605902 caring for a child with type 1 diabetes …...to treat type 1 diabetes you have to match...

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Caring for a ChildWith Type 1 Diabetes

What’s Inside

Meet Your Diabetes Team ................................................................................................ 5

What is type 1 diabetes? .................................................................................................. 7

Food and Diabetes ............................................................................................................ 9

Insulin ............................................................................................................................. 11

Monitoring ..................................................................................................................... 15

Low Blood Sugar ............................................................................................................. 17

High Blood Sugar ............................................................................................................ 19

Exercise, Activity, and Diabetes ...................................................................................... 21

Back to School Tips ......................................................................................................... 23

Adjusting Insulin ............................................................................................................. 25

A1C Testing ......................................................................................................................27

Treating Severe Low Blood Sugar ................................................................................... 29

Managing Diabetes When a Child is Sick ........................................................................ 31

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Meet Your Diabetes Team

Your diabetes team is made up of:• an endocrinologist (a pediatrician who takes care of children with diabetes) • a diabetes nurse • a dietitian • a psychologist• a social worker

The diabetes healthcare team:The endocrinologist, diabetes nurse, and dietitian help families manage their child’s diabetes by adjusting food and insulin doses and by teaching self-care skills and knowledge.

The psychologist:• helps children and families adjust to diabetes, both at the time of diagnosis and over the

longer term• helps parents of younger children learn how to manage any behavioural issues that are

affecting diabetes care• explores personal or mental health problems that may affect how children manage their

diabetes

The social worker:• helps families deal with emotions such as shock, grief, and anger that a diagnosis of diabetes

can often bring• explores ways to cope with the changing emotional and physical demands of diabetes• helps find ways to lessen the effect diabetes has on children and families• connects families to community and financial resources• helps parents find ways to encourage their child to take good care of his or her diabetes

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What is type 1 diabetes?

After food is eaten, it breaks down into glucose (sugar). The pancreas, which makes insulin, helps the body use glucose for energy. Without insulin, glucose can’t move into the cells. Glucose builds up in the bloodstream and passes into the urine. A person with type 1 diabetes doesn’t make insulin.

The common signs of diabetes are:• urinating (peeing) more• being thirstier than usual• losing weight without trying

• feeling tired• nausea and vomiting (sometimes)

About 1 in 500 children have type 1 diabetes, also known as insulin dependent or juvenile diabetes. There is no cure for type 1 diabetes.

What causes type 1 diabetes?No one knows for sure. We do know that eating too much sugar doesn’t cause type 1 diabetes. Researchers think a combination of 3 things is involved:• genetic factors• an environmental trigger (maybe viruses)• an autoimmune response (the body destroys its own insulin producing cells)

You can’t prevent a child from developing diabetes. No one is to blame.

How is it treated?There is no cure for type 1 diabetes. It’s treated by:• insulin injections • following a meal plan • checking the blood sugar

To manage diabetes means to manage 3 factors that affect the blood sugar. These are:• food• insulin• activity

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The goals of managing diabetes are:• keeping the blood sugar as close to normal as possible (4 to 7 mmol/L)• making sure the child’s growth and development is normal• the child’s social and emotional well-being• preventing long-term complications

Remember: Your child is a child first and a child with diabetes second. Diabetes shouldn’t stop your child from taking part in normal childhood activities.

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Food and Diabetes

After food is eaten, it breaks down into glucose (sugar), which is absorbed into the blood stream. Insulin is released from the pancreas to transfer the sugar into cells, where it is used as energy. To treat type 1 diabetes you have to match injected insulin with carbohydrate (food that is made up of sugar particles). To help balance injected insulin with carbohydrate your dietitian will set up a meal plan for your child.

Meal Planning• Times will be set for each meal and snack, based on your family’s eating times.

• The meal plan will have 3 meals and usually 2 to 3 snacks per day.

• Taking into account your child’s usual way of eating, the dietitian will assign carbohydrate goals for each meal and snack. (These may change over time based on changes in appetite.)

• The meal plan will be set up using Beyond the Basics food choice system.

Beyond the Basics divides food into 8 groups: • Grains & Starches• Fruits• Milk & Alternatives• Other Choices

• Vegetables• Meat & Alternatives• Fats• Extras

Each of these food groups has a portion size for one “choice”. The meal plan will show how many grams of carbohydrate or food “choices” to have from each food group at each meal and snack.

