1. Presentation title
Routine Care
In this session, we shall be discussing the routine care of children with diabetes. This care shall be co-ordinated at echelon 3-4. the role of health care workers at echelon 1-2 is to support the routine care of childhood diabetes. Therefore, the material presented in this session is to provide you with an understanding of the principles and priorities of treating children with diabetes so that you are able to assist with the continuing care of the child and to provide local support of the child and family.

2. Programme 1 2 3 4 5 6 7 Principles of care Insulin therapy
Quality of care indicators
Use of HbA1c
Dietary advice
Blood glucose testing
Insulin therapy 7
Monitoring growth in childhood

3. Principles of Care Goals of care include: Eradicate symptoms.
Prevention of acute complications
Hypoglycaemia
Diabetic ketoacidosis
Optimum growth and pubertal development
Ensure good psycho-social adaptation and function
Prevention of long term complications
The first principle is to set goals for the care of children with diabetes. The first goal is to eradicate symptoms. Adequate control of glucose values will usually mean that the presenting shall be abolished. Once this is done, it is important to prevent acute complications of diabetes. In the previous session, we discussed how to manage these acute emergencies but it is even more important to prevent these episodes. Good management of diabetes shall result in achieving the next goal of care, namely for the child to achieve optimal growth and pubertal development. As type 1 diabetes is a challenging condition to live with and to manage, ensuring good psycho-social adaptation and function is important for the successful long term management of diabetes. This would included acceptance of the diabetes and compliance with the dietary and medications regimens. In the long term, complications of diabetes are the greatest risks for children with diabetes. Meticulous management and control of diabetes is needed from diagnosis to prevent the long term complications of diabetes

4. Components of care Education Insulin Diet Monitoring
Support of the child and family
FOOD
INSULIN
To achieve these goals, a number of different aspects of care need to be considered. One of the main components that need to be addressed is education of the child and the family. The education of the child depends on age and intellectual maturity and needs ongoing revision as the child gets older. Education of the family is critical to ensure adequate self care of diabetes. Administration of insulin in regimens that are appropriate for the child is the main medical intervention. Dietary adaptation is needed to help control glucose levels. Self monitoring of glucose is the only way for the child and family to understand diabetes and the effects of food and insulin. Finally the child and family need ongoing support to deal with this condition. All of these elements needs to be optimally administered in order to get the best outcome for the child with diabetes.

5. Management - who? Multi-disciplinary team Medical personnel
Diabetes educator
Dietician
Social worker
Psychologist
Such an extensive list of tasks cannot be done by one person. This is one condition that demands a multi-disciplinary team for management. This team has the child at the centre of care but has to include a medical professional to direct care. A diabetes educator is important to teach the family all the technical aspects of care and to provide ongoing education and support. While most educators are nurses, people of many different backgrounds can perform this function. A dietician who understands local eating customs is also needed to help modify diet. A social worker and or psychologist can be invaluable in dealing with the numerous psychological and social issues the are highlighted in this condition.

6. Presentation title
Insulin therapy
Insulin therapy for the basis of management of diabetes

7. Insulin Human insulin Produced by recombinant DNA technology
Usually U-100 concentration
Beware of older U-40 insulins
Different types classified by their duration of action
Since the 1980s, animal insulin has been replaced by human insulin (insulin identical to that in the human body) but which is produced in large quantities by DNA recombinant technology. As a range of different insulins are available on the market, a specific type of insulin treatment can be chosen according to the patient’s lifestyle and based on one, two or more injections per day, in order to match the insulin peaks with the time of food intake. The choice is between short-acting and long-acting insulins, and between fixed-ratio or other combinations of different insulins.
Insulin today is usually manufactured at a concentration of 100 units per milliliter. Be aware that you may still encounter insulin with a concentration of 40 units per milliliter. The dose of insulin is always recorded in units and not milliliters.
The different insulins are classified by their duration of action.

