There is evidence that glycaemic control deteriorates during adolescence and there is an increased risk of admission to hospital with diabetic ketoacidosis. In addition the early signs of microvascular complications of diabetes may begin to appear in those who have had a significant duration of diabetes.
Aims of Diabetes Care during Adolescence
- Promotion of physical and psychological well being
- Normal growth and development
- Avoidance of diabetes related hospitalisation
- Achievement of good glycaemic control to limit the risk of long term microvascular complications
- Regular screening (annually) for the detection of complications ie urinary microalbumin excretion, blood pressure, and retinal examination.
- Integration into the school, social and working life of people in their age group
Insulin Regimens
- Once daily insulin regimens are not appropriate for teenagers and young adults as they can neither achieve the degree of glycaemic control necessary to prevent long term complications, nor the flexibility to accommodate a busy teenage lifestyle.
- Some teenagers manage with twice daily injections of premixed soluble and isophane insulins prior to breakfast and the evening meal.
- Use of intensive insulin therapy (either multiple daily injections or insulin via continuous subcutaneous infusion) has become the preferred regimen over the last few years. Using this more intensive insulin programme along with more careful matching of insulin dose to carbohydrate (carbohydrate counting) allows greater freedom in the timing and quantity of meals and the spontaneity to join in sport and other activities
Monitoring
- Home blood glucose monitoring is the method of choice
- Young people with diabetes are encouraged to perform sufficient tests to be confident of their control and to record results in a log book. For those using intensive insulin regimens this may require very frequent monitoring (at least 4 tests per day). There is now software available to download blood glucose meters in the out-patient clinic –this can be a valuable teaching tool.
- All young people with diabetes should be able to check for ketones using either urine ketone test or blood ketone meter.
Life-style issues
School/College
Young people with diabetes should not have to miss more school, apart from visits to the clinic, than anyone else. They can undertake all normal activities and their academic and sporting achievements should not be limited. Diabetes UK provides information material for teachers, which may be obtained from the Paediatric Diabetes Specialist Nurses.
Exercise/Sport
Many young people with diabetes enjoy sport and some participate at a highly competitive level. With careful planning and monitoring of blood glucose levels, insulin doses and food sporting performance can be optimized. For further information visit www.runsweet.com
Alcohol
- Most young people with diabetes use alcohol to the same extent as their peers and this can have serious consequences.
- Alcohol excess is one of the common causes of ketoacidosis in this age group
- Alcohol consumption is also a major contributing factor towards hypoglycaemia
- Alcohol excess in the longer term can lead to weight gain and deterioration in glycaemic control
- Information about the effects of alcohol on blood glucose levels should be given along with sensible advice regarding moderate and safe consumption.
Sexual Health
- Contraception and pregnancy should be routinely discussed because of the adverse effect of poor glycaemic control on fetal development.
- Young people with diabetes run the same risk of sexually transmitted infections
- It is important to optimize glycaemic control prior to becoming pregnant to ensure the best health outcomes for both mother and baby.
- Unplanned pregnancy can be associated with major problems – including difficulties in controlling diabetes and serious complications in fetal development
- Counselling and contraceptive advice is available to those attending the Young Adult Clinic. For further information visit- www.fpa.org.uk
Recreational drugs - Use of recreational drugs is illegal
- Use of illicit drugs by young people with diabetes may result in potentially serious adverse metabolic consequences eg ketoacidosis, severe hypoglycaemia.
- Ecstasy has been associated with severe dehydration and the development of ketoacidosis.
- For further useful information visit: www.talktofrank.com
Other Activities
Many young people with diabetes respond well to the opportunity to meet socially to develop their own support structures. The Youth Diabetes (YD) Project started in 1983 and provides a nationwide network of young people to meet and share experiences of diabetes.
Events include:
- The Firbush project, run by Dr Alan Connacher from Perth Royal Infirmary, which provides an annual adventure camp for 16-21 year olds on Loch Tay.
- An annual Youth Diabetes Conference, held in Spring and aimed at 15-25 year olds
- Locally, an activity day is arranged every 2 years for young people aged 14-18yrs with diabetes
Further information can be obtained from the Youth Diabetes Group of Diabetes UK or from the local Diabetes team.
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Transition from Children’s to Adult Diabetes Services
Recommendations for the transition of care in Adolescents with Type 1 diabetes, Type 1 diabetes: diagnosis and management of Type 1 diabetes in Children and young people, National collaborating centre for women’s and children’s health Commissioned by the national institute for clinical excellence (NICE), September 2004
NICE guidelines contain the following recommendations about transition of care in adolescence
- Young people with Type 1 diabetes should be encouraged to attend clinics on a regular basis (three or four times per year) because regular attendance is associated with good glycaemic control.
- Young people with Type 1 diabetes should be allowed sufficient time to familiarize themselves with the practicalities of the transition from paediatric to adult services because this has been shown to improve clinic attendance.