• Some foods are “free” as they don’t affect the blood sugar. They are water, diet drinks, diet Jell-O®, sugar-free pop, and most vegetables.

• Your dietitian will also help you include as many foods as possible that are family favourites.

Remember:• Eat meals and snacks at set times.• Measure and weigh foods for correct portion sizes.

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How do I figure out recipe amounts?Family recipes can be calculated and given a carbohydrate choice or grams of carbohydrate value for a serving.

In the beginning, your dietitian will calculate recipes for you. Later, you will be shown how to calculate the carbohydrate content of your dishes and baking recipes.

Reading LabelsBy law, large companies must now put nutrition information (for example: carbohydrate, protein, and fat per serving) on product labels. Your dietitian will teach you how to use label information.

What do I do for special occasions and holidays?You may be wondering how to manage treats and desserts served at birthdays, school parties, Christmas, Easter, Halloween, or other celebrations. There are excellent recipes, other treat ideas, and food choice values for holiday favourites.

The best thing is to plan ahead and know what is being served and when it will be eaten. Your dietitian can help you plan for special occasions.

There are times that food can be made less of a focus for holiday events. For example, an Easter basket could include a small amount of chocolate, plus non-food items like hair barrettes, hockey cards, and small toys, or free foods such as sugarless gum and diet pop.

What are some guidelines to follow when eating out?Eating out can be eating at restaurants or any time you’re away from home for meals and snacks (for example: family gatherings or a banquet).

These basic guidelines will allow your child to enjoy eating out:

• Know the meal plan well.

• Plan ahead when possible.

• Be familiar with portion sizes visually. This comes with practice by weighing and measuring at home.

• Use available food values for fast food restaurants (many fast food restaurants have information on the Internet).

• Try to stay as close to the meal plan as possible. Your dietitian or nurse may be able to offer some flexibility with food and insulin. Be sure to ask for help if your usual routine just doesn’t work!

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Insulin

Brands Your child will be taking human insulin. It doesn’t come from humans but is made in a laboratory. It’s like the insulin our bodies make. There are 3 companies that make insulin: • Lilly (Humulin N® and Humalog®) • Novo Nordisk (Novolin® ge NPH, Novo Rapid®, and Levemir®)• Sanofi (Lantus® and Apidra®)

TypesThere are many types of insulin. Most children and teens will be on rapid-acting insulin in combination with intermediate-acting or long-acting insulin.

Rapid-Acting • Called Humalog®, NovoRapid® or Apidra®

• ClearBegins to work 10–15 minutesPeak action 1–1½ hoursDuration 3–5 hours

Begins to work 1–3 hoursPeak action 5–8 hoursDuration up to 18 hours

Begins to work 1½ hoursPeak action no peakDuration up to 24 hours

Long- Acting• Called Lantus® or Levemir®

• Clear

Intermediate Acting • Called NPH® or N®

• Cloudy

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Common Insulin ProgramsInsulin at breakfast, supper, and bedtime: This program is used with children and teens that aren’t able or willing to give insulin while at school or away from home. It’s important to follow carbohydrate goals and to eat all meals and snacks fully and on time. Sleeping-in and delayed meals are hard to work into this program.

rapid-acting rapid-acting

Breakfast Lunch Supper Bedtime Breakfast

N or NPH N or NPH

• Breakfast blood sugars tell you about the bedtime N® or NPH®.

• Lunch blood sugars tell you about the morning rapid-acting (Humalog®, Novo Rapid® or Apidra®).

• Supper blood sugars tell you about the morning N® or NPH®.

• Bedtime blood sugars tell you about the supper rapid-acting (Humalog®, Novo Rapid® or Apidra®).

Basal/bolus insulin: This most closely acts the way the pancreas does when it releases insulin. Long-acting insulin is given once a day. This basal (background)) insulin works with the glucose that the liver is always releasing. When the child or teen eats a meal or snack they give a bolus (burst) of insulin to work with the carbohydrate in food. This program gives flexibility with the timing of meals and amount of food eaten.


Long-acting

rapid-acting


• Breakfast blood sugars tell you about the long-acting (Lantus® or Levemir®).

• Lunch blood sugars tell you about the morning rapid-acting (Humalog®, Novo Rapid®, or Apidra®).

• Supper blood sugars tell you about the lunch rapid-acting (Humalog®, Novo Rapid®, or Apidra®).

