Today's soundtrack is Arvid: Goodnightdaydream., an indie psychadelic pop release that I came across last month in this Reddit thread and added to my Randomizer's album list. Today is the day that the Randomizer has pulled it up. As always, if you want to check out all the music that I've listened to while blogging, check out the "Music I've Blogged To" playlist on Spotify.
This morning, I'm learning about diabetes in an online course. Disclaimer: I'm just writing down my notes; nothing here can be taken as instructive, and I cannot be held responsible for any misinformation due to either errors in source material or my paraphrasing of that material.
This course is for anyone working with children with diabetes in a school or childcare setting
What is diabetes?
A chronic condition where the body can't use the sugar from food for energy
There are two kinds of diabetes:
Type 2
No cure, but can be managed with:
Balanced diet
Exercise
Healthy weight
Monitoring blood sugar
Insulin
Pills that make the body use insulin better (cannot be used for type 1 diabetes)
Type 1
No cure, must be managed
Caused by the pancreas not making insulin
Unless given insulin, people with type 1 diabetes will not survive
The most common type of diabetes in children and teens
1 in 400 children develop type 1 diabetes, and that rate is increasing by 3% per year
Cause of Type 1 diabetes
Probably a combination of three factors:
Auto-immune disorder where the body attacks and destroys insulin-producing cells
Genetic risk - hereditary
Environmental triggers
Managing Type 1 diabetes
Goals for management of type 1 diabetes:
Keep blood sugar in target range with few lows
Child will function at full potential both physically and mentally
Family will support child's adjustment to living with diabetes
Balance the needs of diabetes care with the needs that all growing children have
The child will participate in all the same activities as their peers at school (gym, recess, etc)
Things to remember...
Diabetes care should disrupt the child's day as little as possible
Separation of child from peers should be avoided
Diabetes care at school may be different from diabetes care at home
Steps for managing Type 1 diabetes:
Check blood sugars at least four times a day
Take insulin throughout the day
Balance insulin with food and activity
Be careful of timing with food and exercise
Insulin
What is insulin?
Insulin is a hormone made by the pancreas
People with type 1 diabetes do not produce insulin
When we eat food, part of the digestive process is breaking the food down into sugar so that it can be absorbed into the blood
Insulin carries sugar into our cells to give us energy
We need energy to grow, produce body heat, and use our muscles (even for breathing)
We need insulin to survive!
The role of insulin
Insulin is like a key. It opens the doors of the cells so that we can use that sugar for energy
If we don't have insulin, the sugar in the blood can't get into the body's cells, making it so that we can't use it for energy
Without insulin, the body will starve
Without insulin, sugar will build up in the blood; some of it will be passed via urine
Without insulin, the body will break down fat and muscle for energy, creating strong acids called ketones, and the blood sugar level will be very high.
High blood sugar with the presence of ketones is a sign that insulin is urgently needed.
Carbohydrates
What are carbohydrates?
Carbohydrates are the body's main source of energy
The body turns carbohydrates into sugar
Where can we find carbohydrates?
Fruit
Fruit juices (including unsweetened)
Drinks with added sugar
Milk and yogurt
Starches and grains (pasta, bread, potatoes, corn, and rice)
Candy and desserts
Managing Diabetes: A Balancing Act
We need to find the right balance between food, insulin, and activity. In children and adolescents, we must also account for growth.
What makes blood sugar rise?
Eating more food than usual
Lack of insulin
Less activity than usual
Hormones
Growth, puberty, stress, illness, infection, menstruation
What makes blood sugar go down?
Not enough food
Too much insulin
More activity than usual
Illness with vomiting or diarrhea
Summary:
v Insulin and activity make blood sugar go down
v Late or missed meals can make blood sugar go down
^ Carbohydrates make blood sugar go up
^ Hormones (growth, stress, and illness) make blood sugar go up
Managing type 1 diabetes requires a balance between food, insulin, and activity
What does this mean for children with diabetes?
