Diabetes Childhood Adolescence: Pocketbook For Management of IN AND in Under-Resourced Countries

I N T E R N AT I O N A L D I A B E T E S F E D E R AT I O N , 2 0 1 3
POCKETBOOK FOR MANAGEMENT OF
DIABETES IN CHILDHOOD
AND ADOLESCENCE
IN UNDER-RESOURCED COUNTRIES
The Pocket Book was prepared and edited by:

Graham Ogle, MBBS FRACP, General Manager, IDF Life for a
Child Program, Sydney Australia
Angela Middlehurst, RN RSCN CDE, Education Manager, IDF
Life for a Child Program, Sydney Australia
Martin Silink, MBBS, MD, FRACP, Professor of Paediatric Endocrinology, University of Sydney and Chairman, IDF Life for a
Child Program and Sydney Australia
A
ssoc. Prof. Ragnar Hanas, MD, PhD, Uddevalla Hospital, NU
Hospital Group, Uddevalla, Sweden (for ISPAD)
For information on the IDF Life for a Child Program see Chapter 14
and also www.lifeforachild.org
This Pocket book has been prepared and printed with financial support from the Leona M. and Harry B. Helmsley Charitable Trust and
the Fondation de lOrangerie.
The information in these guidelines is aimed to assist health

care professionals in developing countries to optimise the clinical practice they are able to give in their particular centre. In
many cases, subsequent referral to a centre with greater expertise is appropriate.
PREFACE
These guidelines have been developed taking into account resource- and cost-related issues affecting care for children and
youth with diabetes in developing countries. Healthcare funding
and available expertise vary from country to country and often
also within a particular country, and therefore it is challenging
to write a broad document to meet all needs.
It is estimated that there are approximately 490,000 children under the age of 15 years with type 1 diabetes worldwide. 70,000
new cases are diagnosed each year and numbers are rising between 3-5% per year (IDF Atlas, Brussels 2010).
In the developed world, children and youth with diabetes have
full access to insulin and other components of diabetes care, so
that they can lead normal healthy lives. However for many children in some countries there is limited access to insulin, blood
glucose monitoring, expert medical care and diabetes education. This may be due to unaffordability, or the expert care may
simply not be available in the area. The consequences of this are
profound. Some children will die undiagnosed or soon after diagnosis. All are prone to life-threatening episodes of low or high
blood sugar levels. Over time, inadequate blood glucose control
frequently leads to serious complications, including blindness
and renal failure. Many have to drop out of school, and struggle
to gain employment or find a marriage partner.
The International Society for Pediatric and Adolescent Diabetes
(ISPAD) has released comprehensive guidelines in 1995, 2000
and 2009, Clinical Practice Consensus Guidelines. Using these guidelines, the International Diabetes Federation (IDF) and ISPAD
published Global Guideline for Diabetes in Childhood and Adolescence in
2011. The Changing Diabetes in Children Program (CDiC) and
ISPAD also released Diabetes in Children and Adolescence - Basic Training
Manual for Healthcare Professionals in Developing Countries in 2011.
The IDF Life for a Child Program and ISPAD decided it was appropriate to develop a shortened version of these guidelines aimed
to be of practical use in emergency situations and in clinics that
are developing expertise in managing diabetes in children. This
Pocketbook provides basic background on diabetes in children,
Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries
PREFACE
and clear advice for initial management of diabetic ketoacidosis,

initiation of maintenance insulin therapy, complications screening, and other key components of care see contents.
The Pocketbook will be available in printed form, on the web,
and as an app for smartphones (as Android and Apple versions).
The three more detailed guidelines mentioned above were all
extensively used as source material. Some information was also
drawn from Caring for Diabetes in Children and Adolescents (Childrens
Diabetes Services, Australia 2010).
We thank the authors of these four works:
Dr. Ragnar Hanas, MD, PhD, Uddevalla Hospital, NU Hospital Group, Uddevalla, Sweden (1,2)
Prof. Kim C. Donaghue, MBBS PhD, University of Sydney, Sydney Childrens Hospitals Network, NSW, Australia (1,2)
Prof. Georgeanna Klingensmith, MD, Professor of Pediatrics, Univer-
sity of Colorado School of Medicine, The Barbara Davis Center, Aurora, Colorado, USA (1,2)
Dr. Peter G.F. Swift, MD, FRCPCH, Childrens Hospital, Leicester Royal
Infirmary, Leicester UK (1,2)
Prof. Stephen Colagiuri, MB BS, FRACP, Sydney Medical School Boden

Institute of Obesity, Nutrition, Exercise & Eating Disorders, Sydney, Australia (2)
Dr. Stuart J. Brink, MD, University School of Medicine, New England Diabetes & Endocrinology Centre (NEDEC), Massachusets, USA (1,3)
Dr. Warren Lee Wei Rhen,
MBBS. M.Med (Paediatrics), Paediatrics,

Growth & Diabetes Centre, Singapore (1,3)
Dr. Kubendran Pillay, MBCh(Natal), DCH(SA), FCPaed(SA), Westville Hospital, Durban, South Africa (3)
Dr. Line Kleinebreil,
MD, Fondation Education et Techerche pour

LEnseignement aux Malades Chroniques (3)
Prof. Geoffrey R Ambler, MBBS, MD, FRACP, University of Sydney, Sydney Childrens Hospitals Network, NSW, Australia (4)
Prof. Fergus J Cameron,
BMed Sci, MBBS, Dip RACOG, FRACP, MD,

Murdoch Childrens Research Institute, Royal Childrens Hospita, Melbourne,
Australia (1,4)
1. Clinical Practice Consensus Guidelines, ISPAD 2009

2. Global Guidelines for Diabetes in Childhood and Adolescence, IDF 2011
3. Diabetes in Children and Adolescence - Basic Training Manual for
Healthcare Professionals in Developing Countries, Novo Nordisk 2011
4.
Caring for Diabetes in Children and Adolescents, Childrens Diabetes

Services (Australia) 2010
Definition and Diagnosis ...................................
Management of Diabetic Ketoacidosis ............
10
Insulin Treatment .............................................
21
Hypoglycaemia ..................................................
30
Sick Day Management ......................................
33
Blood Glucose Monitoring ................................
35
Nutritional Management ..................................
39
Physical Activity ................................................
40
Diabetes Education ..........................................
42
10
Ongoing Care, Management of Complications
43
11
Psychological Care ............................................
47
12
Diabetes and Adolescence ...............................
48
13
Diabetes and School .........................................
49
14
Diabetes and Pregnancy ...................................
50
15
Other Types of Diabetes in Children,

including Type 2 .................................................
51
16
IDF Life for a Child Program .............................
53
CONTENTS
Pocketbook for Management of

Diabetes in Childhood and Adolescence
in Under-Resourced Countries
DEFINITION AND
DIAGNOSIS
Diabetes is a group of disorders characterised by a sustained elevation of blood glucose levels (BGL).
Glucose is the main source of energy for the body. Insulin, a
hormone made by the beta cells in the pancreas, facilitates
the movement of glucose from the blood to the cells so it
can be used. Diabetes occurs either because the body does
not produce enough insulin, or because cells do not respond
to the insulin that is produced (insulin resistance).
Symptoms and Signs

More Common
Less Common
Severe
(Diabetic ketoacidosis)
Weight loss
Excessive hunger
Frequent vomiting and

acute abdominal pain
Polyuria in younger
children bedwetting is
common
Blurred vision
Flushed
cheeks
Excessive thirst
Mood changes
Dehydration with
continuing polyuria
Tiredness - not wanting to work or play
Skin infections
Decreased level of
consciousness
Oral or vaginal thrush
Kussmaul respiration
(deep, rapid, sighing)
Abdominal pain
Coma
Acetone
smell on
breath
Shock
In diabetes the body is unable to fully use glucose, and starts

to break down fat and muscle, resulting in weight loss. The
kidneys are unable to reabsorb all the filtered glucose. The
glucose is excreted in the urine (glycosuria), dragging water
with it resulting in polyuria (excessive urination) and polydipsia (excessive drinking). Younger children often resume
bedwetting.
In babies and young infants, signs and symptoms may be

less easily detected.
Diabetes in children is often misdiagnosed as some other
condition e.g. as pneumonia or asthma (laboured breathing), as appendicitis or gastroenteritis (abdominal pain,
vomiting), as a serious infection such as malaria, typhoid,
HIV/AIDS, tuberculosis, or meningitis (coma etc.), as a urinary tract infection (urinary frequency), or as malnutrition
(weight loss, tiredness).
DEFINITION AND
DIAGNOSIS
Breakdown of fat causes ketones to accumulate in the blood

(acidosis). If the diagnosis is not made, glucose and ketone
levels become very high, resulting in severe dehydration
and loss of electrolytes from the body. This is called diabetic ketoacidosis (DKA). The presence of ketones and the
accompanying acidosis may cause an acetone/sweet smell
on the breath, vomiting, abdominal pain, decreased level of
consciousness and rapid deep breathing called Kussmaul
respiration. If untreated, shock, cerebral oedema, coma and
death may occur.
Diagnosis of diabetes is made when:

Symptoms + random BGL
11.1 mmol/L (200 mg/dl)
(or)
Fasting BGL 7mmol/L ( 126 mg/dl)
(or)
2 hour post load glucose
11.1 mmol/l ( 200 mg/dl) during an oral glucose
tolerance test
75 gm glucose is given as a sweet drink after fasting
In the absence of clear symptoms, diagnostic testing should
be repeated on a separate day.
If resources are limited and blood glucose testing is unavailable, diagnosis can be made by testing urine for high
levels of glucose and ketones.
DEFINITION AND
DIAGNOSIS
Types of Diabetes
Most diabetes in children is type 1 diabetes, resulting in lifelong insulin dependency. Type 2 diabetes can also occur in
children (mainly in adolescents). Other rarer types can also
occur, even in neonates.
In more detail:
Type 1 Diabetes
Type 1 diabetes is the most common autoimmune disorder in
childhood and adolescence. Both genetic and environmental
factors are important in determining an individuals risk, however the mechanisms are not fully understood. Incidence varies widely between different countries, within countries and
between different ethnic populations. Finland has an incidence
of 64 per 100,000 children <15 years per year, with some others
<1 per 100,000 children <15 years per year. Type 1 diabetes is
increasing by 3-5% per year.
Onset can be at any age after the neonatal period, but it is most
common in childhood and adolescence.
Clinical presentation can vary from non-urgent presentation (see
to severe presentation
with dehydration, shock and DKA (see table on page 6).
more common symptoms in the table on page 6)
Newly diagnosed children should be transferred to a centre that

has expertise in paediatric diabetes, if this is possible.
Treatment of diabetes consists of
lifelong insulin dependency with multiple injections per day
a healthy eating plan
regular physical activity.
Maintaining this balance in children and adolescents can be
difficult due to their variable growth, activity and eating patterns.
Antibody testing should be performed at diagnosis where possible.
For further reading please refer to Chapter 1 ISPAD Guidelines 2009.
Type 2 Diabetes
People with type 2 diabetes produce insulin but the insulin produced does not work effectively (insulin resistance). Type 2 diabetes often responds initially to a healthy eating plan, appropriate
exercise and weight reduction. However, metformin is frequently
needed (+/- an insulin sensitiser), and later insulin may be required.
For further reading please refer to Chapter 3, ISPAD Guidelines 2009
Other Types of Diabetes

Other rarer types of diabetes occur, including:
The imperfectly understood entities of malnutrition related
diabetes and fibrocalculous pancreatopathy also occur in
some countries in the developing world. Fibrocalculous pancreatopathy usually presents with abdominal pain and calcification of the pancreas is evident on X-ray or ultrasound
DEFINITION AND
DIAGNOSIS
Type 2 diabetes usually affects people over the age of 40, may run
in families and is often associated with being overweight. It is increasingly being seen in older children, particularly adolescents
who are overweight and inactive, have a family history of type 2
diabetes or in those who are of particular ethnic backgrounds
where type 2 diabetes in adults is more prevalent.
Some forms of diabetes do not neatly fit type 1 or type 2 atypical diabetes
Neonatal Diabetes (presenting in the first six months of life)
results from the inheritance of a mutation or mutations in a
single gene (monogenic diabetes). If this is suspected, genetic
testing should be undertaken because it may influence management. This testing can be done free-of-charge through
centres in the U.K. and elsewhere. For further reading please refer to
Diabetes Genes and Chapter 4, ISPAD Guidelines
Monogenic diabetes outside the neonatal period. This was

previously known as MODY Maturity Onset Diabetes in the
Young. These cases generally have a strong family history of
diabetes.
Diabetes associated with syndromes such as Down Syndrome, Prader-Willi Syndrome
Gestational diabetes can also occur in pregnancy in younger
women
For further reading please refer to Chapter 1, ISPAD Guidelines, 2009
MANAGEMENT OF
DIABETIC KETOACIDOSIS
Diabetic Ketoacidosis (DKA) occurs when there is profound
insulin deficiency. It frequently occurs at diagnosis and also
in children and youth with diabetes if insulin is omitted, or if
insufficient insulin is given at times of acute illness.
The biochemical criteria for DKA are:

Hyperglycaemia
(blood glucose >11mmol/l (~200 mg/dl))
Venous pH <7.3 or bicarbonate <15 mmol/l
Ketonaemia and ketonuria
DKA results in vomiting, abdominal pain, flushed cheeks,

acetone (sweet) smell on breath and dehydration with continued polyuria. Breathing at first is rapid and shallow and
later deep sighing respirations (Kussmaul breathing). The
level of consciousness decreases and coma can ensue.
DKA is a medical emergency and correction of the clinical and chemical changes must occur gradually to prevent
the complications associated with DKA, particularly cerebral oedema. Fluid replacement is initially more important
than insulin therapy, as early mortality is due to dehydration and shock rather than hyperglycaemia. Insulin therapy is needed to correct the acidosis and hyperglycaemia.
Treatment should be initiated at the healthcare site of first
contact, and the child should be transferred as soon as
possible to the best available site of care with diabetes experience. If insulin is not available at the healthcare site,
transfer is urgent, however fluid treatment must be initiated immediately.
10
Managing DKA includes the following components:

Initial assessment and monitoring
Correction of fluid replacement
Insulin treatment
Potassium replacement
Role of bicarbonate
Treatment of infection (if present)
Management of cerebral oedema
Monitoring of the child
Transitioning to subcutaneous insulin
Page 19 gives a summary flowchart for recommended care settings and

Page 20 a summary flowchart for resource-limited care settings.
TREATMENT OF DKA
2.1. Initial Assessment and Monitoring
Carry out a clinical assessment including history and examination. Be careful to include:
a. Severity of dehydration. If uncertain about this, assume 10%
dehydration in significant DKA
b. Level of consciousness
c. Evidence of infection
MANAGEMENT OF
Correction of shock
Weigh the child

Measure blood glucose (both blood glucose meter and
laboratory measurement if possible)
Measure ketones by urine dipstick (and blood ketone measurement if possible)
If a laboratory is available on site, carry out the following
tests: blood glucose, electrolytes, HbA1c, urea and creatinine, bicarbonate, haemoglobin and white cell count. Venous or arterial pH should also be measured if available.
Take appropriate microbiological samples if infection is
suspected. If no laboratory is available, take the appropriate samples and send to the next level of care.
11
MANAGEMENT OF
During management of DKA, the child needs to be carefully

monitored as follows:
Record hourly: heart rate, blood pressure, respiratory rate,
level of consciousness, glucose meter reading
Monitor urine ketones in every sample of urine passed
Record fluid intake, insulin therapy and urine output
Repeat blood urea and electrolytes every 2-4 hours
2.2. Correction of Shock

Ensure appropriate life support (Airway, Breathing, Circulation)
Give oxygen to patients with severe circulatory impairment or
shock.
Set up a large IV cannula. If this is not possible set up intra-osseous access if this is not possible insert a nasogastric tube
(transfer child to a site with IV facilities as soon as possible)
Treat decreased peripheral perfusion with fluid (IV or intraosseous) at 10ml/kg of Normal Saline (0.9%) Saline or Ringers Lactate over 1-2 hours. Repeat boluses of 10ml/kg up to
three times until perfusion improves.
In the rare cases of shock or severe circulatory collapse, rapidly restore circulatory volume with Normal Saline (0.9%) in
a 20mL/kg bolus infused as quickly as possible. Additional
boluses of 10ml/kg may need to be administered cautiously
once or twice.
If the only access is by nasogastric tube, give the same volume
of fluid over 60 minutes (Normal (0.9%) Saline, half strength
Darrows Solution with Dextrose or Oral Rehydration Solution
(ORS)) until perfusion improves.
Important:
Shock must be adequately treated before proceeding. There

should be good peripheral perfusion and adequate blood pressure.
Important:
Fluid replacement, insulin therapy and potassium replacement will slowly correct the acidosis, deficits in
electrolytes, and the hyperglycaemia over 24 hours. Dehydration should be slowly corrected over 48 hours.
12
2.3. Fluid replacement
Do not add the urine output to the replacement volume

Reassess clinical hydration regularly
Once the blood glucose level is <15 mmol/l (<270 mg/dl),
add glucose (also known as dextrose) to the saline (add
100ml of 50% glucose/dextrose to every litre of saline, or
use 5% glucose/dextrose saline)
If intravenous/osseous access is not available, rehydrate
orally with Oral Rehydration Solution (ORS). This can be
done by nasogastric tube at a constant rate over 48 hours.
If a nasogastric tube is not available, give ORS by oral sips
at a rate of 5 ml/kg per hour
When oral fluid is tolerated, IV fluid should be reduced
accordingly, so that the total amount of fluid given to the
patient per hour does not exceed the calculated hourly
rehydration volume
Important:
The more ill the child, the slower the rehydration should
be because of the risk of developing cerebral oedema.
Example of volumes needed to replace fluid and provide

maintenance for a 10% deficit to be given evenly over 48
hours (if deficit is estimated at <10%, then the infusion rate
needs to be appropriately reduced).
Weight
(kg)
Infusion rate for maintenance and a 10% deficit

(ml/kg/h)
49
10 19
20 39
40 - 59
3.5
60 - 80
MANAGEMENT OF
Rehydrate the child with Normal (0.9%) Saline. Aim to

provide maintenance and to replace any deficit (up to
10%) over 48 hours. This volume should be distributed
evenly over the 48 hours.
Example: If 10% dehydrated, a 6 year old boy weighing 20

kg will be given 80 ml per hour or a total volume of 1920 ml
per 24 hours for two days.
13
MANAGEMENT OF
2.4 Insulin Treatment

