Management of Diabetes

in School

ABUHB Paediatric Diabetes

Team

2015

Overview of the Session

Welcome and introduction to diabetes

Diet and diabetes

Work stations

Calculating Insulin Doses

Work stations

Comfort break

Hypoglycaemia

Hyperglycaemia

Sport

Work stations

Evaluation and close

Aim

• Highlight and provide an overview of

the skills and information required to

support a child with diabetes in school.

Type 1 Diabetes

Our bodies need fuel to give us

energy. When we eat carbohydrate,

it is converted into glucose.

The glucose travels around our

blood stream. It cannot be used as

energy until it enters the cells.

The pancreas is the part of the

body where insulin is made.

Insulin works as a key, allowing

the glucose to enter the cell. The

glucose can then be used for

energy.

When you have diabetes your

pancreas does not produce

insulin. You have to inject the

insulin.

Type 1 Diabetes

Type 1 Diabetes

When there is not enough insulin, the body will create an

alternative source of energy resulting in the production of

ketones

Signs and Symptoms of Diabetes

Signs and Symptoms

• Thirst +++

• Urine +++

• Weight loss

• Tiredness

• Infections

Importance of ‘Good’ Diabetes Management

• Maintain blood glucose levels between 4- 8

mmol/L

• Ensure child reaches full growth potential

• Reaches full academic potential

• Children develop into independent healthy

adults

Importance of ‘Good’ Diabetes Management

To prevent short term complications associated with diabetes:

• Hypoglycaemia

• Hyperglycaemia

• Reduce hospital admissions

Importance of ‘Good’ Diabetes Management

To avoid long term complications associated with diabetes:

It is essential that children are supported to manage their diabetes effectively in

school. The longer a person has diabetes that is poorly controlled, the higher the

risk of developing problems.

• Eyes - Diabetes is the leading cause of blindness in people of working age

• Kidneys – The leading cause of renal failure

• Feet – The 2nd most common cause of lower limb amputations

• Heart - Mortality rates from coronary heart disease are 5 times higher

• Pregnancy - Women with diabetes face additional risks during pregnancy, at birth and to the baby

• Life expectancy can be reduced by more than 11-14 years – EASD 2013

DoH, 2007

Documentation

Every Child Matters - Supported by the Children Act 2004

Managing Medicine in Schools and Early Years Setting – DOH 2005

National healthy schools Programme DOH 2007

Making Every Young Person with Diabetes Matter- DOH 2007

Equality Act 2010 (DUK 2010)

Diabetes Guidelines for Schools Colleges and Early Years Setting-

September 2013

Taken from http://www.trumanlibrary.org/histday/insulin/impact.html

Any questions??

Dietary

Management

Principles of Dose Adjustment

• Rapid acting insulin is given at each meal and a

background insulin is given once or twice daily

Food

Food consists of a mixture of nutrients. The ones that

provide energy in the diet are:

• Protein

• Fat

• Carbohydrate

It is important to eat a healthy varied diet for long

term health

Digestion of Food

Protein

Meat

Fish

Eggs

Cheese

Nuts

Soya

Minimal effect on blood glucose levels

Amino acids

Digestion of Food

Fats

Butter

Margarine

Cream

Oil

Minimal effect on blood glucose levels

Fatty acids

Digestion of Food

Carbohydrate

Starchy food

Sugary food

Increase your blood glucose levels

Glucose

Learning more about

Carbohydrate

Which Foods contain

Carbohydrate? Carbohydrate is found in the following foods:

Starchy carbohydrate

Cereal starch

• Grains (Wheat, barley, rye and oats)

• Bread and flour products

• Breakfast cereals

• Pasta

• Noodles

• Rice and rice products

• Couscous

Cereal starches are digested to glucose

Which Foods contain

Carbohydrate?

