Type 1 diabetes

  • What is type 1 diabetes?

    Type 1 diabetes is a condition that occurs when the body loses its ability to produce a hormone called insulin. This life-long autoimmune condition affects over 120,000 people in Australia alone and is predominately diagnosed in childhood. Insulin is normally produced by the pancreas and allows glucose (sugar) to move from the blood to tissues such as muscle where it is required for energy.

    A children's guide to type 1 diabetes

    An adult's guide to type 1 diabetes

    What are the symptoms of type 1 diabetes?

    Type 1 diabetes may cause some of the following symptoms.   If you think you or someone you know has these symptoms, seek medical help immediately, and drink sugar-free fluids to prevent dehydration.

    • Extreme thirst
    • Constant hunger
    • Sudden weight loss
    • Frequent Urination
    • Blurred Vision
    • Nausea
    • Vomiting
    • Lethargy
    • Infections

    When there is not enough insulin the blood glucose levels build up and eventually "spill over" into the urine. This results in excessive urine production and thirst. Thus, prior to treatment, affected children and adolescents have usually had the symptoms of thirst and increased urination for some time (usually 2-3 weeks). If this situation is allowed to progress unchecked, fat stores begin to break down, weight loss occurs and the blood becomes increasingly acidic. Eventually affected people become dehydrated, start vomiting and lose consciousness. This is called diabetic ketoacidosis (DKA).

    How do people manage type 1 diabetes?

    The treatment of type 1 diabetes involves replacement of insulin. Insulin can be replaced in the body either via insulin injections (twice daily insulin or four injections per day) or with insulin pump therapy. Checking blood glucose levels provides information on how much glucose is currently in the bloodstream and is a crucial part of managing diabetes. It is the only way to know if the body is getting the correct amount of insulin that it needs. Managing diabetes involves balancing insulin, food, and exercise.

    When people are first diagnosed with type 1 diabetes, they will be medically stabilised and start on insulin injections. They will usually be required to stay in hospital for a short period of time to commence diabetes education which can then be finished as an outpatient after discharge. These education sessions will be with a diabetes nurse educator (approx. three-four sessions), dietitian (approx. two sessions), and social worker (approx. one session).

    The goal of diabetes education is to provide the needed support to young people and their families to feel comfortable and confident with diabetes management in their day to day life.

    A young person with diabetes will have an appointment with an endocrinologist (diabetes doctor), diabetes educator and dietitian a few weeks after their diagnosis. Following this appointment, diabetes care involves an outpatient appointment every 3-4 months with the endocrinologist.

    Diabetes nurse educators, diabetes dietitians and social workers are available to be contacted in between the young person’s doctor appointment for support with diabetes management.

    Long term management and HbA1c targets

    It’s important to note that despite our best efforts, blood glucose levels (BGLs) will not always be in our target of 4-8 mmol/l. Variations will happen on a daily basis, sometimes they will be low i.e. less than 4mmol/l and other times high i.e. greater than 8 mmol/l. Often we can account for blood glucose levels that are out of the target such as the impact of food which may raise BGLs or exercise that may lower BGLs.

    What is the Hba1c test?

    Every 3 – 4 months, children with type 1 diabetes will have a blood test called an HbA1c. These blood tests measure the amount (as a percentage) of haemoglobin in red blood cells that has glucose attached to it.  The higher the glucose levels in the blood (the more BGLs out of target per day/week) the more will become attached to the haemoglobin.

    At the RCH we aim for any HbA1c 7.5% or less. If a child has any HbA1c higher than this on a regular basis, their risk of developing complications will increase dramatically.

    Haemoglobin

    Remember: BGLs in target range = HbA1c in target range.

    At the RCH we expect our children to enjoy long and healthy lives so the aim of our diabetes management during childhood and adolescence is to allow day to day activities and quality of life whilst minimising the risk of long-term diabetes related complications. We do this by encouraging regular reviews of your child’s BGL’s, adjusting insulin doses in response to patterns and performing the HbA1c test every three months in clinic.

    Targets can be achieved by ongoing contact with a dedicated paediatric diabetes care team, education and motivation to maintain a healthy lifestyle with particular emphasis upon diet and exercise. The diabetes team can teach you how to adjust your child’s insulin and support you to become independent with this over time.

    How do you measure your risk of developing complications?

    All children who have been diagnosed with type 1 diabetes at the RCH will have a fingerprick blood test done in clinic every three months to test their HbA1c. This test is the best measure for long-term blood glucose control. It can tell us about how much glucose has been circulating in the blood stream on average over the last three months which tells us about the relative risk of complications associated with chronically (long term) elevated blood glucose levels. (See graph below)

    Complications graph

    This can be achieved by ongoing contact with a dedicated paediatric diabetes care team, education and motivation to maintain a healthy lifestyle with particular emphasis upon diet and exercise. The diabetes team can teach you how to adjust your child’s insulin.

    Blood glucose levels

    A blood glucose level (BGL) measures the concentration of glucose in the blood at the time of the test. Performing blood glucose test is the only way you will know how to determine the correct dose of insulin to give. You need to know how to adjust insulin doses.

    BGL’s need to be checked a minimum of four times a day:

    • Before breakfast
    • Before lunch
    • Before dinner
    • Before supper
    • Overnight 2-3 times a fortnight.

    BGL’s may need to be tested at other times of the day:

    • If hypo is suspected
    • If you feel unwell
    • Before commencing sport or exercise
    • Before driving a car

    The target range BGLs is 4.0mmol/L – 8.0mmol/L

    An assessment of blood glucose levels tell you if you are getting the correct dose of insulin. Growing children will require regular insulin dose adjustment.

    • If the BGL’s are consistently less than 4.0mmol/L you are getting too much insulin
    • If the BGL’s are consistently above 8.0mmol/L you are not getting enough insulin

    All BGL readings and insulin doses should be recorded in a record book. Keeping a detailed record of your BGL’s allows you to assess if you need to make changes to your insulin doses.

    Always wash and dry hands before taking a BGL as food on your fingers can alter the BGL reading.

    The ACCU-CHEK FastClix lancing device has been proven to be the least painful and overall easiest to use. This should have been provided for you to use at diagnosis. For video instructions on how to use the lancing device please click here. NOTE: the RCH advices that lancets should only be changed once a day not at each BGL test as per the video

    Hypoglycaemia

    Printable version

    What is hypoglycaemia?

    p>Hypoglycaemia (“Hypo”) means a low level of glucose in the blood. For people with type 1 diabetes, this is a blood glucose value of less than 4.0 mmol/L. Mild to moderate hypoglycaemia is common and is an expected to occur in good diabetes care. True physiological hypoglycaemia does not occur until the BGL is less than 3.5mmol

    Hypoglycaemia can be caused by:

    • Too much insulin
    • Vigorous exercise without extra carbohydrate
    • Missing or delayed meals
    • Not eating all serves of carbohydrate
    • Alcohol intake

    Or, there may be no obvious reason.

    People affected by hypoglycaemia may start to experience symptoms when the blood glucose level is less than 4mmol/l, or more commonly when the BGL is less than 3.4mmol Sometimes the blood glucose level can be lower than this and no symptoms are experienced, this is referred to as "hypo unawareness".

    Common signs and symptoms of hypoglycaemia are:

    • paleness
    • heart pounding
    • shakiness
    • irritability, change in mood
    • headache
    • lack of concentration
    • sweating
    • confusion, vagueness
    • feeling hungry
    • crying
    • dizziness
    • weakness

    All BGLs less than 4mmol need to be treated, regardless of their signs and symptoms.