We must match the amount of insulin to the amount of carbohydrates
Eating meals and snacks on time and in specific amounts
If more active than normal, may need more food than normal
Parents must be informed of school events that involve extra activity or extra food so that they can send extra food in case it is needed
If child is sick, caregivers must do extra checks for blood sugars and ketones. Students with diabetes should not be at school if they are sick!
Target Blood Sugars
We try to keep blood sugars as close to the optimal range as possible, with few low blood sugar tests.
For children under the age of six, we want 6-10 mmol/L (millimoles per litre)
For children 6-12 years old, we want 4-10 mmol/L.
For adolescents 12 and up, we want 4-7 mmol/L.
Most of the blood sugars should be in the target range if diabetes is managed well.
If the blood sugar level is above the optimal range, we say that it is hyperglycemic; if it is under, we say it is hypoglycemic.
Very generalized age-specific diabetes management tasks for children
Preschool (3-4 years old)
Pick a finger for blood sugar check
Put a strip in the meter
May say they feel funny or are hungry if experiencing a low
School-aged children (5-12)
Want to learn new things
Help with blood sugar checks - may be able to do their own checks by age 7-8
Usually can recognize symptoms of low blood sugar
Can treat low blood sugar with assistance
May use a pen to give insulin
May be able to help with some of the steps in giving insulin
Teenagers (13-18)
Should be interdependent with all diabetes self-care skills - still need parental support and supervision with diabetes care and insulin adjustment
Able to give own insulin
Checking Blood Sugar
Blood sugars tell us about the balance between food, insulin, and activity
Checking blood sugars provides us with important information so that parents can make informed decisions about adjustments to insulin doses
It is impossible to always be in range; our goal is that most of the blood sugars are in target.
If we have the odd day where things aren't adding up, it doesn't mean that an adjustment needs to be made; adjustments are based on patterns, not individual readings.
When to check blood sugar at school
Children with type 1 diabetes need to check blood sugar at least four times a day.
Critical times:
Before recess
Before lunch
Any time there are symptoms of low blood sugar
Before physical activity
During special events (ski trip, field trip, sports day)
Before going home if student has long commute
We should check blood sugar before the child eats. Preferably, we should wait at least 1.5 hours to check since the last time the child ate.
How to check blood sugar
The student should do as much as they can
Wash and dry hands
Insert test strip into the meter
Prick finger with lancing device to get a small drop of blood
Apply blood drop to the test strip and wait for result
Record blood sugar
Remove strip
Remove lancet and dispose in sharps container (lancets are single-use)
NEVER let anyone share the student's lancing device! Infection risk!
Hypoglycemia
Important notes:
Blood sugar less than 4.0 mmol/L is low and needs to be treated right away to keep it from getting any lower
Blood sugar of 4.0 mmol/L is still in the normal range; treat it quickly, but do not panic!
Lows can happen quickly and can become an emergency if they aren't treated
Signs of low blood sugar
Shaking
Dizziness
Blurred vision
Extreme tiredness and pale skin
Mood changes
Headaches
Hunger
Sweating
Managing low blood sugar
Anyone who is confused or unable to treat a low on their own needs help
Most young children need help
If possible, first check the blood sugar to make sure that it is actually low
If it is not possible to check the blood sugar by the symptoms are showing, treat it as a low!
If you suspect that a student is having a low, stay with the student until the blood sugar is above 4.0 mmol/L and there are no low blood sugar symptoms
Treating low blood sugar
Give 10-15 grams of fast-acting sugar
1/2 - 3/4 cup (125-175 ml) of fruit juice, or
Four Dex4 tablets, or
5 DextroEnergy tablets, or
1 tablespoon honey, maple syrup, or pancake syrup; or
15 Skittles (1 fun-size packet)
Wait 15 minutes
This allows time for the fast-acting sugar to work
Do not give any other food! Eating other food will slow down the sugar
Recheck blood sugar
If still less than 4.0mmol/L, return to step 1
When blood sugar is above 4.0mmol/L,
if more than 45 minutes remain until the next scheduled meal or snack, give the student an extra snack with carbs and protein: for example, a granola bar, or cheese and crackers
If less than 45 minutes remain until the next scheduled meal or snack, return to regularly scheduled eating plan
The "15-15-15" Rule
The easiest way to remember this is:
15 grams of fast-acting sugar
15 minutes of waiting
15 grams of slower carbohydrate with protein or fat
Severe low blood sugar
If student's blood sugar is so low that they are confused or disoriented, they need help right away.
