.

Will my child become overweight as a teenager or adult because they have diabetes?

No. It is important to have a healthy balance between food intake, insulin and exercise. Genes are also a factor, so if there is a tendency to being overweight in the family, there is increased risk. Sensible, healthy eating, particularly keeping the diet reasonably low in fat, and adequate exercise are the keys to avoiding gaining too much weight. If you are concerned about your child’s weight, speak to your diabetes doctor and dietitian who can help to get the balance right.

Is it OK to have artificial sweeteners?

Sweeteners such as sorbitol in diabetic sweets should be kept to small quantities only, since diarrhoea and tummy cramps may occur. Artificial sweeteners are widely used in diet drinks and cordials and if taken in moderation are safe and acceptable. Some sweeteners (e.g. Splenda, stevia) can be used in baking, but using ordinary sugar is a reasonable alternative since in a mixed food type the effects on blood glucose levels are likely to be small. Extensive use of artificial sweeteners is not necessary because sugar can be used in moderation as part of a healthy, balanced diet without upsetting diabetes control.

How accurate are blood glucose meters?

Blood glucose meters have are accurate within ten per cent. Many meters will give inaccurate results (read low) if not enough blood is applied. Using the same meter consistently will decrease any variation that occurs between different meters.

My child will only checks BGLs twice daily,at breakfast and dinner. Is this OK?

No. The minimum number of BGLs that are required for safety and to guide insulin adjustment is four per day and at least one overnight BGL a week. Children can tire of BGL testing and it is very important that you encourage and support your child to do their tests.

My son will not keep a diabetes record book as he says the readings are all in the memory of his blood glucose meter. Is this a problem?

A record of BGLs need to be kept, but there are many of ways doing this. There is an electronic record book available from RCH where the results can be typed it. Many BGL meters now have a download function. When a book/download is used, many readings are easily seen and give immediate feedback on how the diabetes is going. It is important that you support your child/adolescent whenever they are doing their BGLs at home.

Help them by writing the result in the book for them. This also allows you a chance to review the results in a non- threatening way. You should review your child’s/adolescent’s BGLs at least once a week. If preferred, computer based versions of log books can be used. For pump users, the pump system can serve as a complete record, provided that all BGLs are entered into or transferred into the system.

I worry that I cannot get all of the blood glucose readings in the target range. What am I doing wrong?

Probably nothing. With diabetes, it is impossible to get all readings in the target range all of the time. There will always be a number of readings above, and occasionally some below. If most of the readings are in or near the target range you are doing well. If many readings are outside the target range, insulin doses need to be adjusted. Your doctor will arrange a HbA1c test every three-four months which gives a check on overall diabetes control.

Does it matter if my child does not wash his hands before a blood glucose reading?

Yes, food or drink particles on the fingers may give a falsely high reading and infection is more likely. If soap and water are not available, wet wipes (alcohol-free) are a good alternative. Make sure the hands are dried properly before testing.

My child has favourite finger prick sites. Does this matter?

Yes. Favourite spots will often get thickened scar tissue and tend to hurt less, but the finger prick sites will heal more slowly and infection may be an increased risk. The finger prick sites should be spread around different fingers and always remember to use the sides of the fingertip. Some people do prefer not to use certain fingers and this is fine as long as they are being spread around a reasonable amount.

My child has difficulty getting enough blood from finger pricks. Any suggestions?

Make sure the fingers are warm and that the prick is done in the correct position where blood can be squeezed toward the end of the finger. If blood is being squeezed toward the end of the finger you should see it getting redder, not paler. It may help to keep the finger below the level of the heart when doing a test. Some lancet devices (finger prickers) have an adjustable setting – try adjusting this to a greater depth. Changing the lancet on a daily basis will ensure its sharp and therefore less blood is required to do the test.

What do we do if our blood glucose meter breaks down?

Call the manufacturer and a replacement should be able to be quickly arranged. It is a good idea to have a spare meter available as a back-up. Alternatively, most pharmacies sell meters.

Should we be using CGMS? Our son is not keen on the idea and it seems expensive?

CGMS is an emerging technology and is likely to be increasingly used. Systems will improve further and it will be used more if it becomes cheaper. Good diabetes management can still occur with sufficient finger prick BGL monitoring, so if you are not keen to pursue CGMS, concentrate on getting a good amount of testing by fingerprick and looking for patterns. However, CGMS can assist with additional glucose profiling and is especially popular amongst some pump users. It is also an option to use CGMS for occasional periods for extra information, rather than continuously. Ask your diabetes team for the latest information.  

