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Education

Types of Insulin

All children diagnosed with Type 1 diabetes will be on both a long-acting and fast-acting insulin regimen. Many children with Type 2 diabetes are also started on insulin.

Type of Insulin Begins Working Main Effect All Gone
Fast-Acting (Clear) Humalog/NovoLog/Apidra <15 min 1/2 to 1 1/2 hours 3 to 4 hours
Intermediate-Acting (Cloudy) NPH 1 to 2 hours 3 to 8 hours 12 to 15 hours
Long-Acting (Clear) Lantus 1 to 2 hours 2 to 22 hours (no peak) 24+ hours
Levemir 2 hours No peak Up to 24 hours

Insulin Storage and Use

Vial
Unopened—Store in the refrigerator.
Opened—May store refrigerated or at room temperature. Discard after 30 days.

Cartridges
Unopened—Store in the refrigerator.
Opened—Keep the cartridge in the pen at room temperature. Discard cartridges after 30 days.

Discard Insulin When:

  • The vials, pens or cartridges have been used longer than 30 days.
  • The insulin froze.
  • The insulin sat in a hot car for any length of time.
  • The insulin is milky looking or has particles sticking to the glass

Diabetes Insulin Regimens

Food and Corrective Dosing

The insulin regimen used most often involves checking the blood sugar before the main meals of breakfast, lunch, and supper. A corrective dose (CD) is given at that time to bring down any high blood sugars. A food dose (FD) is also given based on the number of carbohydrates eaten. These two doses are combined in one injection. Snacks high in carbohydrates between meals also require a food dose. The blood sugar may not need to be checked at snack time because a corrective dose is not always given with snacks. Corrective doses at bedtime may also be needed if the blood sugar is >250 or 300. Check with your doctor or nurse practitioner to see if you need a corrective dose at snack or bedtime.

The food and corrective doses are treated with fast-acting insulin such as Humalog, Novolog or Apidra. Fast-acting insulin doses must be separated from each other by at least 2 hours. If given closer than that, a low blood sugar could result. Blood sugars between meals are controlled by a long acting insulin such as Lantus or Levemir. Lantus is given once a day at the same time every day. The family chooses a time that works with their schedule. The dose is the same every day. Levemir can be given once or twice a day at a fixed time with a fixed dose.

Breakfast Lunch Snack Supper Bedtime
EXAMPLE OF FD/ CD REGIMEN
Check blood sugar Check blood sugar   Check blood sugar Check blood sugar
CD (+) CD (+)   CD (+)  
FD FD FD FD  
Fast-acting Fast-acting

Fast-acting

Fast-acting Long-acting

Sliding Scale

Another regimen uses a sliding scale to determine the insulin dose. The blood sugar is checked before the meal and the insulin dose is chosen from a sliding scale based on the blood sugar. The insulin for the food is built into the scale so the carbohydrates for the meal are a fixed amount. A food dose is set for snacks. The long-acting insulin is still a set amount given at a set time once (or twice) a day.

Breakfast Lunch Snack Supper Bedtime
EXAMPLE OF SLIDING SCALE REGIMEN
Check blood sugar Check blood sugar   Check blood sugar Check blood sugar
Choose dose from scale Choose dose from scale   Choose dose from scale  
Fixed carbs Fixed carbs FD Fixed carbs  
Fast-acting Fast-acting Fast-acting Fast-acting Long-acting
Units of Insulin Blood Sugar Before Meal
EXAMPLE OF SLIDING SCALE
3 < 100
4 101 - 200
5 201 - 300
6 301 - 400
7 401 - 500
8 > 500

Troubleshooting Insulin Injections

Leak back: Insulin leaks out of the injection site.

Solution: Be sure to release the pinch before pulling the needle out of the skin. If the leak back continues, then once the insulin is completely injected, release the pinch and count to five before pulling the needle out. This should allow the fat layer below the skin to accept the insulin more easily.

Bleeding: Blood leaks out of the injection site.

