Newly diagnosed diabetic – not in DKA (Walking wounded)

Diagnosis

• Most patients will present with classic symptoms of diabetes or hyperglycaemic crisis (see below), with  a random plasma  glucose concentration  of ≥11.1 mmol/litre (200 mg/dL)  on two different occasions or
• Fasting plasma glucose  of ≥ 7.0 mmol/L (≥126 mg/dL). Fasting is defined as no caloric intake for at least 8 h
• In certain situations, the diagnosis of diabetes maybe unclear. It should be confirmed with observation, fasting and 2hour post prandial blood glucose or an oral glucose tolerance test. These situations include:
  • Hyperglycaemia found incidentally in a patient participating in a screening study
  • Presence of mild or atypical symptoms of diabetes
  • Hyperglycaemia in situations of acute infection, trauma, or other  stress

Symptoms

• Polydypsia
• Weight loss
• Thrush
• Excessive tiredness
• Polyuria
• Nocturia
• Polyphagia

Please note that classical symptoms may be absent.

If patient is obese, of Black or Asian descent, has no ketonuria or there is evidence of insulin resistance (e.g. acanthosis nigricans), consider type 2 diabetes¹

When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there is a strong indication for type 2, monogenic or mitochondrial diabetes¹

Initial Investigations

• Height and weight
• Blood for : (Available on the Order comms test group as Paediatric New Diabetic patient under or over 10 years of age)
  • Venous glucose, Blood ketones
  • Electrolytes(sodium, potassium, urea, creatinine)
  • Venous gas (pH, Bicarbonate)
  • Haemoglobin A1c (HbA1c)
  • Thyroid Function tests (TSH and fT4)
  • Thyroid peroxidase antibody
  • Tissue Transglutaminase (TTG) ( immunology request form needed)
  • Islet cell antibodies (GAD antibodies & Anti-IA2)
  • Cholesterol and triglycerides  if more than 10 years of age

Management

Inform diabetes team, doctor, dietician, diabetes specialist nurse and the clinical psychologist.

Education

• Ward Staff should commence basic diabetes education focussing on practical elements, encouraging families to download the diabetes education app ‘deapp’ on their electronic devices.
• Continuing diabetes education will be provided by the diabetes team.

Target blood sugar levels

• Pre meal blood sugar targets 4-7mmol/l
  • 2 hour Post meal blood sugar targets 5- 9 mmol/l

Insulin

• Start all patients on multiple daily injections/Basal Bolus Regimen.
• The usual total daily insulin is about 0.7 units/kg/day

Basal Insulin

• For all patients,  start  Levemir (Detemir) on 0.4units/kg/day, split into 2 divided doses – i.e. 0.2units/kg in the morning and 0.2units/kg in the evening
• For children more than 5 years old in whom it is felt that compliance with management might be an issue – start on Tresiba (insulin degludec) on 0.3 units per kg once daily.

Bolus Insulin is Fiasp (insulin aspart)

• Start patients on a Insulin to Carbohydrate ratio as follows
  • 1-3 years  1 unit for 30 grams of carbohydrates
  • 4-6 years 1 unit for 25 grams of carbohydrates
  • 7-9  years 1 unit for 20 grams of carbohydrates
  • 10-12 years 1 unit  for 15 grams of carbohydrates
  • More than 12 years 1 unit for 10 grams of carbohydrates

If a blood sugar before meal is within target (4-7mmol/l) and a child less than 3 years eats 10 or less grams of carbohydrates it is possible to skip insulin. The 2h post meal capillary blood glucose (CBG) should be checked.