If student loses consciousness or has a seizure:
Roll student onto their side
Call 9-1-1
Do not give anything by mouth to prevent choking
Administer glucagon if trained and designated to give it
Caregivers may be trained to give glucagon if emergency services are far away in the instance of a student experiencing severe low blood sugar
Glucagon is a hormone made in the pancreas that lets the body use stored glucose from the liver, and is used to treat severe low blood sugar
Glucagon is mixed with sterile water and given by injection
Call parents
Preventing low blood sugar
Fast-acting sugar and food should always be available and restocked regularly by parents
Treat low blood sugar immediately
If possible, check blood sugar before treating to confirm that low blood sugar is in fact the culprit of the symptoms
Ensure lunch and snacks are eaten on time
Ensure parents provide extra food for extra activity
If student receives insulin at lunch, student must start eating within 10-15 minutes of injection
School staff need to know how to treat low blood sugar
Student with diabetes must wear medical ID at all times
Recognizing and treating low blood sugar early is the best way to prevent severe low blood sugar!
Hyperglycemia
High blood sugar is not an emergency, but
Long-term high blood sugar can cause problems
Causes of high blood sugar:
Too much food
Not enough insulin
Less activity than normal
Hormone changes (growth, illness, infection, stress)
Insulin levels should be raised as children grow; older/larger children need more insulin.
Signs of high blood sugar
Drowsiness
Frequent urination
Blurred vision
Dry mouth
Bed wetting
Extreme thirst
If we see these symptoms in children who do not have diabetes, the teacher should tell the parents that the child should be brought to a doctor as soon as possible
Treating high blood sugar
In a student's care plan, the parents may need to be called if blood sugar is very high: usually 15-20 mmol/L
Do not tell the student to exercise to burn off the blood sugar - this can actually raise blood sugar even higher!
Give student access to drinking water and the bathroom
Check for ketones if the blood sugar is more than 15 mmol/L
Parent needs to pick up child if:
Student is sick or vomiting
There are ketones and blood sugar is above 15 mmol/L
High blood sugar and illness
Blood sugar can be high during illness or infection
Children who are sick should not be at school!
Nausea, abdominal pain, and vomiting can be signs of the presence of ketones
Ketones are not usually checked at school; however, if there is nausea or vomiting and the blood sugar is over 15 mmol/L, if the parent directs a student who is able to check his or her own ketones, the student can do so
If blood sugar is high (more than 15 mmol/L) with ketones, insulin is urgently needed and parents must be contacted
What could give a student ketones?
Sick and vomiting
Student hasn't been taking insulin
Insulin pump is not working
Physical activity
Physical activity will usually lower blood sugar, and can continue to cause low blood sugar for several hours, even after the activity is completed
If a student with diabetes is going to be more active than usual, the student will need to eat extra long-acting carbohydrates with proteins or fats before they start - not fast-acting sugar!
If a student has a special activity planned such as a field trip, or a sports day, etc., the parents must provide extra food
Approximately 15-20 grams of extra carbohydrates are needed for each hour of extra activity
Half a sandwich
Cheese and crackers
Granola bar
Chocolate milk
Digestive cookies
Food Choices and Timing
Students with diabetes need to balance insulin with carbohydrate-containing foods (and their exercise)
Lunch and snacks must be eaten at scheduled times
No extra foods or drinks can be given without parental approval
Student does not trade/give away lunch
Young children need supervision
We need to understand that students with diabetes can't be expected to eat differently from their peers
Children with diabetes can eat all foods EXCEPT liquid sugars (juice, sugared pop, other sweetened beverages), as those kinds of drinks are used to treat low blood sugar
Food at School
Students with diabetes who count carbohydrates should have their snack and lunch labeled with the carbohydrate content
If a student is at a school where the class schedule is to play before eating
Check blood sugar
If blood glucose is higher than 8 mmol/L, student can eat after playing
If blood glucose is under 8 mmol/L, student should eat 10-15g of their snack or lunch before going out to play (fruit, milk, granola bar, fruit to go, yogurt tube, 1/2 sandwich, trail mix)
Insulin
Who needs insulin?
