DOI: 10.1111/pedi.

12767

ISPAD CLINICAL PRACTICE CONSENSUS GUIDELINES

ISPAD Clinical Practice Consensus Guidelines 2018: Limited

Care Guidance Appendix

Ethel Codner | Carlo L. Acerini | Maria E. Craig | Sabine E. Hofer |

David M. Maahs

D E F I N I TI O N , E P I DE M I O LO GY , A N D • Diabetes-associated autoantibodies: glutamic acid decarboxylase

C LA S S I F I C A TI O N O F D I A B ET E S I N CH I L D R E N 65 autoantibodies (GAD); Tyrosine phosphatase-like insulinoma
AND ADOLESCENTS antigen 2 (IA2); insulin autoantibodies (IAA), and β-cell-specific zinc
transporter 8 autoantibodies (ZnT8). The presence of one of more
Whenever possible, follow the guidance described in the full chapter for of these antibodies confirms the diagnosis of type 1 diabetes.
recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 7–19). • Molecular genetic testing can help define the diagnosis and treat-
ment of children with suspected monogenic diabetes and should be
• Diagnostic criteria for all types of diabetes in children and adoles- limited to those who on clinical grounds are likely to be positive.
cents are based on laboratory measurement of plasma glucose
levels (BGL) and the presence or absence of symptoms. If blood
S T A GE S O F T Y P E 1 DI A B E T E S I N C H I L D R E N
glucose testing is unavailable, diabetes can be provisionally diag-
AND ADOLESCENTS
nosed, in the presence of symptoms, by the finding of high levels
of glucose and ketones in the urine.
Whenever possible, follow the guidance described in the full chapter for
• In geographical areas where the known incidence of type 1 diabe-
recommended care (Pediatric Diabetes 2018: 19 (Suppl. 27): 20–27).
tes is low, health care professionals should be aware that there is
a higher rate of diabetic ketoacidosis at presentation due to lack
• Individuals with a first-degree relative with type 1 diabetes have
of consideration of the diagnosis. an approximately 15-fold increased relative risk of type
• The possibility of other types of diabetes should be considered in 1 diabetes.
the child who has: • The majority of children at risk of type 1 diabetes with multiple
○ an autosomal dominant family history of diabetes. islet antibodies progress to diabetes within the next 15 years,
○ age less than 12 months and especially in the first 6 months compared to ~10% who have a single islet antibody.
of life. • Individuals with islet autoimmunity who are followed regularly
○ associated conditions such as deafness, optic atrophy, or syn- until clinical diagnosis present with lower HbA1c and a lower risk
dromic features. of diabetic ketoacidosis.
○ mild fasting hyperglycemia (5.5-8.5 mmol [100-150 mg/dL]), • Health care professionals should be aware that there are no inter-
especially if young, non-obese, and asymptomatic. ventions at present are proven to prevent or delay the onset of
○ marked insulin resistance and acanthosis nigricans. type 1 diabetes.
○ a history of exposure to drugs known to be toxic to beta cells • Diagnostic difficulties that may delay diagnosis include:
or cause insulin resistance. ○ The hyperventilation of ketoacidosis may be misdiagnosed as
○ long interruption of insulin therapy without the occurrence of pneumonia or asthma (cough and breathlessness distinguish
ketoacidosis. these conditions from diabetic ketoacidosis).
• The differentiation between type 1, type 2, monogenic, and other ○ Abdominal pain associated with ketoacidosis may simulate an
forms of diabetes has important implications for both treatment acute abdomen and lead to referral to a surgeon.
and education. Diagnostic tools, which may assist in confirming ○ Polyuria and enuresis may be misdiagnosed as a urinary tract
the diabetes type if the diagnosis is unclear, include: infection.

© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
328 wileyonlinelibrary.com/journal/pedi Pediatric Diabetes October 2018; 19 (Suppl. 27): 328–338.
APPENDICES 329

○ Polydipsia may be thought to be psychogenic. present as a spontaneous case due to a de novo mutation [ie, not
○ Vomiting may be misdiagnosed as gastroenteritis or sepsis. inherited from parents]).
• The child with newly diagnosed type 1 diabetes needs to be cared • Transient neonatal diabetes is usually diagnosed within the first
for in a center with maximal expertise. At diagnosis, insulin treat- week of life and resolves at around 12 weeks of age.
ment may need to be initiated prior to transfer. • Approximately half of neonatal diabetes cases diagnosed during
• Parents and children with type 1 diabetes should be counseled infancy will require lifelong treatment to control hyperglycemia.
that the remission phase of diabetes is transient and does not • Genetic testing should be considered in all children presenting
indicate total remission of diabetes. with diabetes before 6 months of age, as it is available free of
charge and its diagnosis may have major effects on treatment.
• Molecular genetic testing can help define the diagnosis and treat-
T Y P E 2 DI A B E T E S ment of children with suspected monogenic diabetes. As these
tests are expensive, genetic testing should be limited to those
The initial treatment of type 2 diabetes mellitus (T2DM) should be tai- who on clinical grounds are likely to be positive.
lored to the symptoms and severity of the clinical presentation, includ- • HNF1A-MODY is the first diagnostic possibility to be considered
ing assessment for diabetic ketoacidosis (DKA) and its appropriate in familial autosomal dominant diabetes.
care. Metformin is the initial pharmacologic treatment of choice, if • Results of genetic testing should be reported in a clear and unam-
insulin is not required for stabilization. Basal insulin, including neutral biguous way to ensure that both clinicians and patients receive
protamine Hagedorn insulin (NPH), can be used alone or with metfor- adequate and understandable information, since results may have
min when acute decompensation is present or if metformin is either a major effect on clinical management (E).
not tolerated or ineffective. Both metformin and NPH are relatively • Some forms of monogenic diabetes are sensitive to sulphonylur-
inexpensive and widely available. Home glucose testing should be per- eas, such as HNF1A-MODY and HNF-4α MODY and many cases
formed as appropriate to the clinical setting and as resources permit of permanent neonatal diabetes (Kir6.2 mutations).
but is routinely required in youth with T2DM. Healthy lifestyle change • Mild fasting hyperglycemia due to glucokinase deficiency is not
focusing on healthy diet and increased physical activity are a critical usually progressive during childhood but may require insulin dur-
component of treatment for T2DM. Care should be taken to imple- ing pregnancy (where an affected mother has an unaffected fetus
ment culturally appropriate therapeutic lifestyle change. Blood pres- and there is in utero evidence of accelerated growth).
sure should be measured at each visit and other complications, such
as albuminuria, retinopathy, dyslipidemia, non-alcoholic fatty liver dis-
ease (NAFLD), and polycystic ovary syndrome (PCOS) should be CYSTIC FIBROSIS RELATED DIABETES
screened for at diagnosis and annually, when possible. Other general
guidelines for the care of youth with T2DM should also applicable in Whenever possible, follow the guidance described in the full chapter for
areas in which resources and care may be limited. recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 64–74).

