If you don’t deal with diabetes frequently, it can be overwhelming Type 2 diabetes in children, which until with type 2 diabetes must improve food …
Preface Thank you in advance for reviewing these materials prior to your Camp Kudzu orientation session Please feel free to print this information and make note of your questions We will expand on this information at orientation as well as learn many other necessary details Being a camp staff member is a job to love Most of us work with children because we want to shape their development so that they will be happy, healthy and well-adjusted Each day we have the opportunity to teach, mentor and build their self-esteem Creative, exciting programs that bring children together with their peers are the best way to teach new skills and enhance the childs ability to work within a group Every child should have the same opportunities And, of course, ensuring a safe environment is critical for success It can be challenging, even scary, to have a child with diabetes in your care If you dont deal with diabetes frequently, it can be overwhelming to think about your regular job broadened to encompass what would ordinarily be defined as nursing or parenting skills Insulin, food, exercise, high and low blood glucose symptoms, special medical devicesYIKES Camp Kudzu is committed to helping you Our
goal is to provide leadership and education to assist you to provide a safe camp experience for the children in your care Ultimately, we hope that every child with diabetes can participate in any activity they choose so that they feel normal and happy just like their peers without diabetes Jill H Sax, RN, CDE Medical Director Camp Kudzu
1 4/22/2008
What is diabetes? Diabetes is a chronic condition that has no cure Approximately 1 in 500-600 children have diabetes In Georgia there are approximately 5,000 children with type 1 diabetes These children require insulin injections daily to survive Type 2 diabetes in children, which until recently affected primarily adults, has been deemed an epidemic Children with type 2 diabetes must improve food intake, increase exercise and may also require oral diabetes medications or insulin Both types of diabetes may have devastating effects on the current and longterm health of children Camp Kudzu serves children with type 1 diabetes Uncontrolled diabetes has immediate health consequences, and longterm complications affecting the eyes, vascular system, heart and kidneys are not uncommon This makes it essential for everyone in a childs life to be
knowledgeable and ready to support healthy diabetes management Diabetes results from the bodys inability to secrete or produce an adequate amount of a hormone called insulin Insulin is produced by the beta cells in the pancreas and acts like a key that opens up the doors to the bodys cells, so that glucose can enter the cells The foods that we eat, especially carbohydrates, are converted to glucose Without insulin, the bodys cells cannot be nourished because the glucose cannot get into cells to be used for energy and cell repair When this happens, the glucose builds up in the bloodstream causing symptoms including: Excessive thirst Frequent urination Extreme hunger Unusual weight loss Fatigue Irritability Blurry vision
2 4/22/2008
In type 1 diabetes, pancreatic beta cells have been destroyed by an autoimmune process, eliminating the production of insulin forever At present, there is no known cause for this process and it occurs quite quickly Many children with type 1 diabetes present to the doctor with serious flu-like symptoms Their blood glucose may be extremely high and hospitalization may be required to stabilize blood glucose When a child has very high blood glucose levels,
the bodys cells are not being nourished The body begins to burn fat for energy The by-products of this process are ketones which can be traced through the urine and the blood This is a serious condition which, if not addressed medically, may cause coma, and in rare occasions, death We will address ketone management later In type 2 diabetes, which is associated with childhood obesity, the body is not able to use insulin to regulate blood glucose Children could have type 2 diabetes and not know it because they have mildly elevated blood glucose levels that may not cause dramatic symptoms Even elevated blood glucose levels with no apparent symptoms have a profoundly negative effect on the body We do not know how many obese children have type 2 diabetes but there is a push to have children screened for the condition Keeping a childs weight in a healthy range is the best prevention for type 2 diabetes Both types of diabetes present a challenge when children are away from parents Maintaining blood glucose levels in a safely tolerated, normal range is the key to a childs immediate and long-term health It requires monitoring of blood glucose, administration and adjustment of medication,
meal planning and daily exercise A child must have support from parents and other adults in order to handle the complexities of their daily diabetes management routine No child should have to manage their diabetes without adult supervision and support
3 4/22/2008
Diabetes Management Routines The key to successful diabetes management is to match food and exercise with prescribed medication in order to maintain normal blood glucose levels In this way, a child with diabetes may participate in any activity they wish Type 1 diabetes: Type 1 diabetes is treated with synthetically made insulin A child must have a constant amount of long-acting insulin called basal 24 hours a day, combined with a burst of fast-acting insulin called bolus to cover either food or a sudden release of stored glucose Insulin is available by injection through the use of syringes, pens, and pumps A typical daily insulin regimen for a child with type 1 diabetes on injections would be a basal injection of long-acting insulin once or twice daily combined with an injection or bolus of fast-acting insulin before or immediately after meals This means that a child taking injections may need 4 - 6 injections every day