- Specific local protocols should be agreed for transferring young people with Type 1 diabetes from paediatric to adult services (see Tayside Transition Arrangements for Managing the Transition from Children’s to Young Adult/Adult Diabetes Services)
- The age of transfer to the adult service should depend on the individual’s physical development and emotional maturity, and local circumstances.
- Transition from the paediatric service should occur at a time of relative stability in the individual’s health and should be coordinated with other life transitions.
- Paediatric diabetes care teams should organize age-banded clinics for young people and young adults jointly with their adult specialty colleagues.
- Young people with Type 1 diabetes who are preparing for transition to adult services should be informed that some aspects of diabetes care will change at transition. The main changes relate to targets for short-term glycaemic control and screening for complications.
Transition Services in Tayside
Clinic services for young people with diabetes are organized slightly differently across Tayside and North East Fife.
- The age bandings below are guidelines.
- The age of transfer between services will depend on the individual’s physical development, emotional maturity and local circumstances.
- Each patient will require to be assessed on an individual basis to consider his or her readiness to transfer from one service to another.
- The patient’s views should be sought and taken into account when making a decision.
- Prior to transferring to the Young Adult Clinic patients should be given the leaflet “What happens at the Young Adult Clinic (currently under development) to help familiarise them with the differences in the Young Adult Clinic.
- The importance of maintaining contact with this group of vulnerable young people with diabetes cannot be underestimated – the need for all staff involved in their care to take a flexible approach is important and maintaining close links between paediatric and adult services essential.
| Age Range | Clinic | Staff | Ongoing Responsibility |
|---|
| 0-18* |
Children’s
- Every Monday 1.30-5pm, Ninewells Hospital
- 1st and 3rd Wednesday of the month 1pm-5pm, Perth Royal Infirmary
- Thursday (monthly) 1.30-4.30pm, Arbroath Infirmary
- 3rd Tuesday of month 9am-1pm, Montrose Health Centre
- 4th Wednesday of the month 1-5pm, St Andrew’s Memorial Hospital
- Every Tuesday 9.30-11.30am – Nurse led clinic, Ninewells Hospital
- 2nd Thursday of the month 1.30-5pm - Nurse led clinic, Arbroath
- 2nd Wednesday of the 1.30-5pm - Nurse led clinic, St Andrew’s Memorial Hospital
|
Paediatrics |
Paediarics |
| 16-18* |
Teenager Clinic – Dundee Only
- Every 3rd Monday of the month at Ninewells
|
Paediarics |
Paediarics |
| 18-21* |
Young Adults
- 3rd Wednesday of the month 4.30-6pm, Ninewells Hospital
- Thursday (two-monthly) 4-6pm, Perth Royal Infirmary
- Patients seen within adult diabetes clinics in Angus
- Every Monday 9am-12.30, pm, Arbroath Infirmary
- 1st and 3rd Wednesday of the month 9am-12pm, Forfar
- 2nd and 4th Tuesday of the month 9am-12pm, Montrose Royal Infirmary
- 1st and 3rd Tuesday of the month, 9am-12pm, Stratcathro Hospital
- Patients seen within adult diabetes clinics in St Andrew’s
- Wednesday pm (monthly), St Andrews Memorial Hospital
|
Adult with Paediatric input at transition** |
Adult |
| 21+ |
General Adult Diabetes Clinic
|
Adult |
Adult |
* Newly diagnosed patients aged 16 or over should go directly to the Young Adult Clinic (Dundee and Perth) or General Adult Diabetes Clinics (Angus and St Andrew’s). Communication between the Adult and Paediatric service is essential to ensure appropriate care is provided according to the needs of each individual patient.
** Paediatric staff (medical and nursing) will accompany all patients transferring to the Young Adult Clinic/General Adult Diabetes Clinics to their first appointment to facilitate "hand over" and ensure a smooth transition.
- In Dundee this will be approximately every 3 or 4 months at the Young Adult Clinic.
- In Perth with the smaller numbers transferring the timing will need to be agreed but will be within the Young Adult Clinic.
- For Angus and St Andrew’s this will be done on an individual basis given the smaller numbers transferring.
In Ninewells the monthly teenage clinic (for those aged 16-18yrs) is staffed by the Paediatric diabetes team – medical nursing and dietetic - and includes access to clinical psychology services. In Ninewells and PRI there is a young adult clinic (staffed by the adult diabetes teams). Transfer to these clinics is at the discretion of the paediatric diabetes team based on the physical and emotional maturity of the individual, along with their life circumstances
In other areas (Angus, Northeast Fife) transfer is to the adult diabetes service in that area. Joint clinic appointments (with staff form both paediatric and adult services) are arranged in all areas to facilitate transition.
Inpatient Care
Cases of DKA in the age-group < 16 should be admitted and managed in the Paediatric Unit.
Occasionally young people aged 14+ are admitted to adult wards and if this occurs it will require good communication between the paediatric and adult service to ensure appropriate care.
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