• Bedtime blood sugars tell you about the supper rapid-acting (Humalog®, Novo Rapid®, or Apidra®).

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Storing Insulin• Keep unopened insulin in the refrigerator. Don’t let it freeze.

• Mark the date of starting a new cartridge on your calendar.

• Once opened, it can be stored at room temperature for 28 days. The exception is Levemir®, which can be stored for 42 days.

• Insulin must not get too hot. Keep it away from direct sunlight. Don’t leave it in a car. Store it in a cooler or insulated bag.

• Throw out insulin if:• the clear insulin becomes cloudy• the cloudy insulin won’t mix evenly or clumps• it’s been frozen or in a very hot place (30 °C or more)

Preparing a Dose of InsulinUsing a Syringe

1. Draw the clear insulin first. Hold the cartridge upside down and insert the needle. Pull back to the right dose. If there are air bubbles, push the entire dose back into the cartridge and repeat until all the air bubbles are gone.

2. Mix the cloudy insulin well.

Roll the cartridge between the palms of your hands 10 times.

Turn the bottle upside down (180 degrees) 10 times.

3. Draw the cloudy insulin into the syringe with the clear insulin. If you draw up too much cloudy insulin, throw out the entire dose and start again.

4. Give the insulin dose right after preparing it.

Using a Pen

1. If the insulin is cloudy, mix it well. Roll the pen between the palms of your hands 10 times and turn the pen upside down (180 degrees) for 10 cycles. See the picture above.

2. Screw on a new pen needle. Take off the outer and inner caps.

3. Check that the pen is working before each injection. Set the dial to 2 units. With the pen needle pointing upwards, press the pen button. You should see drops or a squirt of insulin. If not, repeat this step.

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4. Set the prescribed dose. The pen is now ready for an injection.

5. Choose a site, insert the needle, press the plunger, and hold the needle in place for 10 seconds.

6. Take off the needle tip after the injection and put it in a sharps container.

Injecting Insulin• Insulin should be injected at about the same time each day. It’s okay to give the injection

1 hour earlier or later than the usual time.

• Give rapid-acting insulin 10 to 15 minutes before the meal. If the blood sugar is below 5.0 mmol/L, give it just before the meal.

• You can give rapid-acting insulin to young children after a meal, as they don’t always eat the same amount of carbohydrate-containing food each time. The dose depends on the amount of food the child eats. Once the appetite is more predictable the insulin should be given before the meal.

Injection Sites• Insulin is injected into the fatty tissue that lies between the muscle and skin. There are 4 sites

used to inject insulin: abdomen, arms, thighs, and buttocks (has the most amount of fat).

• Your diabetes nurse educator will assess your child or teen’s injection sites and teach you how to give the injection into the fatty tissue.

• Make sure not to inject into the same area all the time, as this will cause a fatty lump to form. Insulin injected into these lumps isn’t absorbed evenly, which affects blood sugar levels.

• It’s important to use at least 2 different areas on the body right from the start and to develop a system of rotating within these areas. It’s much harder to rotate later on if your child has favourite spots.

Front Back

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Monitoring

Monitoring is an important part of managing diabetes. You’ll need to monitor your child’s blood sugar and check the urine or blood for ketones.

Doing a Finger Poke to Check Blood Sugar• Make sure your child washes his hands with soap and water before you start. If he isn’t able

to wash, he can clean the finger tip with an alcohol swab. Let it dry thoroughly.

• Change the lancet at least once a day. One tip is to put a new one in at breakfast and take it out after the bedtime blood sugar check. If your child says the finger pokes hurt, try changing the lancet each time.

• Use the sides of the finger tip and make sure that your child uses all fingers. It’s important to rotate well to prevent scarring and possible infection. You can use toes as well.

• Don’t let anyone else use your child’s finger poker. Infections and diseases that are carried in the blood can be spread by sharing equipment.

Monitoring Blood Sugar • Check the blood sugar at least 4 times a day, before meals and the bedtime snack.

• You may also need to check in the middle of the night if you think your child has a low blood sugar or the bedtime reading is low.

• Wait at least 2 hours after eating before you check the blood sugar. If your child’s routine doesn’t allow for a 2-hour gap, speak with your diabetes nurse or dietitian.

• Record the blood sugar result in the diabetes logbook. Also record the insulin dose and make a note about your child’s activity, stress, illness, special occasions, and changes from the meal plan.

