Childhood diabetes Practical Reference Manual
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Childhood diabetes Practical Reference Manual Childhood diabetes Practical Reference Manual Presentation Transcript

  • A practical reference manual Treatment of children and adolescents with diabetes Dr. Birthe S Olsen, Consultant Paediatrician Dr. Henrik Mortensen, Chief Physician, Senior Paediatric Endocrinologist Department of Paediatrics, Glostrup University Hospital, Copenhagen, Denmark
  • Childhood diabetes
    • 90% Type 1 diabetes
    • Absolute or relative insulin deficiency
    • Auto-immune process
    • Pancreatic beta-cell destruction
    Definition
  • Aetiology
    • Genetic susceptibility:
      • HLADR3, HLADR4: risk increased
      • HLADR2 : risk reduced
    • Environmental factors:
      • viral factors
      • nutritional factors
    Definition
  • Epidemiology
    • Most common endocrine disease in childhood
    • Highest incidence in Finland and Sardinia
    • Highest incidence in males
    • Highest incidence at 10–12 years and 5–7 years
    • Increasing incidence in very young children (0–4 years)
    • Seasonality
    • More common in families where father has diabetes
    Definition
  • Pre-diabetes phase
    • Gradual destruction of beta-cells
    • Development of auto-antibodies:
      • ICA
      • IAA
      • GADA
    Definition
  • Prevention
    • Primary intervention:
      • aim: reducing the prevalence of a given condition in susceptible individuals
        • Example: cow's milk exclusion in infancy
    • Secondary intervention:
      • aim: early detection of a given disease and stopping or slowing further progression
        • Example: ENDIT study
    • Tertiary intervention:
      • aim: preventing complications associated with a disease
        • Example: improvement in glycaemic control, screening for complications
    Definition
  • Management – primary goals
    • To ensure that insulin is available for all children
    • To ensure that the child gradually takes over the responsibility for the disease (self-care)
    • To ensure optimum glycaemic control
    • To ensure freedom from diabetic complications
    • To ensure normal growth and development
    The newly diagnosed child
  • Early diagnosis
    • Symptoms and signs:
      • polydipsia
      • polyuria
      • night-time incontinence
      • loss of weight
      • irritability
      • abdominal pain
      • visual disturbances
      • frequent infections
    The newly diagnosed child
  • Early diagnosis
    • Diagnosis:
      • fasting blood-glucose concentration > 7.7 mmol/l
      • random blood-glucose concentration > 11 mmol/l
      • glucosuria
      • ketonuria
      • ketoacidosis
    • Differential diagnosis:
      • inflamed appendix
      • pneumonia
      • urinary tract infection
    The newly diagnosed child
  • The multi-disciplinary team
    • The cornerstone in childhood diabetes management:
      • a paediatric endocrinologist
      • a specialised nurse
      • a specialised dietician
      • a chiropodist
      • a specialised social worker
      • a childhood psychologist
      • close collaboration with other relevant departments
    The team
  • The multi-disciplinary team
    • The team should…
      • have common attitudes and philosophy
      • meet regularly for discussion and education
      • develop written material dealing with daily-life and emergency issues
      • encourage research into childhood diabetes
      • attend in-service training
    The team
  • Diabetes education 1
    • Initial ‘survival’ education:
      • the causes of diabetes
      • insulin management
      • injection technique
      • blood glucose measurements
      • acceptable blood glucose values
      • advice about hypo- and hyperglycaemic episodes
      • dietary advice
    Diabetes education
  • Diabetes education 2
    • aetiology and pathology
    • injection devices and methods
    • blood-glucose monitoring
    • diet
    • insulin adjustments
    • hypoglycaemia
    • insulin-treatment
    • hyperglycaemia
    • sick-day management