8. Short acting regular insulin
Onset=30-60 minutes
Peak=2-4 hours
Duration=4-8 hours
Given 30 minutes before meal
Actrapid, Humulin R
Short-acting insulin or regular insulin (e.g. Actrapid from Novo Nordisk, Humulin R by Eli Lilly) has an onset of action of minutes, a peak at 2-4 hours and an action of 4-8 hours’ duration. Because of the slow onset of action, it is best given 30 minutes before a meal. In order to reduce glucose peaks, low glycaemic index foods (e.g. whole meal grains, basmati rice, high fibre foods) are preferable to processed carbohydrates and sugary foods.

9. Rapid acting analogues
Onset: 15 minutes
Peak: 30 min-3 hours
Duration: 3-5 hours
Given 15 minutes before food
Time (min)
1320
1200
1080
960
840
720
600
480
360
240
120
330
300
270
210
180
150 90 60 30
-30
Serum insulin (pmol/L)
Insulin profile
NovoRapid®, adolescents aged 13–17 years
NovoRapid®, children aged 6–12 years
HI, adolescents aged 13–17 years
HI, children aged 6–12 years
Rapid-acting insulin analogues: insulin aspart (Novorapid from Novo Nordisk), insulin lispro (Humalog by Eli Lilly), insulin glulisine (Apidra by Sanofi Aventis) generally have an onset of action of less than 15 minutes, a peak between minutes and a duration of 3-5 hours. They can be given immediately before eating a meal and could even be given after the meal, especially for children who are picky and slow eaters. For high carbohydrate meals, rapid-acting analogues are best given minutes before the meal.
NovoRapid, Humalog, Apidra

10. Intermediate-acting insulin
Onset: 2-4 hours
Peak: variable
Duration: hours
Not related to meals
Usually twice daily
Sometimes 3-4 times/day
NPH, Insulatard, Monotard, Protaphane, Humulin N
NPH insulin or Neutral Protamine Hagedorn insulin (e.g. Insulatard from Novo Nordisk, Humulin N from Eli Lilly) is a suspension of crystalline zinc insulin combined with the positively charged polypeptide, protamine. When injected subcutaneously, it has an intermediate duration of action, meaning longer than that of regular insulin. NPH has an onset of 2-4 hours and a duration of hours. It has a variable peaking effect.

11. Insulin profiles Plasma Insulin Levels Hours Aspart, lispro, glulisine11
Slide no 11
Insulin profiles
Aspart, lispro, glulisine
Regular
NPH
Detemir
Plasma Insulin Levels 2 4 6 8 10 12 14 16 18 20 22 24
Hours
This slide summariazes the profile of action of the different types of insulin available.

12. Mixing insulin Fixed ratio combination insulin Self-mixed combinations
Combination of short and long acting insulin
Most commonly 30% and 70% combination
E.g. Actraphane, Mixtard 30
Two peaks of action
Often used in twice daily regimens
Self-mixed combinations
Mixed regular/rapid insulin with NPH in syringes
Create own mix to suit patient
It is very common to combine long-acting and short-acting insulins, in order to cover basal needs, plus heightened need when eating.  
Fixed ratio combinations combine short and long acting insulin. To use them properly it is important to understand how much rapid-acting insulin is included in the combination, in order to adjust to food intake. In these combinations, the onset of action is the onset of the rapid-acting component, while the duration of action is that of the NPH or protamine component (the long-acting insulin). There are 2 peaks of action – the rapid-acting component peak and the protamine component peak.
An example is Mixtard 70/30 is a combination of 30% Actrapid (rapid-acting insulin) with 70% Insulatard (long-acting protaminated insulin). Ten units of Mixtard 70/30 would be equivalent to 7 units of Insulatard and 3 units of Actrapid. These fixed ratio combinations are most often used in twice daily regimens.
 Regular insulin or rapid-acting analogues can be combined with protamine-based insulins in the same syringe. The rapid-acting insulin is always drawn into the syringe first. This method is flexible. The rapid-acting dose can be adapted every day to food intake and physical exercise, thus creating mixes in porpotions that suit the child.