Insulin treatment can be started once shock has been
corrected and fluid replacement has been commenced.
It should be started 1-2 hours after initiating fluid therapy
as earlier onset of insulin treatment has been associated
with cerebral oedema.
Insulin is best given intravenously by an infusion.
1. I ntravenous infusion of 0.1 unit/kg/hour. This can be given in
two ways:
a. U
sing a syringe pump - dilute 50 units short-acting (regular, soluble) insulin in 50 ml Normal (0.9%) Saline, 1 unit
= 1 ml).
or
b. Use a side drip (if a syringe pump is unavailable) - put 50
Units of short-acting (regular) insulin in 500 ml of Normal
(0.9%) Saline the concentration of this solution is 1 Unit
= 10ml.
For example:
a 25 kg child should receive 2.5 Units per hour:

2.5 ml per hour of the syringe pump solution a. above
25 ml per hour of the side drip solution b. above
An IV bolus is unnecessary and should not be used at
the start of therapy.
In children under 5 years of age, and also patients with
a hyperglycaemic hyperosmolar state (HHS) consider
using a lower rate of insulin delivery, e.g. 0.05 unit/kg/
hour, provided that the acidosis continues to resolve.
2. If insulin cannot be given intravenously by a side drip or infusion pump, use deep subcutaneous or intramuscular insulin:
Give 0.1 unit/kg of short-acting (regular, soluble) or rapid-acting insulin SC or IM into the upper arm, and repeat this dose every 1-2 hours. (Arrange transfer to
a facility with greater resources as soon as possible).
Once the blood glucose is less than 15 mmol/l (270 mg/dl),
add glucose/dextrose to the saline (add 100ml of 50% glucose/
dextrose to every litre of saline, or use 5% glucose/dextrose
14
saline). Sometimes higher concentrations of glucose/dextrose

are needed to maintain the blood glucose between 5-15 mmol/l
(90-270mg/dl) while the metabolic acidosis (as shown in the
continued presence of ketones) is still being cleared.
2.5 Potassium replacement

Potassium replacement is needed for every child in DKA.
Measure blood potassium level as part of the initial assessment
If this measurement cannot be done immediately, hypoand hyperkalaemia may be observed on an ECG. Flattening of the T wave, widening of the QT interval and
the appearance of U waves indicate hypokalaemia. Tall,
peaked, symmetrical T waves and shortening of the QT
interval are signs of hyperkalaemia.
MANAGEMENT OF
Important:
Continue to give 0.05-0.1 U/kg/hour insulin until ketones

have been cleared. Do not correct glucose too rapidly.
During initial volume expansion the blood glucose concentration falls rapidly. Aim for a glucose reduction of
about 5 mmol/l (90 mg/dl) per hour. A more rapid decline
may contribute to the development of cerebral oedema
(see 2.9). If glucose declines very rapidly, decrease the
rate of insulin delivery, but not lower than 0.05 U/kg/hour
in this case increase glucose concentrations in the fluid
instead.
Ideally start replacing potassium once the serum potassium value is known or urine output has been documented. If this value cannot be obtained within 4 hours of staring insulin therapy, start potassium replacement anyway.
Replace potassium by adding potassium chloride to the
IV fluids at a concentration of 40mmol/L. Increase according to measured potassium levels. The maximum
recommended rate of intravenous potassium replacement is usually 0.5 mmol/kg/hour
If potassium is given with the initial rapid volume expansion, a concentration of 20 mmol/l should be used
If hypokalaemia persists despite a maximum rate of potassium replacement, then the rate of insulin infusion
can be reduced.
15
MANAGEMENT OF
For a child being rehydrated with Oral Rehydration Solution (ORS), no added potassium is needed as ORS contains potassium
Serum potassium should be monitored every six hours
or more frequently if indicated
If intravenous potassium is not available, potassium
could be replaced by giving fruit juice, bananas or coconut water orally.
2.6. Role of bicarbonate

Bicarbonate should not be routinely given, but in very rare
cases, if the child is in shock with severe acidaemia, it may
be appropriate to use bicarbonate
If bicarbonate is considered necessary, cautiously give 1-2
mmol/kg IV over 60 minutes. Watch out for sudden hypokalaemia when administering bicarbonate.
2.7 Treatment of infection

Infection can precipitate the development of DKA. It is often difficult to exclude infection in DKA as the white cell
count is often elevated due to stress and acidosis. Fever
is a more reliable sign of infection.
If infection is suspected, treat with broad spectrum antibiotics.
2.8 Cerebral oedema

Cerebral oedema is a rare but often fatal complication
of DKA.
It can be idiosyncratic, but its occurrence may be related
to various factors including the degree of hyperglycaemia, acidosis, dehydration and electrolyte disturbance at
presentation, as well as over-rapid correction of acidosis,
dehydration or hyperglycaemia.
16
The rapidly rising intracranial pressure may present as:

Headache, vomiting or slowing of heart rate, in combination with an increase in blood pressure
Specific neurological signs (e.g. unreactive pupils,

cranial nerve palsies), abnormal respiratory pattern,
decorticate posture
Decreased oxygen saturation (cyanosis)
If cerebral oedema is suspected TREAT URGENTLY:
Exclude hypoglycaemia as a cause of the change in
neurological state.
Reduce the rate of fluid administration by one third
Give mannitol 0.5-1 g/kg IV over 20 minutes, and repeat if there is no initial response in 30 minutes to 2
hours.
Hypertonic saline (3%) 5ml/kg over 30 minutes may
be an alternative to mannitol, especially if there is no
initial response to mannitol
Elevate the head of the bed
Intubation may be necessary for a patient with impending respiratory failure
After treatment has been started, if available, a cranial CT scan should be done to rule out other possible
intracerebral causes of neurological deterioration,
especially thrombosis or haemorrhage which may
benefit from specific therapy.
MANAGEMENT OF
Change in neurological status (restlessness, irritability, increased drowsiness, incontinence, seizures,

coma)
Cerebral oedema is an unpredictable complication of DKA.

Survivors are often left with significant neurological deficits.
Meticulous management of the DKA can decrease the risk of
developing cerebral oedema. DKA should therefore be managed at the best available facility.
17
MANAGEMENT OF
2.9 Monitoring the Child

If biochemical parameters of DKA (pH, anion gap*,
urine ketones) do not improve, reassess patient, review
insulin therapy, and consider other possible causes of
impaired response to insulin, e.g. infection or errors
in insulin preparation. Also consider that the primary
illness may be a serious infection (such as malaria)
with stress hyperglycaemia rather than diabetes.
* For further reading please refer to Chapter 10, ISPAD Guidelines 2009
If replacing fluid orally, ensure that the child has ORS or

fruit juice once the glucose is below 15 mmol/l (270 mg/dl).
Once the urine ketones are absent, consider making the
transition to subcutaneous (SC) insulin.
Where available, measurement of blood -hydroxybutyrate
concentration (blood ketones) is useful to confirm ketoacidosis (usually 3 mmol/L or above) and monitor the response to treatment.
2.10. Transitioning to subcutaneous insulin

Once the DKA has been adequately treated (hydration
corrected, glucose controlled, ketones cleared) the child
can be transitioned to subcutaneous insulin.
The first SC dose of short-acting insulin should be given
1-2 hours before stopping the insulin infusion.
(If the child has been receiving SC or IM insulin, stop the
additional fluids).
Important: It is often easier to transition to subcutaneous
insulin at the next mealtime. If the child is newly diagnosed, refer to Chapter 3, otherwise determine insulin
dose from consideration of the dose before
admission.
Page 19 gives a summary flowchart for recommended care settings and

Page 20 a summary flowchart for resource-limited care settings.
18
Figure 1
DKA Management Recommended Care
Clinical Signs
Clinical History
Polyuria
Polydipsia
Weight loss (Weigh)
Abdominal pain
Tiredness
Vomiting
Confusion
Assess dehydration
Deep sighing respiration (Kussmaul)
Smell of ketones
Lethargy/drowsiness vomiting
Biochemical features &

investigations
Ketones in urine
Elevated blood glucose
Acidemia
Blood gases, urea, electrolytes
Other investigations as indicated
Diagnosis confirmed
Diabetic Ketoacidosis
Contact Senior Staff
Shock (reduced peripheral pulses)

Reduced conscious level/coma
Resuscitation
Airway NG tube
Breathing (100% oxygen)
Circulation (0.9% saline
10-20 ml/kg over 1-2h. & repeat
until circulation is restored) but
do not exceed 30 ml/kg
Dehydration >5%
Not in shock
Acidotic (hyperventilation)
Vomiting
IV Therapy
Calculate fluid requirements
Correct over 48 hours
Saline 0.9%
ECG for abnormal T-waves
Add KCL 40 mmol per litre fluid
Minimal dehydration
Tolerating oral fluid
Therapy
Start with SC insulin

Continue oral hydration
No improvement
Continuous insulin infusion, 0.1 U/kg/h
started 1-2 hours after fluid treatment
has been initiated
Critical Observations
Hourly blood glucose
Hourly fluid input & output
Neurological status at least hourly
Electrolytes 2 hourly after start of IV therapy
Monitor ECG for T-wave changes
Acidosis not improving
Blood glucose 17 mmol/l (300 mg/dl)

or
blood glucose falls >5 mmol/l/hour (>90 mg/dl/h)
IV Therapy
Re-evaluate
IV fluid calculations
Insulin delivery system & dose
Need for additional resuscitation
Consider sepsis
Change to 0.45% saline + 5% glucose