• Don’t panic if one blood sugar is high or low. Look for patterns in the logbook. If you see a pattern of low or high blood sugars, or if your child has more than 2 lows in a week, call your diabetes nurse to have the insulin dose changed.

Blood Sugar Targets Based on Age

Age in years Blood sugar target before meals

Blood sugar target2 hours after meals

under 6 6.0 to 10.0 mmol/L does not apply

6 to 12 4.0 to 10.0 mmol/L does not apply

13 to 18 4.0 to 7.0 mmol/L 5.0 to 10.0 mmol/L

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Monitoring the Urine for Ketones• If the blood sugar is high, the body may start to burn fat for energy. If fat is burned, the

body makes ketones. Too many ketones are bad for the body.

• Check the urine or blood for ketones when:• the blood sugar is greater than 14 mmol/L• your child is sick• your child has thrown up (vomited)

• If ketones are + (small), ++ (moderate), or +++ (large) your child needs extra insulin. Call the diabetes clinic.

Taking Care of Your Supplies• Store blood and urine test strips in their original containers.

• Protect blood and urine test strips from light, moisture, and heat. Don’t leave your monitoring supplies in the car.

• Don’t use test strips after the expiry date. Check the package insert on blood and urine test strips. Some brands must be thrown out 4 to 6 months after opening.

• Make sure that you’re shown how to use your meter.

• Have a lab-to-meter comparison done when you buy a new meter, and every year thereafter.

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Low Blood Sugar

Low blood sugar is called hypoglycemia. Knowing the causes of low blood sugar can help prevent them.

What are the causes of low blood sugar?• a missed or delayed meal or snack• not finishing all of the meal or snack• too much insulin

• extra exercise or activity• drinking alcohol

What are signs and symptoms of mild to moderate low blood sugar?Signs and symptoms of mild to moderate low blood sugar are:• sweating• trembling• hunger• weakness

• paleness• dizziness• headache• blurred vision

• mood changes• drowsiness• clumsiness• confusion

What do I do if my child has a low blood sugar?• If your child has any of the above symptoms, check the blood sugar. If it’s less than

4.0 mmol/L, treat right away (see the next page for treatment options).

• Wait 15 minutes and re-check the blood sugar. If it’s less than 4.0 mmol/L, repeat the treatment.

• If your child has a low blood sugar before a meal or snack, treat it, wait 15 minutes, and then give the usual meal/snack.

• If your child has a low blood sugar and it’s more than 1 hour until the next meal or snack, treat it, wait 15 minutes, and then give a snack containing 15 grams of complex carbohydrate plus a protein.

• If your child has a low blood sugar during exercise, treat it, and then have your child rest for at least 15 minutes or until feeling better.

Important:

• A low blood sugar can happen at any time. You or your child should always have a treatment for low blood sugar with you (glucose tablets, candy, juice etc.).

• Your child should wear a bracelet or necklace saying that he or she has diabetes and takes insulin.

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How do I treat my child’s low blood sugar?To raise the blood sugar, give a rapid-acting carbohydrate. Glucose tablets, gels, liquids, and sugar (in candy and pop) work the fastest. Juice works more slowly.

The amount of rapid-acting carbohydrate needed to treat a low blood sugar is based on a child’s weight.

Weight below 15 kg Weight 15 to 30 kg Weight above 30 kg

5 grams Carbohydrate 10 grams Carbohydrate 15 grams Carbohydrate

⅓ Dex4® glucose gel 2 to 3 Dex4® glucose tablets 3 to 4 Dex4® glucose tablets

⅓ Dex4® glucose Liquiblast 2 tsp. sugar 3 tsp. sugar

1 tsp. sugar in water 2 large marshmallows 3 large marshmallows

1 tsp. syrup 10 Skittles® 15 Skittles®

3 tbsp. regular pop 6 gummy bear candies 9 gummy bear candies

3 tbsp. apple juice 1½ packs of Rockets® 2 packs of Rockets®

1 Dex4® glucose tablet ⅓ cup of regular pop ½ cup of regular pop

10 Rocket® candies ⅓ cup of apple juice ½ cup of apple juice

3 gummy bear candies

Note: Liquids and syrups are recommended for infants and young toddlers. These can be given by a medicine dropper or a liquid medicine dispenser.

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High Blood Sugar

High blood sugar is called hyperglycemia. Knowing the causes of high blood sugar can help prevent them.

