Children's diabetes

Diabetes is a condition where the amount of glucose (sugar) in your blood is too high. Insulin helps the glucose move from the blood to our cells, and in diabetics the insulin is not working correctly.

All carbohydrates that we eat affect our blood glucose including both starchy carbs (like bread, rice, pasta and potatoes), and sugary carbs (like sweets, chocolate, biscuits, jams, fruit and milk).

The most common types of Diabetics are Type 1 and Type 2 but there are also some other less common types.

Type 1 Diabetes

Type 1 Diabetes is an autoimmune condition where blood glucose levels are too high because the pancreas cannot produce the hormone insulin.

Type 2 Diabetes is where your pancreas doesn't produce enough of the hormone insulin, and/or the insulin that is produced does not work correctly (insulin resistance).

Type 1 Diabetes is an autoimmune condition where the body's own immune system attacks the cells in the pancreas which produce insulin. This results in blood glucose levels being too high because the pancreas cannot produce insulin.

People with Type 1 Diabetes need to monitor their glucose levels so they can keep their blood glucose levels within the target range. They need to know what to do when their blood glucose is too high, or too low, and which diet and lifestyle factors could cause their glucose levels to change.

When diagnosed with Type 1 Diabetes, the Diabetes team can offer you support and education to learn more about diabetes, carbohydrate counting and insulin management. It's important to remember that nothing you have done has caused Type 1 Diabetes, and there is nothing that you could have done to prevent it.

People with Type 1 Diabetes should follow a normal healthy diet, including the food groups from the Eatwell Guide. Carbohydrates have the biggest impact on blood glucose. Patients should learn about carbohydrate counting, and adjusting their insulin dose dependent on the amount of carbohydrates eaten. We do not recommend low carbohydrate diets in children/young people with Type 1 Diabetes.

Exercise and physical activity can impact your blood glucose, but it is important to include regular physical activity as part of a healthy lifestyle. Dietitians and other health professionals can help you learn about balancing blood glucose levels whilst exercising.

Type 2 Diabetes

Type 2 Diabetes is a condition where the pancreas doesn't produce enough insulin, or where the insulin that is produced does not work correctly (insulin resistance). This results in blood glucose levels being too high because there is not enough insulin to break down the glucose.

Some people with Type 2 Diabetes will need to monitor their glucose levels so they can keep their blood glucose levels within the target range, and some may be treated with insulin and other medications.

When diagnosed with Type 2 Diabetes, the Diabetes team can offer you support and education to learn more about diabetes, including offering support around healthier diet and lifestyle changes.  Type 2 Diabetes is less common in children and young people.

People with Type 2 Diabetes are encouraged to make diet and lifestyle changes to manage the risks of complications. This could include losing weight if they have obesity or overweight, following a diet lower in carbohydrates, higher in fibre, or by counting carbohydrates. We may suggest following a Mediterranean-style diet which has more fresh foods, wholegrain foods, vegetables fish and nuts.

Carbohydrates have the biggest impact on blood glucose, so many patients find it useful to reduce the amount of carbohydrates to help control their blood glucose levels.

Regular exercise and physical activity are an important part of a healthy lifestyle. Being active can help control blood glucose and keep the insulin working effectively. It can also help with losing weight, supporting mental wellbeing and reduce risk of other complications. Aim for at least 60 minutes of exercise or physical activity, every day.

Children/young people with Type 1 Diabetes should follow the same healthy diet as someone without Diabetes. Carbohydrates affect your blood glucose much more than other food groups, view more information about counting carbohydrates. Children and young people should eat to provide enough energy and nutrients for their growth and development therefore it's important they follow a healthy balanced lifestyle. One of the Paediatric Dietitians in our team can help provide further advice and support around healthy eating. Low carbohydrate diets are not recommended for children/young people with diabetes.

Glycaemic Index

Glycaemic Index (GI) tells us how fast a food or drink affects our blood sugar levels. Foods we digest slowly release glucose into the bloodstream gradually and have a low GI value, (remember as slow foods are low GI). Foods we digest quickly release glucose into the bloodstream quickly and have a high GI.

The GI Index is a scale from 1-100 Glucose as a reference point has a GI of 100 so we can compare all other foods against this score. We can describe foods as low, medium or high GI.

• Low GI Foods GI of 55 or lower
• Medium GI Foods GI of 56-69
• High GI Foods GI 70 or more

For healthy eating and to help manage blood glucose levels, low GI foods are best for meals and snacks. What we eat with these carbohydrates (carbs) can also affect how fast the digested glucose enters the blood stream. So meals that are high in fat and protein will also slow down digestion.

See the Glycaemic Index Food List for more information.

For people with Type 1 Diabetes, counting the amount of carbohydrates eaten can be an effective way to keep blood glucose levels in the target range. Carb counting is the method of counting up all the carbs you have for a meal so that you can work out the correct insulin dose.

Each individual child/young person will have their ratio of insulin to carbohydrate, which is provided by your Diabetes Team. A carb ratio tells us how much insulin to give for how many carbs you eat (e.g. 1:15g means 1 unit of insulin for every 15g of carbohydrates). This means by being aware of the amount of carbohydrate eaten can help you take the correct amount of insulin.  Your child/young person may have a different carb ratio for each meal time. This is because the hormones in your body fluctuate with your body clock and this affects how insulin works. As a child/young person grows their carb ratios are likely to change as their body needs more insulin.

To count carbohydrates we can look at food labels, restaurant menu nutritional information, or apps and websites such as Nutracheck, Carbs and Cals, and company information websites (e.g. food producers like Kellogg’s, or restaurants like McDonalds). It's important to look for the full carbohydrate value not just the sugars. Portion sizes can vary so it is important to weigh the amount of food eaten.