Starchy carbohydrate

Vegetable starch

• Potatoes and potato products

• Legumes and pulses e.g. baked beans, red kidney beans,

peas, sweetcorn and lentils

Vegetable starches are digested to glucose

Which Foods contain

Carbohydrate? Sugary carbohydrate

These include both natural sugars found in food and sugars added

to food.

Natural sugars found in food

• Fruit and fruit juices

The sugar found in fruit are fructose and sucrose.

• Milk and milk products e.g. yoghurt, mousse, custard and ice-

cream The sugar found in milk is lactose.

Sucrose and Lactose are digested to glucose

Which Foods contain

Carbohydrate?

Sugary carbohydrate

• Sugar added to food

Sucrose is the name of the sugar added to food to make

them sweet

e.g. sweets, chocolates, biscuits, cakes, jam, marmalade and

sugar drinks

Sucrose is digested to glucose

Guide to Identifying

Carbohydrate in your Diet Foods Containing Carbohydrate

These foods contain significant amounts of

carbohydrate and need to be counted in your

diet

Cereal Starch

Breakfast cereals

Bread and flour products

Rice and grains e.g. couscous

Pasta

Noodles

Vegetable Starch

Potatoes and potato products

Beans and pulses

Sweet potato/Yam

Sugary Carbohydrates

Fruit and fruit juices

Milk and milk products

Foods containing added sugar

e.g. cakes, sweets and chocolates

Foods Containing Minimal Carbohydrate

These foods contain minimal amounts of

carbohydrate and do not need to be

counted in your diet

Protein

Meat

Fish

Eggs

Cheese

Nuts

Soya

Fat

Butter

Margarine

Cream

Oils

Most vegetables

Salad

Carbohydrate Counting

Aim of

Carbohydrate Counting

• Encourage a healthy balanced diet

• Allow the child to choose the type and amount of

carbohydrate they wish to eat

• Match it with the appropriate amount of rapid

acting insulin

Resources available to help

Calculate Carbohydrate

• Books and leaflets

• Carbohydrate ready reckoner

• Food labels

• Internet websites

• Apps

• Weighing scales

Calculating

Carbohydrate

• Use the total carbohydrate to calculate insulin

doses

• Do not use the “of which sugars” on food labels

• Inaccuracy can result in hypoglycaemia or

hyperglycaemia

Food Labels

548Kj

Per 25g Pack Per 100g

Energy 131 kcal 2190 kj

525kcal

Protein 1.8g

Carbohydrate

of which sugars

12.5g

0.6g

50.0g

2.5 g

Fat

of which saturates

of which mono-unsaturates

of which poly-unsaturates

8.3g

0.7g

6.5g

0.7g

33.0g

2.6 g

25.9g

2.8g

Fibre 1.0g 0.50g

Sodium 0.13g 1.27g

12.5g

• When calculating the carbohydrate content of a food, it is important you use the TOTAL carbohydrate value and not the ‘of which sugars’ value.

Scales

Carbs & Cals Book

Foods are

arranged in

logical

sections

Carbs and Cals App

Workstations

Split into 3 groups and move around the

following workstations:

• Carbs and Cals

• School menus

• Food labels

Food Portion Carbohydrate (g)

Pizza slice -chicken, deep pan

oven baked

1 small slice

(65g)

20g

Sausage roll 1 sausage roll

(63g)

16g

Gingerbread man 1 gingerbread man

(58g)

38g

Chicken Drumstick 1 chicken drumstick (75g) 0g

Chocolate cake 1 slice of cake

(40g)

20g

Total Carbohydrate = 94 (g)

Food Portion Carbohydrate (g)

Egg fried rice Pack 65.6g

Nakd Raisins 1 pack (25g) 17.3g

School bars 1 bar 16.6g

Mini cheddars 1 pack 12.7g

Pure fruit Yoyo bear 1 yoyo 6.3g

Total = 118.5g

Food Portion Carbohydrate (g)