    Mild hypoglycaemia is common and is an expected to occur in good diabetes care.

    Note: The treatment must be taken to the person having the hypo. Never make them walk to get treatment as this may exacerbate the hypo.

    Treatment

    A blood glucose test should be done to confirm the hypoglycaemia before treating. Treat the hypo if the blood glucose level is 3.9mmol or lower. Do not delay treatment.

    Step 1

    Give 5-10grams of high GI (quick acting) carbohydrate to raise the blood glucose levels quickly
    Treatment options are based on age
    5 years old or younger, or less than 25kg give 5 grams
    6 years old and older, or more than 25kg give 10 grams

    e.g.

    • 60-120mls Juice
    • Glucose tablets (1.5-2 TRUEplus™ or 3-6 Glucodin™)
    • Polyjoule/Sucrose Solution
    • 50-100ml Lemonade
    • 100-200ml Cordial
    • 1-2 teaspoon Honey
    • 2-4 jelly beans(Glucojel™)

    Step 2

    WAIT 15 minutes, perform another blood glucose test.

    If BGL remains under 4mmol/L : REPEAT Step 1.

    If BGL is above 4mmol/L : Give 10-15 grams of a sustaining (low GI) carbohydrate to keep the blood glucose in the target range.

    e.g.

    • 4 - 6 Savoy biscuits/7-10 rice crackers
    • 200-250mls of milk
    • 1 apple or small banana
    • ½ cup of fruit yoghurt
    • I slice of bread

    If a hypo occurs within 20 minutes of meal time, please use the meal as your STEP 2, low GI carbohydrates.

    If hypoglycaemia occurs immediately before a meal when insulin is due:

    • Give a sugar serve, wait a few minutes until feeling better
    • Give the normal dose of insulin
    • Serve the meal immediately
    Remember that the less sticky the hypo treatment, the better it is for good dental hygiene. Regular flossing and brushing will also help this!

    You can see in the picture below, hypo’s must be treated with high GI carbohydrates immediately to raise blood glucose levels quickly. Following on with low GI carbohydrates, will minimise the chance of repeated hypoglycaemia once the initial fast acting high GI food has worn off.

    Blood glucose levels image

    Over treating hypoglycaemia can be a problem for many families. If you are experiencing high BGLs after treating a hypo, please contact the diabetes allied health team to discuss hypo treatment.

    Tips for assisting with hypoglycaemia

    • Always carry fast acting high GI carbohydrates on you at all times
    • Hypo treatment should be kept at school, in the car and other places that are easily accessible
    • Check blood glucose levels whenever possible to confirm hypoglycaemia
    • Do not ignore mild symptoms. Do not delay treatment
    • Eat meals and snacks on time
    • Supervise your child’s injections
    • Never give rapid acting insulin unless food is available
    • Give extra serve of low GI carbohydrates before any activity
    • Teach family and friends how to recognise and treat low blood glucose levels
    • If low blood glucose levels continue to happen without explanation, please contact the diabetes team.
    • Wear a diabetes identification bracelet at all times.

    Hypoglycaemia on an insulin pump

    The treatment of a hypo changes on an insulin pump. There is less circulating insulin in the body, which means less carbohydrate needs to be consumed to treat the hypo.

    • A  BGL less than 4.0 mmol/L is hypo and needs immediate treatment
    • BGL must be above 4.0 mmol/L to bolus for a meal or snack
    • Common reasons for BGL going low on a pump:
      Too much insulin (basal, carb ratio or sensitivity setting)
      Exercise without reducing basal rate
      Eating less carbohydrate than you bolus for
      Alcohol

    Mild Hypoglycaemia: BGL between 2-4 mmol/L

    • Give QUICK ACTING carbohydrate only (5 grams if ≤5 years old, 10 grams 6 years old and over) e.g. glucose tablets or fruit juice. DO NOT BOLUS FOR THIS TREATMENT,
    • Enter BGL in the pump after hypo treatment
    • Rest until you feel better
    • Recheck BGL in 15 mins. If your BGL is still under 4.0 mmol/L repeat the treatment.
    • After 1st hypo BGL entry, do not put further BGL readings in the pump for 1 hour
    • When BGL is above 4.0 mmol/L all carbs eaten must be bolused.  (Do not enter BGs for one hour after initial hypo entry)

    Moderate Hypoglycaemia: BGL below 2.0 mmol/L

    • Give QUICK carbohydrate (5 grams if ≤5 years old, 10 grams 6 years old and over) e.g. glucose tablets or fruit juice.DO NOT BOLUS FOR THIS TREATMENT,
    • Enter BGL in the pump after hypo treatment
    • Then eat 15 grams LONG ACTING Carbohydrate e.g. Milk or crackers. DO NOT BOLUS FOR THIS TREATMENT
    • Rest until you feel better
    • Recheck BGL in 15 mins

    * If BGL still Below 2.0 mmol/L repeat the above treatment

    * If BGL between 2-4 mmol/L give QUICK ACTING serve of carbohydrate

    When BGL is above 4.0 mmol/L all carbs eaten must be bolused.  (Do not enter BGLs for one hour after initial hypo entry)

    Severe hypoglycaemia

    A severe hypo has occurred if your child’s BGL is less than 4mmol and is unconscious, is having a seizure (fitting), is too drowsy to eat or drink or is being uncooperative. If this occurs, please do not attempt to administer anything by mouth.

    Call 000 for an ambulance

    Glucagon is a hormone that raises the blood glucose level by making the liver release its store of glucose into the bloodstream. This medication can be used to treat your child if they are having a severe hypo.

    Glucagon is a very safe medication to give and is injected into either the subcutaneous tissue or the muscle to raise blood glucose levels. If it is possible to do a blood glucose check before administering Glucagon, please do so.

    Glucagon injection kit

    Instructions for administering Glucagon:

    1. Place the child on their left side in the coma position to prevent anything from being breathed into the lungs.
    2. If you haven’t already called an ambulance, please do so. Call 000.
    3. If possible please do a blood glucose check
    4. Remove the orange plastic cap from the bottle of white powder (glucagon) and the needle guard from the syringe containing sterile water.
    5. Inject all the water into the bottle containing glucagon. Leave the needle in the bottle. The glucagon will dissolve into the fluid with gentle rotation of vial.
    6. Turn the bottle upside down. Pull ½ the needle out of the bottle to keep the end of the needle in the solution.
    7. Draw up the glucagon into the syringe.
    8. Inject all the glucagon into a muscle on the outside of your child’s thigh.

    How much glucagon do I give my child?

    • 0.5mls: Children who weigh less than 25kg or less than 6 years old
    • 1ml: Children who weigh more than 25kg or who are older than 6 years old

    How long will it take my child to recover after giving them glucagon?

    Glucagon may take 5 to 15 minutes to work, therefore don't expect an immediate improvement.

    What do I do after I have given my child glucagon?

    Glucagon can cause nausea, vomiting and headache.

    Once your child is rousable, encourage high GI carbohydrates fluids such as juice or lemonade. Because Glucagon depletes glycogen stores, you must be give your child sugary food or drink by mouth as soon as they have roused and are able to take it. This will prevent the occurrence of secondary hypoglycaemia.

    Within the hour it is important to give a low GI carbohydrate, such as bread or milk in order to prevent recurrence of the hypoglycaemia and assist in return to normal eating. The liver needs to replenish its store of glycogen before glucagon can work again

    Monitor blood glucose levels every 15 minutes for the first hour then every hour for 4 hours.