Adjust sodium infusion to promote an increase
in measured serum sodium
Neurological deterioration
WARNING SIGNS:
headache, slowing heart
rate, irritability,
decreased conscious level,
incontinence, specific
neurological signs
Exclude hypoglycaemia
Is it cerebral edema?
Improvement
Clinically well, tolerating oral fluids
Management
Transition to SC Insulin
Start SC insulin then stop IV insulin after
an appropriate interval
Give mannitol 0.5-1 g/kg

Restrict IV fluids by one-third
Call senior staff
Move to ICU
Consider cranial imaging
only after patient stabilised
19
Figure 2
DKA Management Limited Care
Clinical History
Clinical Signs
Polyuria
Polydipsia
Weight loss (weigh)
Abdominal pain
Tiredness
Assess dehydration
Deep sighing respiration (Kussmaul)
Smell of ketones
Biochemical features &

investigations
Elevated blood glucose
Ketones in urine
Diagnosis confirmed
Diabetic Ketoacidosis
Contact Senior Staff
IV fluids available?
NO
YES
Assess peripheral circulation
Decreased?
Urgent transport to another facility

Oral rehydration with ORS 5 ml/kg/h
in small sips or via nasogastic tube.
Give as fruit juice or coconut water
if ORS is not available
YES
NO
Shock?
NO
YES
0.9% NaCl
20 ml/kg bolus.
Repeat if necessary
Rehydrate slowly over 48

hours. Begin with 0.9% NaCl.
4-9 kg: 6 ml/kg/h
10-19 kg: 5 ml/kg/h
20-39 kg: 4 ml/kg/h
40-59 kg: 3.5 ml/kg/h
60-80 kg: 3 ml/kg/h
0.9% NaCl 10 ml/kg /h

over 1-2 hours
IV insulin available? Begin with insulin

1-2 hours after fluid treatment has
been initiated
YES
IV dose 0.1 U/kg/h
(0.05 U/kg if < 5 years)
NO
YES
Oral rehydration with ORS 5 ml/kg/h
in small sips or via nasogastic tube.
Give as fruit juice or coconut
water if ORS is not available.
Give SC or IM insulin 0.1 U/kg every
1-2 hours (0.05 U/kg if < 5 years)
SC or IM dose 0.1 U/kg/

every 1-2 hours
(0.05U/kg if < 5 years)
NO
Improved condition?
Decreasing blood glucose AND
decreasing ketones in urine indicate
resolving of acidosis.
Transport if possible,
otherwise oral
potassium
YES
YES
20
Insulin available?
NO
IV potassium available?
Begin potassium replacement at same
time as insulin treatment
Give potassium
40 mmol/l in
rehydration fluids
No transport available or possible,

or transport > 6-8 hours
Monitor potassium and sodium

Give 5% glucose when blood glucose
approaches 17 mmol/l (300 mg(dl)
Add sodium, according to lab tests,
80 mmol/l initially
When acidosis
has resolved
SC insulin
NO
Transport MUST
be arranged
INSULIN
TREATMENT
All children with type 1 diabetes and some children with

other forms of diabetes require insulin. The aim is to replace insulin as physiologically as possible so that blood
glucose levels are within the target range avoiding hypoglycaemia and sustained hyperglycaemia. Prolonged underinsulinisation results in chronic hyperglycaemia which increases the risk of stunted growth, diabetes complications,
including diabetic ketoacidosis.
Comprehensive diabetes management includes insulin
treatment, blood glucose monitoring, nutritional management, physical activity, education, rules for sick days, and
psychosocial support (see subsequent sections).
Partial Remission or Honeymoon Phase

in Type 1 Diabetes
Insulin requirements can decrease transiently following
initiation of insulin treatment.
This has been defined as insulin requirements of less
than 0.5 units per kg of body weight per day with an
HbA1c < 7%.
Ketoacidosis at presentation and at a young age reduce
the likelihood of a remission phase.
It is important to advise the family of the transient nature
of the honeymoon phase to avoid the false hope that the
diabetes is spontaneously disappearing.
21
Insulin requirements
INSULIN
TREATMENT
Pre-pubertal children (outside the partial remission

phase) usually require 0.7-1.0 IU/kg/day.
During puberty, requirements may rise substantially
above 1 and even up to 2 U/kg/day.
The correct dose of insulin is that which achieves the
best attainable glycaemic control for an individual child or
adolescent, without causing obvious hypoglycaemia, and
resulting in normal growth and development.
Types of Insulin
In most developing countries, human insulin is available.
This comes in three forms:
Short-acting (regular/soluble) - e.g. Actrapid, Humulin R,
Insuman Rapid
Intermediate-acting - NPH insulin e.g. Humulin NPH,
Protaphane, Insulatard
Pre-mixed short-acting (regular) and intermediate-acting (NPH) insulins usually in the combination 30/70 or
25/75
Analogue insulins are also available in some countries but
are substantially more expensive.
Examples are:
Rapid-acting - e.g. Aspart, Glulisine, Lispro

Long-acting e.g. Glargine, Detemir
22
Insulin Action
Preparations
Onset of
Action
Peak of
action
Duration
of action
When to
give
Rapidacting
Aspart,
Glulisine,
Lispro
15-30
minutes
1-2 hours
3-5 hours
immediately
prior to
meal
Shortacting
(regular)
Actrapid,
Humulin R,
Insuman
Rapid
30-60
minutes
2-4 hours
5-8 hours
30 minutes prior
to meal
Intermediateacting
Humulin
NPH, Protaphane,
Insulatard,
2-4 hours
4-10
hours
12-24
hours
30 minutes prior
to meal
Longacting
Detemir
1-2 hours
6-12
hours
20-24
hours
once or
twice
daily
Glargine
2-4 hours
relatively
peakless
24 hours
or less
once or
twice
daily
Rapid/longacting mix
or
Short/longacting mix
30/70 or
25/75
30 minutes
4-12
hours
8-24
hours
30 minutes prior
to meal
Mixed
INSULIN
TREATMENT
Insulin
type
The two most common regimens used are:

Twice-daily insulin using both short-acting and also
intermediate-acting insulin. (If these insulins are not always available, pre-mixed insulin can be used as an alternative regimen).
Basal bolus regimen (the preferred option) - with shortacting insulin given with main meals (usually three times
per day) and intermediate-acting insulin given once or
twice daily (evening, or morning and evening).
Insulin can also be given by an insulin pump but this is very
expensive and requires expert education to initiate and monitor therapy.
23
INSULIN
TREATMENT
A note on the use of pre-mixed insulins in children:

Pre-mixed insulins may be convenient (i.e. few injections), but
limit the individual tailoring of the insulin regimen, and can be
difficult in cases where regular food supply is not available.
Notes on analogue insulins in children:
1. W
here available, rapid-acting analogues can be given immediately before meals because of their shorter duration of
action. Also there is evidence that the rapid action reduces
postprandial hyperglycaemia and also possibly nocturnal hypoglycaemia. They offer the useful option of being given immediately after food when needed (e.g. infants and toddlers
who are reluctant to eat). The benefit of the rapid-acting insulin analogues in children is related to the reported reduction
of hypoglycaemia. At the present time there is no evidence to
show improvements in HbA1c using analogues compared with
human insulin.
2. W
here available, basal (long-acting) analogues given 1-2 times
daily show a more predictable insulin effect with less day to day
variation compared to NPH insulin.
3. W
hile the effect of basal analogues on HbA1c improvement is
controversial, there is evidence for a reduced rate of hypoglycaemia and a greater treatment satisfaction.
Guidelines on insulin dosage

Initiating therapy in a child not in DKA
Day 1
Give short-acting (regular) insulin (0.1 U/kg) every second
hour until blood glucose is < 11 mmol/l, then every 4-6 hours.
If hourly monitoring of blood glucose cannot be provided, begin with half the above dose.
Day 2 (from morning/breakfast):
Total daily dose 0.5-0.75U/kg/day.
a. TWO INJECTIONS PER DAY
A starting point is to give two-thirds of the total daily insulin in the morning before breakfast and one-third before
the evening meal
24
For example:
For a 36 kg child who is started on 0.5 U/kg/day, the total

daily dose is 18 Units. Two-thirds of this is given in the morning (before breakfast) (12 Units), and one-third before the
evening meal 6 Units. At each injection, 1/3 is short-acting
and 2/3 is intermediate-acting.
Therefore the doses, for this 36 kg child, would be:

Short-acting
Intermediate-acting
Before breakfast
4 Units
8 Units
Before evening meal
2 Units
4 Units
INSULIN
TREATMENT
On this regimen, at the start, approximately one-third of

the insulin dose may be short-acting (regular) insulin and
approximately two-thirds may be intermediate-acting insulin, although these ratios change with greater age and
maturity of the young person.
For mixed insulin, always think of the components separately (i.e. 10 units of mix 70/30 equals 3 units of short-acting
(regular) and 7 units of intermediate-acting (NPH)), and adjust doses as above.
b. BASAL BOLUS REGIMEN
A starting point is:

If short-acting (regular) and intermediate-acting insulin
is used, give:
>>
70% of the total daily dose as short-acting (regular) insulin