To calculate carbohydrates eaten:

• Step 1: Weigh the portion of food in grams (g) e.g. 63g portion of cornflakes (no milk)
• Step 2: Look up grams of carbohydrate per 100g of the product (by looking at the food label, or searching online or on an app - view more information about diabetes apps) e.g. the cornflakes contain 79g of carbohydrate per 100g
• Step 3: To work out how many carbs in 1g, divide the answer to step 2 by 100 e.g. 79g ÷ 100 = 0.79g
• Step 4: To find the number of carbs in your portion, multiply the weight of your food (step 1) by the carbs per 1g (step 3) e.g. 63g (your portion) × 0.79g (carbs in 1g) = 49.8g (carbs in your portion)

See our Carbohydrate Counting Guide with Photos for more information.

All types of carbohydrates need to be counted including natural sugars (in fruit and milk), starchy carbohydrates (in bread, pasta, rice etc.), and added sugar (in cakes, biscuits, sweets etc.).

Some foods have no or very few carbohydrates in them so do not need to be counted. This includes:

• Meat and fish (with the exception of breaded, battered or processed e.g. sausages/burgers as these may contain carbs)
• Cheese
• Eggs
• Pure fats (such as butter and oils)
• Vegetables
• Nuts
• Beans and pulses (with the exception of baked beans as these will contain carbs)

Most restaurants, cafes, takeaways and fast food outlets will have nutritional information either available instore or online. However sometimes you may not have access to the carbohydrate information of the food your child/young person is going to eat, such as if eating at a café/restaurant where nutritional information is not available. In this case, you may have to make estimates based on the information provided in the Carbs and Cals book/app, or alternative books/apps/websites. When an estimate is used rather than a carbohydrate calculation it's a good idea to re-check your child's blood sugar 2-3 hours after their meal.

• If your/their blood sugar is too high (above 7mmol/l) then you may have under-estimated carbs.
• If your/their blood sugar is too low (below 4mmol/l) then you may have over-estimated carbs.

Knowing whether the estimate was too high or too low can help you choose a different carbohydrate value next time you estimate this food.

Regular exercise is good for Diabetes, your general health and healthy growth and development. Exercise is also good for your mental health as it often has a positive effect on your mood, can relieve stress and improve sleep quality. Take a look at this resource provided by Moving Medicine for helpful exercise advice.

When doing sports and exercise your body uses more blood glucose for fuel which can increase your risk of a hypo therefore it's important to monitor your blood glucose. You may also need to adjust the amount of insulin you take, or eat more carbs.

The amount of bolus insulin you take with the previous meal before you exercise may need to be adjusted. You do not want to take too much insulin as exercise alone reduces blood sugar but with insulin on board your risk of hypo could be increased further. The reduction in insulin depends on many factors including the timing of your meal to exercise, the type of foods you are eating, your current blood glucose, the intensity of exercise and more. As it is very complex, this usually involves some 'trial and error' before you figure out what works best for you/your child/young person, and you should discuss these adjustments with our Diabetes team. Some recommendations the team may suggest trying are:

• If eating 30 mins before starting exercise, you are not likely to need as much insulin with this meal, so your bolus could be reduced to half or a quarter of what you usually take.
• If eating 2 hours before starting exercise, you could still have some insulin on board when you exercise if you take your usual full amount, therefore you might find it best to reduce the insulin you take to around three-quarters of your usual dose.
• If eating 3-4 hours before exercising, this will have little impact on the exercise and you can usually take your normal bolus insulin.

If doing competitive sports the hormones your body releases in response to nerves, stress and excitement can also affect your blood glucose - therefore keep checking your blood glucose before, during and after competitive sports.

The target range for blood glucose during activity is usually 7-10mmol/l.  If your blood glucose is low before starting exercise, you may need to take some glucose before starting to exercise and wait until blood glucose is in the target range before starting.

If your blood glucose is high, you may need to take a correction dose of insulin. You may need to check for ketones before starting exercise if blood glucose is above 14. Plus drink extra water during exercise to prevent dehydration. If ketones are high you need to wait for them to return to normal before exercising.

On days where your child/young person is feeling unwell, it's important to be aware of the effect this can have on their blood glucose levels. Our natural response to illness increases our blood sugar and stress hormones. This means making sure their blood glucose is checked more frequently (every 2-3 hours), and adapting the amount of insulin given. You should not stop insulin all together, but may need to increase or decrease the amount of insulin. It is important to always correct a blood glucose that is above target, with bolus insulin.

When unwell it's also important to check for Ketones, as your body may produce more of these when unwell and they can have harmful effects on your body. When your body is not able to use glucose due to the lack of insulin, it produces ketones which can make you dehydrated and thirsty, and eventually can lead to Diabetic Ketoacidosis.

Sick day rules (as recommended by the ADAC Patient Advice for Management of Type 1 Diabetes Mellitus during illness in children and young people under 18 years)

1. Never stop the insulin. Even if you are eating less than normal, your body needs insulin to use glucose and to get rid of ketones.

2. Check your blood glucoses more frequently e.g. every 2 hours including throughout the night.

3. Check for blood ketones. Give additional fast acting insulin every 2 hours if blood glucose is above target. (See Table 1)

4. If ketones are present when blood glucose is low, they are called 'starvation ketones and respond to drinking extra fluids containing sugar. Monitor blood glucose very closely and extra insulin may be required when blood glucose starts rising.

5. Keep well hydrated by drinking plenty of fluids.

a. Water, or sugar-free fluids are probably most appropriate in the majority of cases where blood glucose levels are normal or high

b. If blood glucose levels are low, drinks containing sugar are required, or eat carbohydrates if possible.

c. Avoid carbonated drinks if possible

6. Inform the diabetes team early to seek advice

Using sick day rules for pump patients

1. Same principles apply for pump patients with regards to glucose testing and fluid intake.
2. In addition, even if unwell and blood glucoses are high, standard checks on the pump should be made for occlusions, disconnection and battery failures.
3. Give correction doses through the pump if blood ketone levels are less than 0.6mmol/l. If one correction dose given via the pump has no effect in 1 hour, repeat the correction dose with insulin pen.
4. If blood ketones are higher than 0.6mmol/l, give additional fast acting insulin using an insulin pen.
5. When blood glucose levels are rising in an unwell child/young person needing frequent additional insulin doses, think about using higher temporary basal rates.