    If you have had to use glucagon, please contact the Royal Children's Hospital to discuss further management over next 24 hours.

    Blood glucose levels are often elevated following a severe hypo. Any high blood glucose levels after a severe hypo requiring glucagon should not be treated with extra insulin.

    Expired Glucagon

    Novo Nordisk provides a service with the ability to register to activate a reminder for when your hypoglycaemia medication is due to expire. Please follow this link to register your glucagon.

    Ketones

    Printable version

    Ketones

    Ketones are produced when the body breaks down fat for energy when there is insufficient insulin for cells to access glucose. Ketones occur most commonly when there is not enough insulin in the body. They are acidic and are dangerous if they build up in the blood as they cause a life threatening condition called Diabetic Ketoacidosis DKA.

    Small amounts of ketones are normal ( 0.0 – 0.6mmol).

    What is Diabetic Ketoacidosis (DKA)?

    Diabetic Ketoacidosis (DKA) is a life threatening condition that occurs when there is insufficient insulin and blood ketones are abnormally high. High ketones are often associated with very high BGLs as well. The high ketones cause imbalances in body fluid and salt levels, leading to dehydration and build-up of acids in the blood. Vomiting and increasing drowsiness result. DKA requires urgent medical assistance.

    What causes DKA?

    • Missing insulin injections
    • Illness
    • Previously undiagnosed type 1 diabetes

    What are the signs and symptoms of DKA?

    DKA can develop rapidly and requires urgent medical assistance. Signs and symptoms may include

    • High blood glucose levels with ketones present
    • Tummy pain
    • Vomiting
    • Dehydration
    • Rapid, shallow breathing
    • Acetone smell on the breath
    • Confusion
    • Drowsiness which may lead to coma

    How do I check for ketones?

    • Ketones can detected in the blood and in the urine.

    Blood and urine testing image

    Urine ketones are positive if a colour change occurs (+, ++ or +++). If positive urine ketones check blood ketones.

    When do I need to check for ketones?

    • When the blood glucose level is greater than or equal to (>) 15 mmol/L
    • Whenever your child is unwell, no matter what the blood glucose is.

    Ketones do not need to be checked more frequently than every four hours if they are less than 1.0mmol/L

    Action is required if keytones are greater than 1.0mmol/l

    What should I do if my child’s ketones are greater than 1.0mmol/L and they are on injected insulin?

    1. If BGL greater than (>)15mmol/L:

    • Give 10% of total daily insulin dose using rapid acting insulin (Novorapid or Humalog) immediately
      • Total daily dose is calculated by adding all insulin doses for a usual day and dividing by 10. This equals 10% of total daily insulin dose.
        • If insulin is due, add 10% of total daily insulin dose to normal insulin dose
        • If insulin is not due, give 10% of total daily insulin dose as an extra injection immediately
    • Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L
    • Extra insulin may be required if BGL remains >15mmol/L & ketones remain > 1.0 mmol/L after 2 hours

    2. If BGL 8.0mmol/L - 15mmol/L:

    • Consider giving 5 -10% of total daily insulin dose using rapid acting insulin.
    • Encourage extra carbohydrate to maintain BGL
    • Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L

    3. If BGL 4.0mmol/L – 7.9mmol/L:

    • Encourage extra carbohydrate to maintain BGL
    • Give normal insulin dose
    • Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L

    4. If BGL < 4.0mmol/L:

    • Treat hypo and encourage sweetened fluids
    • Seek medical advice if insulin is due – reduction in insulin dose may be required
    • Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L

    Remember

    • If vomiting and ketones present, call the RCH early for support with insulin doses
    • If unsure of appropriate treatment, call the RCH and ask for the sick day diabetes service:
      • The RCH switchboard 9345 5522

    What do I do if my child is on a pump?

    Positive ketones = 0.6 mmol/L or higher.

    If you have ketones you have not been receiving adequate insulin.

    Insulin pump therapy carries a much higher risk for developing ketones than injected insulin because if there is interruption to insulin delivery, there is no background or long acting insulin

    Insulin pump users need to have access to injected insulin at all times.

    A ketone reading of 0.6mmol/L and higher is positive and needs immediate treatment:

    • Inject emergency dose of short acting insulin via pen or syringe
    • Calculate emergency dose dividing your pump total daily dose of insulin by six (PTDD÷6)
    • Do a full line and cannula change
    • Check BGL’s and ketones 2 hourly (Do not enter a BG into the pump for at least 2 hours). Bolus for any carbs consumed.

    Please update and record your PTDD regularly and keep it with your emergency pack.

    How do I know what my child’s PTDD is?

    Pump total daily dose (PTDD) can be found in the pump or on the download.

    Medtronic Veo

    In utilities menu, daily totals, daily average, 7 days to average, total insulin: Page 2 of download, right hand side – statistics box

    Medtronic 640G

    History menu, summary, 7 days, TDD: Page 2 of download, right hand side – statistics box

    Animas Vibe

    History, total daily dose. TDD done individually so need to average 5-7 days: Compilation page, average daily dose

    Insulin

    With type 1 diabetes, the body does not produce insulin. This means that giving insulin injections is a vital part of managing type 1 diabetes in children and adolescents.

    Insulin is usually made by the beta cells in the pancreas. In type 1 diabetes, the beta cells are destroyed and can no longer make enough insulin to meet the body’s requirements.

    What is insulin and why do we need it?

    Insulin is the hormone needed to move the glucose from the bloodstream into the cells. Insulin is the “key” which opens the door of the cell, allowing glucose to flow inside. Without insulin most of the organs cannot take up glucose.

    When there is not enough insulin in the body the glucose stays in the bloodstream. The blood glucose level rises very high because it cannot move into the cells. The body tries to clear the glucose from the bloodstream by offloading glucose in the urine.

    "When glucose cannot be used for energy the body uses fat instead. If fat is used for energy, some harmful substances called ketones begin to build up in the blood. The ketones that build up will make the person with diabetes very sick"

    - Diabetes in Children and Adolescents, 3rd ed, 2010

    When a person is diagnosed with type 1 diabetes, insulin needs to be replaced by an injection of manufactured insulin. This insulin is made in a laboratory and does not use any animal products.

    Insulin is essential for survival. There is never a time when the body should be without insulin. There is no alternative treatment to insulin.

    What are the different types of insulin?

    There are a number of different types of manufactured insulin available: rapid-acting, short-acting, intermediate-acting and long-acting.

    The types and combination of insulin will be advised by your treating Endocrinologist.

    Rapid acting insulin

    • Begins to work 5-15mins after injection
    • Can last 3-5hrs
    • Will be working at its peak action between 1-3hrs
    • Is a clear solution
    • Please give immediately before food

    Short acting insulin

    • Begins to work 20-30mins after injection
    • Can last 5-8hrs
    • Will be working at its peak action between 2-4hrs
    • Is a clear solution

    Intermediate acting insulin

    • Begins to work 1-2hrs after injection
    • Can last 16-24hrs
    • Will be working at its peak action between 4-12hrs
    • Is a cloudy solution

    Long acting insulin

    • Provides a steady level of insulin over 24hrs
    • No peak
    • Clear solution
    • Please give at the same time each day

    When you have a child with type 1 diabetes,  it’s important you know how to change insulin doses in response to ‘patterns’ of hyperglycaemia (highs) and hypoglycaemia (lows), whether this be a dose adjustment for injections or setting changes on insulin pumps.