(divided up between 3-4 pre-meal boluses)
>>
30% of the total daily dose as a single evening injection of

intermediate-acting insulin
If short-acting (regular) and long-acting analogue insulins are used, give:

>>
50% of the total daily dose as short-acting (regular) insulin

(divided up between 3-4 pre-meal boluses)
>>
50% of the total daily dose as a single evening injection of

long-acting analogue insulin. (Sometimes this dose does not
last for 24 hours and then can be split into two doses morning and evening).
25
Subsequently, doses can be adjusted daily according to blood

glucose levels (see Chapter 6).
INSULIN
TREATMENT
It is important to note that:
1. The level of blood glucose can rise in the early morning

(dawn phenomenon) and so care should taken if increasing the evening intermediate/long-acting dose as hypoglycaemia can occur in the middle of the night and this can be
dangerous.
2. A
s mentioned on page 18, insulin requirements can decrease for a time during the honeymoon period before rising again.
3. T
he total daily dose required will generally increase as the
child grows, and once puberty ensues a higher dose per kg
per day is often needed.
During periods of regular change in consumption of food

(e.g. Ramadan) the total amount of insulin should not be reduced but redistributed according to the amount and timing
of carbohydrate intake. However, if the total calorie intake is
reduced during Ramadan, the daily amount of bolus insulin
for meals usually needs to be reduced, for example to twothirds or three-quarters of the usual dose.
Mixing Insulins in the same syringe

It is very common to combine intermediate-acting and
short-acting/rapid-acting insulins, in order to cover both
basal needs plus the extra need from eating.
Short-acting insulin or rapid-acting analogues can be combined with intermediate-acting insulins (e.g. NPH) in the
same syringe. Begin by injecting air into both bottles. The
short-acting insulin is generally drawn into the syringe first.
If the intermediate-acting insulin is a cloudy insulin, mix
by tipping the vial/bottle up and down 10 20 times. Do not
shake the insulin as this damages the insulin. The doses can
be adapted every day according to food intake, physical activity, and blood glucose readings.
For further reading please refer to Page 31, Chapter 5, Insulin Treatment,
Caring for Diabetes in Children and Adolescents
26
Giving an injection with a syringe

see: www.diabeteskidsandteens.com.au: Living with Diabetes/Insulin/Giving
Insulin and YouTube video How to give an insulin injection dLife.com
2. Before injecting, check the expiry date, and the name (correct
amount of the correct insulin)
3. Pull the plunger down to let air in the syringe, equalling the
amount of insulin to be given. Inject this air into the vial.
4. Draw up the insulin
5. Take a small pinch of skin with the index finger and thumb. The
pinch needs to be at least to the depth of the needle. This is especially important in lean people, otherwise the injection may
go too deep into the muscle layer, hurt more, and absorption
will be affected.
INSULIN
TREATMENT
1. Use insulin syringes if possible (preferably with a needle no

longer than 8mm). Ensure that the syringes are made for the
correct strength of insulin (U-100 or U-40). Ensure that the syringes have adequate gradations and that the dose is correctly
understood.
6. Insert the needle at a 45 degree angle into the pinched-up skin

to a distance of 4-6 mm. Give the injection.
7. Leave the needle in for about 5-10 seconds, then gradually let
go of the skin and pull out the needle.
8. Dispose of the syringe appropriately depending on local advice
e.g. sharps container, tin, or strong plastic bottle.
Pinching the skin to give an

insulin injection. A small
pinch with the finger and
thumb is enough.
For further reading please refer to Chapter 5, Insulin Treatments, Caring

for Diabetes in Children and Adolescents
Image: Caring for diabetes in children and adolescents (3rd edition)
27
INSULIN
TREATMENT
Injection sites
Recommended
sites for injection
1. Good technical skill concerning syringes/ pens is important.

2. Injections in the abdominal area are preferred with insulin absorbed more evenly and less affected by exercise than other
sites. If insulin is injected into an area that is going to be exercising significantly, it will be absorbed quicker.
3. Children and adolescents should be encouraged to inject consistently within the same area (abdomen, thing, buttocks) at a
particular time of day, but must avoid injecting repeatedly into
the same spot to avoid lipohypertrophy.
For further reading please refer to Chapter 5, Insulin Treatment, Caring for
Diabetes in Children and Adolescents
Image: Caring for diabetes in children and adolescents (3rd edition)
28
Insulin storage
2. Insulin must never be frozen.

3. Direct sunlight or extreme heat (in hot climates or in a vehicle)
damages insulin.
4. Patients should not use insulins that have changed in appearance (clumping, frosting, precipitation, or discolouration).
5. After first usage, an insulin vial should be discarded after 3
months if kept at 2-8oC or 4 weeks if kept at room temperature.
INSULIN
TREATMENT
1. Unused insulin should be stored at 4-8oC in a refrigerator

where available or in some other method of cooler. In hot climates where refrigeration is not available, cooling jars, zeer
pot, earthenware pitcher (matka) or a cool wet cloth around the
insulin will help to preserve insulin activity.
29
HYPOGLYCAEMIA
The aim of diabetes treatment should be to achieve the best

possible glycaemic control without the occurrence of hypoglycaemia. Hypoglycaemia can be fatal, or result in permanent long-term sequelae.
Hypoglycaemia unawareness can occur.
Definition
Hypoglycaemia occurs when the blood glucose level is 3.9
mmol/L (70 mg/dl) or where there are symptoms of a hypo
at a level close to this.
Causes
The main causes of hypoglycaemia are:
Delayed or missed meals (review reasons for this)
Physical activity (where possible BGL should be checked
prior to exercise, and extra carbohydrates should be eaten based on the BGL and the expected intensity and duration of the exercise).
Not eating enough carbohydrate (assess timing, amount
and peak glucose effect of food eaten)
Too much insulin (assess insulin profile, time of administration, peak and intensity of action)
30
Symptoms
Symptoms of Neuroglycopenia
Trembling/shaking
Inability to concentrate
Rapid heart rate
Blurred or double vision
Palpitations
Slurred speech
Sweating
Confusion/vagueness
Pallor
Dizziness/unsteady gait
Hunger
Loss of consciousness
Nausea
Seizures
Mild Hypoglycaemia occurs when the patient can recognise

hypoglycaemia and is able to self-treat without assistance
of others. BGL is 3.7mmol/L or 70mg/dl.
For further reading, refer to Chapter 3.2 Page 59, Diabetes in Children and
Adolescents 2011.
Severe Hypoglycaemia is when the patient either loses
consciousness or has a seizure associated with low blood
glucose, or is unable to help him/herself.
HYPOGLYCAEMIA
Clinical Symptoms
Treatment of Hypoglycaemia
Always stay with the person with hypoglycaemia
STEP 1
Give fast acting glucose immediately 0.3g/kg. An example
for a 50kg child giving 15 gm carbohydrate, is:
150-200 ml (1/2 a cup) of a sweet drink e.g. cola or fruit
juice OR
3-4 teaspoons of sugar or honey OR
6 large or 12 small jelly beans
STEP 2
Follow with one exchange or serve of slow acting carbohydrate (1015 gm = one slice of bread/2 plain biscuits OR one apple OR one banana OR 250ml or one cup of milk) to maintain the BGL OR if a meal
or snack is due within 30 minutes, give that meal or snack earlier.
31
HYPOGLYCAEMIA
Where BG testing equipment is available, re-test blood glucose 10-15 minutes after treatment, to confirm the BGL is
within normal limits. If the BGL remains low, repeat Step 1.
32
If the patient is unconscious or convulsing and unable to

take anything by mouth, lie them on their side and keep
their airway clear i.e. the ABC of resuscitation airway,
breathing, circulation.
Severe hypoglycaemia with loss of consciousness convulsions (or if the child is vomiting)
a. If glucagon is available:
Hypoglycaemia is most safely and rapidly reversed by an intramuscular or subcutaneous injection of glucagon 0.5 mg
for age < 12 years, 1.0 mg for ages > 12 years, or 10-30 mcg/
kg body weight.
b. If glucagon is unavailable
Give intravenous glucose carefully and slowly over several

minutes, using 10% or 25% glucose/dextrose solution (or
50% if these are unavailable). Total dose over a several minutes is 0.2-0.5 gm / kg of glucose/dextrose. 50% Dextrose
is very hypertonic, and so if it is given it should be administered slowly into a large vein.
SICK DAY
MANAGEMENT
Many illnesses, especially those associated with fever, raise blood

glucose levels because of the effect of stress hormones. The increased resistance to insulin can increase ketone production.
Illnesses with gastrointestinal symptoms (e.g. diarrhoea and vomiting) may lead to lower blood glucose levels and hypoglycaemia
due to decreased food intake, poor absorption and changes in intestinal motility.
Sick day management should be an integral part of the initial education of the child and family, and then reinforced at regular intervals.
Management
1. Do not stop insulin during sick days, even though the child or adolescent is ill and not eating normally. The insulin dose may frequently need
to be increased or decreased, based on the blood glucose level and
food intake, but insulin should not be stopped. If there are no facilities
for home monitoring of glucose and ketones, the child or adolescent
should be taken to a healthcare facility for regular testing.
2. Evaluate and treat the acute illness.
3. Increase monitoring of blood glucose levels to 34 hourly (and more
frequently if the glucose level fluctuates widely or changes rapidly).
>>
Monitor ketones 1-2 times per day if possible.
>>
Check weight if scales are available as a measure of

dehydration.
>>
If blood glucose is high with ketones, more insulin is

needed.
>>
If blood glucose is low with ketones, (i.e. starvation ketosis) more

sugary drink is needed before extra insulin can be given.
>>
If home glucose and/or ketone monitoring is unavailable, frequent

contact with a health professional or clinic review is advisable.
33
DEFINITION AND
DIAGNOSIS
4. Supportive care includes:

>>
Adequate fluid intake. Fever and hyperglycaemia can cause increased fluid losses. Oral rehydration fluid provides a source of
both fluid and energy.
>>
Easily-digested foods when there is loss of appetite.
>>
Treating fever with anti-pyretics and treating or prevent vomiting

by frequently offering small volumes of fluid to drink.
>>
Admitting the child or adolescent to a healthcare facility if these

supportive measures cannot be ensured as an out-patient.
5. Additional insulin is usually necessary to control blood glucose (unless

the illness causes hypoglycaemia)
a. Elevated blood glucose results, with absence or small amount of
ketones:
Give: 5-10% of total daily dose of insulin (or 0.05-0.1 U/kg) as

short or rapid-acting insulin repeated every 2-4 hours. Total
Daily Dose is the sum in units of all insulin injections on a normal day.
b. Elevated blood glucose results with moderate or large amount of
ketones.
Give: 10-20% of total daily dose of insulin (or 0.1 U/kg) as short
or rapid-acting insulin (if available) repeated every 2-4 hours.
6. When vomiting occurs in a child with diabetes, it should always be
considered a sign of insulin deficiency (impending ketoacidosis) until
proven otherwise.
7. Strenuous exercise should be avoided
8. Consider admission under the following circumstances:
>>
Very young children with diabetes, who may become dehydrated more rapidly than older children or adolescents.
>>
Parents inability to check blood glucose at home
>>
If supportive care cannot be ensured at home
>>
If the acute illness is severe
>>
If there is persistent ketonuria
34
BLOOD GLUCOSE
MONITORING
Blood glucose monitoring is essential in the safe management of childhood and adolescent diabetes to help
prevent acute and chronic complications, and also educate and empower the child and family.
When possible, blood glucose monitoring should be available for all children with diabetes.
Blood glucose monitoring should ideally be carried out
4-6 times a day, however, this is dependent on the availability of testing strips. Even a couple of tests a week can
assist management, and two tests per day gives much
useful information.
Blood glucose testing delivers a picture of what blood
glucose levels are like over a period of 24 hours and helps
to identify problems early.
Urine glucose testing may be used as an alternative to
blood glucose testing, but provides less information.
Ideally a record should be kept of blood glucose tests.
Recommended target blood glucose

levels:
Before meals
4-7 mmol/l (72-126 mg/dl)
After meals
5-10 mmol/l (90-180 mg/dl)
At bed time
6-10 mmol/l (108180 mg/dl)
At 3am
5-8 mmol/l (90-144 mg/dl)
Reference: Caring for Diabetes in Children and Adolescents
35
BLOOD GLUCOSE
MONITORING
When to Test Blood Glucose Levels

(BGLs)
Patterns of BGLs are generally more useful than single blood
glucose readings, however, two tests per week is better than
no tests at all. Should test strips be scarce, it is best to test
at different times of the day a few days a week rather than the
same time each day.
For instance, if possible, it is advisable to test before and two
hours after breakfast, and before and two hours after other
meals, and overnight at 3am (checking for hypoglycaemia) periodically. If strips are readily available, a blood glucose test
should be done prior to and following exercise. Exercise, physical activity or play may result in low BGLs during or immediately after exercise, or a delayed hypoglycaemic effect many
hours later (up to16 hours).
Designing a Blood Glucose Strategy

There are two basic strategies that can be used to achieve glycaemic control:
1. Prescribe a meal plan with a set amount of carbohydrate (either in
grams or exchanges) for each of the major meals and snacks, and
a pre-determined dose of short- and longer-acting insulin.
2. Match the pre-meal short-acting insulin dose to the amount of
carbohydrate about to be eaten. This works best with a basalbolus regimen.
Patterns of BGLs are more important than a single BGL.

If a pre-meal BGL is always high, the preceding dose of
intermediate or long-acting insulin is insufficient.
If the pre-meal BGL is always low, the previous dose of intermediate or long-acting insulin is too high.
If a pre-meal BGL is sometimes very high and at other
times very low, either insulin, food or exercise are not consistent and should be reviewed.
If the BGL 2 hours after the meal is too high, the meal dose
of short-acting (regular) insulin was too low.
36
If the BGL 2 hours post-meal is too low, the previous meal

dose of short-acting (regular) insulin was too high.
Carrying out a Blood Glucose Test

Before using a meter for the first time ensure that:
Batteries are not flat
Required units are set: mg/dl or mmol/l
Correct strips are available, correct coding has been entered, expiry date has not passed (in more recent meters,
coding may not be required)
A log book is useful for recording information such as:
BLOOD GLUCOSE
MONITORING
It is important to note that the level of blood glucose can rise

in the early morning and so care should be taken if increasing the evening intermediate/long-acting dose as hypoglycaemia can occur in the middle of the night and this can be
dangerous.
Time of test
BGL
How much and type of insulin given
Comments e.g. amount and type of food eaten prior to
test, type of activity before test e.g. rest, work, exercise.
Sample page of a logbook
37
BLOOD GLUCOSE
MONITORING
HbA1c
HbA1c (glycated haemoglobin) provides information about average blood glucose levels over the last 2-3 months. This test
measures the amount of glucose that attaches to haemoglobin
this depends on how much glucose is in the bloodstream.
Ideally HbA1c is measured four times per year. If resources
are limited, less frequent measurements are still helpful
The target HbA1c for all age-groups is a value less than
7.5% (58 mmol/mol).
The table below shows the relationship between HbA1c
and average blood glucose (from Nathan et al. Diabetes Care
2008;31:1473-1478)
Table of HbA1c versus mean blood glucose

HbA1c
(DCCT)
(%)
Estimated Average Blood Glucose

(mmol/l)
Estimated
Average Blood
Glucose(mg/dl)
HbA1c in IFCC
Units (mmol/
mol)
5.4
97
31
7.0
126
42
8.6
154
53
10.2
183
64
11.8
212
75
10
13.4
240
86
11
14.9
269
97
12
16.5
298
108
Ketone testing
Ketone testing with either urine strips, or blood when available, should be performed:
During illness with fever and/or vomiting.
When blood glucose is above 15 mmol/l (270 mg/dl) in
an unwell child or when persistent blood glucose levels
above 15 mmol/l (270 mg/dl) are present.
When there is persistent polyuria with elevated blood glucose, especially if abdominal pain or rapid breathing are
present.
38
NUTRITIONAL
MANAGEMENT
Children with diabetes need a healthy diet with food in

amounts and proportions appropriate to the age and stage
of growth.
Nutritional advice should be adapted to cultural, ethnic and
family traditions as well as the cognitive and psychosocial
needs of the individual child.
Encourage the child to take the right dose of insulin for the
right type and amount of food, and to eat the right amounts
for that dose of insulin, at the right time.
Insulin doses must be matched to the carbohydrate content
of the food consumed, or alternatively the carbohydrate
content of food consumed must be matched to the timing
and the type of insulin injections.
Nutritional advice should address food availability, diet,
food intake and physical activity patterns.
Excessive restriction of carbohydrate intake to lower blood
glucose levels should be avoided.
Sugary soft drinks or foods with high levels of saturated fat
should be avoided.
There are various approaches used to measure carbohydrate intake - such as exchange or portion control, and
carbohydrate counting. For further reading please refer to Chapter 9,
ISPAD Guidelines 2009
Prevention and management of hypoglycaemia, particularly before, during and after exercise should be addressed.
Education should include preventing hypoglycaemia.
Ideally there should be an experienced paediatric dietitian
in the diabetes team.
Unexpected weight loss may be a sign of 1) illness (infections, coeliac disease etc.), 2) insulin omission, or 3) an eating disorder.