My four-year-old doesn’t have many hypos, but when he does he doesn’t seem to recognise them. What should I do?

Young children are often not good at recognising hypos, and even if they do feel funny, may have trouble knowing what this is or expressing it. With time they usually learn what it feels like and are able to tell you. When a hypo occurs, after treating it spend a few moments asking how the child felt and whether they felt any symptoms. This can help the learning process.

My seven-year-old daughter seems to be having hypos at school every morning and asking the teacher for jelly beans. The teacher says she looks OK, but treats it as a hypo because she is worried. What should I do?

It may be hypoglycaemia, but some children can go through a stage of saying they are low to get lollies. The only way to sort out what is happening is to test the blood glucose at these times, and where possible always monitor before treating a hypo. It may also be wise to change the hypo treatment you have available at the school to a less favoured choice (e.g glucose paste or tablets).

How many hypos is too many?

Most children have occasional mild hypos, often up to four per week. Usually there is a logical explanation such as extra activity or eating less. If more than this number is occurring, if there is no explanation for frequent hypos or there are any severe hypos, some adjustment to the diabetes management may be needed. Contact your diabetes team if unsure.

My 15-year-old son is very particular about his diabetes control and always has excellent blood glucose levels. In the past three weeks he has had three major hypos which came on without warning. Luckily we were there to treat him. What is happening?

This is hypoglycaemia unawareness, and can happen if the blood glucose levels are generally running too low. The body does not produce a hypo response until the blood glucose becomes very low, and then it is too late for the person to respond. The problem can be corrected by adjusting the insulin so that the blood glucose levels are in a more normal range and he may need to run his BGLs a little higher for a few weeks. If this is happening you need to contact your diabetes team as soon as possible.

We worry about our daughter having a hypo at night, and possibly having a fit. How can we avoid this?

The risk of night hypos can be minimised by checking the blood glucose before bed, and if the level is less than 6 mmol/l, having some extra supper. It is wise to periodically check some blood glucose levels at night, either in the late evening or middle of the night. It is especially a good idea to test in the late evening or overnight if your child has exercised a lot that day, eaten less or is not well. Reducing the evening dose of insulin after vigorous sport or exercise will also help reduce the risk of night hypos. For some insulin plans, having some supper is important to reduce the risk of night hypos. The availability of CGMS (continuous glucose monitoring systems) also allows night BGLs to be monitored and can be used regularly or occasionally to check the overnight BGL profile.

How can we tell if our child is having a hypo at night?

Children sometimes wake up if they are having a hypo and they may have a bad dream. If your child has had a restless night or wakes up feeling unwell you should be suspicious of hypos and think about overnight testing. Some night testing is recommended for all people with diabetes.

My three-year-old receives insulin via injections and sometimes has blood glucose levels around 16 to 18. Should I give him extra insulin at these times?

Usually, no. High BGLs are usually caused by insufficient insulin for the food that has been eaten. Check for ketones when BGL is above 15 mmol/l, or he is unwell in any way. If ketones are more than 1.0mmol/l on injected insulin, or more than 0.6 mmol/l on a pump, please refer to the sick day guidelines. Check with your diabetes team if unsure.

When we check our daughter’s blood glucose level before supper and bed it is often high, but this is only about one hour after her dinner. What should we do?

The blood glucose will often be elevated just after a meal. Leave the test until at least two hours after a meal where possible, even if this means testing after she has gone to bed. This is a better guide to whether the insulin needs adjusting.

My son’s BGLs are often high despite increasing the insulin dose, and my educator suggested that he may not be giving his insulin. I am not happy about this suggestion because my son is a good boy and he knows that he needs his insulin.

Insulin omission is very common, not only with children and teenagers but adults as well. Many children and adolescents will omit insulin repeatedly if they are not helped or supervised with their injections or pump boluses. The reason children and adolescents miss some insulin is due to an inability to prioritise and plan because they have not yet reached this stage of brain development. This inability to do injections or boluses without assistance is not the child/adolescent being 'bad'; it is expected if they don’t receive enough help and supervision. Also, giving insulin every day is hard work and to do it in the long term, the person needs support from their family and friends.