    The Diabetes Allied Health Team understands that making changes to insulin doses can be daunting to begin with, but with support and guidance from the team we aim to build your confidence in making independent changes at home.

    See > Management of T1D > Dose adjustment

    How do I give the insulin injections?

    Insulin is injected into the subcutaneous layer (fat layer) just underneath the skin. This is done by pinching up the skin and injecting the syringe or pen on an angle. For pen insulin this should be a 90 degree angle and for syringes a 45 degree angle.

    How to give an insulin injection image

    Where do I give my injections?

    Insulin injection site rotation is extremely important in good diabetes management. It will help prevent lumps from forming under the skin and ensure good insulin absorption. If insulin is injected into the same spot repeatedly, fatty lumps will form. This is called Lipohypertrophy (or lipo).

    Lipos don’t absorb insulin in the same way as healthy tissue and can lead to increased insulin doses and more glycaemic variation.

    98% of people who have lipo, don’t rotate correctly!

    People with lipo use on average 15 units more of insulin than people without lipo!

    Sites that can be used for insulin injections include stomach, hips, arms and legs.

    Insulin injection sites on the body image

    If your child has little or no fat tissue in the stomach area please do not use.

    Exercise increases insulin absorption so the arms and legs may need to be avoided on days when young people are very active with sport.

    If you are unsure where you should inject your child or if they have any changes to their skin, please contact your diabetes educator.

    How do I care for my insulin?

    Unopened insulin needs to be stored in the fridge.

    Open insulin needs to be stored in a dry cool place and can be used for up to a month after opening.

    Insulin can lose its effectiveness and should be discarded if exposed to direct sunlight, heat, frozen or shaken.

    Dose adjustment

    Printable version

    Dose Adjustment

    Throughout life your insulin requirements will change and doses need to be adjusted accordingly in order to keep BGLs in target.  Growth, sport, activity, lifestyle and food all play a part in affecting blood glucose levels.

    To maintain diabetes control it is important to adjust insulin doses when BGL’s start to drift outside the target range.

    Your target BGL is 4.0 mmol/L - 8.0mmol/L

    Some tips

    • Do not adjust insulin because of a single high or low BGL
    • Look for patterns in your BGL over a minimum of 3 days
    • A BGL out of target range 3 days in a row or 4 times in one week at the same time of day is a good indicator that the insulin doses should change.
    • Wait 3 days to assess the effect before making a second change

    BD Insulin Regimen (2 injections/day)

    Hyperglycaemia (high blood glucose) at:

    • Breakfast or over night - Increase your dinner dose of Protaphane/Levemir by 1-2 units
    • Lunch or morning tea - Increase your breakfast dose of Actrapid/Novorapid by 1-2 units
    • Dinner or afternoon tea - Increase your breakfast dose of Protaphane/Levemir by 1-2 units
    • After dinner or before bed - Increase your dinner dose of Actrapid/Novorapid by 1-2 units

    Hypoglycaemia (low blood glucose) at:

    • Breakfast or over night - Decrease your dinner dose of Protaphane/Levemir by 1-2 units
    • Lunch or morning tea - Decrease your breakfast dose of Actrapid/Novorapid by 1-2 units
    • Dinner or afternoon tea - Decrease your breakfast dose Protaphane/Levemir by 1-2 units
    • After dinner or before bed - Decrease your dinner dose of Actrapid/Novorapid by 1-2 units

    Basal Bolus Regimen (4 injections/day)

    Hyperglycaemia (high blood glucose) at:

    • Breakfast or over night - Increase your Lantus/ Levemir by 1-2 units
    • Lunch or morning tea - Increase your breakfast dose of Novorapid / Humalog by 1-2 units
    • Dinner or afternoon tea - Increase your lunch dose of Novorapid / Humalog by 1-2 units
    • After dinner or before bed - Increase your dinner dose of Novorapid / Humalog by 1-2 units

    Hypoglycaemia (low blood glucose) at:

    • Breakfast or over night - Decrease your Lantus/ Levemir by 1-2 units
    • Lunch or morning tea - Decrease your breakfast dose of Novorapid / Humalog by 1-2 units
    • Dinner or afternoon tea - Decrease your lunch dose of Novorapid / Humalog by 1-2 units
    • After dinner or before bed - Decrease your dinner dose of Novorapid / Humalog by 1-2 units

    This advice does not apply if your child is on sick day management

    Diabetes nurse educators

    9345 6661 8am – 4pm for non-urgent advice (routine dose adjustment)

    9345 5522 out of hours for all urgent/sick day advice

    CSII dose adjustment

    Your goal is to be able to make rate and ratio adjustments independently.

    Throughout life insulin requirements will change. Growth, sport, activity, lifestyle and food all play a part in affecting blood glucose levels. To achieve a target HbA1c (measure of complications risk) it is important to change pump settings when BGL’s start to drift outside the target range. If you have tried making changes but are still having problems you can call or email the diabetes nurse educators during office hours for advice.

    Your BGL target is 4.0 mmol/L- 8.0mmol/L.

    Your HbA1c target is < 58 mmol/mol (<7.5%)

    Some guides

    • Do not adjust settings because of a single high or low BGL Look on the download for patterns in your BGL over a minimum of 3 days (except on sick days)
    • BGLs out of target range 3 days in a row or 4 times in one week at the same time of day is a good indicator that a change could be made.
    • Wait 3 days to assess the effect before making a second change
    • Try not to have more than 5 basal rates
    • Try not to have more than 3 Insulin to Carbohydrate Ratios (ICR) or Insulin Sensitivity Factor ratios (ISF).

    Hyperglycaemia

    Is it basal rate or bolus ratio?

    • If BGLs elevated overnight or more than 4 hours after food it is likely to be a basal rate. Consider increasing the basal rate by 0.1 - 0.2 units/hr 2 hours before the rise. If your child is under 4yrs old then only increase by 0.05-0.1 units/hr
    •  If BGLs high 2- 3 hours after a meal bolus it is likely to be the insulin to carbohydrate ratio (ICR). Consider lowering the carbohydrate ratio by 5%-10%.
    • If BGLs high 2-3 hrs after correction it is likely to be the sensitivity factor. Consider lowering the ISF by 5%-10%.

    Hypoglycaemia

    Is it basal rate or bolus ratio?

    • If BGLs low overnight or more than 4 hours after food it is likely to be a basal rate. Consider decreasing the basal rate by 0.1-0.2 unit/hr 2 hours before the lows . If your child is under 4yrs old then only decrease by 0.05-0.1 units/hr
    • If BGLs low 2- 3 hours after a meal bolus it is likely to be the insulin to carbohydrate ratio (ICR). Consider raising the carbohydrate ratio by 5%-10%.
    • If BGLs low 2-3 hrs after correction it is likely to be the sensitivity factor. Consider raising the ISF by 5%-10%.

    Refer to initial pump education documents for more detailed information.

    This advice does not apply if your child is on sick day management

    Diabetes nurse educators

    9345 6661 8am – 4pm for non-urgent advice (routine dose adjustment)

    9345 5522 out of hours for all urgent/sick day advice

    Sick days

    Printable version

    Sick days

    Children with well controlled diabetes have no greater risk of contracting infections than anybody else. Having diabetes introduces the need for closer monitoring during sick days. Good management during illness can prevent diabetic ketoacidosis and hospital admissions

    Sick day management falls into two different categories:

    • Illness causing hyperglycaemia
    • Illness causing hypoglycaemia

    Both situations will require the child to stay home from school with adult supervision.

