BNF for Children 2011-2012

BNFC 2011–2012 6.1.1 Insulins 351Soluble insulin by the intravenous route is reserved forurgent treatment e.g in diabetic ketoacidosis, and forfine control in serious illness and in the peri-operativeperiod (see under Diabetes and Surgery, below).Monitoring All carers and children need to be trainedto monitor blood-glucose concentrations (section 6.1.6).Since blood-glucose concentration varies substantiallythroughout the day, ‘normoglycaemia’ cannot always beachieved throughout a 24-hour period without causingdamaging hypoglycaemia. It is therefore best to recommendthat children should maintain a blood-glucoseconcentration of between 4 and 10 mmol/litre formost of the time (4–8 mmol/litre before meals andless than 10 mmol/litre after meals), while acceptingthat on occasions, for brief periods, it will be above thesevalues; efforts should be made to prevent the bloodglucoseconcentration from falling below 4 mmol/litre.Children using multiple injection regimens shouldunderstand how to adjust their insulin dose accordingto their carbohydrate intake. With fixed-dose insulinregimens, the carbohydrate intake needs to be regulated,and should be distributed throughout the day tomatch the insulin regimen. The intake of energy and ofsimple and complex carbohydrates should be adequateto allow normal growth and development but obesitymust be avoided.Hypoglycaemia Hypoglycaemia is a potential problemfor all children using insulin, and they and theircarers should be given careful instruction on how toavoid it.Very tight control of diabetes lowers the blood-glucoseconcentration needed to trigger hypoglycaemic symptoms;an increase in the frequency of hypoglycaemicepisodes may reduce the warning symptoms experiencedby the child. Loss of warning of hypoglycaemiaamong insulin-treated children can be a serious hazard,especially for cyclists and drivers.To restore the warning signs, episodes of hypoglycaemiamust be minimised; this involves appropriate adjustmentof insulin type, dose, and frequency, togetherwith suitable timing and quantity of meals and snacks.Diabetes and surgery Children with type 1 diabetesshould undergo surgery in centres with facilities for, andexpertise in, the care of children with diabetes. Detailedlocal protocols should be available to all healthcareprofessionals involved in the treatment of these children.Children with type 1 diabetes who require surgery:. should be admitted to hospital for general anaesthesia;. should receive insulin, even if they are fasting, toavoid ketoacidosis;. should receive glucose infusion when fasting beforean anaesthetic to prevent hypoglycaemia;. should have careful monitoring of blood-glucoseconcentration because surgery may cause hyperglycaemia.Elective surgery Surgery in children with diabetes isbest scheduled early on the list, preferably in the morning.If glycaemic control is poor it is advisable to admitthe child well in advance of surgery. On the eveningbefore surgery, blood-glucose should be measured frequently,especially before meals and snacks and at bedtime;urine should be tested for ketones. The usualevening or bedtime insulin and bedtime snack shouldbe given. Ketosis or severe hypoglycaemia require correction,preferably by overnight intravenous infusion(section 6.1.3 and section 6.1.4), and the surgery mayneed to be postponed.For minor procedures that require fasting, a slightmodification of the usual regimen may be all that isnecessary e.g. for early morning procedures delay insulinand food until immediately after the procedure.For other types of elective surgery, consult local treatmentprotocols.Emergency surgery Intravenous fluids and an insulininfusion should be started immediately (see IntravenousFluids and Continuous Insulin Infusion, below). If ketoacidosisis present the recommendations for diabeticketoacidosis should be followed (section 6.1.3).Intravenous fluids and continuous insulin infusionBlood-glucose and plasma-electrolyte concentrationsmust be measured frequently in a child receiving intravenoussupport. Intravenous infusion should be continueduntil after the child starts to eat and drink. Thefollowing infusions should be used and adjusted accordingto the child’s fluid and electrolyte requirements:. Constant infusion of sodium chloride 0.45% andglucose 5% intravenous infusion together withpotassium chloride 20 mmol/litre (provided thatplasma-potassium concentration is not raised) at arate determined by factors such as volume depletionand age; the amount of potassium chlorideinfused is adjusted according to plasma electrolytemeasurements;. Constant infusion of soluble insulin 1 unit/mL insodium chloride 0.9% intravenous infusion initiallyat a rate of 0.025 units/kg/hour (up to 0.05 units/kg/hour if the child is unwell), then adjusted accordingto blood-glucose concentration (frequent monitoringnecessary) in line with locally agreed protocolsand the child’s volume depletion and age;. Blood-glucose concentration should be maintainedbetween 5 and 10 mmol/litre. If the glucose concentrationfalls below 5 mmol/litre, glucose 10 %intravenous infusion may be required; conversely, ifthe glucose concentration persistently exceeds14 mmol/litre, sodium chloride 0.9% intravenousinfusion should be substituted;. The insulin infusion may be stopped temporarily for10–15 minutes if blood-glucose concentration fallsbelow 4 mmol/litre.The usual subcutaneous insulin regimen should bestarted before the first meal (but the dose may need tobe 10–20% higher than usual if the child is still bedboundor unwell) and the intravenous insulin infusionstopped 1 hour later. If glycaemic control is not adequatelyachieved, additional insulin can be given in thefollowing ways:. additional doses of soluble insulin at any of the 4injection times (before meals or bedtime) or. temporary addition of intravenous insulin infusionto subcutaneous regimen or. complete reversion to intravenous insulin infusion(particularly if the child is unwell).Neonatal hyperglycaemia Newborn babies are relativelyintolerant of glucose, especially in the first week of6 Endocrine system