Practice Point

Diabetic camps for children - effects on control and hypoglycaemia

D Kerr MRCP Research Fellow Sara Kerr SEN State Enrolled Nurse, University Hospital, Nottingham

Correspondence: David Kerr, Diabetic Department, Metabolic Unit, University Hospital, Queens Medical Centre, Clifton Boulevard, Nottingham NG7 2UH

Abstract Educational holidays provide an opportunity to assess the advice given to

parents and diabetic children and provide insight into the difficulties that they face in everyday life. We describe our experience of camping with 43 diabetic

children for two weeks. Hypoglycaemia was common but severe nocturnal episodes may be avoided by assessing the blood glucose in the evening and

providing extra carbohydrate if the glucose value is less than 4.5 mmoYl at that time. Children describe hypoglycaemic symptoms which may differ from those

described in standard textbooks and are predominantly neuroglycopaenic. It was impossible to improve diabetic control using only twice daily blood

glucose monitoring. In conclusion, children should be encouraged to increase the frequency of daily blood glucose testing and parents should be provided with alternative methods of assessing diabetic control such as the results of

glycosylated haemoglobin measurements.

Introduction Parents of diabetic children face a

daunting task; they are encouraged to strive for near normoglycaemia which informed medical opinion believes is the best way to avoid the 20-30 fold increased mortality previously found in early adult life of those who develop diabetes as children (Ref l), although in the shorter term they must prevent excessively frequent hypoglycaemia whilst encouraging the child’s indepen- dence and psychosocial development. All too frequently these two aims con- flict and it is important to strike the happy mean by developing methods which will prevent this conflict.

One such method has been the development of the British Diabetic Association summer camps. The per- ceived benefits of such camps are to:

(a) provide an environment in which diabetes is the norm and to lessen the child’s feelings of being out on a limb.

(b) educate the children in self- management and strengthen their internal ‘locus of control’ (Ref 2) ie encourage the feeling that ‘you can control your diabetes, it does not control you’ give the children (and their parents) a holiday in a safe en- vironment where they can partici- pate in activities that may have been denied t o them by their parents or school.

Participation in these camps by doctors and nurses may provide an other- wise unobtainable insight into the realities, of a child’s life with diabetes, and allow them toevaluate the success or otherwise of the advice they routinely give about improving diabetic control and avoiding hypoglycaemia (Ref 3).

The Camp Forty-three insulin-dependent child-

ren, most under the care of paediatri- cians, attended for a two week holiday under canvas with three children to each tent. The staff consisted of one medical officer, four dietitians, three nurses (none of whom were diabetic nurse specialists), a senior warden and 11 assistant wardens as well as cooking and domestic staff. Seven of the assistant wardens had previous experience with this particular camp and two of the others were long standing insulin- dependent diabetics.

Each child measured blood glucose 45 minutes before breakfast and the main evening meal with BM-Test-glycaemie 1- 44 test strips (BCL Corporation, Lewes, Sussex). The children performed the tests themselves but each strip was checked by a member of staff. Blood glu- cose was also tested by a doctor or nurse if the child reported symptoms or appeared unwell. A Reflolux I1 meter (BCL Corporation, Lewes, Sussex) was available but most strips were read by eye.

Children drew up and administered their own injections supervised by the nurses and were encouraged to vary the anatomical site with each injection, eg arm in the morning and buttock in the evening. Insulin dose was adjusted by the medical officer twice daily depending on blood glucose levels and frequency of hypoglycaemia. Mealtimes were 8.30 a.m. (breakfast), 10.30 a.m. (mid-morn- ing snack), 12.30 p.m. (lunch), 3.30 p.m. (mid-afternoon snack), 6.30 p m . (dinner) and 8.30 p.m. (supper). The diet for each child contained the same amount of carbohydrate as the clinic thought they were having but was altered if necessary on the advice of the dietitians.