Calculate insulin sensitivity (ISF)/ correction factor (CF)

• Calculate total daily dose (TDD). This will be 0.7units per kg ( For a 20 kg child it will be 20 X 0.7 = approximately 14 units per day)
  • The correction factor will be 100 divided by the TDD = (100/14= 7)
  • So the Correction factor now is 1:7 mmols – one unit of insulin will reduce the blood glucose by 7mmols.
  • See Correction factor sheet (appendix 1) for the amount of extra insulin to be given according to CFs and blood sugar readings

Ketone dose

•  Extra insulin for ketones should be given according to the ketone management guideline

Example 1: A 4year old weighing 15 kg admitted to the ward with diabetes

• Long acting insulin  will be
  • Levemir  = 0.2units/kg/dose – 3 units at breakfast (7 am) and 3 units at and evening meal (7pm)

• Fast  acting insulin with meals- fiasp
  • 1 unit of fiasp for 25g of carbohydrates
  • Insulin sensitivity/correction factor= 1 unit for 7mmol.
    • Correction doses should be given with meals and not more than 4 hourly. See attached correction factor sheet.
  • Extra insulin for ketones should be given according to the ketone management guideline

Example 2: A 15 year old weighing 60kg admitted to the ward with diabetes

• Long acting insulin- Tresiba 0.3 units/kg once daily = 18 units daily
• Fast acting insulin with meals- 1 unit of Fiasp with 10grams of carbohydrates.

Monitoring

• Check capillary blood glucose(CBG)
  • Before each meal
  • 2 hours after meals
  • Before bed
  • 4  hourly overnight
  • If capillary blood glucose is >14mmol/l check ketones and manage using the  ketone guideline
    • If ketones  are more than 2mmol/l discuss with consultant on call and
    •  Continue to test for ketones every 2-4 hours till they are less than 1.0mmol/L.

Managing high blood sugars and ketones

• Calculate the patients total daily dose as above
  • Give extra insulin as per Ketone correction guideline (appendix 2)
  • Consider informing the consultant on call

Managing low blood sugars <4mmol/l

Please use guideline on management of hypoglycaemia in patients with diabetes

Discharge and Follow up

• Prescribe:
  • Insulin detemir 100 units per ml (3 ml cartridge)
  • Insulin aspart (fiasp) 100 units per ml (3 ml cartridge)
  • Insulin degludec (Tresiba) 100 units per ml (3 ml cartirdge)
  • needles 4mm  if <5years and 5 mm if >5years
  • 1 pack glucogel triple pack
  • 1 box lancets (Microfine plus)
  • GlucaGen hypoKit (glucagon) 1 kit
    • 500 microgram <25 kg, 1 mg >25 kg
  • 1 box blood glucose sticks- appropriate to blood glucose monitor
  • 1 box blood ketone sticks
  • Blood sugar diary

On discharge

• Patient should:
  • Monitor blood sugar at least 5 times a day(in the morning on waking, before meals, and before bed)
  • Carry out a blood glucose profile once every 2week (usual blood sugar checks and 4 hourly blood sugar tests overnight)
  • Ensure patient/family has the Diabetes booklet and the Carbs & Cals Book
  • Ensure that the discharge tick list has been completed and the patient/family has received training on hypoglycaemia management and the glucagon injection.
  • Arrange clinical contacts as follows:
    • Every week for 4- 5 weeks following discharge for review by a member of the diabetes team.
    • MDT clinic appointment – within 4 weeks of discharge.
    • Diabetes specialist nurse –  48 hours after discharge and then weekly.
    • Dietitian clinical contact with in the week.

Education

References

1. Diabetes (type 1 and 2) in children and young people: diagnosis and management. NICE guideline published 01 August 2015 last updated 29 June 2022: https://www.nice.org.uk/guidance/ng18/chapter/recommendations#blood-glucose-and-plasma-glucose .  Last accessed 09 October 2022.
2. World health organisation definition, diagnosis and classification of diabetes mellitus and its complications. Part 1:  Diagnosis and classification of diabetes mellitus. WHO/NCD/NCS/99.2.Geneva; 1999
3. ISPAD guidelines for diabetes in childhood and adolescence  2018
4. Hansa R (1998). Type 1 Diabetes in children, adolescents and young adults. 5th ed. london: class publishing. 1-388
5. Rewers M, Pihoker C, Donaghue K et al. Assessment and monitoring of glycaemic control in children and adolescents with diabetes. Paediatric diabetes 2007:8:480-18