Causes of high blood sugar are:• eating too much food• less activity than usual• not enough insulin

• not taking insulin • illness or stress

What are the signs and symptoms of high blood sugar?Signs and symptoms of high blood sugar are usually seen when the blood sugar is greater than14 mmol/L for several hours. Some signs and symptoms of high blood sugar are:• peeing a lot (increased urination)• dry mouth• being more thirsty than usual

• having no energy• trouble concentrating• being more irritable or cranky

If the blood sugar is greater than 14 mmol/L for a long period of time, the body may burn fat for energy.

Signs and symptoms that the body is using fat for energy are:• ketones in the urine• ketone breath (smells like nail polish

remover)• no appetite

• nausea, vomiting, or pain in the abdomen• deep, fast breathing• being very tired (may lead to

unconsciousness)

The last 3 symptoms are serious. Your child may have diabetic ketoacidosis (DKA) and needs emergency treatment.

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What do I do if my child has a high blood sugar?• If there’s a pattern of high blood sugars, more insulin needs to be given. Your doctor or

diabetes nurse will make insulin adjustments after speaking with you. Later you will learn how to adjust the insulin on your own.

• Your doctor or diabetes nurse will also teach you how to correct high blood sugar by giving extra rapid-acting insulin.

• If your child’s blood sugar is greater than 14 mmol/L, check the urine or blood for ketones.• If ketones are +, ++ or +++ (small, moderate or large), your child needs extra insulin. Call

the diabetes clinic. Early treatment can prevent DKA.• Your child must not exercise when the blood sugar is high and there are ketones in the

urine. Exercise will make the blood sugar go even higher.• If the blood sugar is high because your child is sick, see Managing Diabetes When a Child

is Sick on page 31 or call the Diabetes Clinic.

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Exercise, Activity, and Diabetes An active lifestyle can be fun and is important for good health. It helps control weight, improves physical fitness, self-esteem, helps with sleep, and reduces stress. It can also make managing blood sugars more challenging.

How does exercise and activity affect blood sugar? Exercise or activity usually lowers blood sugar—it makes insulin work harder. During exercise, more sugar moves into the muscle cells, leaving less behind in the bloodstream. This can cause a low blood sugar during exercise and/or several hours after (delayed lows). Strenuous or extended activity late in the day or in the evening can lead to low blood sugar in the middle of the night.

Injecting into an exercising arm or leg may cause the insulin to be absorbed faster, causing a low blood sugar.

Sometimes exercise can cause high blood sugar (post-exercise highs). Doing sports can cause the release of stress hormones that raise the blood sugar. If the blood sugar is high when the exercise is started, the exercise acts as a stressor, causing the blood sugar to go higher. Not drinking enough fluids during exercise can also lead to a high blood sugar.

What are some guidelines for my child to follow? • Teach coaches and gym teachers about low blood sugar—the signs and symptoms,

treatment, and how to prevent it.

• Carry rapid-acting carbohydrate to treat low blood sugar.

• Drink lots of fluids during exercise.

• Don’t inject insulin into an arm or leg that was just exercised or is going to be exercised.

• Check the blood sugar before, during, and after exercise.

• Check the blood sugar at 3 a.m. after a long active day or evening activity.

• Think about decreasing the insulin for a planned activity (see guidelines).

• Think about giving extra food for increased activity (see guidelines).

• Record the insulin and food changes in the logbook to see if they’re working.

• If your child has a high blood sugar after exercise, don’t correct it using the usual dose. Try using only half the correction.

• If blood sugar is greater than 14 mmol/L, check for ketones. Don’t exercise if ketones are positive.

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What are the guidelines for decreasing insulin?If certain activities cause low blood sugar, then think about giving less insulin. The insulin that’s having the greatest effect at the time of exercise is the one that’s decreased. For example, supper rapid-acting insulin is decreased for evening soccer.

The insulin is decreased by: • 10% for light activity (walking, baseball) • 20% for moderate activity (biking, down-hill skiing) • 30% to 50% for strenuous or day-long activity (soccer, hiking)

If a low blood sugar happens after a very active day, decrease the bedtime intermediate-acting insulin (N or NPH) by 10 to 20%.

What are the guidelines for giving extra food?If the blood sugar is high at the time of the activity, it will either drop or go higher. Don’t give extra food. Check the blood sugar 30 to 60 minutes into the activity. Give extra food if the blood sugar is below 10 mmol/L and the activity will be continuing.

