EAST OF ENGLAND CHILDREN AND YOUNG PEOPLE S DIABETES NETWORK. Optimising Glycaemic Control for Children and Young People with Diabetes

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1 EAST OF ENGLAND CHILDREN AND YOUNG PEOPLE S DIABETES NETWORK Optimising Glycaemic Control for Children and Young People with Diabetes Local diabetes teams need to take on the responsibility of ensuring that any staff in their trust who are expected to use these guidelines are given training in how to use them. Authors: 2 nd edition, this edition has been updated in light of NG 18. Updated by Barbara Piel, Consultant Paediatrician, The Queen Elizabeth Hospital King s Lynn Contributions: Jacqueline Angelo-Gizzi, Babita Khetriwal, Cristina Matei and Kalika Shah- Enderby 1 st edition, June 2014 Nadeem Abdullah, Consultant Paediatrician, Cambridge University Hospitals Foundation Trust Heather Mitchell, Consultant Paediatrician, West Herts Hospitals Trust Contributions: John Hyde, Retired Consultant Paediatrician Julia Brown, PDSN, Bedford General Hospital, Bedford, EoE Paediatric Diabetes Network Text East of England Children and Young People s Diabetes Network

2 Optimising Glycaemic Control CONTENTS 1. Purpose and scope 3 2. Monitoring glycaemic control 3 3. Targets 3 4. Insulin 3 a. Basal insulin 4 i. MDI ii. CSII b. Bolus insulin 5 5. Hyperglycaemia 5 6. Hypoglycaemia 6 7. Insulin injections and sites 6 8. Diet 7 9. Exercise CGMS Education Psychosocial support References Appendix 1 9 Page 2 of 9

3 1. Purpose and Scope This guideline offers guidance on optimising glycaemic control in children and young people (CYP) with type 1 diabetes who are managed by the Paediatric Diabetes team. These patients should be offered an ongoing integrated package of care by a multidisciplinary paediatric diabetes care team. To optimise the effectiveness of care, the team should include members with appropriate training in clinical, educational, dietetic, lifestyle, mental health and foot care aspects of diabetes for CYP. 2. Monitoring Glycaemic Control Patients should be encouraged to test their cutaneous blood glucose (CBG) regularly, at least 5 x/day 2. In particular, on waking, pre and if possible 2 hours after meals, after school, pre child s and /or parents bedtime and if they feel unwell. Patients who are reluctant to test should be encouraged to test their CBG at the most useful times to target their insulin adjustment. Their HbA1c levels should be tested four times per year (more frequent testing may be appropriate if there is concern about poor glycaemic control or in very young children - see guideline care of children and young people with an HbA1C greater than 75 mmol/mol (9%) ). 3. Targets: Patients should be encouraged to aim for stable CBG levels and an HbA1c of 48 mmol/mol if possible without troublesome hypoglycaemia. They should aim for a blood glucose of 4-7mmol/l pre meals and 5 9 mmol/l 2 hours after meals 2. Before driving however the blood glucose level must be 5 mmol/l. Each child or young person should have agreed individualised objectives, which are written if possible and include a timescale for achievement. These should be reviewed and updated regularly. They should cover: Lifestyle goals Target CBG and how to achieve this through insulin adjustment. Therapeutic interventions (both pharmacological and non-pharmacological) Self-care Education and care plan for school/college Early warning signs of high and low CBG, and what to do if these occur Who to contact for advice and their contact details Planned review date and how to access a review more quickly, if necessary 4. Insulin Offer children and young people with type 1 diabetes multiple daily injection (basal bolus) insulin regimens from diagnosis. If a multiple daily injection regimen is not appropriate for a child or young person with type 1 diabetes, consider continuous subcutaneous insulin infusion (CSII or insulin pump) as per NICE guidance. Provode level 3 carbohydrate counting from diagnosis. If neither MDI nor CSII is appropriate the patient should b e given a twice daily (mix insulin at breakfast and at bedtime) or t.d.s (mix insulin at breakfast, rapid acting insulin at dinner and basal insulin at bedtime) insulin regimen. This should be discussed with the CYP diabetes team. Page 3 of 9

