Jo Summerton Paediatric Diabetes Nurse Specialist University Hospital

Jo Summerton Paediatric Diabetes Nurse Specialist University Hospital Southampton NHS Trust Solent NHS Trust October 2015

Diabetes Mellitus • • Facts and figures What is diabetes? How is type 1 diabetes treated? Factors affecting blood sugars Low blood Sugars High blood Sugars The role of the school

Facts and figures • 400, 000 people in the UK with type 1 diabetes, 29, 000 of whom are children. • The most common age for developing type 1 is between 10 and 14 but in recent years the greatest increase in incidence has been in the under-five’s in which it is rising at a rate of 5% per year • 97% of cases of diabetes in children are type 1 diabetes. • In addition to the medical complications that type 1 causes, a child diagnosed with type 1 at the age of five, faces up to 19, 000 injections and 50, 000 finger pricks by the time they are 18.

What is diabetes? In order for the glucose to enter the cell where it can be transformed into energy, insulin is required. As the level of glucose rises in the blood, usually following a meal, the amount of insulin that is released is increased, allowing more glucose to be moved into the cell, maintaining the blood glucose level at a constant rate.

The Symptoms of Type 1 diabetes

Awareness Campaign

Treatment. Type 1 Type 2 Multiple insulin injections or insulin pump Blood glucose monitoring at least 4 times a day Carbohydrate counting Both healthy eating frequent clinic follow -up regular exercise Tablets or liquid medication or injections Blood glucose monitoring infrequently Weight management

Insulin Injections MDI • Insulin needs to be injected as it would be destroyed by the stomach acid if it was taken by mouth; • Most children inject with a pen device and very small needles making it less painful and easier to do.

Injections • Many children require injections of rapid-acting insulin whenever they eat, so many children will require an injection during school hours; (Supervision or administration – safety needles) • Many children adjust the dose of insulin needed depending upon the current BG level and the amount carbohydrate in the meal they are eating;

Insulin Pump Therapy • An insulin pump is a small pager-sized device which continually delivers insulin through a small tube sited just under the child’s skin; • Extra insulin can be delivered with food and/or when the blood glucose level is high;

Insulin Pump Therapy

Blood Glucose Monitoring A “normal” blood sugar level is 4 – 7 mmols/l • • • When to test: Pre meals and snacks Whenever they feel unwell Pre exams Before (and after) PE Before bed Target range for a child with type 1 diabetes 4 – 7 mmols/l before a meal 4 – 8 mmols/l up to 2 hours after a meal

Responsibilities of Schools • Required to be trained in diabetes incl: blood glucose testing/insulin injections/pump management • Perform or supervise/support blood glucose test/injection technique/pump bolus • Treat hypo/hyper events as directed by IHCP • Document any care given. • Liaise with parents and HCP’s as directed by IHCP • Ensure IHCP is in place and reviewed annually.

Food and Diabetes • Due to more intensive and effective diabetes management, children and young people with diabetes are now encouraged to follow a normal healthy diet that is encouraged for every CYP.

Food and Diabetes • CYP with diabetes are able to have either a packed lunch or a cooked school meal. • Eating carbohydrate at mealtimes is essential. • Many CYP who need injections at lunchtime or use insulin pumps need to calculate the amount of carbohydrate that they have eaten so they can inject the appropriate dose of insulin. • Many YP can independently ‘count carbs’ but younger children will need help doing this or will have their food supplied by the family with the carbohydrate content already calculated • Some children will use a ‘smart meter’ which calculates the insulin dose required for their lunch, depending upon the child’s blood glucose level and carbohydrate intake.

Hypoglycaemia 4 IS THE FLOOR! A hypo is any blood sugar <4 mmols/l Why does is happen? • Insulin is taken at the wrong time • Too much insulin is injected • Too little carbohydrate food is eaten • Eating too late or missing a meal or snack • Taking the insulin after a meal instead of before • Not enough food taken during or after exercise • Sometimes for unknown reasons.

Hypoglycaemia

Hypo treatment Always test BS. If < 4, eat something from list A followed by something from List B. Pump patients just list A List B Glucose tablets 2 to 3 Lucozade (original Slice of toast or bread not Sport) Sandwich 50 ml Coca cola/Sprite/Pepsi (not diet) 2 Plain biscuits 100 ml Honey Cereal Bar Jam - 2 teaspoons Bowl of cereal Sugar Fruit Juice 100 mls Glucogel – 1 tube

Hypo Treatment Glucogel may be used to treat a hypo when/if the CYP is uncooperative or too shaky to hold their usual treatment or as directed by the IHCP. Glucogel must never be given if the CYP is drowsy/sleepy or unconscious.