When analog insulin is not available, NPH insulin (eg, Humulin N,

D I A G NO S I S A N D M A N A G E M E N T O F Protaphane, Novolin N, Insulatard, Isophane, etc) and regular/soluble
MONOGENIC DIABETES insulin can be used to treat cystic fibrosis related diabetes (CFRD) but
care needs to be taken to avoid late postprandial hypoglycemia. One
Monogenic diabetes is uncommon, accounting for 1% to 6% of pedi-
possible regimen is NPH insulin at bedtime, and regular insulin with
atric diabetes cases. However, the diagnosis should be suspected in
breakfast, lunch and supper, in a patient who is eating three meals and
cases where:
three snacks a day.

• Diabetes presents in the first year of life, especially before age of

6 months. D I A B E T ES E D U C A T I O N
• Absence of ketosis at diagnosis or subsequently during intercur-
rent illnesses. Whenever possible, follow the guidance described in the full chapter for
• Preserved beta-cell function, with low insulin requirements more recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 75–83). Some
than 5 years after diagnosis. particular aspects for countries with limited resources are pointed out below:
• Presence of hearing, visual, or renal impairment. In particular,
mitochondrial diabetes should be suspected in patients with dia- All children and adolescents with diabetes and their caregivers
betes and maternally inherited sensorineural hearing loss. should have access to basic education and practical skills training to
• Mild stable fasting hyperglycemia which does not progress. enable them to survive the onset of diabetes safely and successfully.
• A family history of diabetes in one parent and first-degree rela- Initial learning should be started as soon as possible after diagno-
tives of that affected parent in patients who lack the characteris- sis and should include immediate knowledge-based education and
tics of type 1 diabetes (note that monogenic diabetes may practical survival skills.
330 APPENDICES

This should be followed by graduated levels of education rein- positive messages, support, and advice cannot be overemphasized. In
forced whenever possible by diagrams, drawings, written guidelines, these settings it is imperative to establish, as early as possible, a sys-
booklets, and other visual media appropriate to the child's age, matu- tematic register of patients, demographics, and treatment records.
rity, and environmental circumstances. Such data is vital in defining the problem and needs of this population
Diabetes education must be given by someone with experience to effectively advocate for these patients and their families. Programs
and expertise in pediatric diabetes management. are underway for this very purpose through organizations such as the
Appropriately adapted diabetes education at all ages must be cen- Life for a Child and the Changing Diabetes in Children programs (see
tered on the needs and levels of understanding of both the child and links to these organizations on www.ispad.org). Champions in the
parents/carers. health care arena need to be identified and supported in their advo-
Diabetes education is most effective when based on self- cacy roles.
management and needs to be child and parent-centered. However, Access to health care can be a large challenge for poor children,
peer education will also serve the purpose and can be part of the edu- more so in developing countries. Shortages of providers with diabetes
cation program. Diabetes camps might be useful tools for structured expertise are widespread. For example, in Ethiopia, which is densely
diabetes education. populated, there is only one pediatric endocrinologist for more than
Who should deliver the message: 40 million children.1 In China, there are only 57 pediatric diabetes spe-
The education teams should consist of at least three disciplines. cialists and 47 pediatricians for 100 000 children in urban and rural
These may be a pediatric endocrinologist/diabetologist or a physician areas, respectively. There are no data about the number of pediatric
trained in the care of children and adolescents with diabetes, a diabe- endocrinologists; multidisciplinary pediatric diabetes clinics are avail-
tes specialist nurse/diabetes educator/pediatric nurse, and a dietician. able only in China's leading children's hospitals. Sometimes lack of
However, involvement of a psychologist and a social worker is very awareness means death before diagnosis, or soon after diagnosis.2,3
important if available. Increasing awareness and education among health care personnel can
Since continuing education may not be possible in other setting help. Additionally, families can be put in touch with each other and
like domiciliary and community, the education should take place can offer peer support and education. While there may not be in per-
where educational teams are available. If telemedicine is available this son access to the diabetes care team outlined in the core section,
might be a tool to establish education despite geographical distances health care providers working with children with diabetes and their
between patients and professional teams. families need to provide self-management education and have regular
The topics to be covered at diagnosis and at the continuum of the follow-up. Communication between visits may rely more heavily on
curriculum, should consider this guideline. A questionnaire handed out telephone calls. Community health workers may serve as an extension
to each patient/family might be helpful to make sure all topics were of the specialized diabetes care team, meeting with families and iden-
covered. This can be useful since there are always changes of care- tifying areas that require attention outside of in-person follow-up.
takers and scheduled visits. More than half of the world's population is poor or extremely
In case of hospital admissions occur, all of them should be poor, and in large parts of the world, medical care is predominantly an
reported and documented whether the admission was due to out-of-pocket expense. Diabetes is an expensive condition to manage,
diabetes-related problems or not. Recurrent admission due to and cost of diabetes care may be prohibitive without external support,
diabetes-related problems may need repetition of diabetes education. for example, government support or health insurance. For example, in
Although carbohydrate counting might be difficult in some areas a study of factors associated with DKA in Ethiopia where the median
we would recommend distinguishing between carbohydrate contain- monthly income was $37, the cost of insulin ($6/vial), blood glucose
ing food and other foods. Concerning the management of hypoglyce- testing ($2/test), and HbA1c measurement ($13) created great hard-
mia, we would recommend Nutrition education and how foods effect ship 3. The treatment prescribed from the onset should be appropriate

glucose control (see chapter Nutritional Management). for the family's economic and educational status. Where costs are
borne by the family, options to reduce costs should be explored, for
example, conventional rather than analog insulins; syringes rather than
D E LI V E R Y O F A M B U LA T O R Y C A R E pen devices; careful reuse of syringes and lancets; meters with inex-
pensive strips; families forming groups to enable bulk purchase of dia-
Whenever possible, follow the guidance described in the full chapter for betes care supplies, obtaining supplies from donor organizations, etc.
recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 84–104). Availability of insulin and diabetes supplies, such as insulin syrin-
ges, glucose meters, and glucose and ketone test strips, may be quite
Great disparities exist in the level of pediatric diabetes care avail- limited, particularly in remote areas. If the family does travel to urban
able to children, resulting from a wide range of factors across the centers for consultation, they can be encouraged to obtain enough
world, from huge imbalances of geographic, economic, and scientific quantities of insulin and supplies in the city. It is possible that the indi-
development to gender discrimination. Limited access to insulin, food vidual family may take greater care with transporting and storing insu-
and supplies, limited access to care, financial burdens, psychosocial lin at the correct temperatures than vendors for whom this is a niche
instability, and detrimental health beliefs can all contribute to subopti- product with very little profit.
mal care of children with diabetes across the world. For all children It is also important to address practical issues around home diabe-
with diabetes, the importance of providing a good start with clear, tes management. Safe disposal of “sharps” (needles, syringes, lancets)
APPENDICES 331