We recommend that you support your child or adolescent on a daily basis with their injections or pump boluses. When at home, the pre-meal BGL and the meal content should be discussed together and the record book filled in. There can be discussion of the appropriate dose of insulin and the need for any adjustments and the dose can be checked and administered. Cross-checking doses will reduce errors and ensures that they are done accurately. Children and adolescents should not go away into another room unsupervised to test BGL or deliver insulin. At school, it is also best when possible to have someone assisting with supervision of BGL monitoring, recording and insulin administration.

My child is vomiting, what should I consider before contacting the hospital?

Whenever your child is unwell, please check for ketones. We always need to rule out ketones as a cause for vomiting before we assume that it is a gastro bug. For more information on ketones and DKA please go to (link). Before calling the diabetes ‘sick day’ service, please ensure you have a recent BGL and ketone reading available. 

When my son gets ear infections and has a fever, he eats much less. Should I lower his insulin doses?

Illnesses with fever and infection often make the blood glucose levels higher than normal, even if the child is not eating well. This is because of glucose output from the liver, which is exaggerated when the body is stressed and lacking in insulin. You should check the blood glucose levels more often and check for ketones. Sometimes extra insulin will be needed. Some illnesses make the blood glucose levels lower, especially vomiting and diarrhoea. If this happens, less insulin may be needed – monitor more often and check with your diabetes team if unsure.

How do extra fluids help when my child is sick?

High blood glucose levels can cause extra fluid losses through passing more urine. Extra fluid helps replace this and helps the body clear ketones.

My daughter has only had diabetes for three months and this is her first illness since the diagnosis. We don’t feel confident about giving extra insulin. What should we do?

It is natural that you will feel anxious and uncertain about dealing with sick days, especially at first. Use the guidelines in this section. If worried or unsure, call the diabetes service who will guide you; this can be done over the telephone.

If my child is sick and does not feel like eating, what can I do?

Measure the blood glucose level more often. Try to give carbohydrate containing fluids or foods that are easy to swallow (e.g. jelly, custard, ice-cream). During sick days, if the blood glucose level is above 8mmol/l, sugar-free fluids should be used. If the blood glucose level is below 8 mmol/l give carbohydrate-containing fluids or food.

Do children with diabetes get ketones whenever the blood glucose is high?

No. If the child is well and the blood glucose is high from eating too much carbohydrate or perhaps because of mood or emotion, then usually there will be no ketones. It is only when there is not enough insulin in the body that ketones develop, and this is more likely at times of illness. Ketones are likely to develop if the BGL is high for more than a few hours.

My seven-year-old daughter with diabetes needs to have her tonsils removed. I have been advised that this can be done in our local private hospital, even though they do not have a children’s section. What should I do?

Surgery on children with diabetes should only be performed in hospitals in which there is experience in looking after children with diabetes at these times. Usually this will be a major children’s hospital or general hospital with a paediatric section. Your diabetes specialist needs to be involved in the planning and during the time in hospital. Contact your diabetes team for further advice about how you should proceed.

Our son tends to have hypos in the night after his athletics days, even though we give him extra carbohydrate. What can we do?

Delayed hypos after exercise are common and exercise can cause blood glucose levels (BGL’s) to be lower for some 12 to 16 hours afterwards because your body uses glucose for energy fuel. Lowering the insulin on these very active days will help manage the delayed hypos – lower the evening dose, or both morning and evening doses, depending on the pattern. Your diabetes team can help you with this.

My 15-year-old son is a keen surfer and on injections. I worry about him having a hypo when he is out in the water. What should I do?

Activities like surfing do require extra monitoring of BGL’s to know which way they’re (BGLs) are trending and extra carbohydrates. In general, exercise lowers your (BGLs) because your body uses glucose as an energy fuel. Always check his blood glucose level before going into the water. As a general rule for surfing make sure BGL is above 5 mmol and they have a serve of quick acting carbohydrate before they go into the surf i.e 125 mls of juice/sports drink (see the guidelines in this section). Some children will lower their insulin doses if planning a very active day of surfing. He should always surf with a buddy who knows he has diabetes and what to do for a hypo. He should come in to the beach every 45 minutes approximately for extra carbohydrate (one to two exchanges). As an extra precaution, a tube of glucose gel can be tucked into the wetsuit or board shorts in case of an unexpected hypo.

My daughter has a school camp which is going to be very active. What should we do about her insulin doses?