    Regardless of the situation NEVER stop insulin even if you are unable to eat.

    • Insulin doses may need to be changed
    • Monitoring of glucose and ketones will increase

    For illness causing high BGL’s:

    Viral and bacterial infections can cause stress hormones to raise BGL’s and cause insulin resistance.

    • Insulin doses may need to be increased
    • Check BGL’s every 2 hours
    • Check blood ketones every 4 hours.
    • Visit GP to treat underlying illness and or infection
    • Give medicine to relieve discomfort e.g. headaches or sore throat.
    • Encourage sugar free fluids to maintain hydration.

    For illness causing low BGL’s:

    Vomiting, diarrhoea, nausea and decreased appetite can all lead to hypoglycaemia.

    • Insulin doses may need to be decreased
      • Insulin can never be stopped but doses can be reduced to minimise the risk of hypo with decreased appetite.
    • Check BGL’s every  hour
    • Check blood ketones every 4 hours.
      • Ketones can be produced during illness even with normal or low BGL's
    • Sip on sugar containing fluids
      • Aim for ½ cup per hour of lemonade or juice
    • Mini doses of glucagon may be used to treat hypoglycaemia when unable to tolerate food or fluids

    Call the hospital for advice when:

    • Unsure about insulin dose adjustment
    • Child is drowsy or lethargic
    • Child has 3 vomits, 3 diarrhoeas or abdominal pain
    • Blood ketones at 1.0 mmol/L or more

    Minidose Glucagon Guideline

    If you have not used this protocol please call the RCH for advice.

    This is used for:

    • Children who are hypoglycaemic (BGL < 4.0 mmol/LO) with inter current illness (vomiting) and cannot tolerate food or fluids (food refusal or feeling sick)
    • How to use:

      • Inject all the water into the glucagon vial and remove the needle.
      • Discard needle into the sharps container
      • Use an insulin syringe to draw up and administer the glucagon solution
      • Use the following table for a dose
      Age (years) units on an insulin syringe
      < 2 2
      2-15 1 per year of age
      >15 15
      • When drawing up the Glucagon, remove all the air bubbles from the syringe and administer as you would an insulin injection
      • BGL rechecked in 30 min. If BGL < 5.5 mmol/L but unable to drink fluids, give double the dose of glucagon previously given, e.g. if 2 units given then give 4 units.
      • Re check the BGL in another 30 min.
      • Glucagon rescue can be given a 3rd time if the BGL remains below 5.5mmol/L.  3rd dose is the same amount as the 2nd dose.
      • Continue to offer child small amounts of fluid and food, refer to sick day management in manual.
      • BGL hourly if maintained BGL > 5.5mmol/L
      • After glucagon has been reconstituted keep in refrigerator for 24 hours then discard (replace supply immediately with script from your GP)

      Please call the RCH if:

      • Your child vomits 3 times
      • Your child has BGL < 5.5 mmol/L after 3 doses of Glucagon or
      • you are unsure what to do
        • The RCH switchboard 9345 5522

    Sport and activity

    Sport and activity

    Keeping active is an important part of your diabetes management. Having diabetes shouldn’t stop you from performing sports at your best! National guidelines encourage children to participate in physical activity for at least 60 minutes on most days of the week. This can be smaller sessions added together e.g. 30mins of walking plus a 30min tennis lesson.

    Limiting your time in front of a screen (e.g. TV, computer, iPad, mobile) to less than two hours a day and walking to school are easy ways to increase your daily activity levels.

    Regular activity can help you to:
    • Feel good
    • Have a healthy heart
    • Give you more energy
    • Keep your body in good shape
    • Improve the action of insulin

    Exercise can affect blood glucose levels and insulin requirements. Everyone is individual and the response to exercise can vary from person to person.

    How does exercise affect blood glucose levels?

    In general, exercise lowers your blood glucose levels (BGLs). This is because your body uses glucose as an energy fuel. Sometimes BGLs can rise just before or during an activity due to the release of a hormone called adrenaline. This is usually short lived, with BGLs returning to target range without requiring extra insulin. If your BGLs are above 15mmol/L and you have ketones then activity should be postponed. Exercising when your BGLs are this high could further raise your levels and increase your ketone production.

    Management of your diabetes during exercise will depend on the type, duration and intensity of exercise.

    To get a better understanding of your blood glucose response during exercise, it is important to keep a record of your blood glucose levels and types of exercise performed.  This includes testing before, during and after exercise. It is important to aim for target blood glucose levels (4-8 mmol/L) to maximise performance during exercise. Hyperglycaemia before exercise can impact on your performance during exercise.

    Recommendations

    Additional carbohydrate “activity food” should be used for sport/exercise.

    Insulin doses may also need to be adjusted because of increased insulin sensitivity from the muscles used during exercise.  Your diabetes nurse educator and dietitian will help you work out carbohydrate intake and/or insulin dose adjustment when planning exercise. 

    Injecting in the lower tummy/abdomen or hips is preferable prior to exercise.

    A general guide for managing exercise

    As a general rule for every 30-45mins of moderate to intensive physical activity you need to consume one extra serve of carbohydrate (approximately 15-20grams), preferably low GI. This is just a starting point, the amount of carbohydrate you require may differ depending on your level of fitness and the type/length of activity you are doing.

    Examples of 1 carb serve activity snacks;

    • 1 piece of fruit
    • 200g tub of yoghurt
    • Glass of milk
    • 2 plain sweet biscuits
    • 1 slice of bread with spread
    • 4-6 crackers
    • 125mls of Juice
    • 1 Muesli bar

    It is usually best to have the extra carbohydrate 30mins before exercising. This is in addition to the carbohydrate you usually have. 

    You do not need extra carbohydrate during recess and lunch breaks at school (even if you are very active). Your daily insulin doses and carbohydrate serves are based on your usual activity levels.

    If you are doing long periods of high intensity activity then you might need to have extra fast acting (high GI) carbohydrate during the activity e.g. sports drink or juice. Your diabetes team can advise you on this.

    When swimming, have one extra serve of ‘fast acting’ carbohydrate just before starting (e.g. 5 jelly beans or 125ml glass of lemonade or juice) and for every 30mins you are in the water. This is to ensure BGLs stay above 4mmol/L as hypoglycaemia can be harder to detect in the water.

    Delayed hypoglycaemia

    Delayed hypo’s can occur, often up to 12-16hours after being active. This is because your muscles continue to use glucose during recovery and your body is more sensitive to insulin after exercise.

    Testing BGL’s prior to bed and overnight is necessary after prolonged exercise. If you are experiencing regular hypoglycaemia during or after activity then a reduction in insulin might be necessary.

    Importance of monitoring!

    Exercise affects everyone differently. Monitor your BGLs carefully to look for patterns and learn how your body responds to different sports. Testing your BGLs before activity is important and can give you an idea as to which direction your BGLs are heading and how much extra carbohydrate you require.

    Guide to extra carbohydrate before and during exercise

    Exercise Blood glucose level before Extra carbohydrate (1serve = approx 15g carbohydrate)
    All activities Less than 4mmol/L Treat hypo and delay exercise until feeling better or BGLs >4mmol/L
    Short duration (less than 30 minutes) or Low intensity exercise (e.g. walking, general play) Less than 7mmol/L, More than 7mmol/L 1 serve before. No extra necessary
    Moderate to High intensity exercises (e.g. basketball, netball, running)

    If BGL is less than 12mmol/L

    Above 12mmol/l

    1 serve before, followed by 1 serve every 30-45 minutes of exercise

    May not need a carbohydrate serve prior to exercise however may require 1 serve after 30-45 minutes during exercise to maintain normal BGL’s

    Exercise should be avoided if ketones are above 1mmol/L on injections or 0.6mmol/L on insulin pump therapy. Less carbohydrate may be needed if insulin has been reduced before the activity.

