Editors

PäiviMiettinen

MariPulkkinen

A Child or Adolescent with Type 1 Diabetes in Primary Health Care

The care of a child with type 1 diabetes requires specialist management.
If a child with diabetes presents with fever, gastroenteritis or another infectious disease and has both glucose and ketones in the urine, contact an on-call pediatric unit.

The care of diabetes is shared between a multidisciplinary diabetic care team and the child and his/her family.
- In addition to a diabetes paediatrician and nurse specialist, the care team should include a child psychologist/psychiatrist or an adolescent psychiatrist, a dietitian, a rehabilitation co-ordinator and a social worker.
The cornerstones of management are regular blood glucose monitoring, administration of insulin based on the observed blood glucose levels, diet and exercise that is adjusted to the aforementioned factors.

See Type 1 Diabetes: Treatment
The insulin need of a child with type 1 diabetes is individual and depends on age, amount and quality of both food and exercise, as well as on psychosocial factors.
Typically, after the child's own insulin production has subsided, the daily insulin dose is about 0.6 units/kg/day (small physically active child) - 1.5 units/kg/day (adolescent).
Long-acting or ultra-long acting insulin is used to cover the insulin requirement of basal metabolism, and rapid-acting insulin to cover the additional requirement imposed by meals. Short-acting insulin is nowadays only seldom used.
Insulin is administered either with an insulin pen or with an insulin pump (very seldom with syringes), and the dosing is guided by continuous measuring of tissue glucose concentrations (=sensing) or by fingertip measurements.
Blood glucose self-monitoring and daily assessment and adjustment of insulin doses is of central importance in the treatment of type 1 diabetes.
It is the task of the diabetic care team to educate the patient and his/her family in adjusting independently the insulin therapy on a daily basis, based on changing needs.

The recommended diet does not essentially differ from that recommended for the rest of the population. When planning the diet the patient's lifestyle, particularly exercise habits, is taken into account, and the diet is adjusted to the insulin dosage. Fibre intake, however, should be higher in a person with diabetes than recommended for the general population.
The patient's individual daily need for calories is calculated. Half the calories (45-60%) should be derived from fibre rich carbohydrates, 10-20% from proteins and 25-35 % from fats, the majority of which should be unsaturated. Fats containing monounsaturated fatty acids should be favoured (10-20%).
The family should be taught to estimate how many grams of carbohydrates each meal contains. A diet plan should list the child's meals and snacks, and the amount of carbohydrates of each meal.

A child will usually visit a diabetic clinic every three months.
Basic blood count with platelet count, concentrations of free T4 (FT4), TSH and creatinine, coeliac screening and microalbuminuria are checked once a year, lipid values every 2 years.
The aim should be to start retinal photography at the age of 10 years, and the test should be repeated thereafter every 2 years.
The target of the treatment is as good as possible control of diabetes: Hb_A1c is <53 mmol/mol (7.0%) and as small as possible variation in the blood glucose levels (coefficient of variation, CV [= standard deviation/average] < 35%).
- Insulin requirements are increased at puberty and maintaining good control (Hb_A1c < 53 mmol/mol [7.0%] without episodes of severe hypoglycaemia) requires rigour.
Tissue glucose sensors are currently in the process of replacing fingertip measurements in the daily monitoring of blood glucose, as they provide nearly real-time information on blood glucose and the fingertips remain intact. The availability of these devices within public health care services varies.
A structured patient education programme should be available for the child and his/her family.
Child health clinic appointments and school health services should continue as for other children.
The medical care team may be consulted as regards, for example, day care and school attendance.
Influenza vaccination is recommended.

It must always be borne in mind that insulin requirement is increased by infection and other stress and decreased by exercise.

The child's need for an adequate amount of fluids and carbohydrates, as well as for regular insulin, continues during gastroenteritis. Blood glucose and urinary ketone concentrations should be monitored more frequently during sick days.
Do not hesitate to consult a specialist diabetes physician or nurse at a paediatric hospital.
Patients using an insulin pump can easily make temporary changes in the basal insulin rate; e.g. in association with fever many patients need an increase of about 20-50% to the dose of basal insulin.

The treating doctor should issue the patient with a written report stating the nature of the illness and the necessity of insulin injections.
It is advisable to pack insulin in the hand luggage and to divide the supply between several bags.
If travelling across time zones, meals and insulin injections should be planned beforehand and written down. In hot climates, the absorption of insulin will be increased. See also Type 1 Diabetes: Treatment.

The child may suffer either from hypoglycaemia (rapid symptom onset) or ketoacidosis (slower symptom onset).
Measure blood glucose immediately.
If the child is hypoglycaemic, or there are no facilities to measure blood sugar, administer immediately an intravenous bolus of 10% glucose (G10) 2.5 ml/kg and continue with a G10 infusion 3ml/kg/hour and/or subcutaneous glucagon (the dose is 0.5 ml if the patient weighs < 25 kg, otherwise 1.0 ml).
Send the child immediately to an emergency unit of a paediatric hospital.