We believe that diabetes should not stop you from doing anything you want to - including holidays! Taking your child/young person with Diabetes on holiday either in the UK or abroad may take more planning but it can still be a brilliant experience to help your family relax, have fun and make memories. It's useful to let the Diabetes team know that you're going away as they can offer advice and support including;

Travel letter

Let us know that you're going on holiday abroad so we can provide a travel letter to let the airline know that your child/young person has Diabetes and that you're carrying medical equipment, including devices and medications.

Weather

Extreme hot or cold weathers can affect your Diabetes including how quickly your insulin is absorbed; in hot weather it is likely to be absorbed more quickly, and in cold weather more slowly. In both cases you should monitor your blood glucose levels more frequently and have extra insulin or hypo treatments available should you need them. It's also important to stay hydrated (especially in hot climates) which may mean drinking more water or sugar-free soft drinks. If you suffer from poor circulation or have neuropathy you may not notice signs of frostbite in the cold, or signs of sunburn in the hot weather so it's important to be more aware.

Supplies

It's important to take extra supplies away with you, therefore you may need extra prescriptions to ensure you have enough to take away. Even if you usually use a glucose sensor and/or insulin pump, it's important to take spare glucose monitoring strips and insulin pen should either of the devices fail. (Remember to transport your spare insulin or other medications in a cool bag, this will ensure it remains effective.) It's important to take a record of all or your ratios and basal or night time insulin, for use with pen injections, even if you are on a pump or pod. If your devices fail then you know what you have to revert back to. Ask your diabetes team if you are not sure. You can keep a record of these in your Digibete app under 'My Type 1'. Taking spare batteries is a good idea too.

Hand luggage or hold luggage

When traveling on an aeroplane it's important to pack your insulin in a cool bag/cooling wallet, and store your insulin and other medical equipment in your hand luggage in the over-head storage, as the main hold luggage is too cold. Having extra hypo treatments in your hand luggage is best too should you need them, along with snacks to help maintain your blood glucose levels. You may want to put some of your medications in a friend/family member's bag so you have spare in case your hand luggage goes missing.

Airport security

It's best to print a copy of the Medical Device Awareness Card provided by the Civil Aviation Authority as this will explain to security officers at the airport how to treat you and your medical devices. You should never be asked to remove your medical device (e.g. blood glucose monitor or insulin pump) and these devices should not go through the security scanners or x-ray machines. Alongside this card you should also have the travel letter provided by your Diabetes team.

Travel insurance

Travel insurance is important as this can cover the costs of any emergency medical care you may need while abroad. It's very important to declare your diabetes and any other medical conditions to your travel insurance provider.

Crossing Time Zones

If crossing time zones you may need to change the time/date on your insulin pump so you get the right basal dose. It's important to speak to your Diabetes team before you travel so we can provide additional advice.

When your child/young person has Diabetes, you may notice some additional extra costs. Additional costs when caring for a child/young person with Diabetes may include resources like buying additional hypo treatments and carb counting books or phone apps (such as Carbs and Cals), getting your child a smartphone for blood glucose monitoring (and mobile data and/or wifi to support this), additional transport costs of attending appointments and needing to take unpaid time off work to look after your child/young person. The NHS pays for all the really necessary items needed to care for diabetes like insulin, pens, needles, test strips, pumps and sensors, but you may find it helpful to look at options for financial support for other additional expenses.

Disability Living Allowance (DLA)

Diabetes is classed as a disability when applying for benefits, when you or your child/young person cannot manage their Diabetes without insulin or another medication/treatment. As a parent or carer of a child/young person with diabetes, we would encourage you to consider applying for Disability Living Allowance (DLA) to help with the additional costs of looking after their Diabetes. This can be applied for 3 months after your initial diagnosis.

DLA is for young people under the age of 16yrs. The DLA rate is currently between £26.90 and £172.50 per week depending on the level of support the child/young person needs. For more information on and to apply for DLA visit gov.uk or visit Diabetes UK to learn more about Diabetes and benefits.

When a young person turns 16yrs old they will need to apply for Personal Independence Payment (PIP). Visit gov.uk for more information on PIP.

Healthcare travel costs scheme (HTCS)

The Healthcare Travel Costs Scheme (HTCS) can be used to claim a refund of reasonable travel costs if attending the hospital for NHS treatment or diagnostic tests. This scheme is only available for families receiving one of the qualifying benefits or who meet the eligibility criteria for the NHS Low Income Scheme.

To claim a refund on your travel costs:

1. On arriving at the hospital, collect the claim form from the cashiers office
2. Complete the form and get a member of staff to sign, confirming your attendance
3. After your appointment, take this form together with:

• Proof of appointment - such as an appointment letter or text
• Travel tickets, parking ticket
• Proof of the benefits you receive or your tax credits award notice.

Local advice and support

The local councils provide a directory of local services including financial support, foodbanks and more which may help you access additional support for your family:

• Locate County Durham
• Livingwell Darlington

For advice around claiming benefits or other financial support you can speak to the local Citizens Advice team (County Durham, Darlington, Redcar & Cleveland) who provide free, independent, confidential and impartial advice.

Paediatric diabetes charitable trust fund

The Paediatric Diabetes Charitable Trust Fund is for the direct benefit of the Children and Young People (CYP) with diabetes cared for by County Durham and Darlington NHS Foundation Trust. For more information on this visit our page about the Paediatric Diabetes Charitable Trust Fund or speak to one of our team.