It is likely that a child in your care for more than a few hours will need food, insulin and blood glucose monitoring Type 2 diabetes: Type 2 diabetes in children may be managed with meal planning, regular exercise and sometimes medication, often an oral medicine, rather than insulin Some children with type 2 diabetes must use insulin
4 4/22/2008
Meal Planning Meal planning is important so that food can be matched to doses of insulin or other diabetes medications Children with diabetes need to have enough calories to provide energy for play and growth If they are hungry or more active they need more to eat Insulin may be adjusted on a meal-to-meal basis to allow a child with diabetes to be flexible Healthy eating is very important The overall goal of meal planning is to include meals and snacks that enhance energy, growth and development You will see how tricky that can be when a child has diabetes The balance of insulin and food with activity is not an exact science That is why blood glucose levels fluctuate widely in children with diabetes It is important to minimize extreme fluctuations in routine by eating at the same time each day, and spacing food throughout the day This
helps to reduce high and low blood glucose Children participating in strenuous activities will certainly need fast acting snacks like juice or glucose tabs and a longer lasting food source such as peanut butter crackers The food we eat is made up of carbohydrates, protein, and fat Good nutrition includes healthy choices of these three types of food, plus plenty of water, vitamins and minerals Carbohydrates have the most significant effect on blood glucose All carbohydrates are converted into glucose The amount of food and the concentration of carbohydrate determine how the blood glucose level rises In other words, the same meal but with a different total calorie count or different portion size, will require different amounts of insulin Even when meals are carefully planned and the right amount of insulin is given, blood glucose readings can vary With rapid acting insulin, it is easier to get the insulin peak to match the food peak, but it is not a perfect process Also, many factors other than just food and insulin can have an effect on blood glucose like hormonal activity and stress
5 4/22/2008
Carbohydrate Counting This method most common involves calculating the number of
grams of carbohydrate in each food group on the plate or in the glass, bottle, carton or can and matching an insulin dose which may be increased for no activity or decreased for major activity to it For instance, a typical insulinto-carb ratio might be 1 - 10 1 unit of insulin for each 10 grams of carbohydrate That means that for every ten grams of carbohydrate eaten, the child must take 1 unit of fast-acting insulin It is important to remember that foods other than bread, pasta, rice, cakes and cookies have carbohydrate An 8 ounce glass of milk has 12 grams of carbohydrate Fruits have carbohydrates as well At Camp Kudzu we use the carbohydrate counting method for all of our meals and snacks One of the goals at camp is to improve a campers carb counting skills This will enable the childs independence in managing their diabetes You will receive detailed instructions in carbohydrate counting at your orientation session
6 4/22/2008
The Counselors Role in the Management of the Campers Diabetes The counselor plays a critical role in providing the camper with a safe and fun environment The counselors will meet with their cabin clinician before the campers arrive at camp to discuss the
medical management tasks and how they will be divided The clinician is responsible for making all of the medical management decisions for each camper in their care Some of the basic tasks that you will perform to assist in the care of the camper are: Check blood glucose levels Calculate total carbohydrates consumed at meals and report to the clinician Assist the clinician in verifying insulin doses and may assist camper in giving injection if approved by clinician Recognize symptoms of low blood glucose and provide treatment Record all blood glucose levels on field BG card and report to clinician at each meal time Have camper check urine ketones if blood glucose is over 240 mg/dL and notify clinician if ketones are positive more information on the specifics of this will be provided at orientation Know when to ask for medical assistance
Check Blood Glucose Levels Knowing a childs blood glucose is the single most important tool for healthy management of diabetes A normal blood glucose for a person without diabetes is 70 110 Ideally, a childs blood glucose levels will be maintained in a near normal range of 80 160 when he/she is away from home Keep in mind that a child with
diabetes will undoubtedly experience blood glucose levels outside this range This is not necessarily because staff or child did anything wrong The goal at Camp Kudzu is to avoid extreme low and high blood glucose levels Typical blood glucose monitoring times for the campers are: First thing in morning, before breakfast Before each meal Before bed
7 4/22/2008