must consider local conditions. If nothing else is available, parents can circumstances, support groups can play a significant role in improving care
be asked to collect all sharps in a thick-walled metal or plastic con- and even survival. Parents getting even minimal financial support and see-
tainer (eg, shampoo bottle) and bring them on each visit to the clinic ing older well-controlled patients who are successfully educated, working,
for safe disposal.4 Insulin cannot be exposed to extreme temperatures, married, etc. are motivated to look after their own child better.
as described in the main chapter. On the positive side, many developing countries have robust fam-
Food can be in scarce supply, and not all children have food on a ily structures. Support may come from the extended family or commu-
daily basis. It is in such situations that multidose modified basal bolus nity. Compliance may actually be better because of social conditioning
regimens are very useful. The child can take small doses of NPH insu- to follow instructions, and provision of free or subsidized diabetes
lin once or twice a day, and regular insulin only when food is eaten, care supplies. Availability of “junk foods” may be limited and physical
the dose depending on the amount of food available. Diet in families activity levels may be higher. Establishing a trusting relationship with
with low socioeconomic status may be high in fats, trans-fats, salt, good communication should allow for identification of the child's and
and processed (low fiber) carbohydrates. Parents are encouraged to family's resources and challenges, so that they can be successful in
use whole grains, for example, partly polished rather than white rice, managing their diabetes.
home baked bread rather than bread bought from the market, low fat
milk and milk products (usually less expensive than full fat), salads
instead of oily cooked vegetables, fresh fruit and roasted rather than A SSE SS M E NT A ND M O NI T O RI NG OF
deep fried snacks; such foods are often less attractive than heavily G L Y C E M I C C O N T R O L I N C H I L DR E N ,
advertised sweetened (or diet) drinks and crisps. Intensive education ADOLESCENTS, AND YOUNG ADULTS WITH
and innovation may be necessary to address such situations. DIABETES
International programs such as Life for a Child, Changing Diabetes
in Children (CDiC) and Insulin for Life can alleviate resource shortages Whenever possible, follow the guidance described in the full chapter for

to a limited extent, and stability and consistency of providing these recommended care (Pediatric Diabetes 2018: 19 (Suppl. 27): 105–114).

resources is essential. It may be more feasible and sustainable to moti- In situations where care is limited by a lack of resources, including

vate local governments and charitable organizations to help, with insulin, equipment for self-monitored blood glucose, and HbA1c mea-
greater awareness of the problem. In Bangladesh, it has been shown surements, targets for assessing and monitoring glycemic control in
that public health measures can make a big difference in diabetes care. children with diabetes may need to be adjusted.
Unfortunately, low costs options are often ignored by health care pro-
viders, corporations, and government. • Every effort should be made to continually improve approaches
Diabetes education typically uses written materials and numerical to optimize quality of care.
insulin dose calculations. When children and their caregiver(s) have lim- • Glucose monitoring is very expensive. We recognize that in many
ited literacy and numeracy, different approaches are needed. For exam- countries the cost of these assessments relative to the cost of liv-
ple, the majority of Ethiopians have little or no education and females ing may make this technology unavailable.
are less educated than males.5 Females are usually the ones who are giv- • All centers caring for young people with diabetes should urge nations,
ing diabetes care, and because females are less educated this will have a states, and health care providers to ensure that children and adoles-
negative impact on the care provided. Even relatively simple tasks such cents with diabetes have adequate glucose monitoring supplies.
as reading and recording blood glucose values and insulin doses may be • Testing 3 to 4 times a day several days a week provides more
difficult. Pictorial educational materials and simple instructions are essen- information than a single daily measurement.
tial for illiterate families. Innovative measures can be used, such as teach- • The creative use of self-monitored blood glucoses (BGs) to provide a
ing the mother or child to draw the numbers because they cannot write profile of glucose over a typical day or days will help to adjust doses
them, providing premarked syringes (wrapped with colored tape to mark of insulin; for example, BG checking before and after a standard
the dose), and using color coding to designate doses of insulin based on meal can help to adjust meal-related insulin dose with only two extra
proximity of glucose reading to target range. Somewhat similar is the tests per day. In this fashion, different meals can be assessed over
problem of multiple languages or dialects: educational and instructional different weeks. Intermittently scanned continuous glucose monitor-
materials may not be available in the local language. In these circum- ing (isCGM) devices may also be available at lower cost than tradi-
stances, self-help support groups can be of great value when available. tional meter-based testing and do not require calibration.
Poverty significantly increases vulnerability because it tends to be • Urine glucose monitoring is an alternative where there are cost
associated with illiteracy or poor education, social deprivation, little or no considerations. It provides useful but different information from
job security, and inadequate access to health care or institutional support. self-monitored BG. Urinary glucose reflects glycemic levels over
In many countries families must assume the cost of health care. The the preceding several hours and is affected by the renal threshold
expenses incurred with a chronic disease can push a family further into for glucose, which in children is approximately 10 to 11 mmol/L
poverty. Such families are then also at higher risk for discrimination. These (180-200 mg/dL).
children tend to have poor glycemic control, and therefore higher rates of
acute and chronic complications and mortality. This worsens employabil- Limitations of urine glucose monitoring include.
ity, income, cost of care, and quality of life. In extreme cases, insulin may
be stopped due to financial stresses or gender discrimination. In such • uncertain correlation with BG levels;
332 APPENDICES

• inability to detect hypoglycemia or monitor response to treatment NUTRITIONAL MANAGEMENT

of hypoglycemia;
• less valuable as an educational tool to identify glycemic patterns; Children and adolescents with diabetes should eat a variety of healthy
and unhelpful in hyperglycemic crises because of the lag phase foods, including fruits, vegetables, dairy, wholegrains, legumes, and
between recovery and changes in urine glucose. lean meat in amounts appropriate for age, stage of growth, and energy
requirements.
Target
Growth monitoring is an essential part of diabetes management.
• As many urine tests as possible should show no glycosuria with- Unexpected weight loss or failure to gain weight appropriately may be
out the occurrence of frequent or severe hypoglycemia. a sign of: (1) illness (infections, celiac disease), (2) insulin omission,
(3) an eating disorder, or (4) issues with food security.
Equipment
An experienced pediatric dietitian should be available as part of the
• Glucose oxidase strips that are relatively inexpensive, convenient, diabetes team to provide education at diagnosis and at regular review.
and safe. Nutritional advice should be adapted to cultural, ethnic, and fam-
• Some non-specific reducing agent methods are used such as Clin- ily traditions as well as the cognitive and psychosocial needs of the
itest tablets or Benedict's test. These are less convenient to use individual child. Where possible all relevant family members should be
and are also potentially dangerous if the chemical reagents come involved in education.