CYP NENC network inequalities project

This project aims to increase the accessibility to diabetes technology. Through the scheme the diabetes team are able to apply for a mobile phone, sim card or laptop that will support the use of diabetes technology (such as bolus calculator phone app, carb calculating app, blood glucose sensor, ability to download sensors or insulin pumps). Please speak to a member of the diabetes team if you feel this project could help your family

As a parent of a child/young person with a new diagnosis of Type 1 Diabetes diagnosis, you may experience many emotions including fear, shock and worry. It can be hard to come to terms with what your child's diagnosis meals and how this impacts your family.

We know there is a lot to learn within those first few days, weeks and months, and most parents will have very little knowledge of diabetes before their child/young person is diagnosed, take a look at our Diabetes Information or visit DigiBete's newly diagnosed page to help understand more about Diabetes. DigiBete provide a selection of videos that can help in the daily management of Type 1 Diabetes, and you can see other children and young people talking about their T1D.

Our team are here to support you though this diagnosis to help you understand what it means, how it impacts your day-to-day life, and our clinical psychologist can support you with your emotions surrounding the diagnosis.

Each child/young person with Diabetes will be offered a minimum of 4 clinic appointments each year. These appointments include seeing the Doctor, Nurse, Dietitian and Clinical Psychologist; all within the same appointment known as a multidisciplinary team or MDT. When attending an MDT clinic the team may all be in the same clinic room, or spread across a couple of clinic rooms which you may be asked to move between within your appointment.

These appointments are usually offered at Chester le Street Hospital, Darlington Memorial Hospital and Bishop Auckland General Hospital, and typically last anything between 60 and 90 minutes.

When your child/young person attends a MDT clinic they will usually be weighed and have their height measured, along with taking a blood sample so they can check your HbA1c (haemoglobin) which is an indicator of how well managed your blood glucose has been over the last 10-12 weeks. These measurements are usually taken by a Healthcare Assistant and the results interpreted by the Doctor, Nurse or Dietitian.

In addition to the MDT clinic's you may be contacted by the team for check-ups, advice and support, school visits or other reasons such as if you have a high HbA1c. Extra appointments generally last 30-60 minutes and may be with any one of the team. The team may recommend support from the clinical psychologist if appropriate.

We aim to keep the professionals you see as consistent as possible so you can build a relationship with the team. Each healthcare professional plays an important role within your child's Diabetes care;

Doctor or Consultant: It's important for a Doctor or Consultant to be involved in your diabetes care to ensure we're supporting you to manage your diabetes and overall health, including helping you to reduce your risks of developing complications.

Paediatric Diabetes Specialist Nurse (PDSN): These Nurses have specialist knowledge of diabetes; they offer advice and support around managing your blood sugar, adjusting your medications and general diabetes care.

Specialist Paediatric Diabetes Dietitian: The Dietitians in our team are experts in food and can help you understand how what you eat effects your diabetes.

Clinical Psychologist: Speaking to a Psychologist within our team can help with your emotional wellbeing. We know that living with diabetes can be difficult for both the child/young person and family, they can help talk through things with you.

During clinic appointments the team may refer to 'The Ormskirk Model', which can be used as a visual prompt for patients and their families to encourage reflection and focus on strengths. It also helps our team to understand what is important to you.

Our clinical psychologists mainly support the children in our service, however we understand that parent's wellbeing is important too therefore parents can request a one-off parent session to review parental wellbeing and signpost to appropriate adult based services as required.

Our clinical psychologist may signpost you to the following services for more support:

• Your GP
• Affective Disorders Team, for community mental health support linked to Anxiety and Low Mood (tel: 01388 645399
• Talking Therapies

All children (under 16 years) in the UK are entitled to free prescriptions. If between 16-18 years, and in full time education you can also get free prescriptions. After this most adults start to pay for their prescriptions.

Did you know

People with diabetes who require insulin or other medications to control their blood glucose levels are exempt from paying for prescriptions as diabetes is a specified medical condition. To claim free prescriptions you must apply for a medical exemption certificate, to do so speak to your GP. Remember you only need to apply for a medical exemption certificate at 18 (or 16 if you leave education).

We believe that diabetes should not stop you from doing anything you want to - including learning to drive. You can still get a driving licence when you have Diabetes, but there is some important steps you should take when learning to drive.

When you have Diabetes you need to make the DVLA and your car insurance provider aware of your Diabetes, you will also need to provide the contact details of your GP and Consultant when applying. You must complete a DIAB1 form, a video showing how to complete this form is available on Youtube.

You may be issued with a licence for between 1 and 3 years, depending on your circumstances, and you will need to update the DVLA on your health each time it is due to expire. The DVLA will contact you, and you will need to complete the necessary forms. You do not need to re-sit your driving test each time the licence expires.

Blood Glucose Levels

When driving with Diabetes the most important thing to remember is 'Five to Drive'. Your blood glucose levels should be above 5mmol/L to drive.

If your blood sugars are between 4mmol/L and 5mmol/L it's important to eat some glucose/carbs before driving, to prevent a hypo.

If they are below 4mmol/L or you have symptoms of a hypo, you should not drive. You must take your hypo treatment, recheck your glucose levels and wait 45 minutes after glucose levels returning to normal before driving. If you're already in the car when you notice a hypo you must pull over as soon as is safe to do so, switch off the engine, remove your keys from the ignition (put them in the floor well so they are not on your person) and move out of the driver's seat.

To keep yourself safe when driving:

• Always check your blood glucose before driving
• If you wear a continuous glucose monitor, ensure that the date and time are correct on the meter/monitor
• Ensure you have you have glucose meter and blood glucose strips with you, even if you wear a continuous glucose monitor
• If taking a longer journey, check your glucose levels every two hours, or more often
• Keep hypo treatment in your car so you always have something to increase your glucose levels
• Although the DVLA don't have any rules on high glucose levels, it's important to take insulin treatment with you should you need to treat a hyperglycaemia. High blood glucose levels can affect concentration and decision making skills.