If the blood sugar is below 10 mmol/L before moderate or strenuous activity, give 10 to 15 grams of carbohydrate for every 30 to 60 minutes of activity.

Check the blood sugar during and after the activity to see how well the food adjustments worked. Record the changes you made in the logbook.

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Back to School Tips

You will need to meet with your child’s teachers before he or she goes back to school. The Canadian Diabetes Association has a resource kit called Kids with Diabetes in Your Care. This kit has been developed for teachers and parents. It will help you teach the teacher. You can get this kit from the Canadian Diabetes Association’s web site at www.diabetes.ca.

• Ask to meet with the classroom teacher, gym teacher, principal or vice-principal, and school secretary. Give them the Kids with Diabetes in Your Care resource before the meeting and ask them to review it.

• Teach school staff about low blood sugar—the signs and symptoms, treatment, and how to prevent it. Ask the principal to let the bus driver, lunchroom supervisors, librarian, substitute teachers, and other staff know.

• Give the teacher a supply of rapid-acting carbohydrate to treat low blood sugar. Check this supply regularly and give more as needed.

• Give the teacher a fanny-pack with rapid-acting carbohydrate in it. The teacher or your child can carry it during outdoor classes or field trips.

• Review the symptoms of high blood sugar. Tell the teacher that your child will be thirsty and need to go to the bathroom. Make sure your child can keep a bottle of water at his or her desk. Let the teacher know that your child may also have trouble concentrating when the blood sugar is high.

• Ask the teacher or principal to find a private, “clean” space where your child can do blood sugar checks, or give insulin injections. Give the school a sharps container so the needles and lancets can be disposed of safely.

• If your child needs help remembering to eat snacks or check her blood sugar, buy a digital watch with an alarm.

• For very young children, start a communication book. You and the teacher can write down important information about the diabetes. Older students can use their school agenda for communication.

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Adjusting Insulin

Three injections with rapid-acting and N or NPH



N or NPH N or NPH

• Breakfast blood sugars tell you about the bedtime N® or NPH®.


• Supper blood sugars tell you about the morning N® or NPH®.


Rapid-acting with meals and background long-acting


Long-acting

rapid-acting


• Breakfast blood sugars tell you about the long-acting (Lantus® or Levemir®).


• Supper blood sugars tell you about the lunch rapid-acting (Humalog®, Novo Rapid®, or Apidra®).


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Pattern Adjustment1. Review the log book every 3 to 4 days to look for patterns.

2. If the blood sugar is above target at the same time of day for 3 days in a row, increase the insulin that is working at this time. Only increase one insulin at a time, and wait 2 to 3 days before increasing again.

3. If the blood sugar is below target at the same time of day for 2 days in a row, decrease the insulin that is working at this time. If there are 3 or more lows per week but no pattern, call the diabetes clinic.

Note: Before adjusting insulin think about other factors such as exercise, food, less than 2 hours between food and blood glucose, check falsified results, etc.

By how much should I adjust?If the insulin dose that you are adjusting is:• less than 15 units, adjust by 1 unit• 15 to 30 units, adjust by 2 units• greater than 30 units, adjust by 3 to 4 units

Note: If your child is very young or is on a small dose of insulin, adjust by ½ units.

What are night time lows?Your child may drop low in the middle of the night. In response to the low, the liver releases a large amount of glucose, which is the cause of the high blood sugar in the morning. To rule out night time lows, check the blood sugar at 3 a.m. for 2 nights. If the blood sugar is low, decrease Lantus®, Levemir®, or the bedtime N (NPH).

How do I correct high blood sugar?Your diabetes nurse or doctor may give you a method for correcting high blood sugar with rapid-acting insulin (Humalog®, NovoRapid®, Apidra®).

If you correct high blood sugar often, you need to do a pattern adjustment and increase the insulin that’s responsible for the high blood sugar.

Don’t give more N (NPH), Lantus®, or Levemir® at bedtime for a high blood sugar. Give extra rapid-acting insulin using your system for correcting. Check the blood sugar 2 to 3 hours later.

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A1C Testing What is A1C? A1C measures the blood sugar control in the past 3 months. Hemoglobin is part of the red blood cell. A red blood cell lives for about 3 months. During that time, the hemoglobin picks up sugar from the blood. If the blood sugar is often high, more sugar will stick to hemoglobin, causing a high A1C. The A1C reflects the average blood sugar over the past 3 months.