into contact with the skin, esophagus, or gastrointestinal tract. Intensive education should be offered on the need to couple the

• Frequency of HbA1c measurement will depend on local facilities preprandial insulin dose with carbohydrate amount. Insulin should be

and availability; however, every child should have an absolute given before the meal. Alternatively, for those on fixed insulin doses, a

minimum of one measurement per year. consistent day-to-day intake of carbohydrate should be consumed to

• Adolescents with stable type 2 diabetes should have at least one match the timing and type of insulin injections. This advice should be

HbA1c measurement per year and symptoms of uncontrolled dia- regularly reviewed to accommodate changes in appetite, food availabil-
ity, and physical activity.
betes reinforced frequently since adolescents generally become
Carbohydrate intake is often >50% energy in limited care settings
insulin-requiring more rapidly than adults.
due to food traditions and the cost of high protein foods. Restriction
of carbohydrate intake <45% of total energy requirement should be

INS U L I N T H E RA P Y avoided as this may impair growth (For further reading please refer to
Nutrition Chapter ISPAD Guidelines 2018).
Whenever possible, follow the guidance described in the full chapter for To enable appropriate matching of carbohydrate intake to the
recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 115–135). insulin profile, carbohydrate may be measured in grams, portions, or
exchanges. A variety of educational tools are available in many coun-
tries to assist health professionals and families understand healthy
• Insulin should be available in sufficient amounts, being consistent
eating concepts, such as the healthy plate model and to enable carbo-
in quality and type.
hydrate quantification.
• Use syringes and vials for insulin administration (or pens, if
Prevention and management of hypoglycemia, particularly during
available).
and after exercise should be discussed.
• The principles of insulin use including professional support, are as
Drinks high in sugar and foods with high amounts of saturated fat
for Recommended care, but a combination of NPH and Regular
should be generally avoided.
insulin may give acceptable blood glucose control.
If financial constraints make food scare or erratic, this is an added bur-
• Regular and NPH insulin may be mixed in the same syringe, given
den that should be discussed openly, and potential solutions identified.
as premixed insulin or given as separate injections.
• A basal bolus regimen with Regular and NPH is preferred to pre-
mixed insulin preparations. NPH insulin should be given twice DIABETIC KETOACIDOSIS AND
daily in most cases, in addition, Regular insulin needs to be given H Y P E R G LY C E M I C H Y P E R S M O L A R S T A T E
2 to 4 times daily to match carbohydrate intake.
• Premixed insulins may be convenient (ie, few injections), but limit Whenever possible, follow the guidance described in the full chapter for
the individual tailoring of the insulin regimen, and can be difficult recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 155–177).
in cases where regular food supply is not available.
• Insulin storage as for Recommended care. 1. Written guidelines should be available for DKA management in
• In hot climates where refrigeration is not available, cooling jars, children.
earthenware pitcher (matka), or a cool wet cloth around the insu- 2. Weigh the child.
lin will help to preserve insulin activity. 3. Immediately infuse 10 mL/kg of 0.9% saline as an initial bolus,
• In children on small doses of insulin, 3 mL cartridges instead of and bolus may need to be repeated until tissue perfusion is ade-
10 mL vials should be chosen for use with syringes to avoid wast- quate. Thereafter, replace fluid deficit over 24 to 48 hours and
age of insulin. provide the maintenance fluid requirement. If unable to obtain
APPENDICES 333

intravenous (IV) access in a severely dehydrated patient, con- BG >11.1 mmol/L (200 mg/dL) can be used to confirm the diag-
sider intraosseous fluid administration. nosis of ketoacidosis and monitor the response to treatment.
4. Subsequent fluid management (deficit replacement) can be
accomplished with 0.45% to 0.9% saline or a balanced salt solu-
tion (Ringer's lactate, Hartmann's solution, or Plasmalyte). The A S S E S S M E N T A N D M A N A G E M E N T OF
sodium content of the fluid should be increased if measured HYPOGLYCEMIA IN CHILDREN AND
serum sodium concentration is low and does not rise appropri- ADOLESCENTS WITH DIABETES
ately as the plasma glucose concentration falls.
5. Potassium: If IV fluids and insulin are available, but potassium is Whenever possible, follow the guidance described in the full chapter for

not available, after 1 hour of fluid therapy, give a dose of insulin recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 178–192).

