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Diabetes In Children

All About Insulin

Wednesday, March 21, 2012 - 18:19

Contributing Author: Guy Slowik FRCS

Before the 1920s, there was no treatment for diabetes, and type 1 was always fatal. Then in 1922, insulin was extracted from the pancreases of animals and given to people with diabetes. Since then, insulin has been greatly improved.

  • Through genetic engineering, we can now make insulin that is the same as that made in the human body.
  • It now comes in very short-acting as well as intermediate and long-acting forms.

Children use a combination of short-acting and longer-acting types of insulin. Together, they can provide a background level throughout the day with peaks of insulin after meals, when it is most needed.

Nice to know information:

Insulin has to be given by injection. That's because it's a protein. If it were given by mouth, it would be digested in the stomach, just like food. It is injected into the fat just under the skin, where it can be absorbed into the bloodstream.

Different Types Of Insulin

These are types of insulin presently used.

Type

Names

Starts to work

Peak effectiveness

Duration

Ultra short (clear)

Lispro (Humalog)

5-15 minutes

45-90 minutes

2-4 hours

Short (clear)

Regular (R)

30 minutes

2-5 hours

5-8 hours

Intermediate (cloudy)

NPH (N) or Lente (L)

1-3 hours

6-12 hours

16-24 hours

Long acting

Ultralente

4-6 hours

8-20 hours

24-28 hours

Preparing The Insulin

Sometimes you may use a single type; sometimes you may need to mix two types and give them together in one shot.

  • If there are clumps in the cloudy insulin or it is sticking to the sides of the bottle, get a new bottle. You can return the clumpy one to the pharmacy.
  • Roll cloudy insulin in your hands or shake it gently to mix.
  • Wipe the rubber stoppers of the bottles with alcohol.

Drawing Up A Single Type Of Insulin

Bottles of insulin are airtight. Before you take insulin out, you need to pump in some air.

  1. Wash your hands with soap and water.
  2. Pull air into the syringe by drawing back the plunger to the mark that shows the amount of the insulin dose.
  3. Stick the needle through the rubber stopper and pump the air from the syringe into the bottle.
  4. Holding the bottle and syringe, turn it so the bottle is on top.
  5. Draw out the amount of insulin you need. If there are bubbles in the syringe, tap it gently to make the bubbles move up. Push in the plunger to get the bubbles back into the bottle; then withdraw a dose of insulin without bubbles. (Bubbles won't harm the child but make it hard to measure an exact dose.)

Mixing Two Types Of Insulin

If your child uses a combination of fast-acting insulin and the intermediate type (which is cloudy), follow these steps:

  1. Draw enough air into the syringe to match the dose of cloudy insulin.
  2. Pump that air into the bottle of cloudy insulin but don't withdraw any of that insulin yet.
  3. Draw air into the syringe to match the dose of clear insulin. Pump that air into the clear bottle, then turn it over and withdraw that amount of insulin, as in steps 2 - 5 above.
  4. Now stick the needle through the top of the cloudy bottle. Be careful not to move the plunger. Turn the bottle over, and pull back the plunger to match the total dose of insulin.

Nice to Know Information:

Insulin pens come ready-loaded with the insulin you need, whether it is a single type or a mixture. The pens consist of a cartridge with a needle attached. You set a dial to the dose you want. Pens have enough insulin for several days and are convenient to carry to school or when traveling.

Where To Give The Shot

The insulin goes into the fat just beneath the skin. Ask your health care team about good sites to use, because there is a difference in the rate that insulin is absorbed from different sites. The best places for the injection are:

  • The abdomen
  • The upper arms
  • The thighs
  • The hips (not the buttocks)
  • The calves

Choosing a Spot

Pick a spot about half an inch from the place where the previous shot was given.

Rotate sites around the body so you give each spot a couple of weeks to recover.

How To Give The Shot

  1. Pull the skin tight. If the child is thin, pinch up the skin, so the insulin goes into fat - not the muscle.
  2. Insert the needle straight in as far as it will go.
  3. Let go of the skin.
  4. Push in the plunger, then quickly remove the needle.
  5. If there is blood or fluid, apply pressure with a tissue.
  6. Note the time and the dose in the logbook.