Any time symptoms are present witnessed or when child tells you he/she is feeling something Every 15 minutes until blood glucose rises 80 during low blood glucose hypoglycemic event Before high level activities At 11:45 pm before the clinician makes midnight rounds Do not be alarmed when a childs blood glucose is out of range on the high side This could be an isolated occurrence and does not necessarily need immediate attention, unless ketones are present However, whenever blood glucose is on the low side of the range, immediate attention is needed in the form of a fast-acting carbohydrate Low blood glucose is an emergency situation because it can continue to drop, resulting in unconsciousness and potentially a seizure Goal: Ensure that blood glucose is checked regularly in a safe, accurate manner and to gather
information to allow for adjustments in insulin, food and exercise
You will be trained in the use of the blood glucose meter in orientation and will review it again on the first day of camp
8 4/22/2008
Hypoglycemia Low blood glucose Goal: Treat low blood glucose quickly and accurately so that childs blood glucose returns to normal range, allowing child to resume activity
A childs blood glucose can be lower than the normal range for many reasons Basically, low blood glucose occurs when there is too much insulin and not enough glucose It can be caused by increased or unexpected exercise, the fact that a child missed a snack or did not eat an entire meal or missed a snack for which an insulin dose had been given, or a slight disproportionate too much dose of insulin being calculated Sometimes, we dont know the reason When blood glucose levels are low there is a risk to the child The brain is not being nourished with glucose and disorientation and more severe symptoms can develop quickly Symptoms can be mild, moderate or severe Hypoglycemia at Camp Kudzu is defined as a blood sugar BELOW 80 Mild Camper feels low, asks for food, checks blood sugar, eats food Moderate Camper does
not recognize that he is low, may need help checking blood sugar, may need help eating Severe Camper is lethargic, unresponsive or having a seizure Having hypoglycemia treatment items with you is essential You should plan to bring a backpack large enough to carry all of the medical supplies and hypoglycemia treatments you will need in the field with you A counselor must be with the child with diabetes at all times, equipped with low blood glucose treatment supplies, to ensure the childs safety
9 4/22/2008
Over-treating hypoglycemia is not a terrible thing, but under-treating can be Remain calm but be assertive in your plan and check the childs blood glucose every 15 minutes until the result is over 80 mg/dL It takes 15 minutes for a food source to begin to stabilize blood glucose Remember to write down the blood glucose readings and what the child ate for future reference It will help with insulin calculations the next time Never force food into the mouth of a child who cannot swallow If the child is losing consciousness, the administration of glucagon may be required Glucagon is not a sugar Rather, it is a pancreatic hormone that triggers the release of stored glycogen from
the liver and helps convert it into glucose Side effects of glucagon include nausea, vomiting and general malaise that may last through the following day Hyperglycemia High blood glucose Goal: Treat high blood glucose so that campers blood glucose returns to normal range, preventing development of ketones and, in the extreme, ketosis high blood sugars and ketones or ketoacidosis high blood sugars, ketones and chemical imbalance, and allowing child to fully participate in all activities
A childs blood glucose can be higher than normal for many reasons Basically high blood glucose occurs when there is too little insulin for the amount of glucose in the body Possible causes for this could be: child eating more food than planned taking too little insulin experiencing stress or illness not participating in planned physical activity rainy days are a common cause becoming dehydrated hydrating child with 8 16 ounces of water or sugar free drink in 30 60 minutes and rechecking blood glucose may avoid need for other measures having an infection Unlike low blood glucose, which has a risk of immediate consequences, high blood glucose can be addressed in many ways More often than not, a wait
and see approach can be taken, especially when blood
10 4/22/2008
glucose levels are between 140 240, or when no ketones are present If blood glucose is over 240, checking for ketones is important If a ketone check by urine check indicates ketones are trace to small, the child should drink a minimum of 8 16 ounces of water and the clinician should be notified Insulin may be required when ketones are trace to large, and the blood sugars are over 240 mg/dL Insulin Administration Goal: Ensure that the child with diabetes receives the correct dose of insulin for their planned food and exercise and that the site of the insulin administration is in good condition
The child with type 1 diabetes requires insulin in order to survive They do not and will never produce insulin themselves Currently, the only recommended insulin must be taken by injection or through continuous infusion an insulin pump An increasing number of children use insulin pumps There are many different kinds of insulin Children on injections take multiple kinds of insulin, ranging from fast-, to moderate-, to long-acting Each of these insulins has a different peak which is intended to be matched to times when blood