    • sport
    • alcohol
    • drug abuse
    • travelling
    • gynaecological issues
    • complications
    Over the next months and years a more comprehensive education programme, adjusted to the age and maturity of the child: Diabetes education
  • Diabetes education 3
    • The knowledge and skills of the child should be regularly assessed
    • Re-education should be performed accordingly
    Diabetes education
  • Treatment
    • At diagnosis
    • Remission phase
    • Long-term
    Initial treatment
  • Non-ketotic child
    • Insulin:
      • subcutaneous
      • multiple dose rapid-acting insulin before meals, or
      • combination of rapid- and intermediate-acting insulin twice daily
      • insulin requirements may exceed 1.5–2 IU/kg/24 hours
    • Potassium:
      • < 12 years 750 mg KCl for 3–4 days
      • > 12 years 1500 mg KCl for 3–4 days
    Initial treatment
  • Non-ketoacidotic child
      • hospital stay as short as possible
      • in paediatric setting
      • frequent visits to out-patient clinic
      • 24-hour hot-line service
      • home and institution visits
    • Always managed at hospital in case of:
      • ketoacidosis
      • severe dehydration
      • very young age
      • infection
      • psychosocial problems
      • language and cultural difficulties
    Initial treatment
  • The remission phase
    • Duration from weeks to months
    • Shorter in young children
    • Blood glucose values between 4–8 mmol/l
    • Decreasing insulin requirements < 0.5 IU/kg/24 hours
    • One daily insulin injection is often sufficient
    • Insulin injections should not be abandoned
    Partial remission phase
  • Long-term management
    • Twice daily or multiple insulin injections
    • Regular blood glucose measurements
    • At least 4 visits to out-patient clinic every year
    • Instant HbA 1c measurements at every visit
    • Height and weight measurements at every visit
    • Physical examination with pubertal staging every year
    • Regular screening for diabetes related complications
    Partial remission phase
  • Insulin
    • All children with Type 1 diabetes must have insulin
    • Consequences of long-term insulin omission:
      • growth retardation
      • delayed puberty
      • poor metabolic control
      • microvascular complications
      • short life expectancy
      • poor quality of life
    Insulin
  • Insulin types and duration of action
    • Insulin
    • preparation
    • Short-acting
    • Intermediate-acting
    • Premixed insulin 10/90
    • Premixed insulin 20/80
    • Premixed insulin 30/70
    • Premixed insulin 40/60
    • Premixed insulin 50/50
    • Rapid-acting insulin analogue
    Onset of action (h or min) 30 min. 1–2 h 0.5–1 h 0.5–1 h 0.5–1 h 0.5–1 h 0.5–1 h 10–20 min. Peak action (h) 1–3 4–12 2–8 5–10 5–9 1–3 1–3 1–3 Maximal duration (h) 6–8 18–24 18–24 18–24 18–24 18–24 18–24 3–5 Insulin
  • Short-acting insulin
    • Clear solution
    • Indications for use:
      • daily management of diabetes, alone or in combination with intermediate-acting insulin
      • hyperglycaemia
      • sick-day management
      • intravenous therapy
    Insulin
  • Intermediate-acting insulin
    • Cloudy solution (should be thoroughly mixed before use)
    • Indications for use:
      • daily management of diabetes, alone or in combination with short-acting insulin
    Insulin
  • Pre-mixed insulin
    • Cloudy solution (should be thoroughly mixed before use)
    • Indications for use:
      • daily management of diabetes, alone or in combination with short-acting insulin
    Insulin
  • Rapid-acting insulin (Insulin Aspart)
    • Clinical benefits
      • improved metabolic control compared with human soluble insulin
      • fewer hypoglycaemic episodes
      • no post-prandial hypoglycaemia
            • rapid onset of action
            • short duration of action
            • better quality of life and improved convenience
    Insulin
  • Rapid-acting insulin (Insulin Aspart)
    • Patient targeting:
      • newly diagnosed children and adolescents with diabetes
