As always, intriguing blog topics are generated by my patients and families. Last week, one of parents expressed a wish to have a handout developed to give to surrogates that may be temporarily responsible for their child or teen with diabetes. Typically this scenario relates to overnighters in which the child is visiting a friend or an invited guest to a party in someone’s home. In this case, the parent is often close by in case of an emergency or need for immediate intervention. In some cases, however, the caregivers are finally given an opportunity to go on vacation wherein a substitute caregiver is completely responsible due to the inability to contact the parents. Therefore, what may be a short “to do, or not to do” list of instructions for a child without diabetes, the instructions related to the child or teen with diabetes becomes a veritable thesis Below is my attempt to concisely generate an instruction guide for substitute caregivers to alleviate anxiety for both primary and secondary caregivers.Please feel free to add to or modify this guide to make it useful for all. Clearly, the family will need to personalize for the unique needs of the child, but this outline should cover all the bases. I also would suggest a practice session with the substitute caregiver to clearly demonstrate how to perform glucose monitoring and determine insulin dosing and administration.
Identifying information (in an emergency)
- Child’s full name and date of birth
- Diabetes team information: physician’s name and emergency number, name of hospital, etc.
- Phone number(s) where the primary caregiver can be reached (if in town)
- Pharmacy phone number
List of supplies necessary for diabetes care (may be with the responsible older child or teen) or given to the substitute caregiver
- Insulin: vials or pens (and needles) and insulin cartridges
- Insulin syringes and needles
- Glucose meter(s) and strips
- Lancing device
- Glucose tabs or gel
- Insulin pump supplies (extra tubing, catheters, and batteries, etc.)
- Blood glucose logs, etc.
- Ketone strips
- All supplies in one place in a backpack (for example) for the substitute caregiver if the child or teen not doing self-care.
Complete information about insulin dosing. Make certain the caregiver knows if the child or teen is capable of managing insulin and blood glucose monitoring on his or her own or if he will need to supervise and do the testing or administering the insulin.
- Timing of insulin doses: type(s) and amounts and sliding scale if used. Make certain vial labels are legible.
- Demonstration of how to draw up insulin in vials and mix insulins (if needed).
- If on a basal bolus regimen
- Basal insulin dose (Lantus or Levemir, and time it is to be administered
- Bolus insulin dose (humalog, novolog, or apidra) for snacks or meals
- Insulin/carbohydrate ratio
- Insulin sensitivity factor
- Examples of application of above principles (this takes a bit of research, so it may be a good idea to provide a list of certain foods and amounts with carbohydrate counts to assist the caregiver. If an overnighter, knowing the brand of pizza or ice cream may give you a heads up about how much insulin to give.)
- Insulin injection sites (where can the insulin be administered)
Typical signs and symptoms of hypoglycemia and hyperglycemia in your child
- Hypoglycemia; sweating, confusion, sleepiness, etc.
- Hyperglycemia: irritability, increased trips to the bathroom
Treatment of Hypoglycemia and Hyperglycemia
- Rapid acting carbohydrate: how much, types (juice, glucose tabs-how many, glucose gel, based on your personal experience)
- If unconscious or seizing: glucagon and call 911 (I would suggest saving an expired glucagon emergency kit and demonstrate how to mix the diluent and the powder
- Increased non-carbohydrate fluids (amount in ounces)
- Increased insulin if necessary (based on your instructions)
- Check for ketones: if present, call physician on call for further instructions (demonstrate to substitute caregiver use of ketone strips prior to visit). NOTE: if this is an overnighter, hyperglycemia noted on two successive occasions may prompt a call to the primary caregiver who can provide further instructions and may come over to check for ketones. (Make sure that you plan ahead and know what the plan is for possible ketones if an overnighter. If the stay is a longer duration, it is important that the substitute caregiver knows how to check for ketones).
The above outline provides the minimal suggestions for the caregiver. I would expect the inclusion of unique additions that are applicable to your child. I would suggest not making the list too long or the caregiver may change his mind. Most surrogate caregivers want to be helpful and prepared. Going over the outline in advance would provide peace of mind to you, the primary caregiver, and empower your substitute caregiver to know the routine and what to do in an emergency.