39
PHYSICAL
ACTIVITY
Any physical activity including exercise is very beneficial

and should be encouraged. Diabetes should not be a barrier to participating in exercise.
Preparations are needed as exercise may result in hypoglycaemia. Where possible, patients and families should
be given tailored advice about what and how much carbohydrate to take before, during, and after exercise, as well
as advice about insulin adjustment. Some children and
adolescents should snack before activities while others
may do better snacking mid-activity or even afterwards.
For short, high-intensity activity, the snack should preferably be a fluid-based high energy drink. For a long duration of low-intensity activity, it should be food that is digested more slowly e.g. fruit.
Where monitoring is available, blood glucose needs to be
measured before exercise, during and following exercise.
Approximately 1-1.5 g carbohydrate/kg body weight/hour
should be consumed during strenuous exercise the child
is unable to monitor and reduce their insulin dosage.
Hypoglycaemia is more likely to occur with prolonged or
intense physical activity. It often occurs during or shortly
after exercise but is possible up to 24 hours afterwards
(increased insulin sensitivity). Risk of post-exercise
nocturnal hypoglycaemia is high. The evening dose of
intermediate- or long-acting insulin often needs to be
decreased after exercise in the afternoon or evening,
especially if not exercising on a regular basis. Particular
care should be taken that the bedtime blood glucose level
is > 7.0 mmol/L (125 mg/dl).
Sugar-free fluids should be consumed to avoid dehydration.
Where unaccustomed exercise is being taken, e.g. at a
diabetes camp, reduction in total daily dose of insulin (2050%) is advised to avoid hypoglycaemia.
Insulin is absorbed quicker when it is injected near to
40
muscles that are being exercised e.g. legs in soccer. Hypoglycaemia is then more likely to occur.
Children and young people engaged in competitive or

more serious sport will require additional support. This
should include detailed discussion about the activity and
tailored advice on insulin and food adjustments.
PHYSICAL
ACTIVITY
If blood glucose levels are high (>15mmol/l, 270 mg/dl)

with ketonuria/ketonaemia, exercise could be dangerous
and should be avoided. Give approximately 0.05 U/kg, or
5% of total daily insulin dose as short-acting (regular)
(or rapid-acting analogue) insulin and postpone exercise
until ketones have cleared (see Sick Day Management
Chapter 5). If ketones cannot be measured, a child who is
feeling nauseous should not participate in exercise.
41
DIABETES
EDUCATION
All children and adolescents with diabetes and their carers have
the right to education and practical skills training to enable them
to survive the onset of diabetes safely and successfully.
Initial learning, started as soon as possible after diagnosis,
should include simple, knowledge-based education and
practical survival skills. For further reading please refer to Life for a
Child Health Professional Education Materials
Myths and false beliefs surrounding diabetes (e.g. catching diabetes) should be dispelled at diagnosis.
Diabetes education is most effective when based on selfmanagement, and is child and parent-centred.
Ongoing education should be learner-centred, and reinforced by visual aids such as diagrams, drawings, puppet/
toy use, written guidelines, booklets, video, DVDs appropriate to the childs age, maturity and environment.
Parents and children require ongoing patience and reassurance, with some parts of the education needing to be
repeated for them to manage effectively.
Where possible, diabetes education should be delivered by a
multidisciplinary paediatric diabetes team (ideally a doctor,
nurse, dietitian, psychologist, social worker), with a clear understanding of the special and changing needs of young people
and their families. Many countries now have trained paediatric
diabetes educators as members of the diabetes team.
24 hour telephone support is extremely helpful to families
to reduce their isolation, helping to develop confidence in
their ability to manage their childs diabetes and cope with
emergencies.
The International Diabetes Federation Life for a Child Programme has a dedicated Education website with pages of
downloadable resources in different languages. Life for a Child
Education Resources
Other useful websites are www.childrenwithdiabetes.com and
www.
diabeteskidsandteens.com.au
42
ONGOING CARE,
MANAGEMENT OF
COMPLICATIONS
Diabetes complications can lead to severe morbidity and mortality. The most important principle in prevention of complications is to achieve as near normal glycaemic control as possible by intensive education and treatment from diagnosis.
Complications may include:

Underinsulinisation leading to growth failure and pubertal
delay
Retinopathy resulting in visual loss and blindness
Diabetic nephropathy causing hypertension and renal failure
Neuropathy causing pain, paraesthesia, muscle weakness
and autonomic dysfunction,
Macrovascular disease causing cardiac disease, stroke
and peripheral vascular disease with limb loss.
Screening for subclinical complications, with early treatment
can delay progression to clinical complications. Other known
risk factors are high blood pressure, smoking and hyperlipidaemia.
Standard screening regimen:

Weight should be measured at each visit, and Height annually. Pubertal status should be noted at relevant ages.
HbA1c is ideally measured every three months. Target
level is <7.5% (58 mmol/mol)
Blood pressure should be measured at least annually
>>
Antihypertensive medication should be introduced if blood

pressure is consistently > 95th centile (see table at end of this
chapter) or > 130/80 mmHg.
43
ONGOING CARE, MANAGEMENT

OF COMPLICATIONS
>>
Angiotensin converting enzyme (ACE) inhibitors (such as

enalapril, captopril) or Angiotensin II receptor blockers (ARB)
are recommended treatment and have been effective and
safe in children in short-term studies, but are not safe during
pregnancy.
>>
Other antihypertensive agents, such as calcium channel

blockers and diuretics can be used if ACE inhibitors are unavailable.
Eyes and visual acuity should be checked for retinopathy

and cataracts after two years diabetes duration, and annually thereafter.
>>
Minimum assessment for retinopathy should be by visual

acuity assessment and where at all possible ophthalmoscopy
through dilated pupils by an experienced observer.
>>
Where available, assessment for retinopathy should be by

fundal photography as well.
>>
Abnormalities should be managed by an ophthalmologist.
Peripheral and autonomic neuropathy should be assessed by history, physical examination and sensory tests
for vibration, thermal sensation or light touch.
>>
Tools include cotton wool, low-frequency tuning forks and

monofilaments.
>>
Feet should be examined for neuropathy, infections, ulcers etc

after two years diabetes duration, and annually thereafter.
Urinary protein should be measured after two years diabetes duration, and annually thereafter. (Persistent microalbuminuria has been shown to predict the progression to
end stage renal failure and is associated with an increased
risk of macrovascular disease).
If possible, microalbuminuria should be measured annually by:
>>
Timed overnight or 24 hour urine collections (AER).
>>
First morning urine albumin/creatinine ratio (ACR).
If assessment of microalbuminuria is not available, dipstick

urine protein measurement can be done. This only shows macroalbuminuria (>500mg/day)
Persistent micro- or macroalbuminuria should be treated with

ACE inhibitors (or ARB blockers if there are side-effects from
ACE inhibitors (e.g. persistent cough)). Other causes of proteinuria (such as urinary tract infection or schistosomiasis)
should be excluded.
44
>>
If normal results are obtained, screening should be repeated

every 5 years.
>>
Target for LDL-C should be lower than 2.6 mmol/l (100 mg/
dl). If interventions to improve metabolic control and dietary
changes cannot lower LDL-C to target levels, statins should
be considered although long-term safety is not established
in children.
Other conditions may occur with diabetes including hypothyroidism or hyperthyroidism, coeliac disease, and
Addisons disease (rare) screening for these may be appropriate depending on available resources. For further
reading refer to Chapter 18, ISPAD Guidelines 2009.
Smoking is totally contraindicated in diabetes as it increases complications rates.
Blood Pressure Values Requiring Further Evaluation
Blood Pressure, mmHg
Age, y
Male
Female
Systolic
Diastolic
Systolic
Diastolic
100
59
100
61
102
62
101
64
104
65
103
66
105
68
104
68
106
70
106
69
107
71
108
71
109
72
110
72
10
111
73
112
73
11
113
74
114
74
12
115
74
116
75
13
117
75
117
76
14
120
75
119
77
15
120
76
120
78
16
120
78
120
78
17
120
80
120
78
18
120
80
120
80

OF COMPLICATIONS
Fasting blood lipids should be performed when diabetes

is stabilised in children aged over 12 years. If there is a
family history of hypercholesterolaemia, early cardiovascular disease, or if the family history is unknown, screening should start at age 2 years.
45

OF COMPLICATIONS
These values represent the lower limits for abnormal blood pressure ranges,
according to age and gender. Any blood pressure readings equal to or greater
than these values represent blood pressures in the prehypertensive, stage 1
hypertensive, or stage 2 hypertensive range and should be further evaluated
by a physician.
46
Source: Kaelber DC, Pickett F. Simple Table to identify children and adolescents needing further evaluation of blood pressure. Pediatrics 2009:123:e972974 Blood Pressure Values according to Age & Gender.
More detailed information on normal BP levels for age, sex, and height is
available at: www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf
The International Diabetes Federation Life for a Child Program has an annual clinical data sheet which is very useful
in ongoing care. This is available as a paper form or webbased database. ISPAD also has a web-based database.
PSYCHOLOGICAL
CARE
The period following the diagnosis of diabetes is a very difficult time for families and they may experience varied feelings
including shock, denial, anger, sadness, depression, fear and
guilt. Children may also feel that having diabetes is a punishment for them doing something wrong. Adjusting to diabetes
takes time, and dealing with it is a daily challenge. It is important to remember that every family is different and manages in
different ways. The diabetes team should routinely assess how
the child and family are coping.
Strategies to help the child and their family cope with diabetes:
Encourage the family to learn about diabetes.
Encourage the family to share their diabetes knowledge
with family and friends to engage support.
Depending on their age and capability, encourage the
child to become involved in some of their care.
Encourage the child to talk to others with diabetes children often benefit from participating in a support group
or camps for children or teens with diabetes.
Encourage the child to talk about their feelings.
Encourage the parents to be positive.
Once settled into a routine, encourage parents to try to
re-focus on their child as a whole person - not just on the
diabetes.
47
DIABETES AND
ADOLESCENCE
Adolescence is a challenging period that brings many