Ham sandwich 2 slices of bread 35.6g

Cereal bar Special K bar 14g

Snack A Jacks

Popcorn

1 packet 4.4g

Jam n Cream biscuit 1 biscuit 10.4g

Nakd Raisins 1 pack (25g) 17.3g

Total = 81.7g

Food Portion Carbohydrate (g)

Cheese & tomato pizza 1slice 30

Jacket wedges 1 serving 30

Sweetcorn 1 serving 10

Mixed salad 1 serving 0

Crunchy Fruit Crumble 1 serving 20

Custard 1 ladle 10

Total Carbohydrate = 100

Calculating Insulin Doses

Calculating Insulin Doses

• The dose of rapid acting insulin depends on

– Carbohydrate content of meal

– Blood glucose level at that time

• The dose of background insulin is not linked to

carbohydrate intake

Calculating Insulin Doses

Each child has an individual

Insulin : Carbohydrate Ratio.

e.g 1 unit of rapid acting insulin is required for every 10 grams of carbohydrate

Insulin: Carbohydrate Ratio

Carbohydrate (grams) Insulin (units)

10 1

20 2

30 3

40 4

50 5

60 6

70 7

80 8

90 9

100 10

1 unit of rapid acting insulin is given for every

10 grams carbohydrate

1/2 unit of rapid acting insulin is given for every

6 grams carbohydrate

Carbohydrate (grams) Insulin (units)

6 ½

12 1

18 1½

24 2

30 2½

36 3

42 3½

48 4

54 4½

60 5

Insulin Correction

Doses

• This is the extra insulin needed to correct

a high blood glucose level before food.

• If the pre-meal blood glucose level is

above the child’s individual target you may

need to calculate a correction dose.

Blood glucose level

before meal in mmol/l

Correction Insulin dose

required

8-10 mmol/l 1 unit

11-13 mmol/l 2 units

14-16 mmol/l 3 units

17-19 mmol/l 4 units

20-22 mmol/l 5 units

23-25 mmol/l 6 units

26-28 mmol/l 7 units

29 mmol/l or above 8 units

1 unit of rapid acting insulin is needed to reduce

blood glucose level by 3 mmol/l

Calculating

Total Insulin Dose

Insulin for carbohydrate

+

Insulin for correction (if required)

=

Total dose of insulin to be injected

Injecting Rapid

Acting Insulin

This can be injected directly before, during

or directly after the meal

Calculating Insulin Dose

Scenarios

Calculating Insulin Doses In your pack you will find an insulin to carbohydrate ratio

sheet and the an insulin correction dose sheet, Use these to

work out the total insulin dose to be injected :

MONDAY

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 14.0 mmol/l

CHO in meal 52g

Insulin for CHO ?

Insulin correction dose ?

Total insulin ?

Calculating Insulin Doses

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 14.0 mmol/l

CHO in meal 52g

Insulin for CHO 5 units

Insulin correction dose 3 units

Total insulin 8 units

Calculating Insulin Doses

TUESDAY

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 6.0 mmol/l

CHO in meal 45g

Insulin for CHO ?

Insulin correction dose ?

Total insulin ?

Calculating Insulin Doses

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 6.0 mmol/l

CHO in meal 45g

Insulin for CHO 4.5 units

Insulin correction dose 0 units

Total insulin 4.5 units

Any Questions?

Hypoglycaemia

Hypoglycaemia

• A hypo is a blood glucose level less than 4

mmol/l

Signs and Symptoms

of Hypoglycaemia

Signs and Symptoms of

Hypoglycaemia

• Weakness

• Hunger

• Shaking

• Feeling sick

• Large pupils/glazed

expression

• Behaviour changes e.g.

irritability

• Tingling around the mouth

• Emotional

• Visual disturbance

• Headache

• Tiredness

• Pale face

• Sweating

• Dizziness

Causes

Causes of

Hypoglycaemia

• Too much insulin

• Too little food

• Physical activity

• Extremes of temperature e.g. Getting very hot or cold

• Stress

Treatment

MILD MODERATE SEVERE

If conscious and able to swallow

If conscious and able

to swallow, but in

need of assistance

If unconscious and

unable to swallow

Give 10g fast acting carbohydrate, e.g:

50ml Lucozade Energy

40ml Gluco Juice

2 teaspoons glucose powder in 50ml

water

3 glucose tablets

100ml coke

100ml original ready to drink Ribena

2 standard jelly babies

3 Starbursts

1 mini bag (16g) of Haribo Starmix

8 jelly tots

100ml orange juice

Give 1 tube of

glucogel or sports gel

slowly squeezed into

mouth. The gel

should be swallowed.

Place patient in

recovery position

Call for the ambulance.

If you have received

training, give your

GlucaGen (glucagon).

Check your GlucoGen is

still in date, it should be

stored in the fridge.

Wait 10-15 minutes and recheck glucose levels, and record.

If reading is still less than 4.0mmol/l, repeat process.

Once patient is

conscious, follow

treatment for moderate

or mild hypoglycaemia

depending on level of

consciousness

When blood glucose level is above 4.0mmol/l, give a 10g carbohydrate snack e.g. a

small piece fruit, 1 digestive biscuit, 1 oat biscuit, 2 rich tea biscuits, 1 fig roll, 1 packet

of mini cheddars or 1 box of raisins

Mealtime considerations

• If child has had any hypoglycaemia during

the morning DO NOT give any correction

insulin with lunchtime dose

Managing Hypoglycaemia at

Lunchtime

• If child has a hypo at the mealtime, give

fast acting carbohydrate and reduce

mealtime insulin by subtracting 10g from

total mealtime carbohydrate

Calculating Insulin Doses

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 3.8 mmol/l

CHO in meal 50g

Insulin for CHO ?

Insulin correction dose ?

Total insulin ?

Calculating Insulin Doses

Insulin: CHO ratio 1:10g

Insulin correction dose 1:3mmol/l

Pre meal blood glucose 3.8 mmol/l

CHO in meal 50g

-10g for hypo

Insulin for CHO 5 units

-1 unit

Total insulin 4 units

Hyperglycaemia

• This is is a blood glucose level above

14mmol/l.

What are the Signs of

Hyperglycaemia?

What are the Signs of

Hyperglycaemia?

• Excessive thirst

• Passing excessive amounts of urine

• Tiredness

• Behaviour change

• Blurred vision

• Headache

• Abdominal pain / feeling sick

• Smell of acetone on child’s breath

Treatment

• Insulin correction dose at meal time

• Sugar free fluids

• Toilet breaks

Follow the school’s sickness policy.

Sport

PE in School

• Before PE, blood glucose levels should be

checked and recorded

• Decide if any additional carbohydrate is required

• Always have a hypo remedy available

(especially if doing water based sports)

• Refer to ABUHB Diabetes and Sport Leaflet

Blood glucose levels

Blood glucose level Action Carbohydrate

needed

Less than 4 Delay exercise

Treat the hypo

1-2 items from snack

attack list

4-7

7-11

OK to exercise. Extra

carbohydrate needed

OK to exercise. May

need extra carbohydrate

1-2 items from snack

attack list

Above 12 Exercise with caution.

Retest after 30min

No extra snack needed

Snack Attack List • Each snack contains 10-20g carbohydrate:

– 50-100ml Lucozade Energy

– 100-200ml Cola

– 150-300ml Lemonade

– 100-200ml fruit juice

– 2-4 jelly babies

– 4-8 fruit pastilles

– 3-6 Starbursts

– 4-8 Chewits

– 10-20 Dolly Mixtures

– 10-20 Skittles

– 1-2 tablespoon raisins

Website

For support material visit:

• http://www.wales.nhs.uk/sitesplus/866/pag

e/55813

• Or search ‘Gwent Children’s Diabetes’

Any Final Questions?