People with Type 1 diabetes do not make any insulin. They need to inject it. The idea here is to imitate the way that the body would naturally do so.
Some people with type 2 diabetes need to take insulin.
How is insulin taken?
It cannot be taken orally; it must be injected
It can be injected in a variety of ways:
Syringe
Insulin pen
Insulin pump
The school is not responsible for deciding insulin doses
If the parents and school agree and if training is provided, staff may agree to supervise or assist young students who administer their own insulin
Safe disposal of sharps is a must
There are multiple kinds of insulin
At school, the only kind used is rapid-acting insulin, which:
starts to work in 10-15 minutes
Is given just before meals or right after food is eaten
Rapid-acting insulin is the only kind of insulin used in an insulin pump
Insulin plans
Physiological insulin delivery
This is the kind of insulin delivery that the body does in people who do not have diabetes. The pancreas releases insulin based on changes in activity, food, illness, and stress. This keeps the body's blood sugar always in the healthy range.
This is the kind of insulin delivery that we try to emulate when managing type 1 diabetes
Conventional insulin plan
2-3 injections per day using intermediate-acting and fast-acting insulin
The most common way that school-aged children are given insulin
Must have 3 meals and 2-3 snacks daily
Not flexible, but fits well with most school routines
Does not require a dose of insulin at lunch
Basal insulin
"Background" insulin that covers the body's basic needs between meals and while asleep; does not cover carbohydrates in food
Bolus insulin
A burst of rapid-acting insulin given with carbohydrate-containing food (meal bolus), or
Extra insulin given to bring down or "correct" a high blood sugar (correction bolus)
Basal-bolus (intensive) insulin plan (also called MDI - multiple daily injections, intensive diabetes management, flexible intensive therapy, or physiological insulin delivery)
Two ways to do this:
Multiple daily injections using long-acting basal insulin and rapid-acting insulin for boluses
Both long-acting basal insulin and rapid-acting insulin are used
1-2 doses of basal insulin given every 24 hours
A bolus of rapid-acting insulin is given with a syringe or insulin pen for carbohydrates and to bring down high blood sugars
Once injected, can't be "turned off" or adjusted
Not attached to a device
Insulin pump therapy, which uses only rapid-acting insulin as both the basal and boluses
Only rapid-acting insulin is used
Continuous infusion of rapid-acting insulin for basal insulin - can be programmed to meet individual needs
A bolus of rapid-acting insulin is given for all carbohydrates and to bring down high blood sugar
Temporary basal rates can be set to increase or decrease the insulin
Pump can only be disconnected for short periods
In this insulin plan, insulin is given whenever carbohydrates are eaten and when the blood sugar level is high
The basal-bolus plan has more flexibility than the other plans (but the students still need to eat their lunch and snacks with the other children!)
Insulin is given when eating, based on the amount of carbohydrates
The student does not need to eat to "feed the insulin"
If the child doesn't want their recess snack, it is usually okay if they are on this plan
Student may not need insulin at recess if their snack is low in carbs
A meal bolus must be given before all meals and snacks that contain carbohydrates
Insulin to carbohydrate ratio
This ratio is used to determine the amount of rapid-acting insulin in relation to the number of grams of carbohydrates eaten
Some students may have different ratios at different times of the day
An example of an I/C ratio is 1:15, which means one unit of rapid-acting insulin is needed for every 15 grams of carbs
How to calculate a meal bolus
School staff do not do this, this is just for understanding of the process
Divide grams of available carbohydrates by the carb ratio
If student ate 48 grams of carbs and their ratio is 1:15, we divide 48 by 15, giving us 3.2 units; therefore, the student would need 3.2 units of rapid-acting insulin
Insulin Sensitivity Factor (Correction Factor)
The ISF tells us how much (in mmol/L) one unit of rapid-acting insulin will drop the blood sugar. An ISF of 4 tells us that one unit of rapid-acting insulin will drop the blood sugar by about 4 mmol/L.