The children went to bed at 9.00 p.m. A ‘hypo’ round was performed by the assistant wardens and a doctor or nurse between 10.00 and 11.00 p.m. Each child was advised to report personal symptoms of hypoglycaemia immedi- ately and also tell the staff if they thought another child in their tent might be hypo- glycaemic. Each night one member of the medical/nursing staff remained on- call for emergencies but no further ‘hypo’ rounds were routinely performed.

Hypoglycaemia needing treatment was diagnosed on the basis of symptoms and a capillary blood glucose of <4 mmol/l. Children who previously used urine tests only, were changed to blood glucose monitoring. Children who were initially treated with a once daily insulin regimen, were changed to twice daily insulin if sequential fasting blood glucose levels were above 8 mmol/l. In addition all children were asked by means of a questionnaire; ‘what would you feel if you were going hypo? Describe two feelings’.

Our experiences The clinical characteristics of the

children are summarised in Table 1. Five were initially on one injection a day of whom three had to be changed to two injections. Thirty-seven routinely took two injections and one had four injec- tions a day (Novopen, Novo Labora-

Practical Diabetes March/Aprill988 Vol5 No 2

Practice Point

Table 1 Clinical characteristics

Number 43 10- 13 years 31 Males

Mean duration 4 years (range of diabetes 6112-8 years)

Age

Table 2 Reported symptoms of

h ypoglycaemia

Number Dizzy1 faint 27 Shaky 14 Tiredlsleep y 12 Sicklun weillill 9 Weaklweary 6 Hungry 4 Lose control 3 Bad temperlirrita ble 2 Headache 2 Hotisweaty 2 Shiver 1 Lose vision 1 floppy I Tingling 1 Heart feels funny 1 Total 86

tories Ltd, Basingstoke, England). Six children suffered from enuresis prior to camp but this was only apparent in one during the holiday. No child developed ketoacidosis and glucagon was only administered twice in the two weeks.

Control The mean daily fasting blood glucose

is shown in Figure 1. Fasting and 6 p.m. blood glucose values did not change sig- nificantly between the first and second weeks of the camp. The average fasting glucose level for week one was 9 mmol/l and for week two, 10 mmol/l. The aver- age 6 p.m. blood for week one was 12 mmolll and 11 mmol/l for week two. Overall insulin requirements did not change during the two weeks of the camp.

Hypoglycaemia There were 140 episodes where pos-

sible hypoglycaemia was reported by the children. In only six (4%) was the blood glucose over 4 mmol/l. The frequency of hypoglycaemia at different times of day is shown in Figure 2. The frequency of hypoglycaemia for each individual child was not recorded. There was no signifi- cant difference between weeks one and two. The reported symptoms of hypo- glycaemia are described in Table 2.

Practical Diabetes MarchiApril 1988 Vol5 No 2

Diabetic camps for children - effects on control and hypoglycaemia

Figure 1 Mean (SEM) fasting and 6 p.m. blood glucose values each day

I l 8 1 J

16 - - 1

1 4 - E W v) 1 2 - 0 0 = 1 0 - 0

8 -

J

T

t 1800 hours

0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4

TIME (DAYS)

Figure 2 Total number ofhypoglycaemic episodes recorded during the two weeks of the

camp and the time of day at which they occurred

60

40

20

0 2400 0830 1030 1230 1530 1830 2030 midnight

TIME hours

Discussion Few children and even fewer adoles-

cents achieve satisfactory diabetic con- trol (Ref 4). Possible explanations include the wrong insulin regimen, insufficient injections, incorrect timing and erratic insulin absorption. These ‘technical’ reasons may be less important than dietary indiscretions, too little exer- cise, insufficient monitoring or psychoso- cia1 problems (Ref 5). Using the tools available to the parents of diabetic chil- dren, control as measured by capillary glucose monitoring did not improve despite regular meals and the oppor- tunity for a ‘health professional’ to

adjust each child’s insulin on a day to day basis. This has been the experience of others (Ref 6).

The frequency of regular blood glu- cose measurements may have been inadequate (Ref 7) but is typical, or possi- bly better than, real life where the fre- quency of children testing more than twice a day ranges between 8% (Ref 8) and 26% (Ref 9). Perhaps the method of glucose monitoring was inadequate but agreement has not been reached as t o the best method (Ref 10).