Complications of Diabetes

People with Diabetes can develop complications with their eyesight, so it is important to look after your eyes and report any problems or treatments to the DVLA. To drive you must be able to read a car number plate from 20 meters away (this can include whilst wearing glasses or contact lenses if needed.)

Likewise, people with Diabetes may have symptoms of neuropathy, where you lose the feeling of your hands or feet. You should make the DVLA aware if you have these symptoms, and your Diabetes team can offer you advice around neuropathy.

If you have any other health conditions you should make the DVLA aware.

We believe that diabetes should not stop you from doing anything you want to - including going to college, university or getting a job.

Employment

The Equality Act 2010 means that it's against the law to discriminate against certain characteristics including disabilities. Although you may not feel as though you have a disability, Diabetes is classed as a disability by law, including under The Equality Act. It also ensures that employers must make reasonable adjustments for people who are disadvantaged because of their condition. You can visit Citizen Advice to understand more about your rights, responsibilities, and how to deal with discrimination.

Some jobs will have additional risks, or have a bigger impact on your Diabetes. This includes jobs that are more active such as involving include heavy lifting, and those that include driving or operating heavy machinery, and those where shift work could impact on your Diabetes routine.

In most jobs you don't need to tell your employer that you have Diabetes, but some jobs will involve a medical check where you should disclose this. Even if they don't ask about your medical history, it's best to make them aware of your condition as they may be able to make adjustments to support you.

Diabetes may even come in useful when applying for jobs because your experience of living with Diabetes will have helped you develop many transferable skills. Employers want to hear about how your experiences have shaped who you are, and Diabetes will have played a role in developing many skills such as being good at decision making, problem solving, and being able to understand data, amongst many more.

University

Having Diabetes shouldn't stop you from going to university.

Like when applying for a new job, when applying for university you may be able to talk about many of the transferable skills you have developed through living with diabetes.

When applying for university it's important to tell them you have a disability. Although you may not think of Type 1 Diabetes as a disability, in terms of the law it is. When applying using the UCAS system you should declare diabetes, and once you have been accepted you should contact the student support services at your university to let them know too. They will be able to help in making adjustments such as getting a fridge in your room for you to store your insulin.

Having diabetes comes with additional costs so it's a good idea to apply for Disabled Students Allowance. This additional financial support can help cover some of the extra costs because of your Diabetes. You do not have to pay this money back, and it's in addition to any student finance.

If you choose to move away from home for University you can choose what you would like to happen with your Diabetes care. You may choose to keep your healthcare at home and continue to work with our local team, or you may choose to get support from another hospital in your new area.

Once you've started university and begun meeting new people, it's useful to make your new friends aware of your diabetes including making them aware of your hypo symptoms and treatment. Having people around you who can support you with your diabetes is important, especially if drinking alcohol.

When going to a festival (either just for the day, or overnight) it's important to be prepared by taking extra diabetes supplies.

Make sure the people you are with are aware of your diabetes, and how to treat a hypo, should this happen. It's a good idea to carry some medical ID, to make people aware of your Diabetes and treatments; most smartphones allow you to add medical information to your home screen for emergency use.

You may need to go through security to get into the festival. Just like at the airport, you should never be asked to remove your medical device (e.g. blood glucose monitor or insulin pump) and these devices should not go through the security scanners or x-ray machines, instead a member of security staff may manually search you, also known as a pat down (this should be done by someone of the same sex as you). Having some medical ID (such as a card or band) with you that confirms your condition may be helpful.

If you wear a blood glucose monitor (e.g. Dexcom or FreeStype Libre) sharing your blood glucose data with friends or family members via the glucose monitor app, may be a good idea. It's a good idea to take a power bank to charge your devices, such as your phone if you use this to monitor your glucose levels.

If planning on drinking alcohol, taking recreational drugs or smoking while at the festival visit our Risk-taking Behaviours page to find out how they affect your blood glucose.

And remember to have fun, don't let your diabetes stop you from going to a festival.

Alcohol

Children and young people are advised not to drink alcohol before the age of 18. However if you do choose to drink alcohol, it's important to be aware of the effect alcohol has on your Diabetes. Alcohol interferes with your blood sugar levels and can make you more likely to have a hypo. The liver stores extra glucose which can be released back into the blood when your body needs it (e.g. when having a hypo), but alcohol effects the liver and can prevent the liver from being able to release the additional stores of glucose.

Alcoholic drinks can have carbohydrates in them, however generally it is not recommended to count these carbohydrates or give additional insulin for these drinks, as this can increase the chances of having a hypo. Alcoholic drinks with carbohydrates in them may increase your blood sugar initially, you may choose to drink diet or sugar-free mixers with alcohol to help stabilise your blood glucose levels.

It's important to make sure the people you are with are aware of your diabetes, and how to treat a hypo, should this happen. It's a good idea to carry some medical ID, to make people aware of your Diabetes and treatments, as people may mistake your hypo symptoms for being drunk if they are unaware.

If you wear a blood glucose monitor (e.g. Dexcom or FreeStype Libre) sharing your blood glucose data with friends or family members via the glucose monitor app, may be a good idea. Making these family and friends aware that you're planning to drink alcohol can help too. If you do not wear a blood glucose monitor you may want to check your blood glucose more frequently when drinking alcohol.

It is usually a good idea to eat before you drink and also have a snack afterwards.  This may help reduce the risk of hypos.  However, if you are on a Closed Loop System you may not need this extra food. Close monitoring of your blood sugar is important so you can track how your body responds to drinking and how best to keep yourself safe.

After drinking alcohol, it's important to drink water before bed, and in the morning when you wake up. Check your blood sugars as soon as you wake up, and frequently throughout the next day you're your blood sugars are low you will need treatment for a hypo straight away, and you should always have breakfast even if feeling hungover.

Recreational Drugs

Different drugs may affect their diabetes in different ways. There hasn't been much scientific research on type 1 diabetes and the effects of recreational drugs, however we would recommend that you don't take them.