13. Insulin therapy No perfect insulin preparation
Choice of insulin individualised to give as physiological insulin profile as possible
Be careful of the concentration of insulin (U-100, U-40)
Need proper storage of insulin
Compliance with treatment regimen is key to success
There is no perfect insulin preparation, but good glycaemic control can be reached with any insulin. The choice of insulin should be individual and based on the patient’s needs depending on the desired characteristics of the insulin as well as the availability and cost of the insulin.
Be careful of the concentration of the insulin. Insulin is available in most countries as U-100 insulin, which means it contains 100 units/ml. However, some countries still use insulin in U-40 strength (40 units/ml). It is important to ensure that the insulin used is the correct strength and the syringes used have the correct markings.
Remember that insulin needs proper storage and that compliance with the treatment regimen remains the key to successful treatment.

14. Insulin regimens Twice daily regimen Multiple daily injections
Mix of short acting and long acting before breakfast and supper
Multiple daily injections
Intermediate or long acting insulin twice daily
Short acting insulin with each meal
This slide demonstrates 2 different insulin regimens. A twice daily regimen can be used (and is very commonly used in many countries). This uses a combination of short and long acting insulins before breakfast and supper. This regimen may use a premixed insulin or a combination that has been adapted for the child. Due to a relatively high peak of insulin in the middle of the day, this regimen requires regular meals during the day. With fixed doses from day-to-day, it also requires a similar meal plan each day.
A multiple daily injection regimen uses smaller doses of long acting insulin twice daily and short acting insulin with each meal. This allows more flexibility in insulin dosing at meal times depending on the quantity and type of food eaten. The dose can also be adjusted based on the blood glucose level,

15. Insulin regimens MDI with CSII Lantus-Levemir15
Slide no 15
Insulin regimens
MDI with
Lantus-Levemir
CSII
This slide demonstrates 2 different insulin regimens. A twice daily regimen can be used (and is very commonly used in many countries). This uses a combination of short and long acting insulins before breakfast and supper. This regimen may use a premixed insulin or a combination that has been adapted for the child. Due to a relatively high peak of insulin in the middle of the day, this regimen requires regular meals during the day. With fixed doses from day-to-day, it also requires a similar meal plan each day.
A multiple daily injection regimen uses smaller doses of long acting insulin twice daily and short acting insulin with each meal. This allows more flexibility in insulin dosing at meal times depending on the quantity and type of food eaten. The dose can also be adjusted based on the blood glucose level,

16. Presentation title
Blood glucose testing
As you may be able to tell, blood glucose testing is an important part of good diabetes care. As strips are expensive, this has not been commonly used in clinical practice.

17. Blood glucose testing
Treating diabetes dependent on blood glucose changes during the day
Identify times when at risk for hyper- or hypoglycaemia
Blood levels related to
Insulin regimen and doses
Pattern of eating
Activity / illness
Blood glucose information is used to help patient and family learn – not done for staff!
Treating diabetes with insulin is completely dependent on having a clear picture of how the blood glucose changes for each patient throughout the day. The purpose of blood glucose testing is to help identify the times when the patient is at risk of either hyperglycaemia or hypoglycaemia. Blood glucose levels can be related to type and dose of insulin, pattern of eating, activity and illness.
Having this information is the basis for deciding how much insulin they need, of what type, and when it should be given.

18. Interpretation Needs records of insulin, food, activity, etc.
Timing of test
Interpretation
Fasting glucose
Evening dose of long acting insulin
After breakfast level
Dose of rapid insulin at breakfast
After lunch level
Dose of rapid insulin at lunch (midday meal)
After supper level
Dose of rapid insulin at supper
Pre-lunch level
Dose of insulin at breakfast, effect of mid morning snack and morning long-acting insulin
Pre-supper level
Dose of insulin at lunch, effect of mid afternoon snack and morning long-acting insulin
All levels
Affected by snacks and exercise
If a patient takes many blood glucose readings, but does not know how to interpret them and does not change either the dose of insulin, the pattern of eating or activity in response to the glucose levels, then testing the glucose readings becomes a futile and wasteful exercise. Repeated daily testing at one time of day alone (eg for fasting glucose levels) is not recommended as it is not helpful.
This table suggests how you should interpret the different readings during the day. The fasting glucose level before breakfast helps to tell us if enough insulin was given the night before to compensate for the evening meal, and also whether the evening dose of long-acting insulin was too little or too much. The after breakfast level tells us about the dose of short/rapid-acting insulin given at breakfast. The after lunch level tells us about the dose of short/rapid-acting insulin given at lunch. The after supper level tells us about the dose of short/rapid-acting insulin given at breakfast. The pre-lunch level tells us about the dose of insulin given at breakfast, the effect of the mid-morning snack (if any) and the effect of the morning long-acting insulin. The pre-evening meal level tells us about the dose of insulin given for lunch, the effect of the afternoon snack (if any) and the effect of the morning long-acting insulin. All levels may be affected by snacks and exercise.
Records of insulin, food, activity and other factors that may affect the glucose levels are needed to help make decisions.
Needs records of insulin, food, activity, etc.