subcutaneous/intramuscular (IM), 0.1 unit/kg (0.05 unit/kg if

In many regions of the world, there are several issues which make
child is younger than 5 years), and then arrange urgent transport
management of hypoglycemia a daunting process in a child with type
to a facility that can provide potassium. If serum potassium mea-
1 diabetes.
surements are not immediately available, an electrogardiogram
(ECG) may be helpful to determine whether the child has hyper-
kalemia or hypokalemia. Prolongation of the PR interval, T-wave Risk factors
flattening and inversion, ST depression, prominent U waves, A significant risk factor is the lack of a regular or sufficient supply of
apparent long QT interval (due to fusion of the T and U waves) food. A child who has received a prescribed dose of insulin may sud-
indicate hypokalemia. A tall, peaked, and symmetrical T-wave is denly be faced with either no food or a smaller portion which will not
the first sign of hyperkalemia. be commensurate with the amount of insulin given. Many children,
6. Insulin: Do not use IV insulin if BG levels cannot be measured at both with and without diabetes, go to bed hungry, therefore nocturnal
least every 2 hours. In circumstances where continuous IV hypoglycemia is common. For every child with newly diagnosed diabe-
administration of insulin is not possible, give IM short-acting tes, it is mandatory that the child and caregiver are trained in recogniz-
insulin (regular) or rapid-acting insulin analogue (insulin lispro, ing the signs and symptoms of hypoglycemia before leaving the
aspart, or glulisine) 0.1 unit/kg (0.05 unit/kg <5 years) every 1 to hospital. However, due to limited availability of resources, in many
2 hours until tissue perfusion has improved. Thereafter, switch cases, blood glucose monitoring is performed once or twice a day and
to the same dose of SC regular insulin or rapid-acting insulin ana- may not be readily available to the child when symptoms suggestive of
logue every 1 to 2 hours, which may be as effective as infusion hypoglycemia arise. Severe hypoglycemia is therefore likely to occur at
of IV regular insulin in patients with uncomplicated DKA. a much higher incidence than that reported in the literature. There may
7. When BG is <14 mmol/L (250 mg/dL), give glucose-containing also be a cultural stigma regarding diabetes in children which prevents
fluids orally and consider reducing the dose of SC insulin from families advising the school, other family members, or neighbors that
0.1 to 0.05 unit/kg (or from 0.05 to 0.025 unit per kg) at 1- to their child has diabetes. Therefore, when the parent is not with the
2-hour intervals aiming to maintain BG ~11 mmol/L (200 mg/dL) child, hypoglycemia can have severe or even fatal consequence. In
until complete resolution of DKA. many regions of limited care, another cause for hypoglycemia is the use
8. IV fluids: When IV fluids are not available, arrange urgent trans-
of 70/30 premixed insulin which does not allow for flexibility in diet or
port to a facility that can provide IV fluid therapy. Giving insulin
exercise. A lack of awareness of diabetes in children makes it difficult
before starting IV fluid treatment may precipitate shock and
for a child with hypoglycemia to obtain immediate help.
increases the risk of hypokalemia and cerebral edema.
9. Give small sips (or small volumes through a syringe) of oral rehy-
Management
drating solution (ORS) as frequently as possible without causing
the child to vomit. If vomiting does not occur after 1 to 2 hours, Management of hypoglycemia is particularly challenging when there is
give ORS at a rate of 5 mL per kg body weight per hour. limited access to medical care. Glucagon is not readily available, and
10. In some cases, it may be possible to insert a nasogastric tube and the expense may be prohibitive. Empirical treatment is usually given
slowly rehydrate with ORS at 5 mL per kg body weight per hour. due to unavailability of glucose meters and strips to confirm hypogly-
11. If ORS is not available, fruit juice and coconut water provide cemia as well as the urgency to treat. In countries where neither glu-
some potassium. cagon nor glucose gel may be available; a powder form (glucose D
12. Transportation: If the child cannot be transported (eg, roads are 25 or anhydrous glucose) is used. Honey is a good alternative but may
blocked), give oral rehydration as above and IM/SC insulin 0.1 to not be readily available. Another option is products derived from cane
0.05 unit/kg every 1 to 2 hours. Decreasing urine ketone con- sugar to which sucrose may be added. However, if the child is semi/
centrations indicate resolving acidosis. unconscious, sugar or any other powdery substance or thin liquids like
13. Laboratory resources: Hourly BG monitoring may not be avail- a glucose solution or honey should not be given forcibly to the child.
able. Try to measure BG level at least every 4 hours. If analysis The child should be put in a lateral position to prevent aspiration and
of acid-base status is not available, a bedside blood beta- a thick paste of glucose (glucose powder with a few drops of water or
hydroxybutyrate (ketone) value ≥3 mmol/L together with table sugar crushed into powdered sugar with consistency of thick
334 APPENDICES

cake icing) smeared onto the dependent cheek pad; the efficacy of When ketone testing is not available
this practice is anecdotal. In situations where there is a danger of aspi-
It is strongly recommended that some form of ketone monitoring be avail-
ration with no IV access available, parenteral glucose solutions may be
able. However, in some circumstances, no ketone testing may be available
administered via nasogastric tubes. In most cases, 5% glucose in water
or affordable during an intercurrent illness. In these situations, it is critical
or in 0.9% NaCl is available and medical personnel are encouraged to
to emphasize the importance of frequent blood glucose monitoring in
use these infusions. Occasionally only 0.9% NaCl and 50% glucose are
order to avoid progression to DKA and need for hospitalization. It can be
available, and practitioners are encouraged to reconstitute instead of
helpful to provide written recommendations in advance of illness that
giving multiple repeated boluses. Add 100 mL of 50% glucose to
outline how much additional insulin to give for particular blood glucose
900 mL of 0.9% NaCl to make a 5% glucose solution.
levels, based on the child's total daily dose (TDD) or weight. One should
also emphasize that the child should be brought to hospital if hyperglyce-
SICK DAY MANAGEMENT mia persists despite extra insulin and fluids, the child looks ill, or there is
persistent vomiting or rapid breathing, as DKA may be developing.
The diabetes care team should prepare brief and easy-to-understand
handouts in the local language(s) to ensure families have clear guid-
Managing at a temporary facility
ance on how to manage diabetes during intercurrent illnesses and
how to contact the diabetes team when any management problems If a sick child is referred to a temporary facility or primary care center
or questions arise. With widespread availability of mobile phones, without IV access prior to transfer to a full medical facility, slow fluid
families can receive reminders of key messages during seasons of administration can be given carefully through a nasogastric tube until
viral illnesses, with potential to direct messages to those in poor gly- IV access is available. Subcutaneous regular insulin given every
cemic control or a history of DKA. Seasons with extreme tempera- 4 hours has been shown to effectively and safely manage children
tures can also be times of concern. During the summer months, with pH >7.0.6 If blood gas testing is not available, serum bicarbonate
diarrheal illnesses and dehydration are common. As summers concentration can be used in lieu of venous pH as an accurate predic-
become more extreme across the globe, they can be times when gly- tor of the severity of DKA.7
cemic control may deteriorate due to poor storage and transport of
insulin in the heat. Families paying out of pocket may be hesitant to
discard insulin or to increase doses if it has become less effective.
E X E RC I S E
So, families should be reminded to purchase insulin only from reliable
Ideally, the child or adolescent should know his/her blood glucose
sources, to carry a thermos or other cooling device when going to
values before and after participating in physical activity. If blood glu-
purchase insulin and during travel, and to store it properly at home.
cose monitoring is not possible, the advice is to participate in lower
As type 1 diabetes is less common than infections and other dis-
intensity activity at same time every day. All activities should include
eases, it is often a lower priority for health centers and health care
eating a snack, for example, a fruit, biscuits (10-15 g of carbohy-
professionals, who may have inadequate knowledge about diabetes
drates), or a sandwich every 30 minutes during activity.
management. Therefore, the diabetes care team may need to inform
Physical activity should be limited/ avoided if:
families on how to cope with poorly informed health systems. For
example, if the nearest health center provides only primary care, fami-
• There is an acute illness.
lies should be encouraged to carry their sick day instruction handout
• Blood glucose is too low, <5 mmol/L (90 mg/dL) or too high,
with them to share the information with the local nurses and other
>14 mmol/L (252 mg/dL) before the activity.
health care workers.
• There is inadequate food for compensation of low blood sugars
Families should also receive instructions on how to use blood glu-
cose strips for frequent monitoring during illnesses, even if such moni- and the duration of activity.

toring is usually not done routinely due to costs. Families should also • Ketones are present at a level >0.6 mmol/L (blood) or presence of

receive guidance to keep urine ketone strips at home and receive edu- urine-ketones which first would require actions with extra insulin

cation on how and when to use them (as limited resources prevent and/or added carbohydrates depending on the reason for the ketosis.

use of the more expensive blood monitoring supplies). Although urine • Patient is dehydrated.