Plan ahead by looking at the activity program and how active it will be. Also ask to see the menus to check for carbohydrate content and number of meals and snacks provided. If the camp is much more active than your child’s usual routine, insulin doses often have to be reduced by 20 to 30 per cent overall. Extra carbohydrate will also be needed. Consult your diabetes doctor or educator well before the camp to discuss. The diabetes team can help you by providing a camp plan for your child so be sure to give them plenty of notice at least two weeks by emailing diabetes@rch.org.au who will send you a  template of the information required in order to prepare the plan.  

What are some good extra carbohydrates for before or during exercise?

Many carbohydrate foods are suitable, ideally choose healthy carbohydrates (carbs). Depending on the type and duration of the exercise a mix of quick and sustaining carbohydrates maybe required. Popular choices of quick acting carbohydrates are juice or sports drinks. Long acting or sustaining carbohydrates are yoghurt, fruit, fruit bars, muesli bars. 

My daughter is sometimes hypo after netball training, but at competition matches her blood glucose levels are often high. Why is this?

Sometimes the stress and excitement of the competition can cause the blood glucose levels to go high through the production of stress hormones like adrenaline which cause glucose to be released from the liver. Usually the blood glucose levels lower during the game. If this affects performance, ask your doctor or educator about some possible solutions.     

My son had a BGL of 18 mmol/l immediately after basketball last week. Should we have given extra insulin injection then?

No. High intensity exercise can push the BGL up temporarily during the exercise and for a period of time afterwards. This is because of a ‘stress hormone’ response. Usually the BGL will settle during recovery. Giving extra insulin at this time is likely to cause a hypo. Check the BGL an hour or so later and continue to monitor regularly after the game so you can get an idea of how his body responds to the basketball game over the next 24-hours.   

Why may insulin needs increase so much in puberty?

Puberty is a time of rapid growth and also hormonal changes and as a result the body needs more insulin to keep BGL’s in target. The body is also more resistant to the action of insulin at this time largely due the hormones released during puberty. After puberty and the growth spurt is complete, insulin doses often decrease.

Do I always need to check with my doctor or diabetes educator before adjusting insulin?

No, only if you are not sure. Many families and teenagers become quite experienced in adjusting their insulin and regular adjustment of insulin is a necessary part of good diabetes management. In time you will learn to do this using the guidelines provided. If you don’t feel confident, are unsure or it just isn’t making sense, contact the diabetes team for advice. It is our aim that through education and support you will become independent with dose adjustment so that you can regularly review your child’s BGL’s and adjust insulin doses as required to effectively manage their diabetes.    

Sometimes my child has a BGL of 18 or 20 mmol/l before bed, with no ketones. Should I give an extra insulin injection to bring this down?

 Generally no. If you are sure your child has not missed any insulin doses, is well and has no ketones, we do not recommend that you give extra rapid or short-acting insulin at bed time because of the risk of a hypo overnight. Often the BGL will fall by itself anyway if the short acting and long acting insulin has been given. You could recheck the BGL and make sure that hands are washed and dried. 

My son is reluctant to tell other children that he has diabetes. How should we approach this?

Children vary in this. Some children don’t mind everyone knowing, but some prefer only a few close friends to know. It is good if your child can have a few close buddies who know he has diabetes and about hypos and how to treat about hypos, so that they can tell an adult if there is a problem. Reassuring them that they have nothing to be ashamed of and how important it is for mates to look after each other regardless of the health condition they may have. There are children with various health conditions in the community and at school knowing who may need help at some time or another. 

My child will be starting school soon. How do I go about making sure the teacher knows what to do about the diabetes?

Planning ahead is important. Visit the school and notify the school your child has Type 1 diabetes with the teacher or head teacher well before the child starts so they can be prepared. The school must be given the 2016 Diabetes Management and Action Plan prepared by the diabetes team which can be obtained by contacting the diabetes team at diabetes@rch.org.au to request one. You will need to discuss this with them and both you, the principal along with a diabetes educator must sign the plan. This plan outlines the child’s diabetes management at school, how to contact you and the schools obligations. They can be given information about Diabetes at School including information about seminars run by Diabetes Victoria for teachers in the school and early childhood setting. 

It is very helpful if you can facilitate the transition to school as much as possible over the first few days especially if the teacher has not had to manage a child with diabetes at school before or your child is on a pump. Showing the teacher how to perform BGL’s and record it in the book or how to enter BGL’s and carbohydrates in the pump and how to treat hypos is very helpful. Prepare hypo packs and activity food to be kept at the school. If there are particular concerns, contact your educator or the diabetes team who can provide additional support and advice.