Solution: When giving the injection, stay away from capillaries (tiny blood vessels) just under the skin. If one of these is “hit” with the needle, you will have a drop of blood come from the injection site. Occasionally you will still get a little bleeding from the injection site, but it should not occur routinely.

Bruising: A bruise forms under the skin following injection.

Solution: Be sure to follow the guideline as stated above for bleeding. Also make sure that an adequate pinch is being used to put the needle into the skin for the injection. If the needle gets too close to the muscle under the fat layer, then bruising may occur more often.

Pain: Your child complains of pain during or after injection.

Solution: Review your injection techniques to make sure that you are following each step. Talk with the diabetes educator about this so that additional techniques may be tried to reduce discomfort.

Targets

The chart shows expected blood glucose target ranges for children who have diabetes. Children are expected to be within their range 60 percent of the time or more. If blood sugar levels are outside of the target range consistently (three or more days within the same timeframe), talk to your child’s doctor about adjusting the insulin dose.

  <2 yrs 2-5 yrs 6-12 yrs >12 yrs
Daytime 100-250 100-200 80-180 70-150
Bedtime or night 130-250 130-200 100-180 90-150

Hemoglobin A1c is a blood test that tells your child’s average blood sugar level over the past two to three months. This test measures the amount of sugar that attaches to hemoglobin, a part of the red blood cell. As hemoglobin travels through the bloodstream, it picks up sugar. The more sugar there is in the blood, the higher the results of this test. Keeping your child’s blood sugar and HgbA1c levels close to normal lowers his or her risk of developing diabetes problems. The chart shows target HgbA1c levels:

  <2 yrs 2-5 yrs 6-12 yrs >12 yrs
HgbA1c 8-9 percent 7.5-8.5 percent <8 percent <7.5 percent

Because percentages may be difficult to understand, the HgbA1c values below have been converted into estimated average blood sugar.

5.5 percent = 111
6 percent = 126
6.5 percent = 140
7 percent = 154
7.5 percent = 169
8 percent = 183
8.5 percent = 197
9 percent = 212
9.5 percent = 226
10 percent = 240
10.5 percent = 255
11 percent = 269
11.5 percent = 283
12 percent = 298

Ketones

Ketones are the product of the breakdown of fat that can appear in the blood and urine. The cells in the body need sugar for energy. The only way for sugar to get into the cells is through insulin. If the body lacks the appropriate amount of insulin to get sugar into the cells, the body starts to break down fat instead of sugar for energy. Too many ketones in the body can cause acidosis and severe illness.

Check ketones:

  • When your child is sick.
  • When your child’s blood sugar measure is over 250 twice in a row.

How to manage ketones:

  • If ketones are trace to small, push sugar-free fluids (8 oz per hour) to help flush them out of the system.
  • If ketones are moderate to large, call the Riley Emergency Line (317.944.5000) for assistance.

Sick Day

Maintaining good diabetes control during periods of illness is not always easy. Even minor illnesses, such as a cold or sore throat, can affect your child’s blood sugar.

It is very important to test your child’s blood sugar and ketone level before each meal and evening snack (or if your child is not eating an evening snack, then measure before going to bed). Test more often if your child’s blood sugar is low. Generally, high blood sugar levels are more common during illness, and your child’s insulin doses may need to be changed. The amount of insulin your child needs may vary depending on his or her blood sugar level, urine ketones and ability to eat. If your child cannot eat a usual meal, the sick day meal plan will provide you with a list of foods that are more easily tolerated during illness. Remember that liquids containing sugar are used to replace usual carbohydrates. It is important for your child to continue taking insulin even if he or she cannot eat.

Call the Riley Emergency Line (317.944.5000), if:

  • You are not sure how much insulin to give during an illness.
  • Your child is vomiting and cannot keep any liquids down.
  • Your child is sick and has moderate or large ketones.

Sick Day Decision Chart

Sick Day Meal Plan

Travel Checklist

Traveling with a child who has diabetes takes extra planning and preparation. This checklist will help you gather the supplies and information you need for traveling.