    Driving

    Printable version

    Driving with diabetes

    Before getting your learners or probationary license your Diabetes specialist will need to declare you ready to drive.  

     It is your responsibility to undertake certain measures prior to every trip you drive in order to ensure you are safe before getting behind the wheel – this is for your own well being and that of others on the road.

    As with everyone with Type 1 or insulin treated diabetes, obtaining and ongoing renewal of your drivers’ license will be conditional on achieving and maintaining certain standards of self-care and wellbeing. Certification of being medically fit to drive must therefore be provided by your treating diabetes doctor at the time of your first licence application and 2-yearly thereafter.  It is your responsibility to ensure that this is done in a timely manner.

    Necessary requirements before obtaining license

    • You must notify VicRoads that you have type 1 diabetes – they will provide you with a medical form that your doctor must complete. Vic Roads reporting a medical condition or driver
    • Notify your motor vehicle insurance company that you have Type 1 diabetes
    • You must not have had a severe hypoglycaemic episode in the preceding 6 weeks
    • You must show evidence to your doctor through your glucometer that you’re already regularly checking your BGL as is the requirement before and during a drive.
      PLEASE NOTE: Interstitial (fatty tissue) glucose sensing such as CGM is not adequate for driving safety requirements at this point in time

    Necessary precautions that you must undertake before every drive

    • Check blood glucose before each trip 
    • Do not drive if BGL is less than 5mmol
    • Take your meter, hypo treatment and long acting carbohydrate with you, even on short or learner drives
    • Check your blood glucose level at least every 2 hours. At the RCH we recommend hourly BGL testing. On longer trips plan regular stops for BGL testing and snacks
    • If your BGL is between 4-5mmol/L, have a sustaining carbohydrate serve
    • If you have a hypo while driving pull over the car and turn engine off. Do not drive until your BGL returns to 4mmol/L or above
    • Do not delay or miss any main meals
    • We also recommend that you wear a medic alert or similar identification bracelet or that states your name and your condition.

    Non-driving period after a ‘severe hypoglycaemic event’

    If a severe hypoglycaemic event occurs the person should not drive for a significant period of time and will need to be urgently assessed. The minimum period of time before returning to drive is generally six weeks because it often takes many weeks for patterns of glucose control and behaviour to be re-established and for any temporary ‘reduced awareness of hypoglycaemia’ to resolve (see below). The non-driving period will depend on factors such as identifying the reason for the episode, the specialist’s opinion and the type of motor vehicle licence. The specialist’s recommendation for return to driving should be based on patient behaviour and objective measures of glycaemic control (documented blood glucose) over a reasonable time interval.

    Reduced awareness of hypoglycaemia

    Reduced awareness of hypoglycaemia exists when a person does not regularly sense the usual early warning symptoms of mild hypoglycaemia such as sweating, tremulousness, hunger, tingling around the mouth, palpitations and headache. It markedly increases the risk of a severe hypoglycaemic event occurring and is therefore a risk for road safety. A person with persistent reduced hypoglycaemia should speak with their treating endocrinologist for assessing if they are fit to drive.

    This information has been adapted from Assessing Fitness to Drive, a joint publication of Austroads and the National Transport Commission (NTC), which details the medical standards for driver licensing for use by health professionals and driver licensing authorities. For more information or to download the full document please visit Austroads

    Below are links to the Vic Roads website for more information on driving with diabetes and reporting your medical condition to Vic Roads

    For more information on driving with diabetes please visit Diabetes Victoria

    School

    Action and management plans

    Request a school plan by an RCH diabetes nurse educator.

    The Department of Education and Training (Victoria) require the Diabetes Victoria Diabetes Action and Management Plans (found at the link below) be used in all early childhood education and care services, primary and secondary schools in the government, Catholic and Independent sectors in Victoria.  These action and management plans are based on current best practice evidence for diabetes care for young people with type 1 diabetes.

    Please click on the link below to be taken to Diabetes Victoria website where you will find all action and management plans in PDF to be printed and completed by your diabetes nurse educator.

    School and management plans

    Diabetes Victoria teachers seminars

    Seminars are run each month by Diabetes Victoria to offer teachers and school support staff the opportunity to expand their knowledge and become more confident in supporting and facilitating the day to day school experience on children with type 1 diabetes. Sessions will include information about diabetes and diabetes management and practical workshops covering a variety of specialised topics in more detail including monitoring, pumps, and camps.

    Seminars are run in Melbourne and Geelong as well as across regional Victoria.

    For more information please click on the link below

    Diabetes Victoria workshops

    Further Information for schools

    Most schools are very supportive of children with special needs, however communicating clearly with the school and your child’s teacher is vital. The following PDF documents have been developed to assist you in giving your child’s teacher the information they will need to keep your child happy and well. Being aware of some of the common misconceptions about diabetes and problems that may occur at school can guide you in what to discuss.

    A note for parents

    Duty of care

    Camp activity

    School camps

    Every child who attends school will attend a school camp at some point. A camp plan is required to provide diabetes information to the child’s care givers whilst they are on camp. Most children will also require a reduction in insulin for camp.

    If the camp is more than 30 minutes from an emergency service we recommend that an adult attending knows how, and is willing, to give Glucagon. We also recommend overnight BGL testing at 2am.

    We require two weeks notice to put together a camp plan. We need the following information:

    • Child’s name and date of birth
    • Dates of the camp
    • Type of insulin regimen
    • Current insulin doses

    Please email diabetes@rch.org.au with the above information

    Diabetes camps

    Diabetes Camp are a separate camp for children/adolescents with Type 1 Diabetes. They are coordinated by the consortium of the RCH, Monash Children’s and Diabetes Victoria. For more information please use the following link

    Diabetes Victoria Camps

    Flights and holidays

    Travelling and holidays should not be restricted because your child has diabetes. However, you will need to make sure that you have planned ahead to ensure your time away is safe and enjoyable.

    Domestic travel

    • A domestic travel letter for the airlines is required – please contact diabetes@rch.org.au to request this letter
    • Take twice as many supplies as you would normally use in the same time frame
    • Carry insulin, syringes/needles and other diabetes supplies (including hypo food/drink) on board with you, divided in two separate bags in case one is lost. Don’t pack any supplies in your checked in luggage in the cargo hold as they may be exposed to extreme temperatures or get lost at the airport
    • Consider comprehensive travel insurance

    International travel

    • An international travel letter for the airlines is required – please contact diabetes@rch.org.au to request this letter
    • A timing of insulin injection plan is required when the time difference at your destination is more than 3 hours. We require 4 weeks notice to put together a flight plan and require the following information:
      - Child’s name and date of birth
      - Flight itinerary (including time and length of flights)
      - Type of insulin
      - Current insulin doses
    • For those on an insulin pump, change the pump time once you reach your destination. Carry back-up injectable insulin and consider taking either long-acting insulin or a replacement pump. Replacement pumps can be obtained by contacting your pump company, not through the RCH.
    • Take twice as many supplies as you would normally use in the same time frame
    • Carry insulin, syringes/needles and other diabetes supplies (including hypo food/drink) on board with you, divided in two separate bags in case one is lost. Don’t pack any supplies in your checked in luggage in the cargo hold as they may be exposed to extreme temperatures or get lost at the airport
    • Consider comprehensive travel insurance
    • Useful websites:
      Diabetes Australia travel advice
      International Association for medical assistance to travellers
      International society of travel medicine
      Medicare (Australians overseas)
      National Diabetes Services Scheme
      Smart Traveller(Department of Foreign Affairs and Trade)