How To Store Insulin

Injections may be more comfortable when insulin is at room temperature.

  • Some people store insulin in the refrigerator door where it will be less cold than in the main compartment. Then they hold it in their hands to warm it before the shot.
  • Others keep their insulin outside the refrigerator. It will stay fresh for one month. If you do this, mark the date. Throw out unused insulin after 30 days.

Keep a spare bottle of each type of insulin in the refrigerator in case there is a problem with the bottle you are using.

How To Information:

Insulin won't work if it is stored below 36 degrees or above 86 degrees. It also can be damaged by sunlight.

  • Don't leave bottles in a car on a hot or cold day.
  • Keep them out of direct sunlight.
  • If traveling by plane, keep the insulin in the hand luggage - not in the cargo hold where it may get too hot or cold.

Care Of Syringes

Syringes can be used more than once but must never be shared. If you are reusing a syringe:

  1. Draw air in and out a couple of times.
  2. Cap the needle. (Don't wipe with alcohol! This will damage the coating.)
  3. Put the syringe back in its protective tube or envelope and store it in the refrigerator.

When the needle starts to get blunt after three or four shots, throw it out. Many states require you to use a special "sharps" container for the disposal of used needles. You can get one of these containers from your pharmacy.

How Much Insulin?

Immediately after diagnosis, your child may need a lot of insulin - and a lot of food - to rebuild the body tissues that were broken down because of lack of insulin.

After the body repairs itself, less insulin will be needed. Once the diabetes is under control, the child will probably need two or more shots a day. One common pattern is:

  • A shot before breakfast, combining intermediate and short-acting insulins.
  • Another combined shot before the evening meal.

As The Child Grows...

The total insulin required will increase as the child grows. As a rule of thumb, the dose is about 1 unit for every 3 pounds of body weight in the course of a day. In adolescence, the need for insulin rises sharply, to about 1 unit for every 2 pounds of body weight.

What May Affect The Need For Insulin?

Precise needs for insulin depend on a number of factors and may vary throughout the day. For example, a child who exercises vigorously may need less insulin (or more food). A child who is sick or under stress may also need more.

  • Your diabetes team will tell you how to increase the short-acting insulin if blood glucose levels rise in response to sickness, anxiety, or a big meal.
  • The team will tell you how to adjust insulin, food, or both on days when the child exercises vigorously.
  • If there's a definite trend towards higher or lower blood sugar, you may need to make long-term adjustments.

Long-Term Adjustments

Your diabetes team will always be your guide in making long-term adjustments, but there are some rules of thumb.

  • Don't change the intermediate insulin on the basis of only one day's measurements. Observe blood sugars closely for a few days to see if the trend lasts.
  • After you adjust the dose of intermediate insulin, wait at least three days before you adjust it again. It can take that long for blood sugar levels to respond.

Here are some examples of when adjustments might be needed:

Scott's morning blood sugar is low.

Scott's diabetes team suggests lowering the before-supper intermediate dose by 10-20%, which increases his morning blood sugar level.

Latisha's blood sugar is low before lunch.

The fast-acting insulin before breakfast is reduced or eliminated.

Paul's blood sugar is high before dinner.

The intermediate insulin before breakfast is increased 10-20%.

Katie's blood sugar is high at bedtime.

The before-supper dose of fast-acting insulin is raised by 10-20%.

The Insulin Pump: Adjustments On Demand

Older teenagers who are highly motivated to control their blood sugar should ask their doctors about the insulin pump. This device lets you fine-tune insulin doses in a way that can almost match nature. But, it requires 6-8 blood sugar tests a day.

The pump is about the size of a beeper and is worn on a belt around the waist. A plastic tube leads to a needle that is implanted in the abdomen. The pump delivers a flow of insulin throughout the day plus extra insulin on demand - for example, before meals.

Diabetes In Children