ketone strips are inexpensive, they can deteriorate quickly after being Practical recommendation to the child with diabetes:

opened and especially when exposed to humidity. It may be possible

for groups of families to form networks to “share in the expense” of • Talk with your doctor or diabetes educator before starting any
blood ketone strips, if available, in order to use them at times of ill- new exercise regimen or changing the time of your activity.
ness, and to bring them to the health center in case of emergency. As • Your doctor will let you know about any changes in testing sched-
availability of blood ketone strips may be problematic, diabetes care ule, medication, or other things you might need to pay attention
teams may need to be involved in arranging access to families. The about for exercise and sports.
costs of blood ketone strips are likely greater than the costs of blood • You may need to test more frequently for first few days and
glucose strips and urine strips, but such costs are less than the costs adjust your insulin accordingly. So, make sure you have enough
of transport to hospital and inpatient care. supply of glucose test strips and strips for urine ketones.
APPENDICES 335

• Make sure you are wearing an ID bracelet or similar that says you 8. Blood glucose monitoring should be performed before, during
have diabetes and have an emergency contact number. and immediately after general anesthesia to detect hypo- and
• Avoid taking injections in the part of the body most used in that hyperglycemia. Aim for blood glucose in the range 5 to
sport (like injecting in the thigh right before playing cricket). The 10 mmol/L (90-180 mg/dL) during and for 7.8-10 mmol/L
abdominal site is probably preferable for injection, for absorption (140-180 mg/dL) after surgery.
of insulin during exercise. 9. In absence of blood gases use urine ketone in freshly voided
• Moderate exercise in (enough to make you puff) uses an extra urine and in case of general anesthesia a temporary urinary
10 to 15 g of carbohydrate each hour. Vigorous exercise may use catheter can be used.
2 to 3 times this amount. Do check blood glucose after 10. Where there are no facilities for urea and electrolytes, use clin-
30-60 minutes after moderate-vigorous exercise. The usual signs ical signs of hydration status and urine output and avoid adding
of hypoglycemia are often not easy to discern during exercise. potassium if patient is oliguria. If no glucometer available use
• It is always advised to tell the coaches and playmates about your (fresh) urine glucose to monitor the patient. If no facilities for
diabetes and give them written instructions so that they can IV fluids use oral rehydration solution.
respond to your hyperglycemia on the ground. 11. The usual recommendation is no solid food for at least 6 hours
before surgery. Clear fluids and breast milk may be allowed up

Always carry a bag pack with you having the following: to 4 hours before surgery (check with the anesthetist).
12. Emergency surgery:

• Glucose tablets or similar or a juice box.

a. If ketoacidosis is present, follow an established treatment protocol
• A sandwich or some other healthy snack.
for diabetic ketoacidosis and delay surgery, if possible, until circu-
• Your glucose meter and supplies.
lating volume and electrolyte deficits are corrected.
• A big bottle of water.
b. If there is no ketoacidosis, start IV fluids and insulin management
as for elective surgery.

MANAGEMENT OF CHILDREN WITH

D I A B E T E S R E Q U I R I N G SU RG E R Y
P S Y C H O L O G I C A L C A R E OF C H I L DR E N A N D
Management of children and adolescents with diabetes requiring sur-
A DO LE S C E NT S W I T H TY P E 1 DI A B E T E S
gery in resource limited countries.
Whenever possible, follow the guidance described in the full chapter for
recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 237–249).
1. Whenever possible follow the guidelines described in the full
chapter for recommended care.
The principles and recommendations in the full chapter are largely
2. Children with type 1 diabetes requiring major surgery should be
generic and therefore should apply to all health care settings irrespec-
referred to a center with sufficient resources to provide safe care
tive of the resources available.
(including but not limited to: infusion pumps, insulin analogues,
blood gases, urea and electrolytes, and bedside glucometers).
• Diabetes care for young people should include the recognition of
3. Elective surgery should be scheduled as the first case of the
the potentially serious impact of diabetes on both psychosocial
day, preferably in the morning.
functioning in the child, adolescent, and the family and also the
4. Children with type 1 diabetes requiring surgery need insulin,
adverse effects on metabolic control.
even if fasting, to prevent ketoacidosis. At least half of the
• Professionals caring for young people with diabetes should be
usual basal insulin dose should be given before surgery.
prepared to discuss the psychological difficulties associated with
5. Insulin can be infused using burettes connected to IV fluids bags
diabetes (including depression, acting out, rebellion) and have
and adding 50 to 100 units of regular insulin to 50 to 100 mL of
access to other professionals with more specialist expertise in this
0.9% sodium chloride (1 mL = 1 unit) and given on a separate line
field.
or with a Y-connection, that should be changed every 6 hours.
6. Alternatively, insulin can be given subQ hourly in the same
dose as the infusion. NPH insulin given once or twice can give ADOLESCENCE
a good basal dose.
7. Children undergoing major surgery (expected to last at least Whenever possible, follow the guidance described in the full chapter for
2 hours) or who have received NPH insulin should receive recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 250–261).
dextrose in their IV infusion to prevent hypoglycemia. Chil-
dren undergoing minor surgery or procedures (lasting for The principles and recommendations in the full chapter are
less than 2 hours) may initially receive an IV infusion with- generic and therefore should apply to all health care settings irrespec-
out dextrose if treated with basal/bolus insulin regimen or tive of the resources available. Understanding the physiological and
continuous subcutaneous insulin infusion. psychological changes of adolescence and developing a specific
336 APPENDICES

approach to the communication, education, and support of the adoles- • Specific and simple tests to evaluate diabetic neuropathy include
cent patient and their family, which is sensitivity to their needs, cul- assessment of sensation, vibration, and reflexes in the feet for
tural and religious background, is essential. It is acknowledged that peripheral neuropathy.
many patients and families with diabetes come from a low-income
background and are cared for in health care systems that are signifi- Blood pressure
cantly resource limited. Nevertheless, the approach to managing the
• Blood pressure (BP) should be measured at least annually. angioten-
adolescent with diabetes in terms of developing trusting and motivat-
sin-converting-enzyme inhibitor (ACEI) are recommended for use in
ing relationships with them, encouraging self-reliance and self-effi-
children with diabetes and hypertension, which is defined in chil-
cacy, and engendering the trust and support from their family are
dren as BP equal to or above the 95th percentile for age, sex, and
general ones that should be applicable to all settings.
height, and in adolescents (age ≥13 years) as systolic blood pressure
(SBP) ≥130 and/or diastolic blood pressure (DBP) ≥80 mm Hg.

M I C R O V A S C U L A R A N D M A C RO V A S CU LA R
C OM P L I CA T I ON S I N C H I LD R E N A N D Lipids
ADOLESCENTS
• Screening for dyslipidemia should be performed soon after diag-
nosis (when diabetes stabilized) in all children with type 1 diabetes
Prevention from age 11.

• Intensive education and treatment should be used in children and

adolescents to prevent or delay the onset and progression of vas- Lifestyle
cular complications.
• Prevention or cessation of smoking will reduce progression of
• Screening for complications should be performed preconception
albuminuria and cardiovascular disease.
and each trimester of pregnancy.