      • children and adolescents currently on basal/bolus regimens
            • children and adolecents with poorly controlled diabetes on twice daily therapies
    Insulin
  • Storage of insulin
    • Stable at room temperature for weeks
    • Should not be exposed to temperatures > 25ºC or under freezing point
    • Unused vials and cartridges should be stored in the refrigerator
    • Should never be exposed to sunlight
    • Should never be frozen
    Insulin
  • Injection sites
    • Short acting insulin:
      • injected subcutaneously into the abdomen at a 45° angle
    • Intermediate-acting and pre-mixed insulins:
      • injected subcutaneously in the front of the thighs or into the buttocks at a 45° angle
    Insulin
  • Insulin absorption
    • Factors influencing insulin absorption:
      • injection site
      • injection depth
      • insulin type
      • insulin dose
      • physical exercise
      • skin temperature
    Insulin
  • Insulin requirements
    • Remission period
      • < 0.5 IU/kg/24 hours
    • Pre-pubertal period
      • 0.6–1.0 IU/kg/24 hours
    • Pubertal period
      • 1.0–2.0 IU/kg/24 hours
    Insulin
  • Insulin regimens
    • Insulin regimens should be:
      • adjusted to age, maturity and motivation
      • as simple as possible
    • Children for multiple injection therapy should:
      • be selected carefully
      • understand the relationship between insulin, food and physical exercise
      • be motivated and have family support
      • be willing to measure blood glucose several times each day
      • be willing to inject insulin at school
    Insulin
  • Insulin regimens
    • Most widely used insulin regimens:
      • twice-daily injections, mixture short and intermediate, before breakfast and the evening meal
      • three daily injections, mixture short and intermediate before breakfast, short-acting before the evening meal and intermediate-acting before bed
      • short-acting insulin before main meals, intermediate before bed
    Insulin
  • Insulin distribution
    • Twice daily injection regimen:
      • 2/3 of daily dose before breakfast,
      • 1/3 before supper
      • both 2/3 intermediate-acting and 1/3 short-acting insulin
    • Three-times daily injection regimen:
      • 40–50% before breakfast (2/3 intermediate- and 1/3 short-acting)
      • 10–15% short-acting before supper
      • 40% intermediate-acting before bed.
    • Multiple injection regimen:
      • 30–40 % (intermediate) before bed
      • the rest (short-acting) before main meals
    Insulin
  • Insulin adjustments
    • Twice-daily injection regimen:
      • Blood glucose high: Dose of insulin to increase
      • Before breakfast or overnight Evening intermediate-acting
      • Before lunch Morning short-acting
      • Before dinner Morning intermediate-acting
      • Before bed Evening short-acting
      • Blood glucose low: Dose of insulin to decrease
      • Before breakfast or overnight Evening intermediate- acting
      • Before lunch Morning short-acting
      • Before dinner Morning intermediate-acting
      • Before bed Evening short-acting
    Insulin
  • Insulin adjustments
    • Three-times daily injection regimen:
      • Blood glucose high: Dose of insulin to increase
      • Before breakfast or overnight Evening intermediate- acting
      • Before lunch Morning short-acting
      • Before dinner Morning intermediate-acting
      • Before bed Evening short-acting
      • Blood glucose low: Dose of insulin to decrease
      • Before breakfast or overnight Evening intermediate- acting
      • Before lunch Morning short-acting
      • Before dinner Morning intermediate-acting
      • Before bed Evening short-acting
    Insulin
  • Insulin adjustments
    • Basal-bolus (multiple injection) regimen:
      • Blood glucose high: Dose of insulin to increase
      • Before breakfast or overnight Evening intermediate-acting
      • Before lunch Morning short-acting
      • Before dinner Lunch time short-acting
      • Before bed Evening short-acting
      • Blood glucose low: Dose of insulin to decrease