Correction bolus formula
Calculating the correction bolus is done by dividing the current blood sugar minus the target blood sugar by the correction factor. This can only be done with an insulin pen if the the amount is at least half a unit. Again, school staff do not do this.
Combining meal and correction boluses
Meal boluses and correction boluses can be given together: for example, if blood sugar is high before dinner, a correction bolus can be taken to return blood sugar to baseline, then the meal bolus is given for the dinner about to be consumed.
Diabetes Support Plan
All students with diabetes need to have an emergency plan
Students who need assistance with diabetes care need a standardized, written diabetes support plan, including such things as:
Signs and symptoms of low blood sugar that the student displays
Clear, consistent treatment of low blood sugar - must fallow the Canadian Diabetes Association guidelines for treatment of hypoglycemia
Timing of snack and lunch
Blood monitoring instructions
Emergency action plan
Instructions on when to contact parent/legal guardian; contact information
Decisions are not left up to school staff; decisions about what to do in all scenarios must be made beforehand and included in the diabetes support plan
Insulin Pumps at School
What is an insulin pump?
It is a small device, worn like a pager - it gives insulin
There is a pump and syringe inside
In most pumps, a thin tube connects the syringe to the child via an infusion set
The infusion set is changed at home every 2-3 days
Some pumps do not use a tube; a handheld unit is used to control a tiny pump
Programming
Insulin pumps continually pump a small amount of insulin into the body 24 hours a day
When carbohydrates are eaten or blood sugar is high, a "bolus" (burst) of insulin is given
Using an insulin pump gives greater flexibility through the day, and, if used correctly, can keep blood sugars closer to normal than other systems would
School staff do not change infusion sites
Debunking myths about insulin pumps
"Using a pump is easy!"
Using a pump involves more planning and work than other methods
Requires checking blood 6+ times a day
Pumps are not "set and forget"
There is a lot to learn about pumps
Exact number of carbs needs to be counted and entered into the pump
"No more injections!"
Infusion set is inserted with a needle and changed at home every 2-3 days
People who use pumps need to carry a pen or syringe with rapid-acting insulin with them in case there is a problem with the pump, if the site is not working, or if the student has high blood sugar with ketones
"The pump checks blood sugar!"
The pump delivers insulin; it doesn't check blood sugar
Some people have a separate device, called a Continuous Blood Glucose Monitor (CGM) that checks blood sugar through a separate site attached to a transmitter, but even these can't replace proper blood sugar checks, as the CGM just looks for trends
"The pump is inserted in the hospital."
The infusion site is changed at home by the family every 2-3 days
The pump is not sterile, so changing it requires a clean technique
The cartridge that holds insulin is filled when the site is changed (or more often if needed)
"Everything will be perfect with a pump!"
The pump is not a "diabetes cure"
The pump is not automatic, and only works as well as the person operating it
The pump is smart, and it can make suggestions, but you can't "set it and forget it"; it does not know if the student is doing exercise, for example.
"Only people with 'bad' diabetes can use a pump!"
Anyone who understands how insulin and carbohydrates work can use a pump
People who are young or who are unable to push the buttons or don't understand how insulin and carbohydrates work may find operating the pump to be difficult
Insulin pumps aren't for everyone!