glucose levels are highest and activities are lowest The clinician will be responsible for making all insulin decisions Syringes for giving insulin injections come in different sizes, usually 30 one of the BD 3/10 syringes that has unit markings, 50 or 100 units Each major mark on most syringes is equal to 1 unit of insulin, except for 100 unit syringes where each mark equals 2 units Depending on the types of insulin taken by the child, one-to-two shots per administration may be needed because some types of insulin rapid and long acting insulins that have different pH levels cannot be mixed together Outside of the home setting, syringes should only be used once Used syringes must be disposed of in a biohazard container sharps container
11 4/22/2008
Drawing Up Insulin A designated person should be trained to administer insulin if the child is unable to give his/her own shot The following is a typical procedure It is imperative to go through the insulin administration procedure with your clinician You will only assist with the insulin administration process if you are comfortable, trained and instructed to do so by your clinician Procedure for single dose one type of insulin: Many
children take an injection of fast-acting insulin before each meal, along with a long-acting insulin that has no peak This works very well for children because the combination provides a basal insulin which is combined with the fast-acting, bolus insulin This regime is similar to an insulin pump and is preferred in many cases since pump management can be complicated At this time, long-acting insulin cannot be mixed with fast-acting insulin in the same syringe In these cases, there is no mixing of insulin since each injection is given separately The procedure for a single type of insulin follows: Make sure your hands are clean Mix suspension of NPH or Novolin N insulin by rolling bottle between hands about 20 times Clean tops of bottle with alcohol swab Replace the insulin you are about to draw up with air so that a vacuum is not created Put insulin bottle on table Hold syringe up hold barrel of syringe in one hand and use second hand to pull plunger and pull plunger of air to appropriate number of units of insulin Push needle straight down into insulin bottle injecting the air into the air of the bottle injecting air into liquid may create air bubbles Do not remove needle
Turn insulin bottle/syringe unit so that the insulin bottle is on top and the needle on the bottom Draw down correct number of insulin units by pulling plunger to total insulin dosage Remove needle
12 4/22/2008
Do not allow the exposed needle to touch any surface before administering insulin Procedure for mixed dose of insulins fast- and long- or intermediateacting: Make sure your hands are clean Mix suspension of cloudy insulin by rolling bottle between hands about 20 times Clean tops of bottles with alcohol swab Replace the insulin you are about to draw up with air so that a vacuum is not created, using the cloudy insulin first Put insulin bottles on table Hold syringe up hold barrel of syringe in one hand and use second hand to pull plunger and pull plunger of air to appropriate number of units of cloudy insulin Push needle straight down into cloudy insulin bottle injecting the air into the air of the bottle and remove needle Injecting air into liquid creates air bubbles Do the same for the clear insulin by holding syringe up and pulling plunger of air down to appropriate number of units of clear insulin Push needle straight down into clear insulin bottle injecting
the air into the air of the bottle Do not remove needle Turn insulin bottle/syringe unit so that the insulin bottle is on top and the needle on the bottom Draw down correct number of clear insulin units by pulling plunger to total clear insulin dosage Remove needle Push needle into cloudy insulin bottle turn bottle upside down and pull plunger down to appropriate number for the total insulin dose Remove needle Do not allow the exposed needle to touch any surface before administering insulin
Note to remember: At the present time, insulin Glargine Lantus and Detimer Levemir cannot be mixed with any other type of insulin in the same syringe and must be given in separate sites
13 4/22/2008
Administration of insulin injection Insulin is injected into the subcutaneous, or fatty, tissue Choose injection site upper arms; upper thighs; abdomen; upper, outer area of buttocks Do not choose a site that will be intensely used for exercise soon after the injection Clean area with alcohol swab and allow to dry Some children do not use alcohol to clean the injection site This step is optional, although the area should be clean and dry before injecting Hold syringe like a pencil or dart
and push needle straight into the tight skin 90 degree angle until it stops do you want to describe a pinch? Do not place thumb on the end of the plunger while inserting needle this may cause premature expulsion of insulin Push plunger down until it stops Pull needle straight out Dispose of sharp in approved biohazard container sharps container If there is bleeding at the injection site, have the child dab the area with a clean, dry cotton ball or tissue Do not give extra insulin Rather, document the amount you believe leaked size of drop and check blood glucose more frequently Administration of injection by insulin pen Clean skin Screw needle in place and remove cap Dial up 2 units to fill needle Hold insulin pen up so the needle is at the top and give an air shot to prime the pen Dial up prescribed dose of insulin for child Hold syringe like a pencil or dart and push needle straight into the tight skin 90 degree angle until it stops The needle should remain in the skin for a count of 5 seconds Remove needle Have the camper cap the needle with the large outer cap, unscrew needle Dispose of sharp in approved biohazard container sharps container