My eight-year-old daughter has her breakfast at 7.30am and recess is not until 11 am. She is having quite a few hypos just before recess. How can we deal with this?

More than three hours may be too long without a snack for young children on some insulin patterns. Options are to reduce the morning rapid acting insulin or to have an extra carbohydrate snack just before going in to class at 9 to 9.30 am. You can contact the diabetes team for management advice. 

My nine-year-old son is starting to come home with half of his lunch left in his bag, and has had low blood glucose levels some afternoons. What should I do?

Talk to your son about why this is happening. Sometimes a simple change of food choices may work – variety is important as is food that is easy to eat. He may not be as hungry as he previously was and in this case the insulin can be adjusted accordingly.   Sometimes they are too eager to start playing and ‘don’t have time’ to eat their lunch so you may need to visit the teacher and check that lunch is supervised and he eats all his lunch and snacks, and reinforce how important it is that he eats all his lunch.

I worry about what will happen if my child has a severe hypo at school. The teachers say they are not able to give glucagon. Is this a problem?

Schools are not obligated to give glucagon and many do not have trained staff to give injections. The school plan advises teachers to how to manage a severe hypo with first aid to call an ambulance in the event of a severe hypo who will know how to manage a severe hypo.  

My two-year-old’s blood glucose levels seem to vary a lot. I think this is because some days he eats really well and other days just doesn’t seem interested in food. What can we do?

This is common at this age and blood glucose levels do vary more with toddlers.

Offer simple choices if not eating well, or carbohydrate-containing fluids. Avoid the temptation to offer treats instead of healthy choices – give simple choices of acceptable foods e.g., would you like yoghurt or banana? Sometimes if your child goes through a phase of less appetite, lowering the insulin dose may be necessary – discuss with your diabetes team. Insulin pumps may be helpful in smoothing control in such situations but this must be discussed with your endocrinologist. 

My eight-year-old is not showing any interest in giving her own injections. How should I encourage this?

Children vary in the age that they feel ready to start doing injections usually they will do their own finger pricks earlier, but many don’t start giving injections until they are nine or ten or sometimes later. It is important they are involved in diabetes routines from early on, even if it is just helping with some part of a procedure. Gradually, involvement in practical procedures can be increased and they start to take more direct responsibility, with continued supervision. 

I was shocked when our educator said that our 14-year-old son was writing down fake blood glucose readings in his record book. He has always been so reliable. Where have we gone wrong?

You haven’t gone wrong. Having diabetes can be particularly difficult in adolescence. Attention to the diabetes may wane and it can be difficult to supervise. Adolescents are striving for independence but may not quite ready for it, especially as far as the diabetes is concerned. Sometimes false readings are written down to try to please parents or stop them from worrying or to appease the medical team .It is important for parents to always oversee their child’s diabetes management especially so when this happens. Try to establish some agreement with your son about how you may cooperate to help with the diabetes. Sometimes the diabetes team can help negotiate this. Hang in there – things will improve!

At what age should my teenager start seeing the diabetes team by himself?

There are no definite rules for this and it is a question of when individuals feel comfortable about it. It is usually harder for the parent! Usually in the early to mid teenage years the diabetes team may start seeing the young person by themselves first as this is important in the transition to independent adult living but this can be discussed before. The parent or parents are usually seen with the teenager afterwards and relevant issues discussed.

I don’t want to encourage my daughter to drink alcohol but if she does, I want her to do it safely. How can I approach this?

These types of dilemmas are faced by all parents of teenagers. The diabetes team will usually raise the issue of alcohol at an appropriate time, since many teenagers will experiment with it. If not contact the diabetes team. While not encouraging alcohol, it will usually be explained that adults can have alcohol in moderation by following certain rules to ensure they are safe which we discuss with them. Then, if or when the teenager does try alcohol they have some information about how to do it with minimal risk. It is important to discuss the issue of alcohol in education.

My child’s diabetes is quite difficult to manage and we can never seem to get the haemoglobin A1c in the recommended target range. What should we do?

Obviously a HbA1c below the target of 7.0% is ideal but, for a variety of reasons, not everyone can reach this. The most common reason is that blood glucose levels are higher than ideal at those times of the day when you are not testing. It may also be that the insulin types or timing are not the most suitable for your child at this time. Your diabetes team will be able to help with these issues. Remember that any improvement in haemoglobin A1c is of benefit in reducing the risk of complications (e.g. improving from 9.6 per cent to 9.1 per cent, even though it is not in the target range).