They only work well if used properly
Need to have solid diabetes knowledge base and problem-solving skills to use the pump
There is a lot of education needed to use the pump properly
Some people do not want to wear something so visible, or they don't like being attached to the pump
"Smart Pumps"
Smart pumps are the pumps we commonly see today
Smart pumps have bolus calculators that suggest the amount of insulin needed after the user enters blood sugars and carbohydrates
Calculations of bolus insulin are based on:
Target blood sugar (set by the parents, not the school staff!)
The insulin sensitivity factor (also called the ISF, or correction factor) - how much 1 unit of insulin will lower blood sugar
Amount of carbohydrates in the food to be consumed
Insulin to carbohydrate ratio (again, set by parents, not school staff)
Amount of time a bolus is expected to last (set by parents, not staff)
High blood sugar and insulin pumps
If a student is using an insulin pump and has high blood sugar, it may be a sign that the pump is not delivering insulin properly. If that is the case, because insulin pumps only use rapid-acting insulin, the body will quickly run out of insulin
If the body runs out of insulin, blood sugar rises quickly and the body will start producing toxic ketones; if not addressed, a very serious condition called diabetic ketoacidosis can develop in as quickly as as 4-8 hours.
If a student with an insulin pump has high blood sugar (15mmol/L or higher), the student will need a correction bolus of insulin; the blood sugar must be checked again within 2 hours to make sure it has come down. If it hasn't, there's likely a problem with the pump's insulin delivery. In that case, if the student is unable to give insulin with supervision and/or change the site, the parent would come to the school to give insulin and change the infusion set.
High blood sugar and ketones
If directed by parent, student can check for ketones when blood sugar is over 15 mmol/L and any time there is nausea or vomiting.
Nausea, abdominal pain, and vomiting can be signs of ketones!
When to call parents
If site comes out
If blood glucose is more than 15mmol/L two hours after a correction bolus is given
If ketones are present
Troubleshooting high blood sugar
If blood sugar is more than 15mmol/L:
Is it the child?
Forgot to bolus?
Stress/hormones?
Carbs underestimated?
Is it the pump?
Infusion set?
Empty insulin?
Dead battery?
Tubing kinked or blocked?
Disconnected too long/too often?
Low blood sugar and insulin pumps
If blood sugar is less than 4 mmol/L:
Give 10-15 grams of fast-acting sugar
Wait 15 minutes to allow the fast-acting sugar to work
Check blood sugar
If less than 4.0mmol/L, repeat process from step 1
If low blood sugar is during or after an activity, give a small snack (with protein or fat) with no bolus
Exercise and insulin pumps
For short-term activity, give an extra 15-20 grams of carbs with no bolus for each hour of activity
For extended periods of activity (field trip, sports day, etc.), parents should set temporary basal rate for duration of activity
If student goes swimming, pump can be disconnected for maximum time of 1.5 hours
Insulin pumps at school
Parents need to make arrangements and agreements with staff who are trained to use insulin pumps; if there are no supports in place, parents must make an alternate plan
Boluses at school
Safety is first priority
Generally it is best to give boluses before eating; however, for unpredictable eaters, it may be safer to give after eating (in case child does not eat the food)
Recess snack may not need bolus if snack is low-carb and student runs around after snack
For lunch, parents can either pack the same carbs daily, or itemize lunch items so that carbs can be easily added
Giving a bolus after a low blood sugar
Check the blood sugar 15 minutes after treating a low to ensure that blood sugar is over 4mmol/L. If it isn't, repeat treatment.
If giving a food bolus after treating a low blood sugar, do not enter the blood sugar into the pump; instead, enter the grams of carbs into the bolus calculator to prevent the pump from suggestion a correction bolus and resulting in another low.
Daily parental expectations:
Ensure enough insulin in pump and enough battery power to last whole day
No redness or swelling at site
Infusion site changed every 2-3 days at home
Tube is not coiled or kinked
No ketones
Lunch is labelled with carb amounts
Parent available in case of problem - can be reached by phone
Backup plan in place if site or pump stops working
PS: I've listened through today's soundtrack album many times today; the instrumental track "Water" is definitely the standout track for me. It reminds me of sitting in a French cafe in the 90s, waiting to meet someone on a date.