Severe hypo treatment - Glucagon • Glucagon is an emergency injection to correct a severe hypo. • Very few schools are trained to use it. • Some schools are happy to store it, in case of emergency, for use by parents/paramedics

Hyperglycaemia Blood glucose level >14 mmols • Why does it happen? • Not enough insulin • Too much food • Less exercise than usual • Just after a meal • Infection or illness • Anxiety and stress

Hyperglycaemia

Treatment of Hyperglycaemia Try to think why the blood sugar may be high? • Did they wash their hands properly? • Have they eaten something different? • Have they missed an injections? • Did they inject into a lumpy area? • Are they feeling poorly? Encourage plenty of sugar free fluids and avoid vigorous or prolonged exercise. Follow IHCP

Treatment of Hyperglycaemia When blood sugar is >14 mmols/l: • Check for blood ketones • If under 0. 6 mmols/l, give correction dose of insulin (as directed by parents/IHCP/PDT) and then recheck BG level in 1 hour • If over 0. 6 mmols/l, ring parents or PDT. • If vomiting, drowsy ring 999. • if hyperglycaemia is left untreated for a prolonged period of time it can deteriorate into a potentially fatal condition called diabetic ketoacidosis or DKA.

GUIDELINES FOR HYPOGLYCAEMIA AND HYPERGLYCAEMIA FOR CYP ON INSULIN PUMP THERAPY

Physical Activity • CYP should be encouraged to test their BG level before taking part in PE and activity. • The child’s IHCP may indicate an ideal blood glucose target range in which the CYP can safely take part in the activity. • All CYP should have swift access to hypo treatment no matter where the activity is taking place. For young children, the teacher or support staff should be responsible for ensuring this.

Physical Activity • CYP using an insulin pump may need to disconnect the device during the activity and reconnect once finished. The pump should be stored in a secure place if disconnected. This may need to be checked by a member of staff and should be documented in their IHCP. • The IHCP will document CYP will require additional carbohydrate via food or drink. . • Some children will need an adjustment to their lunchtime insulin dose depending on when the activity session is – this will be documented in their IHCP.

School Trips and Residentials • Diabetes should not prevent a child from going on school or residential trips. Full participation and opportunities in all academic, social and sporting activities should be encouraged as development of self-esteem and confidence in such activities can have positive effects on the management of diabetes. (ISPAD, 2000).

Important points to remember … for day trips: • Provide a plan for the day for the parents / carers. This should include times of arrival and departure, and the likely activities during the day. • Ensure a risk assessment is carried out by the school and appropriate action taken; • Identify at least 1 keyworker that the child / young person and their parents / carers can liaise with both before and during the trip. • Provide an emergency contact number for the parents / carers for the day. • Ensure a copy of the IHCP is reviewed and taken on the trip.

Important points to remember… for residential visits: • Provide a plan for the trip, including itinerary, meal plans etc. • Ensure a risk assessment is carried out by the school and appropriate action taken; • Identify at least 2 keyworkers that the child / young person and their parents / carers can liaise with both before and during the trip. • Additional training may be required for the overnight care of a child / young person with diabetes. Ensure that these training needs are identified and discussed to allow plenty of time to ensure an adequate number of staff are trained and supported.

Residential Trips • For younger children it may be advisable for contact to be made with the parents / carers each evening to review the day and highlight areas of concern. • Ensure a copy of the IHCP is reviewed and adapted to include evening and overnight care and taken on the trip.

England – legal duties on schools Children and Families Act 2014 The Children and Families Act 2014 includes a duty on schools to support children with medical conditions. This is inclusive of children with diabetes. Schools must make arrangements for supporting pupils at schools with medical conditions and in meeting that duty they must have regard to the statutory guidance issued by the Secretary of State. The statutory guidance, Supporting pupils at school with medical conditions, is available to read on the Government website, Gov. uk. : .

Specialist Team Solent PDNS Team – Southampton (UHS) 08706260364 • Jo Summerton • Gill Crouch • John Whiteside New Milton Lymington Waterside Totton Romsey Eastleigh Hedge End West End Hamble Netley Southampton (Warsash, Locks Heath, Sarisbury, Fareham) We visit each school at least once annually.

Local Resources Southampton Paediatric Diabetes Team Diabetes Education and Care plans for Nurseries, Pre schools and Schools

Any questions?