4 Patients and their families should be encouraged to adjust their own insulin to achieve target glucose levels. In younger children < 2 years of age it may be more appropriate to commence insulin pump therapy at the time of diagnosis or as soon as possible after the diagnosis. a. BASAL INSULIN MDI For those on MDI regimen the waking CBG should be used to adjust the basal insulin. If the waking CBG is regularly >7 mmol/l (despite bed time readings in target range) patients should increase their dose until the waking glucose is <7mmol/l. If the waking CBG is usually <4 mmol/l the basal insulin should be reduced. Basal insulin analogues available are Glargine (Lantus ), Detemir (Levemir ) and newly licensed in children Degludec (Tresiba ), the latter could be beneficial in patients who struggle to gove their insulin at reliable times or who suffer from frequent hypos particularly whilst sleeping. Levemir in small doses may not provide 24 hour basal insulin action. Therefore, it may be appropriate to consider administering Levemir twice daily especially in those who struggle with giving insulin at meal times. Insulin pump therapy The ability to deliver pre-programmed basal insulin to meet increased or decreased demands throughout 24 hours is particularly important in paediatric practice due to the wide range of insulin requirements relating to puberty and other physiological factors. The successful insulin pump therapy depends on appropriate contribution of basal insulin to the total daily dose and is dependent on the age of the child. The diabetes team members should be aware of the circadian profiles in insulin pump therapy as they differ for preschool, prepubertal, adolescents and young adults. Basal rates can be increased during early morning to prevent the rise in blood glucose before breakfast associated with the dawn phenomenon or decreased during exercise or at other times when hypoglycaemia is anticipated. Carbohydrate-free periods (basal testing) may be used to help with the basal rate adjustments. Alternatively use of CGMS for 3 to 7 days may be helpful to adjust the basal rates. CYP may need different basal profiles during weekends or holidays. Temporary basal rates can be used for short term adjustments such as for febrile illnesses or exercise. Page 4 of 9

5 b. BOLUS INSULIN Timing of insulin bolus in relation to meals is critical in preventing post prandial hyperglycaemia. Indirect evidence suggests that post prandial hyperglycaemia is an independent risk factor for the development of long term complications of diabetes and contributes significantly towards higher HbA1c. MDI If a post prandial CBG (2 hours after meal) is >2mmol/l higher than a pre meal CBG the mealtime bolus needs increasing. This can be done by increasing the dose gradually if on fixed doses or by reducing the insulin carb ratio (ICR). If post prandial CBGs are erratic while carb counting, the patient should be reviewed by the dietitian to ensure accuracy in carb counting. Varying ICRs may be required for different times of the day. Patients should be encouraged to give bolus insulin for all food including meals and snacks (any amount of carbohydrate will elevate the blood sugar, therefore even for snacks below 20 g CHO insulin would be beneficial). A correction bolus should be given with their mealtime bolus if their CBG is high (100 rule). All bolus doses should be administered pre meals unless the patient had a hypoglycaemic episode just before the meal, when a post meal injection may be appropriate. Insulin pump therapy In addition to the above the children on insulin pump therapy should be encouraged to give more boluses each day. More than 7 boluses are associated with significantly improved HbA1c. Consider other types of boluses (extended/square wave or dual wave/combo/multiwave), if there are unexpected episodes of hypoglycaemia within two hours after meal despite accurate counting of carbs. 5. Hyperglycaemia All patients should know to give a correction bolus when their CBG is high. Consider the use of bolus wizards for more accurate dose calculation. Consider causes for hyperglycaemia by looking back at the preceding few hours examining insulin doses, food intake, hormones, exercise and emotions. Morning hyperglycaemia secondary to growth hormone is common in growing young people. Increase the dose of overnight basal insulin; for MDI give the basal insulin as late as possible and for those on insulin pump increase the basal rates between 02:00 to 06:00 hours of the morning. Remember adolescent girls need higher doses of insulin around the time of their periods. Every effort should be made to prevent post prandial hyperglycaemia. For HBA1c <64 mmol/mol, post-meal BG contributes to 70% of elevated HBA1c. See appendix 1 as a guide on how postprandial hyperglycaemia can be prevented. Page 5 of 9

6 6. Hypoglycaemia In order to obtain a target HbA1c level of 48 mol/mol (6.5%) or less, it is reasonable to expect 2 to 3 hypoglycaemic episodes per week which are mild, able to be detected by the child/young person (except for infants / young children) and in which the cause can usually be determined. Hypoglycaemic episodes that occur at particular times of the day, forming a pattern should be investigated further and an adjustment in insulin dose may be required. Episodes that are severe in nature, requiring third party assistance and where a cause cannot be determined should be investigated further. CYP with type 1 diabetes, their parents and other carers should be informed that they should always have access to an immediate source of carbohydrate (glucose or sucrose) and blood glucose monitoring equipment for immediate confirmation and safe management of hypoglycaemia (see Hypoglycaemia in Children and Young People with diabetes EoE CYP diabetes network February 2017 ). Consider causes for hypoglycaemia by looking back at the preceding few hours examining insulin doses, food intake, exercise and emotions. Where a cause is identified discuss alternative strategies. Encourage appropriate treatment of hypos, while avoiding hyperglycaemia. Be aware that some patients may choose to run their CBG levels high in order to avoid hypos. Care should be taken to avoid increased hypos when increasing their insulin in order to help them keep confidence in the process. 7. Insulin injection sites and technique MDI There should be no doubt of the importance of good injection technique. Injecting into the subcutaneous tissue allows insulin to be absorbed at a more predictable rate and results in better glycaemic control. Poor technique, such as using the incorrect needle length, can lead to intramuscular deposition of insulin, which can result in unpredictable glucose levels. The health professional should follow the best practice recommendations as laid out in The FIT UK Injection Technique Recommendations, 4 th edition October Many children and young people experience lipohypertrophy. NICE (2015) recommends monitoring of injection sites at each clinic visit 2. Opportunities for children, young people and their families to refresh their injection technique skills should be provided as part of their annual review. Children and young people face several psychological challenges presented by injections and these should be addressed as part of annual review. Page 6 of 9