19. Patterns of testing (1) Pre- and post-meals, bedtime (7 tests/day)
Pre-meals, bedtime (4 tests/day)
Pre-breakfast, pre- and post-selected meal for 1 week (3 tests/day)
Change selected meal weekly
When symptoms of hypoglycaemia occur
When a top-up dose of insulin is needed for extra food or during illness
It is important to consider the principles of designing a glucose testing strategy that will maximise returns for the individual patient, while conserving scarce resources. Since the blood glucose level may be affected in so many ways, but patients are usually on a relatively fixed dose of insulin, the patterns of blood glucose levels are generally more important than individual glucose readings.
The following alternative patterns for routine blood glucose testing may be useful options in working out the patient’s pattern of changes in blood glucose level throughout the day. Pre- and post-meals and bedtime (total = 7 tests/day). Pre-meal and pre-bedtime (total = 4 tests /day). Pre-breakfast, then select a meal and do pre- and post-meal glucose testing for 1 week. Rotate the selected meal weekly (total = 3 tests /day). Three pre-meal tests, a late-night test (e.g.12 midnight)   and one more the following morning on alternate days (average total = 2.4 tests/day) or the cycle can be repeated every 3rd day (average total = 1.7 tests/day or 50 strips / month ). Whenever symptoms of hypoglycaemia occur or when a top-up dose of insulin is needed for extra food or during illness.

20. Patterns of testing (2) Strips are expensive Patterns determined by
Availability of strips
Insulin regimen
Level of control
Patient factors
Pattern changed to get useful information
Needs patient records of food and insulin for readings to be valuable!
As strips are expensive, very frequent testing may not be possible. The patterns of testing should be determined by availability of strips, insulin regimen, level of control, patient factors. Changing patterns of testing can be useful to get a more complete picture of glucose values. As mentioned previously, patient records of food and insulin are needed for readings to be valuable!!

21. Presentation title
Date
Dietary advice

22. Principles Need to have a healthy diet
Amount and proportions appropriate for age and growth
Carbohydrate content of food matched with insulin regimen
Understanding of how to match insulin with food is key
Best done with the assistance of a dietician
Best done by a dietician, but the unavailability of dieticians mean that you may have to help with this task. An overridding principle is that the child with diabetes needs to have a health diet (not a ‘diabetic diet’). The amount of food and proportions of different food groups should be appropriate for the age and growth of the child. The food choices should be matched with the insulin regimen. Therefore, understanding how to match insulin with food is important and a key to successful diabetes management. Dietary advice is best done with the assistance of a dietician.

23. Dietary review Taken at diagnosis Review regularly (annually)
Correct food, correct amount and correct times
Review food patterns, activities and insulin regimen
Growth and stage of puberty influence diet
What is important at a echelon 1-2 site is a dietary review. This should be taken at diagnosis and repeated at least annually. The objective is to see if the patient is eating the correct foods, in the correct amounts and at the correct times. The review should include food patterns (2 meals/day, 3 meals/day, range of foods etc.), daily activities (walk/bike a long distance to school, help to do housework, sports etc.), insulin types , doses and injection timing, growth and stage of puberty
Give practical and feasible suggestions, review the progress regularly and be aware of difficulties that may be caused by suggested changes to the child’s diet. It is important to involve the family members and caregivers as much as possible. Continuing reminders and reinforcement of the messages are needed.
Diet shall be discussed in more detail later today

24. Presentation title
Use of HbA1c
Glycosylated haemoglobin A1c or HbA1c ( also known as A1c) is an objective indicator of glycaemia, and of acute as well as chronic risk for complications.