Like with drinking alcohol, when taking drugs your judgement may be impaired which can affect your diabetes management. For example, you may forget to take your diabetes kit with you, you may forget to administer your insulin, or you may mis-calculate your carbohydrate counting. Your appetite can be affected when taking drugs, you may eat more or less than usual which will affect your blood sugars. You may be more active than usual (e.g. dancing) which can increase your risk of a hypo. You may feel unwell which can also impact your diabetes management. You or others may mistake your hypo symptoms with the effects of the drug which may delay treatment for a hypo.

When there is not enough insulin and you have a high blood sugar, the body breaks down fat for energy. The leftover chemicals are ketones. It's important to note alcohol and recreational drugs can cause blood glucose levels to be normal but ketones to be high (above 0.6). Remember to check for ketones if drinking alcohol or taking recreational drugs.

Smoking

Smoking makes it harder to manage your diabetes as it can cause your blood glucose levels to rise. The nicotine in cigarettes (and vapes) can cause insulin resistance; where the cells change so they no longer respond to insulin. This means smoking increases peoples risk of developing Type 2 Diabetes. In people who already have Diabetes (including Type 1), smoking can still cause insulin resistance, so you may need more insulin to control blood glucose levels.

People with Diabetes (especially those who have poorly controlled blood glucose levels) have an increased risk of cardiovascular complications (e.g. heart attack, stroke, circulation problems). Smoking also increases risk of cardiovascular problems too, so when you have diabetes and smoke this increases risks even further. Both smoking and diabetes cause damage to the artery walls, which can lead to the build-up of fatty deposits and the narrowing of arteries. This makes it harder for the blood to transport oxygen around the body, and if they become blocked you may have a heart attack or stroke.

Likewise both smoking and poorly managed diabetes can damage your eyes, kidneys and feet.

The nicotine in cigarettes can damage the blood vessels in your eyes which can cause sight loss. Poorly controlled blood glucose (regular highs) can also damage the blood vessels in the eyes, (specifically in the retina). If these blood vessels leak and become blocked this can also lead to sight loss, known as diabetic retinopathy.

When the blood vessels around the kidneys are damaged (either by smoking, poorly controlled diabetes, or both) the kidneys stop working as well as they should. The kidneys filter out waste products from our blood into our urine, such as toxins. When the kidneys aren't working properly, they become leaky and more protein will be passed into the urine.

When the blood vessels around the feet are damaged they become stiffer and narrowed, which stops blood reaching them properly which can cause sores, ulcers and gangrene. These wounds and ulcers cannot heal properly. Diabetes can also cause damage to the nerves in the feet, leading to a loss of feeling, and potentially bone and muscle weakness.

Vaping

There has not been a lot of research on vaping and diabetes, however as vapes contain nicotine, they can have the same risks as smoking. Vape flavorings can be sugar based therefore can raise blood glucose levels when inhaled.

Between the ages of 16 and 18 young people begin to move towards adult clinics. The transition from paediatric to adult services can be challenging for some young people as this involves getting to know a new healthcare team, and learning new skills to be able to manage your Diabetes.

During this transition period, you may attend clinics with more health professionals than usual (such as both a paediatric nurse and an adult nurse). This is because the aim is to introduce you to the adult team during this time before your care is transferred to adult services.

During transition you can expect the same frequency of appointments as paediatric services (minimum of 4 per year). However once over 18 and in adult services the frequency of appointments may reduce, and you may need to be more proactive in engaging with the service. You may also receive less support from Dietitians and Psychologists in adult services.

Currently the transition clinics take place in Paediatric Outpatients at both Darlington Memorial Hospital and Chester le Street Community Hospital, but at Bishop Auckland General Hospital transition clinics are held in Main/Adult Outpatients. We may be able to move all transition clinics to Adult Outpatients in the future so please check appointment letters.

Once over 18 and in adult services, all appointments will be in Main/Adult Outpatients, regardless of which hospital you attend. If you're usually seen at Chester le Street, you may be invited to addend appointments at either University Hospital North Durham, or Shotley Bridge Community Hospital.

Clinic checks

When attending clinics the Diabetes team are checking your health to see how well your Diabetes is being managed, and to help identify any current or future complications. Most of the things they need to check will stay the same as you transition from paediatric to adult services, including checking your urine ACR, blood pressure, eyes and feed.

Some of the methods for checking your health during clinic may change when in transition. In paediatrics, blood samples to check your HB1AC and TSH are usually just a finger prick, however in adults this will move to a venous sample  (from your vein). During transition clinic they might use a mixture of both methods to prepare you for adult clinics.

In adult services the blood checks are usually completed at your GP surgery approx. 1-2 weeks prior to your outpatient appointment (so the results can be checked during your appointment). You will need to book this appointment with your GP practice.

A Clinical Psychologist that works across all sites (Monday- Thursday)

The Clinical Psychologist is also a Clinical Supervisor for Clinical Psychologists in training, as such there are often 'Trainee Clinical Psychologists' on placement in the paediatric diabetes team

Our Assistant Psychologists support with: developing resources linked to wellbeing, helping with service development projects and complete school based observations as required

The Clinical Psychologist offers clinics in parallel to the diabetes team, meaning the following availability:

• Monday - Bishop Auckland
• Tuesday - Chester le Street Hospital
• Wednesday - Darlington Memorial Hospital
• Thursday - Morning:  Community Clinics (Schools, home visits)/ Afternoon: Telephone Clinics

Ask in clinic or contact the Diabetes Duty phone: 01388 455 880 - a message will be passed on to the Psychology team or email: cdda-tr.CDDFTpaediatricdiabetesteam@nhs.net using the subject Psychology

CAMHS:

• Single Point of Access (SPA): 0300 123 9296
• Crisis Team (24/7): 08000 516171

Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

The Durham and Darlington Neurodevelopmental Pathway team are best placed to answer your query on 01740 626 300 or by email: tewv.darlingtonneuro@nhs.net

Referral forms and additional information can be found at:  https://nenc-countydurham.icb.nhs.uk/our-work/needs-led-neurodevelopmental-pathway/

As your diabetes team, we do provide supporting information for your neurodevelopmental assessment, if this is requested by the Neurodevelopmental Pathway. We will notify you of the request and review consent for us to share information.