      • Before breakfast or overnight Evening intermediate-acting
      • Before lunch Morning short-acting
      • Before dinner Lunch time short-acting
      • Before bed Evening short-acting
    Insulin
  • Diet
    • Nutritional advice should take into consideration:
      • individual requirements
      • local customs
      • family dietary habits
    • General recommendations:
      • eat a broad variety of food
      • eat plenty of bread, cereals, vegetables and fruit
      • eat only small amounts of sugar
      • in young children fat intake should not be restricted
      • older children and adolescents should eat a low fat diet
      • choose food with small amounts of salt
      • encourage breast-feeding at least until six months of age
    Diet
  • Diet: principles
    • Number of meals:
      • 3 main meals
      • 3 snacks
      • adapted to age, physical activity and insulin regimen
    • Energy intake:
      • 1000 calories (4180 Kj) + 100 calories/year of age
      • 50–55% of energy from carbohydrates
      • 30% of energy from fat
      • 15–20% of energy from protein
    Diet
  • Carbohydrates
    • Glycaemic index (GI):
      • carbohydrate ranking system
      • based on post-prandial blood glucose response
      • low GI = slow, sustained blood glucose response (e.g. rice, pasta)
      • high GI = rapid and high blood-glucose response (e.g. white bread, candy/sweets, cornflakes, honey, sugar)
    Diet
  • Carbohydrates
    • Carbohydrate exchange system:
      • based on the carbohydrate content and not the weight of the food
      • makes it easy to exchange carbohydrate containing food elements (e.g. 15 g carbohydrates in candy for 15 g carbohydrates in fruit)
      • one exchange usually contains 10–15 g carbohydrate
    Diet
  • Effects of exercise
    • Increases insulin sensitivity
    • Improves the physical state
    • Reduces the risk of cardiac diseases
    • Reduces the risk of hypertension
    • Does not improve metabolic control
    • Increases the risk of hypoglycaemia
    Exercise
  • Food adjustments Exercise from 2nd hour 25-50 g/h 10-15 g 10-15 carb rich meal after 2 hrs 25-50 g/h 25-50 g 7-10 50 g within the 1 st hour 25-50 g/h 50 g below 7 Strenuous exercise (football, basketball, running, swimming, aerobics) carb rich meal after 2 hrs from 2nd hour 15-25 g/h nothing 10-15 15-25 g/h 10-15 g 7-10 50 g within the first hour 15-25 g/h 25-50 g below 7 Moderate exercise (tennis, jogging, golf, cycling) nothing above 7 if necessary 10 g from 2nd hour 10-15 g/h 0-15g below 7 Mild exercise (walking, slow speed cycling) After During exercise Before Before exercise Carbohydrate intake Blood glucose (mmol/L) Type of activity
  • Guidelines
    • Measure blood glucose before, during and after physical exercise
    • Increased risk of hypoglycaemia 12–40 hours after strenuous physical exercise
    • Reduce short-acting insulin accordingly
    • Blood glucose before bedtime should be > 10–12 mmol/l
    Exercise
  • Definition and causes
    • Blood glucose < 3 mmol/l
      • Mild (Grade 1): recognised and treated orally by the patient
      • Moderate (Grade 2): treated orally, with help from someone else
      • Severe (Grade 3): unconscious or having fits – nothing by mouth
    • Causes:
      • strenuous exercise
      • missed meals
      • injection errors
    Hypoglycaemia
  • Symptoms
    • Neurogenic :
      • sweating
      • hunger
      • tremor
      • pallor
      • restlessness
    • Neuroglycopenic :
      • weakness
      • headache
      • change in behaviour
      • tiredness
      • visual and speech disturbances
      • vertigo
      • lethargy
      • confusion
      • fits and unconsciousness
    Hypoglycaemia
  • Treatment
    • Mild hypoglycaemia (Grade 1):
    • 10–20 g glucose tablets, juice or sweet drinks
    • 1–2 slices of bread
    • Moderate hypoglycaemia (Grade 2):
    • 10–20 g glucose tablets
    • 1–2 slices of bread
    • Severe hypoglycaemia (Grade 3):
    • Outside hospital:
      • children < 10 years: 0.5 mg glucagon i.m.
      • children > 10 years: 1.0 mg glucagon i.m.