25. What is HbA1c Red blood cells contain Haemoglobin (Hb)
Glucose sticks onto Hb  HbA1c
Slow and irreversible
HbA1c reflects average blood glucose over 2-3 months
High glucose = increased HbA1c
Non diabetics: 4-6% (normal range)
The red blood cells contain the oxygen-carrying protein compound called haemoglobin. Since the red blood cells are always suspended in blood plasma, which contains glucose, some glucose molecules will stick onto haemoglobin by a process known as glycosylation, to make a new compound called glycosylated haemoglobin or haemoglobin A1c (HbA1c). The reaction is non-enzymatic, slow and irreversible, so the HbA1c level in the blood reflects the average blood glucose level during the life of the red blood cell (approx 100 days). It is usually expressed as the percentage of haemoglobin which is glycosylated (but see below). The normal level of HbA1c in a non-diabetic person is %.

26. What does it tell us Measure of the average blood glucose
Correlates with risk of long-term complications
Rising HbA1c requires action
Ideal HbA1c <6.5%
fix slide pix
Add EAG table vs A1c???
A single blood glucose test can only tell us how the blood glucose control was at a certain point in time, but the HbA1c value is a measure of the average blood glucose level over several months.
The HbA1c value is highly correlated with the risk of having diabetes complications and can be used as a measure of an individual patient’s diabetes control. This graph shows the change in risk of a complication with changes in HbA1c (need an explanation of the graph).
 A rising HbA1c over time means that adjustments need to be made to the dose of insulin, to the food and to exercise levels as the risk of complications is increasing.
A fall in HbA1c usually indicates better control and a lower risk of long-term diabetic complications, but as HbA1c approaches or falls below 6%, the risk of hypoglycaemic episodes is increased.
An ideal HbA1c is less than 6.5%

27. A1c vs estimated average glucoses

28. ASK: How many of you know your A1C?
One of the measurements your health care provider may use to determine whether you are reaching your goals is to check your A1C levels and ensure that your therapy is helping you achieve the lowest possible A1C that can safely be obtained.
ASK: How many of you know your A1C?
An A1C test is an indication of a person’s average blood glucose levels for a 2-to-3 month period of time. It is based on the life expectancy of a red blood cell (which is approximately days). Hemoglobin is part of a red blood cell and it carries oxygen to the cells. When glucose exceeds a certain level, glucose molecules attach themselves to the hemoglobin in a red blood cell. The A1C test measures the amount of glucose that has attached to the hemoglobin of a red blood cell. We know from experience that this amount is directly proportional to the average blood glucose level over a 2-to-3 month period.
The American College of Endocrinologists recommends a goal of 6.5%2 or less. Depending on your particular situation, your health care provider may recommend an initial goal that is different from this.
REFERENCES
1. Skyler JS. Diabetic Complications: The Importance of Glucose Control. Endocrinol Metab Clin North Am. 1996; 25:
American Association of Clinical Endocrinologists. AACE Diabetes Mellitus Guidelines, Endocrine Practice. 2007;13(Suppl 1):16. 28

29. Quality of care indicators
Presentation title
Quality of care indicators
As you have seen, children with diabetes are able to monitor their blood glucose levels each day and understand the day-to-day variations in their glucose. Health care workers are able to look at medium term control of diabetes with an HbA1c. It is also necessary to have long term monitoring of diabetes. Quality of care indicators are the tools used to assess the long term control of diabetes. Long term monitoring is aimed both at the affected person and at a clinical service.

