A substantial part of the information in this section has been sourced from:

Caring for diabetes in Children and Adolescents: A Parent’s Manual (editors: Geoff Ambler, Vicki Barron, Chris May, Elizabeth Ambler, Fergus Cameron) which is available in book form www.chw.edu.au/eshop/ or online version www.kidsdiabetes.org.au. Permission to use this material is gratefully acknowledged by diabetes Australia–NSW.

The Role of Insulin

Insulin is an integral part of the treatment of type 1 diabetes, together with healthy eating and regular physical activity. Type 1 diabetes is a constant balancing act between insulin and physical activity which lower the blood glucose level (BGL) and food and stress hormones which raises the BGL.

Insulin Prescriptions

You must have a prescription from your Endocrinologist or GP in order to obtain insulin for your child. Cost will vary according to whether you have a Health Care Card. For more information on the Health Care Card, click here.

Types of Insulin

Short-Acting Insulin

Actrapid®, HumulinR®
These insulins are absorbed quickly into the bloodstream following injection and have a shorter duration. They are commonly used in combination with long acting insulin in children and teenagers.

Onset: 30-60 minutes
Peak of action: 2-4 hours
Duration: 6-8 hour

Ultra Short-Acting Insulin

Novorapid®, Humalog®, Apidra®
These insulins have been designed to be absorbed even faster than Actrapid® and HumulinR®. They are absorbed immediately after the injection and have a shorter duration. They can be given immediately before a meal and may reduce hypoglycaemia because of their shorter action. They may not suit everyone as some individuals may be too sensitive to the rapid onset of action or the insulin action may not last long enough.

Onset: Immediate within 15 minutes
Peak of action: 1 hour
Duration: 4 hours

Long-Acting Insulin

Protaphane®, Humulin NPH®
These insulins have a slower action and longer duration, however there is a lot of variation in individual responses. They have limitations in that they don’t always act for the desired period, may peak at the wrong time in certain individuals and may vary considerably in the way they work from day to day.

Onset: 1-2 hours
Peak of action: 4-12 hours
Duration: 8-24 hours

Lantus®
Lantus has been developed with different absorption characteristics and to give a background insulin effect for about 24 hours with no distinct peaks or troughs. Lantus is a “clear” long-acting insulin, so it looks different from other long-acting insulins which are “cloudy”. Lantus does not need to be tipped up and down and should not be mixed with other insulins. Lantus is recommended for use in children aged 6 years and above, however in clinical practice, it is being used in younger children.

Onset: 2 hours
Peak of action: no distinct peak
Duration of action: approximately 24 hours

Levemir ®

Levemir has been developed to be a long acting insulin analogue with a duration of action up to 24 hours.  Compared with isophane insulins (eg. Protaphane, Humulin NPH) Levemir has much less variation from day to day and therefore is much more predictable in its action. Levemir is a clear colourless, neutral  long acting insulin, so it looks different from the older long acting insulins which are cloudy.If Levemir is mixed with other insulin preparations the profile of action of the insulins may change. Clinical trials have been conducted with Levemir in children aged 6 years and above, however, in clinical practice it is being used in younger children.

Onset:  Not Applicable
Peak of action: 3-14 hours
Duration of action: up to 24 hours

Beef
Nowadays beef insulins are used much less than human insulins. They have a slower onset of action and a less obvious peak than human insulins. They are still available to those few patients who do not respond as well to human insulins.

Pre-Mixed Insulin

Mixtard®, NovoMix®, Humulin®
Pre-mixed combinations of insulin are available, however, they are not commonly used in children and adolescents. This is because the ratios of the two types of insulin need to be changed and this cannot be done with the pre-mixed type. Sometimes they may be used in young people in certain situations.

Insulin Delivery Devices

Insulin can be mixed in a syringe and given as one injection, given by an insulin pen or via an insulin pump.

Syringes/Needles
These are available in various sizes – 25,30,50 and 100 units depending on the dose required. There are two different needle lengths – 8mm and 12.7mm. Your educator will advise on which is best for your child. In general the smallest syringe that will hold the required dose is best for accuracy and 8mm needles are more suitable for children.

Insulin syringes are disposable and for single use only. NB Needles, syringes, pens, cartridges and bottles of insulin should NEVER be shared.

Syringes are available through the National Diabetes Services Scheme (NDSS) of which your child should be a member. Click here for more information on the NDSS.

Insulin pens
Insulin pens are another means of giving insulin and may be preferred by children as they get older. If your child is on two types of insulin they cannot be mixed in a pen. In this case a syringe must be used.

Types of pens
The following devices are available for use with these Novo Nordisk insulins – Novorapid, Actrapid and Protaphane and pre-mixed insulins:

NovoPen 3® It holds a 3ml cartridge and can deliver doses in one unit increments up to a maximum dose of 70 units. This pen comes in different colours, which makes it easier to differentiate between types of insulin. It can be used with the PenMate® automatic injection device.

DemiPen®: It holds a 3ml cartridge and delivers doses in half unit increments to a maximum dose of 35 units. It is mostly used for the short acting insulins in younger children in whom finer dose adjustments may be helpful. It can be used with the PenMate® automatic injection device see below.