After diagnosis or when starting a new school a meeting is held with the school, family and a paediatric diabetes specialist nurse. At this meeting the young people under our care with be provided with a school care plan, which is an agreement between the young person and school in order to support fitting the young person's diabetes management into school life.

The following organisations provide resources to help support schools:

JDRF: We would recommend that all school staff involved in the care of a young person with diabetes completes the two JDRF modules online.

Digibete: For carbohydrate counting support please click here to watch a virtual presentation, provided by Digibete which is aimed for kitchen and lunchtime support staff. Digibete also provide really useful video resources to support schools, click the following links to take you to the online resources:

• Pre-school
• Key stage 1 & 2
• Key stage 3 & 4

Diabetes UK: For more information about schools and Diabetes including ordering free printed schools packs visit Diabetes UK.

If you have not been able to access the information you need via the resources above please contact the paediatric diabetes specialist nurses to provide support and training.

When moving from primary school to secondary school a lot of things will change and this can feel overwhelming. This may include meeting lots of new people, having different teachers for each lesson instead of just one teacher, your journey to and from school will likely change and you may travel more independently, and there may be a lot more choices of foods at lunch and break times.

Getting to understand how these changes may affect your diabetes management is important and there are many things you can do to help it all seem easier.

Before starting secondary school, you/your parents can ask to meet some of the staff at your new school to talk about your Diabetes including going through your care plan. You may find it useful to make them aware of the technology you use and how you are likely to need access to your mobile phone during the school day, along with why you might need extra snacks, drinks and visits to the toilet throughout the day. You may be able to ask for additional supplies to be kept somewhere safe in school should you need them, such as hypo treatments and insulin.

You may find it useful to carry a card in your pocket which shows that you have diabetes, including key information about your symptoms of hypos/hypers and what type of equipment/technology you use. You may choose to show this to new teachers as you meet them, and new friends if you feel comfortable doing so.

Travel

If your travel to and from school is becoming more independent you may choose to practice your journey to and from school ahead of time to help you feel more relaxed and confident on your first day. If your travel to school makes you feel nervous or stressed this can affect your blood glucose levels. If actively travel to school (e.g. walking/cycling) this can lower your blood glucose levels so it's important to check these before you start your journey and after you arrive.  You may also be walking around more during the day such as between lessons.

School meals

The school food at secondary school is likely to be very different to primary school food. At secondary there will be a much greater selection of food, including more choices available at break-times too. At primary, meals tend to be ordered in advance, or at the start of the school day, whereas at secondary it's much more like being at a café where students can take a look at what is available on the counter and make their choices during the lunch/break service. For students with diabetes this can be more challenging as most diabetics count the carbohydrates and inject the insulin before eating the meal. You may find it useful to speak to the catering team about what can be done to a make eating school meals easier for you; e.g. asking for a copy of the carbohydrates in each menu item, asking if you can pre-order your meals so your carbohydrates can be counted in advance, asking about queue jump so you can receive your meals first and asking about whether they can weigh your portion as they dish up. 

Primary Schools:

In County Durham most of the primary schools have menus created by the catering company Chartwells. Chartwells' Registered Nutritionists calculate the nutrition information for their menus - including carbohydrate (carb) counts. If your child attends a primary school in County Durham ask your school to provide you with the form to get these menus.  You need proof of diagnosis, such as the school care plan or a hospital letter.

If your child attends a private school, goes to school in Darlington or outside of the County Durham area, then it is best to contact your school directly to find out if their catering company has calculated the nutrition information. If no information is available you may need to use a book/website/app to estimate the carbs of your child's favourite meals. If you need help with this please ask your Dietitian.

Secondary Schools

The school food at secondary school is likely to be very different to primary school food. At secondary there will be a much greater selection of food, including more choices available at break-times too. At primary, meals tend to be ordered in advance, or at the start of the school day, whereas at secondary it's much more like being at a café where students can take a look at what is available on the counter and make their choices during the lunch/break service.

For students with diabetes it remains important to inject insulin before eating your meal. This can be especially challenging if you inject using pens in a room separate to the dining hall and you do not yet know what you want to eat. You may also find that you need to calculate the amount of carbohydrates in your school meal yourself.

Here are some ideas you may like to try whether on pens or pumps:

• Look on the school website at the menu to see what they offer and for contact details of the catering team and/or catering company.
• Speak to the catering team and ask if they have nutrition information on carbohydrates or average weights of food portions?
• Can you pre-order your meals so they can put them aside for you?
• Can you get an early lunch pass or a pass to jump the queue?
• Can the dinner service staff weigh your portion as they dish up?
• If the school does not have any nutrition information, look at the menu the day before and estimate the carbs using an app/book* or see if our leaflet on school food has an example of carbs per portion for you.
• Make a list of the foods you usually eat at school with their carbs either on your phone or keep with your diabetes kit.
• If you know other children with Type 1 diabetes at the school ask if they have worked out the carbs in the food.
• If you need help with carb counting please ask your dietitian for extra support.

If you are not usually allowed phones in school, you may need to ask permission to use your mobile phone for medical purposes (which includes checking carbohydrate information). If you have to estimate the carbohydrates then it's a good idea to re-check your blood sugar 2-3 hours after the meal.

• If blood sugar is too high (above 7mmol/l) then you may have under-estimated carbs.
• If blood sugar is too low (below 4mmol/l) then you may have over-estimated carbs.

It can be challenging to get used to, so you might consider taking a packed lunch to start with and building up confidence with the school meals by trying a dish one day a week. Your dietitian will be able to offer you further advice around school food.