Medical and Dental Procedures

Before the procedure

  • Try to schedule all procedures first thing in the morning so your child does not have to go without eating for an extended period.
  • Talk to your nurse practitioner a week before the procedure to make plans for insulin doses (both before and after the procedure) and follow-up care. Try to find out when your child must stop eating and drinking before the procedure, how long the procedure lasts, the time of the procedure and when you child will be allowed to eat after the procedure.
  • Most doctors and dentists want blood sugar to be consistently below 250 before doing a procedure.

Day of the procedure

  • Take a glucose meter, insulin, ketone test strips, a can of soda, a sugar-free drink and a glucagon kit to the procedure site. Corrective doses may be given in the recovery room after checking blood sugar. Of course, food doses should be held until your child begins to eat.

After the procedure

  • Check your child’s blood sugar every three to four hours for the first 24 hours after a procedure.
  • If your child does not want to eat solid food, offer liquids that contain carbohydrates and cover the carbohydrates ingested with an appropriate insulin injection.
  • Give a correction dose at mealtimes even if your child doesn’t eat. If your child is nauseated or has vomited, call the Riley Emergency Line (317.944.5000) before giving the corrective dose.
  • Check ketones if the blood sugar is above 250 or if your child is sick.
  • Call the Riley Emergency Line (317.944.5000) if your child is vomiting, is unable to eat, has moderate or large ketones or if you have other concerns.

General Diabetes Education

What is diabetes?

Diabetes is caused when the body is not able to make insulin or the body is not able to respond as it should to the insulin that is made. Insulin is a hormone made in the pancreas that allows the sugar from the foods we eat to enter our body’s cells. Sugar is the primary source of energy for cells. In a child with Type 1 diabetes, the cells cannot get the sugar because of the lack of insulin. The body then turns to fat for its energy. Along with the breakdown of fat, there is often weight loss, fatigue, weakness, increased thirst and increased urination. You may have noticed these symptoms when your child was diagnosed. Once your child has been started on insulin, these symptoms should disappear after a few weeks and he or she should be as active as before.

Types of diabetes

There are primarily two types of diabetes—Type 1 and Type 2. In people with Type 1 diabetes, the pancreas does not make insulin and daily insulin injections are required. In people with Type 2 diabetes, the pancreas either does not make enough insulin or the insulin that is made does not work well enough. This type of diabetes can sometimes be controlled by diet and exercise, but often requires insulin, oral medication or both.

Nothing that anyone did caused your child’s diabetes. Type 1 diabetes develops from a combination of factors. First, a genetic predisposition must be present. Then, at some point in the child’s life, an exposure to a common viral illness or other environmental cause will “trigger” the body’s immune system to attack its own beta cells in the pancreas, making them unable to produce insulin. Nothing could have been done to prevent this from happening. Type 2 diabetes is largely inherited but can occur at an earlier age depending on the child’s diet and exercise regimen.

What is involved in caring for a child who has diabetes?

Diabetes management often involves a lifestyle change. Maintaining good blood sugar control will require frequent blood sugar testing, insulin injections, and attention to food eaten, physical activity and stress. Your child will have to test his or her blood glucose (commonly called blood sugar) four or more times a day using a blood glucose meter and record the results in a log book. Insulin will be given four or more times a day. At diagnosis, you or another caregiver will learn to give your child insulin injections. Because the insulin is injected into the fat tissue instead of the muscle, children usually tell us that it doesn't hurt. As children reach the ages of 8 to 12 years old, they gradually learn to do the testing and injections by themselves. Even though they are doing these tasks independently, they need to continue to be supervised. It is not uncommon for them to not want to do it on occasion, in which case you or another caregiver will again take the responsibility. Another important part of your child’s care is the meal plan. It is easier for your child if everyone in the family is eating the same thing. Your child should have three meals and possibly some snacks each day. It is important to count the number of carbohydrates eaten at meal and snack times so that the appropriate amount of insulin can be given. Physical activity is also an important feature of diabetes management. Exercise will assist the body in using the insulin. Your child will benefit from incorporating some type of physical activity into his or her daily life. Keeping stress levels down is also an important aspect of overall diabetes control as stress tends to make the body more resistant to insulin.

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