How often should this test be done? The A1C should be done every 3 to 4 months. A blood sample can be taken from the fingertip or from a vein in the arm. Ask your diabetes team what kind of sample is needed and where to have it done. If your child needs to have a blood sample taken from a vein, you can use EMLA™

or Maxilene™ cream, or Ametop Gel™ to numb the site.

What should the A1C result be? A person without diabetes will have an A1C between 4.3 and 6.1%. Most people with type 1 diabetes don’t have a normal A1C. Research shows that lower A1C levels can greatly decrease the risk of long-term complications, such as nerve, kidney, and eye damage. Based on age, the 2013 Clinical Practice Guidelines from the Canadian Diabetes Association recommend the A1C targets below:

Age (years) A1C

Less than 6 Less than 8.0%

6 to 12 Less than 7.5%

13 to 18 No more than 7.0%

Your diabetes team will talk with you about your child’s A1C value at each clinic visit. If it’s higher than it should be, your team will help you create an action plan to help lower it.

Diabetes Care, 2002. 25:275-278.

Average blood sugar (mmol/L)

A1C Value (%)

19.5 17.5 15.5 13.5 11.5 9.5 7.5

12%11%10%9%8%7%6%

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Treating Severe Low Blood Sugar

A severe low blood sugar causes the brain to have less of the glucose it needs to work. This can cause: • confusion and poor coordination• seizures • unconsciousness• temporary paralysis on one side

How to treat if your child is awake Give one of these 20 gm rapid-acting carbohydrates: • 5 Dex4® glucose tablets • ⅔ cup of regular pop or apple juice • You will need to firmly coax your child to eat or drink

How to treat if your child is unconscious or having seizures • Don’t force food or liquid into the mouth. • Place your child on his side, in a safe place. • Measure the blood sugar. • Give an injection of Glucagon®.

• 4 years or younger, give 0.5 mL (0.5 mg) of Glucagon®. • 5 years or older, give 1 mL (1.0 mg) of Glucagon®.

• Call 9-1-1 if you don’t have Glucagon® or your child isn’t awake after 10 minutes. • Call the Diabetes Clinic or the endocrine doctor on call afterwards to let them know.

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Glucagon • Glucagon is a hormone that triggers the liver to release stored sugar. It takes about

10 minutes for the sugar from the liver to reach the brain and for your child to wake up.

• Draw up Glucagon® using the instruction sheet in the box.

• Give Glucagon® the same way you give an insulin injection.

• Once mixed, Glucagon® must be used or thrown out within 24 hours.

After Using Glucagon • When your child is awake, give ½ cup of juice or regular pop. Wait 15 minutes and then

offer a snack of starch and protein.

• The side effects of a severe low and Glucagon® are nausea, vomiting, and headache. Monitor the blood sugar. Your child may need to come to emergency until blood sugars are stable.

• Reduce the insulin dose by 20% for 2 to 3 days after a severe low.

How to Prevent Severe Low Blood Sugar • Decrease insulin when you see a pattern of low blood sugars or 3 or more lows per week.

• Supervise insulin injections.

• Have a safe plan for sleeping in.

• Know that the risk of a severe low goes up in the spring.

• Adjust for exercise (decrease insulin and/or increase food).

• Make sure meals and snacks are eaten on time and that all the food is eaten.

• Check the blood sugar in the middle of the night after an active day or evening, or when the blood sugar is low at bedtime.

• Make sure that your teenager knows that alcohol causes low blood sugar and drinking too much can cause a severe low.

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Managing Diabetes When a Child is Sick Being sick (such as with an infection or flu) often causes high blood sugars and ketones, even if your child isn’t eating. This has to be managed closely or your child can develop a dangerous condition called diabetic ketoacidosis (DKA). Sometimes blood sugar can be low if there’s vomiting and diarrhea. As well, an illness can cause dehydration. Below is what to do to help you manage your child’s diabetes during an illness:

1. Check the blood sugar every 2 to 4 hours around the clock.

2. If the blood sugar is greater than 14.0 mmol/L, check urine or blood for ketones.

3. Never stop giving insulin when your child is sick. See How do I adjust insulin when my child’s sick? on the next page.