14 4/22/2008
Insulin
Pumps Insulin pumps deliver rapid fast-acting insulin 24 hours a day basal rate through a catheter placed under the skin Pumps were developed for better blood glucose control and flexibility of lifestyle They can be very beneficial for children when they and their parents have the maturity to monitor their function routinely Frequent blood glucose checking is critical when a child uses a pump Insulin pumps are programmed specifically for the childs diabetes routine and combine a set basal rate with bolus doses which are given at meals calculated with an insulin-to-carb ratio and correction doses to bring high blood glucose levels in range calculated with a sensitivity or correction factor Some kids use an insertion device to insert the infusion set The infusion set is inserted with a needle, but the needle comes out and only a small tube stays under the skin The infusion set connects to tubing, which leads to a device about the size of a beeper Children can wear their pump on a belt buckle or in a pocket A pump may be removed for swimming or contact sports for short periods While some pumps claim that they are waterproof, it is advisable to remove pumps during water activities When
pumps are removed from the campers for specific activities, one counselor needs to be in charge of storing all the pumps The pumps should be placed in a safe container near the activity Each camper will change his/her pump site every day based on a published schedule The counselor will accompany the campers to the Pump Palace at the specified time for pump site changes Campers need to take their pump supplies with them to the Pump Palace for their site change If the camper requires a pump site change at another time, this will be supervised by the clinician or the med lodge
15 4/22/2008
Emotional Adjustment A myriad of emotions are experienced when a child, youth or parent is told of the diagnosis of diabetes Some families take the diagnosis in stride But for others, diabetes seems as if it is the worst possible thing that could happen This can be especially true for those who have had a previous family member suffer complications of diabetes In all cases, emotions may shift from time-to-time Feelings of sadness, guilt and frustration are common for the child and family even though diabetes, and the difficulties in managing it, are no ones fault Sometimes children see diabetes as
a punishment and, later on, may see high or low blood sugars as their fault Children need to understand that they did nothing to cause diabetes They also need to understand that blood sugars fluctuate even when a child is following his/her prescribed diabetes management routine Diabetes is a condition that requires intensive intervention on a daily basis The more educated, confident and organized a child and family are, the easier diabetes will be Teachers, coaches, camp counselors and the childs health care team can join to provide a supportive network around the child and family Helping children to understand the emotions they experience and helping them balance their response to those emotions is very important Stressful situations, because of the bodys fight or flight response, can involve an adrenaline release, causing blood sugars to rise Balancing a childs emotional responses to many of lifes stressors a test in school, a big game, going into a new environment, fighting with friends can be very helpful Problem solving techniques, cognitive behavior therapy breathing techniques and quick relaxation exercises are also effective Peer support is one of the best ways to improve
a childs self worth Camps and other programs that bring children together in a supportive, healthy environment with caring mentors are an important part of healthy development But the best medicine of all is to build a network of caring people around the child with diabetes a network that understands diabetes and can help the child make healthy decisions on a daily basis
16 4/22/2008
Preparation Being prepared is essential when you have a child with diabetes in your care Packing a diabetes kit for an adult supervisor who has been trained to monitor and assist the child with diabetes is essential Supplies can fit into a backpack, tackle box or other discreet, easy-to-carry container It is always best to have more than you think you need since children may experience low blood glucose multiple times during the day Problematic blood sugars can take some time to balance and multiple treatments can be needed Being ready before an incident occurs gives you the most opportunity to minimize the outcome A childs low blood glucose can be treated on the soccer field and he or she can be back out playing in 15 minutes Without readiness, the same child could be having a seizure on the way to
the hospital Make a list, pack supplies and be ready to tackle the situation with confidence Conclusion Having read this information you may have more concerns than ever about having a child with diabetes in your care Diabetes, especially type 1 diabetes, is difficult for everyone involved Education and team support is the best method to overcome your worries and to stay on top of diabetes management At Camp Kudzu you will have the support of a very experienced group of clinicians and medical staff available to help you Your reward will evolve as you realize that you befriended and helped a child with diabetes to have a regular experience at camp Success is a few careful steps away I look forward to meeting you at Camp Kudzus orientation session Jill H Sax, RN, CDE Medical Director Camp Kudzu
17 4/22/2008
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