Type 2 diabetes
Albuminuria
• Complications screening should commence at diagnosis. Attention
• Screening for albuminuria should start from age 11 years with to risk factors should be escalated because of the increased risk
2 to 5 years diabetes duration using a first morning urine samples of complications and mortality.
for urinary albumin/creatinine ratio (ACR).
• Because of biological variability, two of three urine samples
should be used as evidence of albuminuria. Confounders are exer- O T H E R CO M P L I C A T I O N S A N D D I A B E T E S -
cise, menstrual bleeding, infections, fever, kidney diseases, and
A S S O C I A T E D C O N D I T I O N S I N CH I L D R E N
marked hyperglycemia. Abnormal screening tests should be
AND ADOLESCENTS
repeated, as albuminuria may be transient.
Whenever possible, follow the guidance described in the full chapter for
• Angiotensin converting enzyme inhibitors or angiotensin receptor
recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 275–286).
blockers agents should be used in adolescents with persistent
albuminuria to prevent progression to proteinuria
• Regular monitoring of anthropometric measurements and physical
development, using growth standards, are essential in the contin-
Retinopathy and other ocular conditions uous care of children and adolescents with type 1 diabetes.
• Screening of thyroid function by measurement of thyroid stimu-
• Screening for diabetic retinopathy should start from age 11 years
lating hormone (TSH) and antithyroid peroxidase antibodies is
with 2 to 5 years diabetes duration and should be performed by
recommended at the diagnosis of diabetes and, thereafter, every
an ophthalmologist, optometrist, or a trained experienced second year in asymptomatic individuals. More frequent assess-
observer through dilated pupils via bio-microscopy examination ment may be indicated in the presence of symptoms, goiter or
or fundal photography. positive thyroid autoantibodies.
• A comprehensive initial eye examination should also be consid- • The diagnosis of hypothyroidism is confirmed by demonstrating a
ered to detect cataracts, major refractive errors, or other ocular low free thyroxine (T4) level (or if not available, total T4) and a
disorders. raised TSH concentration.
• Screening for celiac disease should be performed at the time of
diabetes diagnosis, and at 2 and 5 years thereafter, as it is fre-
Neuropathy
quently asymptomatic. More frequent assessment is indicated if
• Screening for peripheral neuropathy should start from age the clinical situation suggests the possibility of celiac disease or
11 years with 2 to 5 years diabetes duration and annually the child has a first-degree relative with celiac disease. Screening
thereafter. for IgA deficiency should be performed at diabetes diagnosis.
APPENDICES 337

• Children with type 1 diabetes detected to have positive celiac management. In the United States, young people of African descent
antibodies on routine screening, should be referred to a pediatric have increased risk of short-term complications (ketoacidosis and severe
gastroenterologist. If small bowel biopsy is not possible in a child hypoglycemia) when adjusted for socioeconomic status, and higher
with positive screening tests, then a trial of a gluten-free diet is HbA1c even when adjusted for mean glucose levels. HbA1c was higher
recommended if celiac disease is suspected. Response should be even when fasting glucose is insulin dosing, and to use self-monitoring
determined from improvement in growth, bowel habit and reduc- of blood glucose (SMBG) at least on sick days if available. With limited
tion in titer of screening antibodies. number of strips, the family can, for example, measure before and
• Upon confirmation of the diagnosis of celiac disease, patients 2 hours after lunch 1 week, and before and after dinner the next to get
should receive educational support from an experienced pediatric a more stringent picture of the day compared with random checks.
dietitian. Educational materials (translated into local language) for Urine strips should be available for ketone monitoring during sick days.
patients and families should be made available. Another issue that may compound the challenge in resource-limited set-
• Diabetes care providers should be alert for the symptoms and signs tings is that some parents may have low levels of literacy and health lit-
of adrenal insufficiency (due to Addison disease) in children and ado- eracy, meaning thereby that they cannot read the numbers on the
lescents with type 1 diabetes although the occurrence is rare.
insulin syringe and on the glucometer. For example, in India, literacy rate
• Routine clinical examination should be undertaken for skin (eg,
is 74.04% according to the 15th official census in 2011 (http://www.
lipodystrophy) and joint changes (eg, limited joint mobility).
census2011.co.in/literacy.php). In such cases, it is helpful to identify a
• Patient education regarding proper injection techniques, rotating
suitably literate relative, friend or neighbor who can undergo diabetes
injection sites with each injection and non-reuse of needles remain
education along with the parents and assist them in the domiciliary man-
the best strategies to prevent lipohypertrophy/lipoatrophy.
agement. The parents should also be encouraged to learn the basics of
• Injection sites should be regularly assessed at each clinic visit for
reading and writing. In the case of low literacy, a simpler insulin regime
lipohypertrophy and lipoatrophy as they are potential causes of
such as twice daily dosing with premixed insulin can be given. Hearing
glucose variability.
the number of clicks from an insulin pen can obviate the need to read
• Screening for vitamin D deficiency, particularly in high risk groups
the number of units. Teaching the parents to recognize “Hi” and “Lo” on
(eg, darker skin pigmentation, covered clothing, celiac disease)
glucometer, to treat hypoglycemia based on symptoms alone, and to
should be considered in young people with type 1 diabetes and
recognize hyperglycemia and ketonuria by urinary strips is also useful to
treated using appropriate guidelines.
prevent life-threatening episodes. Vomiting in a child with diabetes
should always be regarded as imminent ketoacidosis, and appropriate
TODDLERS treatment should be sought immediately in the absence of knowledge
and diagnostic measurements. If the child is not feeling well with other
Whenever possible, the guidelines described above in the preceding symptoms, the first line of treatment should be something containing
sections should be followed. It is important to remember that building a sugar to treat impending hypoglycemia. This should be well known by
good rapport with the family and providing comprehensive diabetes all the older children and adults who are close to the child with diabetes,
education are inexpensive and remain the most effective strategies to and they should know where to readily find a source of sugar. To con-
improve diabetes management by the family. Knowledge about the clude, the goals of management of type 1 diabetes in resource-limited
effects of insulin, food, and physical activity on glucose levels are essen- settings must be situated in the context of the resource-limited environ-
tial to protect the child from acute and chronic complications of diabetes ment and based on the family's educational and financial status. Avoid-
under all circumstances. The first few visits of the family are the most ance of acute life-threatening complications and continuation of regular
crucial in this regard. Initial approach to diagnosis and treatment is based treatment and follow-up are the immediate goals.
upon staffing and facilities at specialized centers for the care of young
children with diabetes, with many centers recommending hospitaliza-
tion. Parents should be counseled and educated in detail. The challenges M A N A G E M E N T A N D SU P P O R T O F C H I LD R E N
in managing type 1 diabetes in the preschool child are several-fold A N D A D O LE S C E N TS WI T H TY P E 1 D I A B ET E S
higher in resource-limited settings. Awareness, health infrastructure, and IN SCHOOL
number of medical professionals trained in the management of child-
hood diabetes are inadequate for a significant proportion of the popula- T1D is both challenging and demanding and, wherever children live
tion in many countries in South East Asia and sub-Saharan Africa. The in the world, sending their child to school is a very anxious and
diagnosis is often delayed, and may even be missed in some cases, daunting time for parents, carers and also for the child with
resulting in death before diagnosis. Common misdiagnoses are gastroen- diabetes.
teritis, pneumonia, asthma, urinary tract infection, genital tract infection In less-resourced settings this can be compounded by other
(candidiasis), enuresis, and malaria. Parents may take longer to come to issues such as lack of insulin and diabetes supplies, food insecurity,
terms with the diagnosis and the need for lifelong insulin therapy. The transport challenges, and even local conflict and war.
financial implications of the condition add to the psychological distress School is a time of learning, making friends, having fun, and find-
brought about by the diagnosis. Risk of acute and chronic complications, ing peer groups. However, for children with diabetes, this can instead
as well as mortality, is higher in these children due to suboptimal be a time when they are excluded or isolated or stigmatized.
338 APPENDICES