7 Insulin pump The infusion set should be placed in the subcutaneous tissue using recommended technique depending on the type of the pump. The infusion set should be changed every 2 to 3 days. 8. Diet CYP with type 1 diabetes should be offered appropriate dietetic support to help optimise body weight and glycaemic control. CYP and their families should be offered education on Carbohydrate counting, if possible at diagnosis and commenced on a smart meter. 9. Exercise CYP and their families should be informed about the effects of exercise on CBG levels and about strategies for preventing exercise induced hypoglycaemia during and/or after physical activity. The type of exercise (aerobic vs anaerobic) and duration along with the likely effect on blood glucose should be considered and advice tailored to the needs of that exercise. 10. CGMS Guidelines on the use of these devices recommend: NICE (NG ) offer continuous CGMS to patients with: frequent severe hypoglycaemia or impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) or inability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities). neonates, infants and pre-school children children and young people who undertake high levels of physical activity (for example, sport at a regional, national or international level) children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (for example corticosteroids) that can make blood glucose control difficult. BSPED - to lower HbA1c when this remains above the individuals target despite optimised use of intensive insulin regimens (MDI or CSII). Also consider using these devices: Where it is difficult to see patterns in glycaemic control Insulin adjustment during sports activities Reluctance to adjust insulin due to fear of overnight hypoglycemia Dawn or Smogyi phenomena To help adjust fine tune adjustments in pump settings Page 7 of 9

8 11. Education CYP with type 1 diabetes and their families should be offered timely and ongoing opportunities to access information about the development, management and effects of type 1 diabetes. The information provided should be accurate and consistent and it should support informed decision-making. 12. Psychosocial support CYP with type 1 diabetes and their families should be offered timely and ongoing access to mental health professionals because they may experience psychological disturbances (such as anxiety, depression, behavioural and conduct disorders and family conflict) that can impact on the management of diabetes and well-being. 13. References 1. ISPAD Clinical Practice Consensus Guidelines NICE guideline: Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18) at: (accessed ) 3. Guideline produced by the Countess of Chester Hospital NHS Foundation Trust 4. Pankowska E, et al. Basal insulin and total daily insulin dose in children with T1DM using insulin pumps. Ped Diabetes 2008, 9: Bachran R, et al. Basal rates and circadian profiles in CSII differ for preschool children, prepubertal children, adolescents and young adults. Ped Diabetes 2011, 3: Battelino T et al. The PedPump survey: a low percentage of basal insulin and more than seven boluses are an option for better glycaemic control in 1806 children on CSII. Diabetologia International diabetes federation. Diabetic medicine 2008, 25: Wilmot EG et al. Insulin pump therapy. Practical diabetes 2014, 31: Frid A. Fat thickness and insulin administration, what do we know? Infusystems International 5: Hicks Det al. (2011). The First UK Injection Technique Recommendations (2 nd edition). Available at: (accessed ) 11. Carloe G. FIT recommendations aim to create a culture of good injection technique. Diabetes care for Children & Young People, 3: Ewa Pankowska et al. Does the Fat-Protein Meal Increase Postprandial Glucose Level in Type 1 Diabetes Patients on Insulin Pump: The Conclusion of a Randomized Study. Diabetes Tech & therap 2011, 13: Ewa Pankowska et al. Application of novel dual wave meal bolus and its impact on glycated hemoglobin A1c level in children with type 1 diabetes. Pediatric Diabetes 2009: 10: Lindholm Olinder A et al. Post-prandial glucose levels following three methods of insulin blousing. A study in adolescent girls and in comparison with girls without diabetes Pract Diab Int April 2009 Vol. 26 No Michele A et al. Optimizing Postprandial Glycemia in Pediatric Patients With Type 1 Diabetes Using Insulin Pump Therapy. Diabetes Care, 2008, 31: Diabetes Care in the UK FIT UK forum for injection technique in UK: The UK Injection and Infusion Technique Recommendations 4 th edition; (accessed ) Page 8 of 9

9 Appendix 1 Step-by-step guide to optimising glycaemic control for patients on CSII Author: N Abdullah Page 9 of 9