Paediatric Diabetes Nursing Guide

• Acanthosis nigricans (dark velvety skin folds — neck/axillae)
• PCOS in adolescent girls
• Strong family history (often 1st degree relative)
• Overweight/obese (BMI >85th centile)
• Screen all obese children >10 years (or puberty onset if earlier)

• Suspect if: negative antibodies, strong family history (autosomal dominant), mild stable hyperglycaemia
• MODY2 (GCK): mild fasting hyperglycaemia, no treatment needed
• MODY3 (HNF1A): responds to sulfonylurea, progressive
• Diagnosis: genetic testing. Misdiagnosis as T1DM common — critical to identify for correct management

Fiasp: Ultra-rapid analogue — onset 2–4 min. Useful in pump therapy and post-meal dosing in young children who eat unpredictably.

• Long-acting once daily (Glargine/Detemir) at bedtime
• Rapid-acting with each meal + snack if >15g CHO
• Carbohydrate counting essential
• Flexible lifestyle — gold standard for school-age+

Sick Day Rules: Never stop insulin. Check glucose and ketones 2-hourly. Increase fluids. If ketones >1.5 mmol/L — medical review urgently.

• Programmable basal rates (multiple rates per day)
• Bolus wizard for meal coverage
• Temporary basal rate during exercise/illness
• Extended bolus for high-fat/protein meals
• Preferred in young children (<7y) — small precise doses

Pump Failure Risk: No long-acting insulin depot — DKA can develop within 4–6 hours of pump failure. ALL pump users must have backup insulin pens. Change infusion sets every 2–3 days.

MILD

Alert, tolerating fluids

MODERATE

Vomiting, unwell

SEVERE

Drowsy/unresponsive

Formula: Deficit (mL) = Body weight (kg) × % dehydration × 10
Total over 48h = deficit + (maintenance × 2)

Cerebral Oedema — EMERGENCY

• ⚠ Headache — new onset or worsening
• ⚠ Bradycardia (slowing heart rate)
• ⚠ Rising blood pressure (Cushing's triad)
• ⚠ Decreasing GCS / behaviour change
• ⚠ Incontinence / agitation in older child
• ⚠ Papilloedema (late sign)

• Hourly glucose, 2-hourly blood gas & electrolytes initially
• Continuous cardiac monitoring (K+ flux)
• Strict fluid balance — hourly urine output
• Neurological obs hourly — GCS, pupils
• Weight on admission for fluid calculations

Placement: Upper arm (most common), abdomen. Avoid active muscle areas. Rotate sites to prevent skin reactions.

Share Function: Parents receive real-time alerts on their phone. Essential for overnight monitoring in young children. 'Follow' apps allow remote monitoring at school.

Evidence: Closed loop systems significantly improve TIR and reduce nocturnal hypoglycaemia. Major advance for paediatric T1DM management.

Problem	Action
Unexplained hyperglycaemia	Check site, cannula, tubing. Change set. Give correction via pen.
Ketones + high BG on pump	Assume site failure. Change set immediately. SC insulin via pen. If ketones >1.5 — seek medical review.
Pump alarm / error	Follow device manual. If unresolvable — use backup pen insulin. Do NOT be without insulin.
Infusion site reaction	Rotate sites. Allow skin to heal. Antihistamine if allergic reaction. Review technique.

Key Safety Rule: Every pump user must have a documented backup plan with pens and a written sick day protocol. Infusion sets changed every 2–3 days maximum.

GCC Context: DHA school diabetes nurses programme provides dedicated nursing support within Dubai government schools. Advocacy for similar services across the GCC region is increasing.

• Do NOT give oral glucose — aspiration risk
• Glucagon IM/SC: <25kg: 0.5mg | >25kg: 1mg
• Nasal Glucagon (Baqsimi): 3mg intranasal — no injection needed
• IV Glucose: 10% glucose 2ml/kg IV if cannula in situ
• Post-recovery: 20g slow CHO when able to swallow
• Seek medical review. Review insulin doses.

Nocturnal Hypoglycaemia: Highest risk 2–3am. CGM overnight alarms essential. Bedtime BG target: 6–8 mmol/L. Bedtime snack if active day. Parents should never switch off overnight CGM alarms.

Deliberate omission of insulin for weight loss. Predominantly female adolescents. Significantly underdiagnosed.

• High-risk period — attendances drop, HbA1c rises
• Prepare from age 14 — gradual transfer of self-management
• Written transition plan + adult service introduction
• Address: alcohol (unpredictable hypoglycaemia), recreational drugs, sexual health, contraception, driving (BG must be >5 before driving)

Peer pressure: Adolescents may skip injections to fit in socially. Discreet CGM/pump use can reduce stigma. Peer support groups and youth diabetes camps are valuable.

• Affects child AND parents — family system approach
• Parents run high BG deliberately to avoid hypos
• Night-time checking anxiety — parental sleep deprivation
• CGM + shared alarms greatly reduces parental anxiety
• Psychological referral for severe anxiety

• Screen regularly with validated tools (PAID-Peds, WHO-5)
• Burnout common — 7-day/week management for life
• Normalise the challenge — non-judgmental clinic approach
• Social worker/CAMHS referral pathways

GCC Context: Cultural stigma around chronic illness in children. Families may conceal diagnosis. Diabetes education must be culturally sensitive and available in Arabic.

• Pre-pubertal children are NOT obligated to fast in Islam
• Adolescents may choose to fast — individual decision with family
• Medical exemption applies if fasting poses health risk
• Religious scholars support diabetes as a valid exemption

• Pre-Ramadan education programme — minimum 4–6 weeks before
• CGM is ESSENTIAL — enables safe fasting
• Adjust insulin: reduce basal/bolus doses at Suhoor
• Structured self-monitoring: check BG every 2 hours
• Break fast IMMEDIATELY if BG <4.0 or >16 mmol/L or symptomatic
• Ketones must be checked if unwell
• Hydration between Iftar and Suhoor is critical

Young children with T1DM should be strongly advised against fasting unless extensively prepared and with CGM & parental supervision.

SCFHS / DHA EXAM

Interactive Tool