As health professionals caring for these vulnerable young people, DIABETES TECHNOLOGY
we must ensure as best we can that they receive the same educa-
tional opportunities as other children in their community, providing Whenever possible, follow the guidance described in the full chapter for
the potential for fruitful employment and the chance for further recommended care (Pediatr Diabetes 2018: 19 (Suppl. 27): 302–325).
education.
Key messages for teachers in less-resourced countries: • In resource limited areas, cell phones may allow patients to utilize
diabetes applications to assist with their care.
• Children with diabetes, wherever they live, should not be limited • Integration of bolus calculators that are available through com-
in what they can do, and should be able to attend school, receive mercial blood glucose meters or accessed on a cell phone may
an education and live happy, fulfilled lives. assist with more precise insulin dosing, which may assist patients
• Most schools are very supportive; however, a child's nurse or doc- in achievement of targeted glycemic control.
tor can visit the school to explain diabetes and its management in • Use of CGM, where available, may serve as a replacement for
a clear and concise manner, or a parent or carer might feel confi- SMBG and provide retrospective data review to allow for more
dent enough to do this themselves with support from the local fine-tuned insulin doses adjustment recommendations.
team. Such visits and contact with the school and the health pro- • Automated decision support systems may help patients optimize
fessional can be extremely encouraging to parents and children. their insulin regimens, regardless of whether the insulin delivery
• A simple individualized management plan for the child with modality is via injection or pump therapy.
diabetes is a good guide for the teacher to follow day-to-day • As provider availability is critical to improve health care accessibil-
at school. This should include step by step instructions for ity, use of telemedicine may allow patients in rural areas to have
management of emergencies and contact details of parents/carers. consultations with subspecialists.
• Many children may be on a twice daily insulin regimen; however, • Local clinicians can also be assisted with management of complex
if they are on multiple daily injections which entails a lunch-time conditions through tele-mentoring through consultation with a
injection at school, a safe, private place is required for them to specialist.
give their injection.
ORCID
• A refrigerator or cool place/container (eg, clay pot) is required for
storage of insulin particularly in hot climates. Ethel Codner http://orcid.org/0000-0002-2899-2705
• Children with diabetes should be allowed to test their BG level as Carlo L. Acerini http://orcid.org/0000-0003-2121-5871
necessary depending on availability of test strips. Maria E. Craig http://orcid.org/0000-0001-6004-576X
• School personnel should be educated on the management of Sabine E. Hofer http://orcid.org/0000-0001-6778-0062
hypoglycaemia, and parents should ensure that appropriate treat- David M. Maahs https://orcid.org/0000-0002-4602-7909
ment and re-treatment is available at the school.
• Emergency assistance should be called if the child is unable to eat
RE FE RE NC ES
or drink to treat the hypoglycemia.
1. Federal Ministry of Health. Health and Health Related Indicators, Addis
• School personnel need to be aware that prior to and during physi-
Ababa, Ethiopia; Federal Ministry of Health; 2011:12.
cal activity the child with diabetes may need to eat or drink to 2. Virmani A, Ushabala P, Rao PV. Diabetes mortality in a tertiary referral
avoid hypoglycemia. hospital in India. Lancet. 1990;335:1341.
3. Bereket F, Etsegenet G. Prevalence of diabetic ketoacidosis in newly
• When blood glucose levels are high (hyperglycemia), children
diagnosed diabetes mellitus pediatrics patients in Tikur Anbessa special-
should be allowed to drink water, and use the toilet as necessary. ized hospital. Ethiopian J Pediatr Child Health. 2008;4:5-8.
• Teachers should be aware that other children may tease the child 4. Virmani A. Safe disposal of used sharp objects. Indian Pediatr. 2008;46:
539-540.
with diabetes. Simple explanation to classmates is encouraged.
5. Ethiopia Demography and Health Survey. Education Attainment. Addis
• Teachers should also understand the classic symptoms of T1D, so Ababa, Ethiopia, and Rockville, Maryland, USA, Central Statistical
they can identify undiagnosed children in the future. It is not at all Agency (CSA); 2016;26–30.
uncommon for T1D to be mistaken for malaria, appendicitis, and 6. Cohen M, Leibovitz N, Shilo S, Zuckerman-Levin N, Shavit I,
Shehadeh N. Subcutaneous regular insulin for the treatment of diabetic
pneumonia in countries with less resources. Posters have been
ketoacidosis in children. Pediatr Diabetes. 2017;18:290-296.
developed in local languages highlighting the symptoms of T1D, 7. von Oettingen J, Wolfsdorf J, Feldman HA, Rhodes ET. Use of serum
and the signs of diabetic ketoacidosis. bicarbonate to substitute for venous pH in new-onset diabetes. Pediat-
rics. 2015;136:e371-e377.

The International Diabetes Federation (IDF) “Life for a Child” ini-

tiative has developed an education website that includes resources
for schools. Also, the IDF “Kids and Diabetes in School” (KiDS) project How to cite this article: Codner E, Acerini CL, Craig ME,
tackles diabetes (including types 1 and 2 diabetes, and healthy food Hofer SE, Maahs DM. ISPAD Clinical Practice Consensus
choices and lifestyle advice) management in school by the develop- Guidelines 2018: Limited Care Guidance Appendix. Pediatr
ment of visual materials, coupled with an education program for Diabetes. 2018;19(Suppl. 27):328–338. https://doi.org/10.
school personnel, parents, and children. This project was successfully 1111/pedi.12767
trialed in Brazil and India and is now available in multiple languages.