    Flying with an Insulin Pump

    • Date/Time in pump: Keep your pump on local time until you reach your final destination. When you arrive, change the pump time to match local time.
    • Pump settings and reports: Ensure you have a current download report from either system i.e Medtronic Carelink Settings report (page 5) or Diasend Settings report (under Insulin tab). If using a Medtronic 640/670G and sensing, it will need to be put into ‘flight mode’.
    • Check for air bubbles in pump line when ascending and descending during the flight. If there are air bubbles disconnect and prime them out before reconnecting. Alternatively, you can disconnect and suspend the pump while the plane is ascending and descending, and check the
    • Pump Failure: In the event of pump failure, you will need revert to injected insulin. 
      Inject Novorapid / Humalog via pen or syringe every 4 hours until you can resite or reconnect the pump.
      Give Total Daily Dose (TDD) divided by 6 (TDD÷6) every 4 hours + 2-3 serves of carbs.
      If you need further clinical advice please refer to the Sick Day Management section of this website
      Contact your pump company regarding a replacement pump.
    • Line/site failure with blood ketones: Hyperglycaemia, blood glucose levels persisting ≥15.0mmol/L despite 2 corrections or blood ketones ≥ 0.6 mmol/L requires pen insulin and a cannula resite.
      Inject TDD ÷ 6 as Novorapid / Humalog via pen/syringe, and resite.
      Until you cann resite the pump you will have to continue to give these injections every 4 hours
    • Pump Supplies: Take your usual blood glucose and ketone testing strips and equipment, hypo food and pump supplies. Other equipment will include extra Novorapid / Humalog in case of pump failure. Medical equipment and supplies are taken as carry-on luggage, as you may require during in flight. Take double the amount

    Please call the RCH Diabetes Service (urgent only):0061 3 9345 5522 if you need further advice 

    Pump therapy

    Printable version

    What is insulin pump therapy?

    An insulin pump is a small computerised device powered by batteries. It delivers rapid-acting insulin continuously in small amounts into the subcutaneous tissue. The pump is about the size of a deck of cards and is worn by clipping it onto a piece of clothing or worn in a pocket. Insulin is delivered through a thin plastic tubing attached to a syringe in the pump. At the end of the tubing there is a small needle which is used to insert the infusion set under the skin into the fatty tissue and is secured by a waterproof dressing. The needle is then removed leaving a small, hollow, flexible plastic tube, called a cannula. These infusion sets are changed every 2-3 days. The pump can be removed for up to 1.5 hours, to enable you to have a shower, go swimming or participate in contact sport. Insulin pumps are not automatic and not an ‘artificial pancreas’. It must be interacted with to give insulin when needed. Blood glucose levels must be checked 6-8 times a day for pump therapy to be safe and effective. The pump does not monitor blood glucose levels! You can purchase continuous glucose monitoring (CGM) separately to work with your insulin pump.

    How does pump therapy work?

    An insulin pump tries to replicate what normally happens in the body. It can deliver insulin in exact amounts as small as 0.025units per hour. Insulin is delivered in two ways:

    Basal: insulin that is delivered continuously 24 hours a day in the background. The job of the basal insulin is to keep blood glucose levels stable when you aren’t eating food. Basal rates can be programmed to change over the day based on individual needs.

    Bolus: Insulin needs to be given in a larger amount when you are eating or when your BGL is above target. These boluses cannot be pre-programmed into the pump. A pre-meal bolus is given based on the amount of carbohydrates about to be consumed. A correction bolus is given when blood glucose levels are above target to try and bring them back down. The pump is able to calculate the amount of insulin required based on BGL and/or carbohydrate grams being entered by the user. It cannot work independently. It requires the user to enter BGLs and amount of carbohydrate to be consumed.

    All rates and ratios are set by the diabetes team at the commencement of pump therapy based on individual needs. With assistance, families are then taught to adjust their own pump settings when required.

    What are the advantages to pump therapy?

    • Insulin delivery is precise and calculated according to each person’s individual needs. Because of the accuracy of insulin administration, it may be possible to keep blood glucose levels in target range, most of the time.
    • There is a greater flexibility in timing and the type of meals and snacks that can be eaten
    • With accurate settings, quality of life can be improved with greater flexibility in being able to accommodate unpredictable events/activity
    • Allows for more frequent adjustments in insulin dose, enabling a rapid response to changing BGL
    • Diminishes variable absorption rates that occurs with long acting insulin
    • May reduce incidence of hypoglycaemia during the night, post exercise and severe recurrent hypoglycaemia
    • When used properly, pump therapy can be responsible for better diabetes control

    What are the disadvantages to pump therapy?

    • There is a higher risk for DKA as the pump only uses rapid acting insulin. If there is an interruption to insulin delivery, blood sugars will immediately begin to rise and ketones will start developing within a few hours without insulin. Rapid acting insulin pens must be available at all times to inject insulin if required and ketones must be checked if BGLs are higher than 15mmol.
    • Potential for skin infection and irritation around the insertion site is much higher. Infusion sets must be changed every 2-3 days and site rotation is just as important and when you are injecting.
    • Intensive BGL testing is required. Pump users need to do 6-8 BGLs per day to ensure basal and bolus doses are accurate
    • The device needs to be attached all the time with only certain exceptions for showers, swimming and contact sport.
    • Learning how to manage pump therapy successfully can be a steep learning curve. Commencing on a pump requires several education sessions and is a lengthy process to learn all the features to the pump.

    Who would be considered for pump therapy?

    Pump therapy is not for everyone. Discuss your options with your Endocrinologist at your next appointment and clarify with them if insulin pump therapy is suitable for you.

    The following need to be considered before commencing on a pump:

    • The young person needs to be able to show evidence  of more than 4 BGLs per day
    • Ability to self adjust insulin appropriately
    • Ability to self administer injections
    • No injection bother
    • Family members must be supportive and motivated to help with management, and must be included in the all education sessions
    • The young person needs to be motivated to improve control and maintain it
    • An interest in learning about carbohydrate counting 

    What are the financial cost involved?

    The pump devices are approx $9,500.  Private health insurance should cover this cost.  This should be confirmed with your health fund before considering insulin pump therapy. Confirmation in writing is preferred.  If you intend to join a private health

    The other costs involved in pump therapy are the consumables; the line, cannula and insulin reservoir/cartridge.  Most consumables are covered by NDSS.  The costs of consumables are approximately $30.00 per month.

    Who are the insulin pump manufacturers?

    CSII pic

    There are two insulin pumps that we recommend for children and young people.  Both are comparable in their features and functions.

    For more information refer to the Medtronic and AMSL Diabetes (Animas) web sites.

    We would like our child to commence on pump therapy, what is the next step?

    The first step is to speak with your Endocrinologist at your next appointment. If you meet the criteria for pump therapy, your doctor will write you a referral to the Diabetes Allied Health team for a pump information session. This appointment will take place with a diabetes nurse educator and one other family.