    • In hospital:
      • bolus glucose (20%) 1 ml/kg over 3 min followed by
      • glucose (10%), 0.2 ml/kg/min
    Hypoglycaemia
  • Definition and aetiology
    • Severity degree:
      • Mild ketoacidosis bicarbonate > 16 and < 22 mmol/l
      • Moderate ketoacidosis bicarbonate > 10 and < 16 mmol/l
      • Severe ketoacidosis bicarbonate < 10 mmol/l
    • Characterised by:
      • absolute insulin deficiency
      • increased level of counter regulatory hormones
    • Aetiology:
      • newly diagnosed
      • infections
      • insulin omission
    Diabetic ketoacidosis
  • Symptoms and signs
    • Dehydration
    • Vomiting
    • Loss of weight
    • Kussmaul respirations
    • Acetone smell
    • Impaired sensorium
    • Shock
    Diabetic ketoacidosis
  • Diagnosis
    • Clinical appearance
    • Hyperglycaemia
    • Ketonuria
    • Ketonaemia
    • Plasma bicarbonate < 22 mmol/l
    Diabetic ketoacidosis
  • Treatment : fluid
    • Due to the risk for overhydration:
      • fluid volume in the first 24 hours should not exceed 4 l/m 2
      • rehydration over 24–36 hours
    • Initiate treatment with isotonic 0.9 % saline:
      • 1st hour: 20 ml/kg body weight (previous)
      • 2nd hour: 10 ml/kg body weight
      • 3rd hour onwards: 5 ml/kg body weight
    • When blood glucose levels are below 12 mmol/l:
      • 5–10 % glucose solution
    Diabetic ketoacidosis
  • Treatment : insulin
    • Low-dose insulin regimen:
      • short-acting insulin
      • intravenously
      • bolus or continuous infusion
      • 0.1 IU/kg/hour
    • Ideal blood-glucose reduction:
      • maximal 4–5 mmol/l
    • Until acidosis is corrected:
      • adjust insulin and fluid to blood glucose level between 5–15 mmol/l
    Diabetic ketoacidosis
  • Treatment : potassium
    • DKA is always accompanied by severe potassium deficiency
    • Treatment:
      • initially add 20 mmol KCl to 500 ml fluid
      • adjust potassium replacements to plasma potassium level:
      • plasma potassium potassium chloride (mmol/l) (mmol/kg/h)
      • < 3 0.5 3–4 0.4 4–5 0.3 5–6 0.2 > 6 nothing
    Diabetic ketoacidosis
  • Treatment
    • Sodium:
      • measured level low due to dilution
      • only correction if values are below 120 mmol/l
      • if values are above 160 mmol/l (hypernatriaemic state)
      • rehydrate over 48–72 hours
    • Bicarbonate:
      • only in very sick children with severe ketoacidosis (pH < 7.0)
      • recommended dose 1–2 mmol/kg
      • ½ of the dose over 30 minutes and ½ over 1–2 hours
    • Hazards of bicarbonate treatment:
      • precipitation of hypokalaemia
      • paradoxical exacerbation of CNS acidosis
      • cerebral oedema
    Diabetic ketoacidosis
  • Cerebral oedema
    • Aetiology:
      • rapid fluid correction
      • hyperglycaemia
      • bicarbonate treatment
    • Treatment:
      • fluid restriction
      • hyperventilation
      • mannitol infusion 1–2 g/kg over 20–30 minutes
    • Prognosis:
      • very poor
    Diabetic ketoacidosis
  • Sick-day management
    • Basis for sick-day management at home:
      • insulin should never be omitted
      • frequent blood glucose measurements
      • frequent urine testing for ketone bodies
      • close contact with the diabetes team
    • Situations where admittance to hospital is indicated:
      • persistant vomiting
      • increasing ketone bodies in the urine
      • increasingly sick child
      • abdominal pain
      • non-compliance and psycho-social problems
      • language and cultural difficulties
      • very young age (< 2 years)
    Sick-day management
  • Sick-day management
    • Situations with high fever, high blood-glucose and ketonuria:
      • most often caused by bacterial infections
      • seek and treat the infection focus
      • give frequent subcutaneous injections of short-acting insulin
      • continue treatment until ketone bodies have disappeared
      • give glucose containing food or drinks to maintain acceptable blood glucose values
      • encourage the child to drink plenty of fluids
    Sick-day management
  • Sick-day management
    • Situations with low-grade fever, low blood-glucose and ketonuria
      • most often caused by viral infections
      • associated with anorexia, vomiting and diarrhoea