Overall insulin reqirements did not change which is at variance with other studies (Ref 11) but regular exercise each day could not be guaranteed because of

75

Practice Point Diabetic camps for children - effects on control and hypoglycaemia

fluctuations in the weather and amount of homesickness. The benefits of chang- ing children from urine to blood testing are dubious unless the frequency of blood testing is increased and the results acted on. Other methods of assessing overall diabetic control such as glycosy- lated haemoglobin or measured growth velocity are used frequently in the clinic but the results are not always made avail- able to parents (Ref 12).

Hypoglycaemia is a common side effect of insulin treatment (Ref 13) and the threat of it is a constant worry to parents of diabetic children (Ref 14). Doctors often underestimate the frequency of hypoglycaemia and the anxiety and disruption which it causes (Ref 15) and the long term consequences of recurrent asymptomatic hypo- glycaemia remain unclear (Ref 16). A long standing part of ‘camp life’ is the hypo round during the night but, like the flashlight test, the validity of this method of screening remains unproven (Ref 17). Reliance on self and/or peer group reporting for the presence of hypo- glycaemia is as reliable (or unreliable) as any other method in this situation.

The predominance of neuroglyco- paenic symptoms is at odds with text- book descriptions or the information which is given to parents as part of the education process. This is not a new observation (Ref 18) and has been reported at other diabetic camps (Refl9). It may reflect alterations in diabetic con- trol or the effects of increasing duration of diabetes on hypoglycaemic counter- regulation (Refs 20,21). Pseudohypo- glycaemia was uncommon, as was manipulative behaviour. This may be a reflection of peer pressure in a group of children who all have diabetes.

The nature of this camp is such that the decision was taken to treat evening blood glucose values of less than 4.5 mmol/l with extra carbohydrate. The basis for this arose from work (Refs22,23) which suggests that blood glucose around 10 p.m. predicts nocturnal hypo-

glycaemia. It is interesting that this pol- icy did not worsen fasting glucose levels significantly. It is important to emphasise to the children that this is a ‘short-term’ measure and adjustments in insulin dose would be necessary if blood glucose is persistently low at this time of day.

Although the frequency of mild day- time hypoglycaemia episodes did not decrease, treatment with glucagon was necessary only twice in 602 patient days. The clustering of hypoglycaemic epi- sodes is difficult to explain and may be simply due to the fact that the children were tested at this particular time. The methods of detecting hypoglycaemia used at this camp may likewise fail to detect asymptomatic biochemical hypo- glycaemia (Ref 24).

In conclusion it would be difficult for parents to improve their children’s stan- dard of diabetic control simply by using home glucose monitoring unless the number of tests performed each day were increased. This may be difficult to achieve. Second, hypoglycaemia is com- mon but severe episodes may be avoided by checking the blood glucose value late in the evening. We did not make mea- surements of educational attainment but these camps appear to be beneficial for all concerned - staff as well as the patients!

Acknowledgements The authors would like to thank

Robert Tattersall for his helpful com- ments and Pat Lister for typing the manuscript.

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Notice

Practical Diabetes Awards 7987 sponsored by Bedon Dickinson UK Ltd and Novo Laboratories Ltd

It has been decided to extend the closing date for the Awards this year to 30 April which should give those of you who applied for details and have not yet entered, the chance to submit.

There are two categories of Awards, as follows:

In each category the following awards will be made: 2nd prize - S O 0

‘This extension means that there is still a chance to enter if you can complete your submission by the end of April. Further details, including rules of the competition and application forms are avalable from the Chairman of the Judges,

Dr M Nattrass Phd, FRCC: Consultant Physician, The General Hospital. Steelhouse Lane, Birmingham B4 6NH, Tel: 021-236 8611

(A) Medical and Scientific Category, sponsored by Novo (B) Non-Medical Category, sponsored by Becton Dickinson

I st prize - f 1,000 3rd prize - f250

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