My 15-year-old son made the switch to four injections per day about a year ago, and was doing well. Now his control has deteriorated; he seems to be doing less testing and it seems he is often forgetting his lunch-time injection at school. What can we do?

It sounds like there are some elements of diabetes burn-out. Explore the reasons for difficulty with the lunch-time injection. Sometimes this is something simple that can be overcome (e.g., lack of privacy or not enough time). By contacting your diabetes team they may be able to help assess if they can re-motivate your son or if there are other particular issues. A review by the social worker or psychologist may help. They will also consider whether it may be appropriate to go back to three or two injections a day for a while. Work with your son in a team effort so he is not carrying all of the load of day-to-day management. It is important for parents to stay involved and assist with diabetes care, even during the teenage years.   

What should we do if our child gets sick when overseas?

Use the information on this website on sick day management. If things are not getting better you will need to see a doctor. You may have been given a contact by your diabetes team before leaving home. Otherwise, find the nearest children’s hospital, or large hospital with a children’s department. If none is available nearby, ask for help to find an English speaking doctor or a doctor who speaks your language. Remember also that you can phone home to your diabetes team who may be able to help over the phone.

What should we do if our blood glucose meter is lost or breaks down when we are overseas?

Consider taking a spare meter, otherwise in many countries it will be possible to purchase a replacement machine, but the meter might read the blood glucose in different units than you are used to (1 mmol/l = 18 mg/dl).

My nine-year-old wants to sleep over at a friend’s house. He can give an injection but cannot reliably draw up. How can we handle this?

It would be best to use insulin pens for this situation, which he should be able to dial up or his carers can easily be taught to dial up or supervise. If you would like more information on insulin pens, please contact your diabetes team. 

My 15-year-old son is erratic with his routines, often forgets his blood glucose testing and has overall poor diabetes control. Should we buy him an insulin pump in an attempt to improve his control?

No. Your son has difficulties with the basic routines of diabetes which are unlikely to be helped by a pump. Using a pump is likely to be more risky for him under these circumstances. Pump users need to be highly motivated and prepared to do six to eight BGLs per day or sometimes more, and to work harder at their diabetes than average. Work with your diabetes team to improve your son’s basic diabetes routines in an attempt to get improved control on his insulin injections.

My 11-year-old daughter works hard at looking after her diabetes and usually has a HbA1c around 8%. Her doctor is very happy with her progress. She read about insulin pumps on the Internet and would like to go on a pump. Should we do this?

Your daughter sounds well motivated and would be a good candidate for an insulin pump. While her control level is reasonable, it is above the recommended target. It is possible that this could be improved with a pump and there would be other potential advantages in terms of flexibility of routines, meals and lifestyle. Ask for more information from your diabetes team. Even if she chooses not to go on a pump she should be able to achieve good diabetes control with insulin injections.

Our son is now 13 and he has had unstable diabetes control for the 12 years that he has had it. We have worked really hard at attempting to stabilise things and our doctor and diabetes team have tried many different insulin combinations and doses.He is always prepared to do as many tests as needed and is generally good with his food. Could a pump help us?

You should discuss this with your doctor and diabetes team, but your son sounds like a person who could benefit from a pump as long as he felt this was good idea.  

My seven-year-old has had diabetes for two years. Does he need his eyes checked?

An eye check is generally not recommended in children under 9 years until they have had diabetes for five years. If your child has eye symptoms at any time, a check should be done, but these would be unlikely to be due to diabetes. Sometimes temporary blurring of vision can occur when blood glucose levels are changing a lot, but this soon goes away.

My 15-year-old daughter has had diabetes for ten years and poor control for two years and has some early eye changes and slight nerve changes in the feet. Is this serious?

These are warning signs of the diabetes starting to affect the body and these could progress to become more serious. The good news is that early problems can often be stopped or reversed if control is improved, so this is the most important thing. Any improvement in control, even if only small, is of benefit.

My 16-year-old son asks why he should work hard at his diabetes when he is going to get complications anyway.

This is a rather pessimistic attitude, and is sometimes used as an excuse to avoid good diabetes care. Be open and honest with your son. You need to say to him that diabetes complications can occur with long duration of diabetes or poor control, but that risks are minimised with good control and can be decreased with any improvement in control. Also be optimistic that with modern diabetes management, long-term complications are expected to be less, and that major improvements in management or even a cure are real possibilities in the next decade or so.