30. Patient indicators Indicator Measurement Growth Height, weight and BMI
Puberty
Age at menarche, breaking voice
Acute complications
No of admissions for DKA
Frequency of severe hypoglycaemia
Social adjustment
Schooling/vocational training/employment
Number of clinic visits in last 12 months
Number of hospitalizations in last 12 months
Missed school days due to diabetes
Food security
Interruption in insulin therapy in last 12 months
This table shows some individual patient indicators.
Read out the indicator and the corresponding measurement of that indicator

31. Clinic indicators Indicator Measurement Prevalence
Number of children in your clinic
Acute complications
Frequency of severe hypoglycaemia
Frequency of severe hypoglycaemia in <5 year old children
Supplies
Interruptions in insulin therapy
Prevention of
microvascular
complications
% of patients tested for proteinuria
% of patients tested for HbA1c
% of patients with recorded BP
% of patients with recorded lipids
This table shows indicators of how well a clinic or service is doing.
Read out the indicator and the corresponding measurement of that indicator

32. Remember Vital to measure regularly the progress of diabetes
Basic patient indicators measured at every visit (e.g. once a month)
Measurement of growth a very good indicator of the quality of care
Each visit an opportunity for repeated information and education
It is vital to measure regularly the progress of diabetes, as it is a long-term condition leading to major complications, and long-term management can significantly improve life for the patient.
Basic indicators of quality of care should be measured regularly at every visit (eg once a month )
Regular measurement of height and weight growth in children with diabetes is a very good indicator of the quality of care.
Insulin doses must be reviewed and adjusted if necessary at each visit (ideally once a month), based on HbA1c (if available) or glucose monitoring results. Each visit is the opportunity for repeated information and education on the care of children with diabetes, prevention of DKA and hypoglycemia, and when other illnesses arise.
Children with diabetes should be brought to the diabetes clinic when suffering from ANY medical problem, as diabetes treatment must be taken into account when considering any other treatment. It is also helpful for children to be seen by the same physician or team, to ensure continuity of care.

33. Monitoring growth in childhood
Presentation title
Date
Monitoring growth in childhood
As you have seen, growth is a relatively easy measure of quality of care of individual children with diabetes. This section deals with tracking growth.

34. Growth Growth follows a predictable pattern over time
Growth can be affected by diabetes, i.e. insufficient insulin dosing can cause stunted growth even if blood glucose levels seem fine
Type 2 diabetes, overweight contributes to the diabetes
Normal growth indicator of adequate diabetes care
Children’s growth in height and weight follows a predictable pattern over time, within well-established ranges. However growth in children with diabetes is often affected by their condition, or in the case of type 2 diabetes, their overweight contributes to the occurrence of diabetes. Regular measurement of height and weight is a useful indicator of how well their treatment is keeping the diabetes under control.
Children with diabetes should achieve normal growth targets for their ethnic group and the community in which they live. If the child with diabetes is growing at the same rate as other childen of the same age, sex and community, that is a powerful indicator of the adequacy of diabetes care.

35. Growth charts Can use population specific charts
Center for Disease Control (CDC) charts
Charts specific for boys and girls and for different age ranges
Height, weight, BMI
Ideally, children should be measured for growth using population-specific charts. Where these charts are not readily available, the CDC (US Centers for Disease Control) charts may be used for plotting height for age as in this chart. 
If the child has put on more than 1 kg in a month, a change of insulin dose may be necessary. Poorer than expected growth rates should prompt an inquiry into the cause, which could be hypothyroidism, poor glycaemic control or poor calorie intake; and corrective action should be taken. There are specific charts for boys and girls and for different age ranges. Charts are available to monitor height, weight and BMI (an indicator of obesity). Copies of these are in the manual.

36. Measurements
Measure height and weight at each clinic visit, once every three months, at least twice a year
Record in medical chart and plot on growth chart 
Standing height without shoes
For young children under 2.5 years, total body length should be measured
Measure weight to nearest 0.1 kg if possible
Every child should have height and weight measured at each clinic visit, preferably once a month. This should be immediately recorded on the child’s medical chart.
 Standing height should be taken without shoes, by a trained staff member, using a standardised height chart and method
 For young children under 2.5 years, total body length should be measured and plotted on a chart for 0-36 month old children.
 The weight should be measured to the nearest 0.1 kg where possible, but at least to the nearest 1.0 kg, with shoes off, wearing light clothes or underwear and having emptied the pockets

37. Measuring equipment

38. 38
Questions
Take questions

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