      • reduce short- and intermediate- acting insulin according to blood glucose values
      • give glucose containing food or drinks to maintain acceptable blood glucose values
      • encourage the child to drink plenty of fluids
    Sick-day management
  • M inor surgery (duration < 3h)
    • Insulin:
      • in the morning intermediate-acting insulin, 1/2 to 2/3 of total daily dose
      • if blood glucose is above 20 mmol/l supply with a small dose short-acting insulin
      • in the evening give intermediate-acting insulin, 1/3 of daily dose
    • Fluid:
      • glucose 5% intravenously, volume according to age
    • Blood glucose monitoring:
      • every 1–2 hours
      • values between 10–14 mmol/l
    Surgery
  • Major surgery (duration > 3h)
    • Insulin and fluid:
      • infusion solution containing 5% glucose and 20 mmol/l sodium chloride (maintenance volume)
      • 50 IU short-acting insulin in 500 ml 0.9 % saline by separate drip infusion 0.5 ml = 0.05 IU/kg/hour
    • Blood glucose monitoring:
      • every 1–2 hours
      • values between 6–14 mmol/l
      • if < 5 mmol/l reduce infusion rate
      • continue infusion therapy until food intake is re-established
    Surgery
  • Tests
    • HbA 1c :
      • average blood glucose over last 4–6 weeks
      • should be measured and available at every out-patient clinic visit
    • Home blood glucose (HBG) measurement:
      • ideally before breakfast, lunch, evening meal and bedtime
      • before, during and after physical exercise
      • during intercurrent illnesses
      • if hypo- or hyperglycaemia is suspected
      • following hypoglycaemia
      • after changing insulin dose
      • frequency of HBG should be adjusted to age, insulin regimen and acceptance of the child
    • Urine testing:
      • ketone testing in case of fever and high blood glucose
    Glycaemic control
  • Goals
    • Well-adjusted children/adolescents with normal growth and development
    • HbA 1c between 7–9%
    • Less than 10–20 severe hypoglycaemia episodes and ketoacidosis per 100 patient years
    • Post-prandial blood glucose values below 10–12 mmol/l
    • Pre-prandial blood glucose values between 4–8 mmol/l
    • Glycaemic goals less strict for very young children
    • Goals realistic and individualised in puberty
    Glycaemic control
  • Microvascular complications
    • Microvascular complications in kidneys, eyes and nerves:
      • closely related to poor long-term metabolic control
      • occur from puberty
      • preceded by subclinical changes
      • can be delayed or prevented by good metabolic control
    Complications
  • Diabetic nephropathy
    • Leading cause of increased morbidity and mortality in Type 1 diabetes
    • Preceded by microalbuminuria (albumin excretion rate > 20 µg/min)
    • Prevalence in adolescence 5–20%
    • Correlated with long-term metabolic control
    • Long diabetes duration
    • Elevated arterial blood pressure
    • Genetic susceptibility
    Complications
  • Diabetic nephropathy
    • Annual screening:
      • after 5 years’ diabetes duration in pre-pubertal children
      • after 2 years’ diabetes duration in adolescents
    • Screening method:
      • albumin excretion rate calculated from night-time urine collections
    • Microalbuminuria treatment:
      • improved long-term metabolic control
      • normalising arterial blood pressure
      • smoking discouraged
      • ACE-inhibition
    Complications
  • Diabetic retinopathy
    • Leading cause of visual loss and blindness in working-age population
    • Prevalence in adolescence: 10–80%
    • Correlated with long-term metabolic control
    • Long diabetes duration
    • Elevated arterial blood-pressure
    • Genetic susceptibility
    • Background retinopathy:
      • not vision threatening
      • stable for many years
    • Proliferative retinopathy:
      • vision-threatening
      • new vessels
      • retinal retraction
    Complications
  • Diabetic retinopathy
    • Annual screening:
      • after 5 years’ diabetes duration in pre-pubertal children
      • after 2 years’ diabetes duration in adolescents
    • Screening method:
      • ophthalmoscopy
      • fundus photography
      • fluorescein angiography
    • Retinopathy treatment:
      • improved long-term metabolic control
      • normalising arterial blood pressure
      • laser therapy in case of proliferative retinopathy
    Complications
  • Diabetic neuropathy
    • Peripheral and autonomic
    • Rare in childhood and adolescence
    • Preceded by subclinical abnormalities
    • Correlated with
      • poor long-term metabolic control
      • long diabetes duration
      • older age
      • higher Tanner stage
      • male sex
    Complications
  • Diabetic neuropathy
    • Annual screening:
      • from puberty
    • Screening method:
      • ankle reflexes
      • sensation (temperature discrimination)
      • non-invasive test of nerve function (biothesiometry)
    • Neuropathy treatment:
      • improved long-term metabolic control
    Complications
  • Adolescence
    • Insulin insensitivity
    • Poor metabolic control
    • Insulin omission
    • Overweight
    • Eating disorders
    • Psychosocial problems
    • Microvascular complications
    Adolescence
  • Treatment strategies
    • Non-threatening open-minded atmosphere
    • Patience
    • Respect
    • Flexible appointment times
    • Opportunity to meet other adolescents with diabetes
    • Planned transition to adult setting
    • Parental involvement
    Adolescence
  • Risk-taking behaviour
    • Alcohol:
      • impairs gluconeogenesis
      • associated with severe hypoglycaemia
    • Advice:
      • drink in moderation
      • eat complex carbohydrates while drinking alcohol
      • if HBG is not measured always eat extra food before bedtime
      • make sure that your friends are aware of your diabetes
      • always wear your diabetes amulet when going to parties
      • measure HBG before going to bed
      • measure blood glucose (HBG) regularly
    Adolescence
  • Risk-taking behaviour
    • Smoking:
      • harmful to the health of all people
      • associated with increased risk of microvascular complications
      • is expensive
      • is addictive
    • Drug abuse:
      • should be considered in connection with other risk-taking behaviour
    Adolescence
  • Gynaecological issues
    • Menstruation:
      • may be irregular due to poor metabolic control
      • may be accompanied by high blood glucose levels
    • Oral contraceptives with low-dose oestrogen:
      • safe for most adolescents with diabetes
      • may be accompanied by insulin resistance
      • not to be used in cases of arterial hypertension
    • Condoms:
      • safe contraceptive method
      • protect against sexually transmitted diseases
    Adolescence
  • School
    • All children should be attending school
    • Academic expectations should be the same
    • Teachers and school nurse should be informed about general rules and emergency situations
    • Written material about diabetes should be handed out to school staff
    • A close communication should exist between home and school
    Camps, school and travel
  • Travelling
    • Appointment in the out-patient clinic 4–6 weeks before travel
    • Improve metabolic control, if necessary
    • Make sure that the family is capable of treating hypo- and hyperglycaemic episodes
    • Make sure that the family is informed about sick-day management
    • Make sure that travel health insurance is valid
    Camps, school and travel
  • Travelling
    • Bring:
      • introduction letter
      • sufficient insulin, needles, blood glucose testing material and glucagon
      • blood glucose meters and extra batteries
      • extra food and drink
    • Long flights:
      • stick to the ‘home-time’ and normal routines
      • 6-hourly injections of short-acting insulin
    Camps, school and travel
  • Psychosocial problems
    • Psychosocial problems in childhood diabetes:
      • imposes major demands on child and family
      • pre-existing problems may interfere with patients compliance
      • different psychological problems may emerge in different age-groups
    • Parents:
      • in shock at diagnosis
    • Young children:
      • needle-phobia and eating problems
    • Adolescents:
      • poor compliance, insulin omission, eating disorders
    • The team should:
      • look for these problems from diagnosis
      • take care that early counselling is initiated
    Psychosocial problems