4. If your child isn’t able to eat, give ½ to 1 cup of clear fluid every hour.• If the blood sugar is below 14.0 mmol/L, the fluids should have sugar

(for example: regular pop, popsicles, or apple juice).• If the blood sugar is above 14.0 mmol/L, fluids should be sugar-free

(for example: water, diet pop, Crystal Light®).

5. If your child is able to eat, follow the usual meal plan and offer foods that are easy to tolerate. See What can I offer my child to eat and drink? on page 33.

6. Give sips of fluids to prevent dehydration. Your child should have ½ to 1 cup per hour.

7. Make sure your child rests. If the blood sugar is high with ketones, more activity may cause the blood sugar to go even higher.

8. Call your family doctor or call Health Link at 811 if you have concerns about your child’s illness.

9. Medication• You can use acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®) for fever and pain. • Use sugar-free products for coughs and colds.• Use prescription medicine (such as antibiotics) as directed by your doctor.

10. Call the diabetes nurse or the endocrine doctor on call if: • you can’t keep your child’s blood sugars above 4.0 mmol/L• your child vomits more than 2 times in 4 hours• your child still has ketones after 2 extra doses of rapid-acting insulin• blood ketones are greater than 3.0 mmol/L (a sign of DKA)• your child has signs of dehydration —dry mouth or tongue, cracked lips, sunken eyes,

dry flushed skin, or isn’t peeing (urinating) much• your child has signs of DKA: high blood sugar and ketones with nausea, stomach pain,

vomiting, fast breathing, fruity smelling breath, and drowsiness

32

Call (403) 955-7211:• Weekdays 8 a.m. to 4 p.m.: Ask for the diabetes nurse on call.• After hours, weekends, or holidays: Ask for the endocrinologist on call.

How do I adjust insulin when my child is sick?

Remember: Never stop giving insulin when your child is sick.

Blood sugar below 10.0 mmol/L WITH vomiting, diarrhea, or not eating

• Don’t give rapid-acting insulin (Humalog®, NovoRapid®, Apidra®).• Decrease N, NPH, Lantus®, Levemir® by 20%.

Blood sugar above 10 mmol/L and negative ketones

• Give the usual dose of insulin.

Blood sugar above 14.0 mmol/L with ketones

Give extra rapid-acting insulin (Humalog®, NovoRapid®, Apidra®) every 2 to 4 hours around the clock until the blood sugar is below 14 mmol/L or the ketones are negative.

• If urine ketones are + (small) or blood ketones are 0.6 to 1.4, use your usual method of correcting high blood sugar.

• If ketones are ++ (moderate) to +++ (large) or blood ketones are 1.5 or greater, give 50% MORE of your usual correction. To do this, multiply your usual correction by 1.5. For example if you would normally correct a blood sugar of 16.2 with 5 units of rapid-acting insulin you would give 7.5 units (5 x 1.5 = 7.5). If you don’t have a ½ unit pen, round up to a full unit.

Page the diabetes nurse or endocrine doctor on-call if: • you don’t have a method of correcting high blood sugar or you aren’t sure how to give

50% more

• your child still has ketones after 2 extra doses of rapid-acting insulin

33

What can I offer my child to eat and drink?

Foods that have about 15 g of carbohydrate

• 1 slice of dry toast• 8 soda crackers• 3 graham wafers• ½ cup (125 mL) ice cream

or sherbet

• ⅓ cup (75 mL) pudding• ¾ cup (180 mL) cooked

cereal• 1 cup (250 mL) soup

• ½ cup (125 mL) regular flavoured yogurt

• ½ cup (125 mL) unsweetened applesauce

Fluids that have about 15 g of carbohydrate

• ¾ cup (180 mL) regular ginger ale• ½ cup (125 mL) regular Jell-O®

• ½ popsicle• ½ cup (125 mL) regular Kool-Aid® or

fruit punch

• 1 cup (250 mL) Gatorade® or Powerade®

• ½ cup (125 mL) fruit juice• 1 cup ( 250 mL) white milk• ½ cup (125 mL) flavoured milk

Fluids that have no carbohydrate

• water• diet ginger ale• diet popsicles

• sugar-free Jell-O®

• Crystal Light®, Dasani®, Mio® • clear broth

Diarrhea

• If your child has diarrhea, use Pedialyte® or Lytren®.

• Use juice, sports drinks, broth/consommé, or diet popsicles with caution, as they can make diarrhea worse.

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35

605902 caring for a child with type 1 diabetes …...to treat type 1 diabetes you have to match...

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