    If you decide that pump therapy will suit your family you will be allocated a series of appointments for your ‘pump start’. The current waitlist from the time of your information session is 6-9 months. The appointments following your information session include:

    1. Choosing your pump (approx. 3hrs)
    2. Receiving your pump and learning how it works (approx. 3hrs)
    3. Pump start (two full days)
    4. Pump start review (approx. 2hrs)
    5. Pump start follow up (6 weeks from pump start)

    These clinics are run on set days and may be with one or two other families

    We are interested in pump therapy for my child however we can't afford private health insurance. Is there another option?

    The Australian Government's Insulin Pump Program provides subsidies to very low income families who have children with type 1 diabetes. The Program aims to improve access and and affordability of insulin pumps for limited income families who have children (up to 18 years of age) with type 1 diabetes, and do not have access to other means of reimbursement, such as private health insurance. Since its inception in 2008, the Program has provided over 800 subsidised pumps to children with type 1 diabetes. For more information on whether you meet the criteria to have a pump funded for your child, please visit the JDRF website

    Where should I direct any additional questions?

    If you have any further questions please speak with your Endocrinologist at your next appointment or contact the Diabetes office on 9345 6661 

    CGM - Continuous Glucose Monitoring

    Printable version

    CGM - Continuous Glucose Monitoring

    There is currently a lot of attention and marketing activity around the use of CGM (continuous glucose monitoring) in diabetes management. There are currently two systems available in Australia- the Medtronic iPro and the Animas Dexcom. Abbott has also released the FreeStyle Libre systems which is not a CGM but has some similar benefits. click here). Please note that this device is currently used in Europe for children, but is not TGA approved in Australia for use in children under the age 18 years. We are hopeful that this may change in the future.

    What is CGM?

    CGM is a small button like device that sits against the skin and records subcutaneous tissue (not blood!) glucose. Tissue glucose levels and blood glucose levels are not always the same. When you use the current CGM devices under optimal conditions the CGM glucose is usually within a 10-13%

    Both the Animas Dexcom and the Medtronic iPro systems require calibrating. This is done by fingerpricks and testing blood glucose on a meter as you have always done. The amount of times that this needs to be done can vary between 2-4 BGLs per day depending on the system that you are using.

    Tissue glucose readings are taken by the CGM every 10 seconds and averaged out over 5 minutes. It is the 5 minutely average reading that is recorded and displayed

    CGM sensors vary in terms of how long they last. Under ideal conditions they will last between 5-13 days depending on the brand. Some people find that electrodes can last longer than this, though the accuracy of the sensors is not guaranteed by the manufacturers once the sensor is used beyond

    Tissue glucose levels that have been measured by the CGM can be seen in ‘real-time’ either on a purchased receiver, a mobile phone or on an insulin pump depending upon the specific device. Displays include the current glucose level and a graph of previous glucose levels over several hours

    For more information on both the Medtronic iPro and the Animas Dexcom CGM systems, please refer to the  Medtronic and  AMSL Diabetes (Animas) web sites.

    Will CGM improve my diabetes control?

    The short answer is yes, no and maybe.

    CGM devices have become much more accurate over recent years and they measure tissue glucose extremely well. But does this translate to better diabetes control?

    Studies performed on CGMs have shown a variety of results. These range from no benefit to only a small benefit in reducing a patients HbA1c, reducing hypoglycaemia and improving quality of life. Individuals anecdotally report a variety of responses in relation to wearability, comfort

    One of the reasons behind these conflicting results is because people use CGMs for a variety of situations. Some patients use CGM with injections, some use it with insulin pumps and others use it linked to the pump where it has limited control over the delivery of insulin in certain

    Studies show that the amount of time the CGM is in use is critical. To gain any benefit in reducing HbA1c, CGM devices need to be used more than 70-80% of the time (i.e. > 5 days per week). Research suggests that for a variety of reasons most adolescents are unwilling to wear CGM more

    The motivation of the user has shown to also significantly affect the benefits of wearing a CGM. If the aim is simply to avoid hypoglycaemia and not to improve metabolic control then HbA1c levels may worsen.

    Finally, for some, CGM provides too much information. Adolescents in particular and some parents find the constant feedback from CGM overwhelming, causing them to switch off and ignore readouts and alarms, particularly if the CGM readings give false-alarms.

    It is important to understand that regardless of how the insulin is delivered, it is difficult to respond to CGM in real time by varying your insulin doses. Once insulin has been injected it cannot be removed. Rapid-acting insulin that has been delivered under the skin will take an hour

    Research is currently underway into CGM as part of a “closed loop” systems. This will predict where a blood glucose level is heading and inform a pump ahead of time about how much insulin to deliver. Being able to change insulin delivery ahead of time rather than in real time is what most clinicians think

    What should I do?

    Currently it appears that the benefits of CGM depend heavily on the needs of an individual patients and family and their particular situation. Depending on your needs and situation, CGM may or may not be of benefit to you. Given the significant financial commitment that CGM requires

    Federal Government Subsidy For Continuous Glucose Monitoring - UPDATED  12/4/17

    On April 1 the Federal Government announced that continuous glucose monitoring (CGM) would be fully subsidised for many children and young adults up to 21 years of age ( Press Release). There is specific criteria for the subsidy to apply ( Criteria), however we anticipate that many of our patients will be eligible.

    The RCH has received a lot of interest in CGM from our families. This interest has ranged from families confident in the device they would like to use for their child as well as families who are looking for more information about CGM and the device that would most suit their needs. We currently do not have the resources to put all families onto the device straight away. In order to speed up this process, we have applied for more funding to employ a Credentialed Diabetes Educator to run this program. Getting the funding to employ this nurse may take some time but we hope it will only be a matter of a few weeks. In the interim, we will be using the resources which we have available to start a CGM clinic, however we ask for your continued patience and understanding whilst we work through an extensive list. 

    All families who have registered interest (with or without the forms) have been placed on a CGM start list. We will notify you  regarding the signing of the form and the date of your CGM start. If you are unsure if a CGM is right for your family, please read the information we have provided on our website and discuss with your treating doctor at your next outpatient appointment. If you would like to be added to this list to commence on a CGM, please email diabetes@rch.org.au with the relevant forms completed.

    For further information on whether a CGM is right for you or if you have not yet decided which device you would like to order please refer to the webinar section of this website where you will find webinars regarding CGM from Diabetes Australia. These have been held in recent weeks and are ongoing for the next month. The RCH also has an upcoming webinar on the 10th May which you can register for here.

    Which CGM devices are available on the NDSS subsidy?

    Dexcom G4 Platinum

    Dexcom G5 Mobile

    Medtronic Guardian Connect

    Medtronic MiniLink

    Medtronic Guardian Link 2

    To assist all parties we suggest that you familiarise yourself with the eligibility criteria via the link below. Please note that this link includes access to an application form you will need to complete.

    https://www.ndss.com.au/cgm

    NB- YOU MUST be registered with the NDSS to access the CGM program.

    Video resources

    Continuous Glucose Monitoring. presented by Professor Fergus Cameron and Rebecca Gebert

    Webinar recorded 10th May and was presented by Professor Fergus Cameron (Endocrinologist) and Rebecca Gebert (Diabetes Nurse Educator)

    In this webinar we will introduce you to the world Continuous Blood Glucose monitoring. What is CGM? Will it improve diabetes management? Is it all it's cracked up to be?

    Why Sensor Glucose (SG) and Blood Glucose (BG) wont always Match

    Blood Glucose (BG) and Sensor Glucose (SG) - What is The Difference