In this section
Diabetic Ketoacidosis (DKA)
Diabetic Mellitus and Endoscopy
Diabetes Mellitus and Surgery
Diabetes phone calls (Management of Diabetes phone calls)
All patients presenting with a blood glucose level (BGL) ≥11.1 mmol/L should have blood ketones tested on a capillary sample using a bedside OptiumTM meter.
<3% dehydration, no acidosis and not vomiting
Investigations for all children newly diagnosed with diabetes
Check blood ketones (bedside test) on all patients presenting with BGL ≥11.1 mmol/L.
Additional tests to consider
For children / adolescents who are overweight or have clinical evidence of acanthosis nigricans:
The decision about the individual insulin regimen will be made by the paediatric diabetes team in discussion with the family and child. The regimens outlined below are a guide only and individual clinicians may recommend an alternative approach.
0.25 units/kg of quick-acting insulin subcut stat.
Standard insulin regimens in newly diagnosed patients may comprise either of the two regimens below:
1. Twice daily injections of a mixture of short and intermediate-acting insulins:
Usually commence with total daily dose (TDD) of 1 unit/kg/day but this may need modification (eg less in younger child aged
This is given as 2/3 of TDD in morning, 1/3 of TDD at night. 2/3 of each dose as intermediate-acting insulin, 1/3 as short-acting insulin.
Note: In children who will be starting twice daily injections but who present after 2200 hrs, it may be too late to start with a mixture of intermediate and short acting insulins. In this instance, give 0.25 U/kg short-acting insulin, which may need to be repeated after 4-6 hours, with a snack (depending on BGL, ketones and interval to breakfast).
2. Multiple daily injections (MDI) of insulin using a long-acting insulin analogue at night and pre-meal injections of rapid-acting insulin analogue
Also start with TDD of ~1.0 U/kg/day.
In general, multiple daily injection regimens offer greater lifestyle flexibility (around mealtimes, sport etc); however the child must be old enough to learn how to administer insulin using a pen device without parental supervision (eg at school). This is usually possible with children aged >10 years. Twice daily mixed injections are usually commenced in children
When to admit/consult local paediatric team:
When to consider transfer to tertiary centre:
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
Information specific to MMC
Diabetes Ambulatory Care Service (DACS) allows for many newly diagnosed children with diabetes to not require hospitalization. Please see relevant paediatric diabetes protocol on MMC intranet policies and procedures site.
Information Specific to RCH
AnGel cream can be used for initial doses of insulin in a newly diagnosed child
Ambulatory care program at diagnosisChildren who are well at diagnosis (not acidotic, well hydrated and tolerating oral intake) may be eligible to have their diabetes education and initial stabilisation as an ambulatory care patient. Additional eligibility criteria include age >3 years, English speaking family, living within the HITH catchment area, contactable by telephone and absence of any familial / psychosocial impediment to safe care in the community.
Prior to linking into this program, children need to have met with the diabetes team (medical team, social worker and diabetes educator) to be assessed for suitability and also to have an initial education session around blood glucose testing and management of hypoglycemia. Hospital in the Home nurses also need to be available to attend the family home to support injections. These requirements generally mean that children who present after lunchtime will not be discharged to HITH until the following day. Direct access to ambulatory care on day of diagnosis is also not possible for children whose initial presentation is on Friday, Saturday or Sunday. Please let the diabetes team know of any new patients in ED as soon as possible, so that every effort to enrol eligible patients in ambulatory care can be made.
Patients with established T1DM who present with hyperglycaemia and ketosis but normal pH, will need additional subcut insulin to clear their ketones.
(i) Patients on intermittent daily injections of insulin (bd or MDI)
Give 10% of the patient's total daily insulin dose as a sub-cut injection of rapid-acting insulin (this is in addition to usual insulin regimen). Monitor BGL and ketones 1-2 hourly. This dose of rapid-acting insulin can be repeated after 2-4 hours if blood ketones are not
(ii) Patients on insulin pump therapy
Need to assume line failure / blockage has interrupted insulin delivery. Give 20% of the patient's total daily insulin dose as a s.c. injection of rapid-acting insulin (higher dose relative to above patient group is because there is no longer acting insulin 'on board' in pump patients). Once subcut insulin has been given, ask the patient or family to resite the pump cannula and commence delivery at usual settings. Monitor BGL and ketones 1-2 hourly. For patients on pump therapy, ketones should clear to
Notify local paediatric team or paediatric endocrinologist if there are any management issues that you want to discuss. If discharged home, the family should be advised to check BGLs and ketones regularly and to follow up with their diabetes nurse educator the following day.
Consider transfer when:
Diabetic educators and the endocrinology team are available for help with management.