changes to the young persons life - physically, psychologically and socially.
Adolescence and diabetes can be an uneasy mix, with diabetes seen as an interference. The required routine interrupts freedom and spontaneity. Young people may worry
about what the future with diabetes holds for them and
very often require additional support and advice. Difficulties
may manifest in various ways, including acting out, rebellion, risk-taking behaviour, and burn-out, and there is an
increased risk of depression and eating disorders.
As adolescents assume increasing self-care and responsibility for their diabetes management, it is important for
parents to take less of the initiative and assume a more
secondary supporting role. Giving too much responsibility to
children too early is a common mistake, however, not giving
appropriate responsibility as young people become more
independent can also cause problems. When the young persons self-care is inadequate, parents and family members
may need to step in and supervise diabetes care once more.
Diabetes camps and other group work targeting coping
skills have been shown to have positive effects on regimen
adherence, quality of life and glycaemic control.
Young people may also receive, and rely on, considerable
support from their friends. Having a friend attend re-education sessions and clinic visits with the young person with
diabetes may encourage acceptance, and adherence to diabetes management.
Alcohol consumption can increase the risk of, and make it
difficult to recognise the symptoms of hypoglycaemia. It
can also cause vomiting and dehydration which may lead to
DKA.
Transition to adult care - All over the world, many youth with
diabetes are lost to care for a period when transitioning from
a paediatric to an adult clinic. It is crucial that every diabetes
service finds effective local solutions for this problem.
48
DIABETES
AND SCHOOL
It is normal for parents to feel anxious about sending their child

to school following the diagnosis of diabetes. The child is also
likely to feel anxious about returning to school and about feeling different. With appropriate planning and support, the child
can participate safely in all school activities and have a productive and fun time at school.
Parents/guardians have a responsibility to advise the school
of their childs medical condition and particular requirements
for the management of their childs diabetes. Most schools
are very supportive. However, communicating clearly with the
school and the childs teachers is vital. Parents should be advised to keep information concise.
A simple individualised management plan should be developed
as a guide to the school staff for managing the child at school.
Education may be given by the parent or a diabetes educator.
Younger children require additional assistance and supervision
in the school setting as they face a range of tasks and problems
that are beyond their level of cognitive development.
It is important that school staff be aware of the risk of hypoglycaemia - symptoms, immediate treatment and possible
re-treatment - and that appropriate hypo treatment is with the
child at all times. Teachers need to be aware that school performance is affected by low glucose levels.
Children may need to test their blood glucose prior to, during
and after physical activity and be alert for signs of hypoglycaemia and receive immediate treatment. Children also may need
to take insulin at school and are entitled to appropriate help in
doing this.
Should a high blood glucose level (>15mmol/l) occur, the child
should be encouraged to drink water and may need to pass
urine more frequently. Parents should be contacted by phone.
Preparation for exams may be required such as taking the meter and strips into the room, carrying a hypo kit, and water being readily available.
49
DIABETES AND
PREGNANCY
Counselling from mid-puberty should include culturally

sensitive discussion on contraception and the effects of diabetes on a pregnant mother and her baby.
Girls with diabetes should be made aware that poor diabetes control around the time of conception markedly
increases the risk of serious complications during pregnancy, both for the mother and the child.
Unplanned pregnancies should be avoided as tight blood
glucose control is ideally needed from before conception
to after delivery.
For planned pregnancies, diabetes should ideally be
monitored by an experienced team from pre-conception
throughout the pregnancy. Establishing good blood glucose control from as early in the pregnancy as possible
will reduce risks of complications during delivery and following the birth.
For patients with type 2 diabetes, metformin and sulphonylureas may be continued during pregnancy, but for
many youth, insulin will be required to maintain optimal
glycaemia and decrease risk for early congenital malformations and foetal macrosomia. Other oral agents
should not be used during pregnancy.
For further reading please refer to IDF Global Guideline on Pregnancy and
Diabetes
50
OTHER TYPES OF
DIABETES IN CHILDREN,
INCLUDING TYPE 2
Type 2 Diabetes
Type 2 diabetes is characterised by insulin resistance
(the insulin produced works less effectively) and often
also insufficient insulin production. It is increasingly being seen in children, particularly older children who are
overweight and inactive, who have a family history of type
2 diabetes or in those who are of particular ethnic backgrounds where type 2 in adults is very prevalent.
Children with type 2 diabetes usually lack the antibodies
seen in type 1 (although there can be overlap between
the two conditions). They commonly have acanthosis nigricans (thickened and darkened skin at the base of the
neck and in the axillae). Other features of the metabolic
syndrome may also be present.
Even with the onset of type 2 diabetes, many people do
not have the dramatic symptoms compared to those with
type 1 diabetes. However, type 2 diabetes can sometimes
present with severe symptoms and signs including dehydration and ketoacidosis like type 1 diabetes. This
has been reported in up to 25% of type 2 presentations in
young people and requires management as in type 1 see
Chapter 2.
Type 2 diabetes often responds initially to a healthy eating
plan, appropriate exercise and weight reduction, but frequently oral hypoglycaemic medicines such as metformin
are needed, and then later, insulin may be required.
For further reading on diagnosis and management please refer to Chapter

3, ISPAD Guidelines 2009
51
OTHER TYPES OF DIABETES IN

CHILDREN, INCLUDING TYPE 2
Other rarer types of diabetes occur,

including
52
The imperfectly understood entities of malnutrition related diabetes and fibrocalculous pancreatopathy also
occur in some countries in the developing world. Fibrocalculous pancreatopathy usually presents with abdominal pain and calcification of the pancreas is evident on
X-ray or ultrasound
Some forms of diabetes do not neatly fit type 1 or type
2 - atypical diabetes
Neonatal Diabetes (presenting in the first six months of
life) results from the inheritance of a mutation or mutations in a single gene (monogenic diabetes). If this is
suspected, genetic testing should be undertaken because
it may influence management. This testing can be done
free of charge (except for shipping costs) through centres
in the U.K. and elsewhere.
For further reading please refer to

guidelines
Diabetes Genes and Chapter 4, ISPAD
Monogenic diabetes outside the neonatal period (previously called Maturity Onset Diabetes of the Young
(MODY)). There is often a strong family history of diabetes.
Gestational diabetes can also occur in pregnancy in
younger women
IDF LIFE FOR A CHILD

PROGRAM
The International Diabetes Federation Life for a Child

(LFAC) Program was established in 2001. Program partners include Australian Diabetes Council and ISPAD. The
program supports diabetes centres in the under-resourced
world that care for children and youth (up until the age of
26 years). The type of support provided varies according to
expressed needs and the programs resources. Centres are
welcome to contact the program to discuss whether help
could be provided for further reading refer to: www.lifeforachild.org
The LFAC website has a section displaying diabetes resources in various languages used in the developing world.
Information is available for children, youth, parents, health
professionals, and teachers for further reading refer to: Life for
a Child Education Resources.
53
Disclaimer
The International Diabetes Federation (IDF) and the International Society for Adolescent and Pediatric Diabetes
(ISPAD) are not engaged in rendering medical services, advice or recommendations to individuals with diabetes. The
material provided in this publication is therefore intended
and can be used for educational and informational purposes
only. It is not intended as, nor can it be considered nor does
it constitute, individual medical advice and it is thus not intended to be relied upon to diagnose, treat, cure or prevent
diabetes. People with diabetes should seek advice from and
consult with professionally qualified medical and healthcare professionals. IDF and ISPAD assume no legal liability
or responsibility for the accuracy, currency or completeness
of the information, opinions or recommendations provided
herein. IDF and ISPAD assume no responsibility or liability for personal or other injury, loss, or damage that may
result from the information, opinions or recommendations
contained within this publication.

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I N T E R N AT I O N A L D I A B E T E S F E D E R AT I O N , 2 0 1 3

POCKETBOOK FOR MANAGEMENT OF

The Pocket Book was prepared and edited by:

The information in these guidelines is aimed to assist health

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

and clear advice for initial management of diabetic ketoacidosis,

Prof. Georgeanna Klingensmith, MD, Professor of Pediatrics, Univer-

Prof. Stephen Colagiuri, MB BS, FRACP, Sydney Medical School Boden

Dr. Warren Lee Wei Rhen,

MBBS. M.Med (Paediatrics), Paediatrics,

Dr. Line Kleinebreil,

MD, Fondation Education et Techerche pour

Prof. Fergus J Cameron,

BMed Sci, MBBS, Dip RACOG, FRACP, MD,

1. Clinical Practice Consensus Guidelines, ISPAD 2009

Caring for Diabetes in Children and Adolescents, Childrens Diabetes

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

Definition and Diagnosis ...................................

Management of Diabetic Ketoacidosis ............

Insulin Treatment .............................................

Sick Day Management ......................................

Blood Glucose Monitoring ................................

Nutritional Management ..................................

Physical Activity ................................................

Diabetes Education ..........................................

Ongoing Care, Management of Complications

Psychological Care ............................................

Diabetes and Adolescence ...............................

Diabetes and School .........................................

Diabetes and Pregnancy ...................................

Other Types of Diabetes in Children,

IDF Life for a Child Program .............................

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

Pocketbook for Management of

Symptoms and Signs

Frequent vomiting and

Tiredness - not wanting to work or play

Oral or vaginal thrush

In diabetes the body is unable to fully use glucose, and starts

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

In babies and young infants, signs and symptoms may be

Breakdown of fat causes ketones to accumulate in the blood

Diagnosis of diabetes is made when:

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

more common symptoms in the table on page 6)

Newly diagnosed children should be transferred to a centre that

For further reading please refer to Chapter 1 ISPAD Guidelines 2009.

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

For further reading please refer to Chapter 3, ISPAD Guidelines 2009

Other Types of Diabetes

Monogenic diabetes outside the neonatal period. This was

For further reading please refer to Chapter 1, ISPAD Guidelines, 2009

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

The biochemical criteria for DKA are:

DKA results in vomiting, abdominal pain, flushed cheeks,

Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries

Managing DKA includes the following components:

Page 19 gives a summary flowchart for recommended care settings and