*Useful apps for carb counting include Nutracheck and Carbs and Cals.

• JDRF Schools E-learning Module

• YouTube - Carbohydrate Counting for School Staff

• DigiBete - Pre-school

• DigiBete - Key stage 1 & 2 (Primary)

• DigiBete - Key stage 3 & 4 (Secondary)

• Diabetes UK - Schools

• County Durham School Meals

• Chartwells School Meals

Most people with Type 1 Diabetes need to regularly check their blood glucose levels. A continuous blood glucose monitor can be used instead of manually checking glucose levels with a finger-prick test.

There are a range of types of Blood Glucose Monitors and the team will discuss which options are suitable for your child/young person. The most common blood glucose monitor brands we use are the Dexcom and the FreeStyle Libre, but others are available. Most glucose monitors use a small sensor that is worn on the skin and connects to your smartphone via an app so you can see your blood sugar levels on your screen.

With most glucose monitors you can set up additional people on your account so family members can follow your blood glucose levels too, along with the Diabetes team. You can also set up an alarm so the app alerts you if your blood sugar levels go too high or too low.

Within the app, you'll be able to track how different things effect blood sugar levels such as food, exercise and the temperature. The app will also show how much time you're in your target range, and our team will be able to offer you advice on changes you could make to increase your time in range. For more information on technology including continuous blood glucose monitor visit DigiBete.

Many apps are available on smartphones which may help you to manage your Diabetes and blood glucose levels.

Educational

Applications are available which contain educational Diabetes resources suitable for different ages. We recommend downloading the Digibete app to access updates from our team. There are 2 versions of the phone app, one for young people with type 1 diabetes and a second for young people with type 2 diabetes. When you download the app it requests a clinic verification by entering a 5 digit code. Our clinic code for type 1 young people is TYHL1 and the clinic code for young people with type 2 diabetes is J27J1. Registering that you receive care from our team allows you to access updates posted by the team. You can also save information such as insulin ratios, pump settings and appointments within the app so it's all available in one place.

Counting Carbohydrates

There are apps available which can help you to count the number of carbohydrates in your food, the most common used apps for this are Nutracheck, Carbs and Cals, and MyFitnessPal.

Bolus Calculator

There are apps available which can help you understand how much bolus insulin you should take. We recommend the MyLife app however others are available. The calculator uses your current blood glucose level, counted carbohydrates, carbohydrate to insulin ratios, type of insulin and target blood glucose range to help you calculate how much insulin you should take. Please ask the Diabetes team for help setting up your bolus calculation settings on the MyLife app.

Monitors and Pumps

If you wear a glucose monitor or insulin pump, you may find it useful to download the manufactures app which links to your technology (e.g. Dexcom G6/G7/Clarity apps, or Freestyle Libre app). These apps may have functions such as a stimulator (e.g. Omnipod 5 Simulator or t:simulator) to help you learn to use the technology, or functions to help you monitor your blood glucose (the MyLife app connects with the Ypso pump, Dexcom G6 CGM and FreeStyle Libre 3 CGM).

An insulin pump is a small electronic device that releases the insulin your body needs automatically. The pump is attached to your body by a small tube (known as tethered, such as a t:slim) or is worn directly on the skin (known as a patch pump, such as a Omnipod). (Please note there are serveral other brands are available).

Diabetics take two types insulin each day, known as basal and bolus doses. Basal insulin covers background insulin needed to keep glucose levels in range between meals and overnight. When using a pump, only fast acting insulin is used. The pump automatically administers a small amount of insulin throughout the day.

Bolus insulin is an additional dose of insulin needed for food (meal bolus) and/or to lower high glucose levels (correction bolus). You will tell the pump when it needs to administer additional insulin, such as when food is eaten or a correction is needed. Like with an insulin pen, you will need to use their 'carb ratio' or 'correction ratio' to calculate how much insulin to administer.

A closed loop system is when you wear both a continuous blood glucose monitor and an insulin pump and they communicate with each other. When using a closed loop system the insulin delivered by your pump can automatically be adjusted in response to your blood glucose levels. Such as; if you're reading high on your blood glucose monitor the pump will increase the amount of insulin being delivered to prevent glucose levels rising further, or if low blood glucose the pump with decrease the insulin to help prevent a hypo. The pump will automatically pause insulin delivery when blood glucose is too low e.g. below 3.3 mmol/L. The Diabetes team will have programmed the target glucose range for the patient. It's important to note that even when using a closed loop system, the pump still needs to be told when a meal is going to be eaten including how many carbohydrates. For more information on technology including insulin pumps and closed loop systems visit DigiBete.

You should insure your insulin pump. Should you experience theft, loss or accidental damage to the insulin pump, having insurance for the pump will ensure it can easily be replaced. For more information on pump insurance visit Diabetes.co.uk or  JDRF.

• DigiBete - Technology
• Tandem t:slim
• Omnipod
• Medtronic
• Dana
• JDRF Pump Insurance
• Diabetes.co.uk Pump Insurance
• Dexcom
• FreeStyle Libre
• DigiBete App
• Nutracheck App
• Carbs & Cals App
• My Fitness Pal App
• MyLife App
• Omnipod 5 Simulator App
• t:simulator App

If you are a patient (or parent/guardian of a patient) with diabetes cared for by County Durham and Darlington NHS Foundation Trust, and you would like to apply for money from this fund please discuss this with a member of the diabetes team in person, via phone or email. We ask that each patient or family consider the following information prior to requesting money from this fund:

• What is your request?
• How might this benefit you?
• How much money are you requesting?
• What contributions can you make to this event/item?
• Is this a one off cost?
• And please consider how many times you have benefitted from the fund already, so we can ensure every patient has fair access to this fund.

We need your help to improve diabetes care – please take a few moments to share your experiences in the National Paediatric Diabetes Audit.