Novolet® pen: This is a disposable pen that contains 3mls of Protaphane insulin and can deliver doses in two unit increments to a maximum of 78 units.

Innolet®: This is a disposable device that contains 3mls of insulin and delivers doses in one unit increments to a maximum of 50 units. It has a dial for setting the dose.

Levemir® Flexpen® This is a prefilled multidose pen with a 3 ml cartridge. The device delivers doses in one unit increments to a maximum of 60 units

The following devices are available for use with these Eli Lilly insulins: Humalog, Humulin R, Humulin NPH and pre-mixed insulins:

Humapen® Luxura  This pen holds a 3ml cartridge of Humalog or Humulin. The device delivers doses in one unit increments to a maximum of 60 units.

Humapen® Luxura HD This pen holds a 3ml cartridge of Humalog or Humulin. The device delivers doses in half unit increments to a maximum of 30units.

For Humulin NPH, Humapen® Luxura  is the delivery device.

The following device is available for use with Sanofi Aventis insulin:

Autopen 24® AN4210 (green): This pen holds a 3ml cartridge and can deliver doses in one unit increments to a maximum of 21 units.

Autopen 24® AN4200 (blue): This pen holds a 3ml cartridge and can deliver doses in two unit increments to a maximum of 42 units.

®Lantus SoloStar® : this pen is a prefilled disposable pen and holds a 3ml cartridge of Lantus insulin. The device delivers doses in one unit increments to a maximum of 80 units.

Apidra SoloStar® :  this pen is a prefilled disposable pen and holds a 3 ml cartridge of Apidra insulin. The device delivers doses in one unit increments to a maximum of 80 units.

Jet Injection Devices
These have no needle and force the insulin under the skin with air pressure. The subsequent injection is not painless and the device is not usually recommended because insulin absorption is unpredictable, it is expensive and may increase injection problems.

Insulin Pumps
This is a computerised device that delivers a programmed continuous background dose of insulin together with bolus doses for meals and corrections through a small cannula left under the skin for approximately three days.

For more information on insulin delivery devices click here

Injection Aids

A number of devices are available to help with needle phobia or to help children give their own injections.

Inject Ease®
This device allows you to load the syringe (with drawn up insulin) into it, the needle is hidden from view and when a button is pressed, the needle is automatically inserted into the skin.

PenMate®
This device is for use with the NovoPen 3 and works in a similar way to the Inject Ease.

Insuflon®
This device is an indwelling catheter (small plastic tube under the skin) that is placed at an injection site for up to 4 days. The insulin can be injected into the rubber membrane attached to the catheter instead of directly into the skin.

Ask your Diabetes Team about the suitability of any of these devices for your child.

Insulin Regimes

While in the past there has been a tendency to try to minimise the number of injections per day, more children and teenagers are being treated with multiple daily injections or insulin pumps. This is to try to more closely match the body’s insulin needs similar to the way the pancreas works in people without diabetes. Many children now start on multiple injections or if started on 2 injections per day, soon evolve to 3 or 4 injections per day.

Twice daily insulin injections
This has been a commonly used combination in infants and children, who receive:
• Before breakfast: a mixture of short-acting insulin and long-acting insulin.
• Before main evening meal: a mixture of short-acting insulin and long-acting insulin.

The graph below shows how this combination is intended to work:

In many infants and young children who start on this combination, the short-acting insulin may become unnecessary after a few days or weeks and they may require only long-acting insulin, especially during the ‘honeymoon’ phase. Later on a combination will again be needed.

Three times daily injections
In this pattern of injections, children have:
• Before breakfast: A mixture of short-acting and long-acting insulin.
• Before afternoon tea or before the main evening meal: Short-acting insulin.
• Before bed: Long-acting insulin or ultra-long acting insulin.

An increasing number of children are having injections three times a day because of advantages it can offer in diabetes control, and the ability to adjust injections for eating pattens, sport and exercise.

The graph below shows how a three times daily insulin combination works:

Four times daily injections (basal-bolus)
In this routine, often called the basal-bolus routine, people have:
• Before breakfast: Short-acting insulin.
• Before lunch: Short-acting insulin.
• Before main evening meal: Short-acting insulin.
• Before bed: Long-acting insulin.

This offers very good flexibility for insulin adjustment, and is often helpful in diabetes control. Many children, teenagers and young adults now have four to five injections per day.

The graph below shows how a four times daily insulin combination works:

Other patterns of insulin dosage
Many other patterns of insulin dosage may be used, depending on individual needs. Those described above are in most common use.

Insulin Adjustment
Insulin requirements will vary according to your child’s activity, food intake and growth. For this reason it’s important to understand how to adjust insulin. Your educator will advise you on how to do this.

Giving Insulin

How to draw up a mixed dose of insulin from penfill cartridges:

1. Wash hands. 2. Check the insulin cartridge - name, appearance and expiry date. 3. Mix the long-acting insulin if it is a “cloudy” type (eg. Protaphane®, Humulin NPH®) thoroughly by tipping the cartridge up and down 10 to 20 times. Do not shake the cartridge as this damages the insulin. Note – short-acting insulins and “clear” long-acting insulins (eg. Lantus) do not need to be tipped up and down and should not be mixed with other insulins. 4. Open a new syringe. Make sure there is no air in the syringe by first pushing the plunger right down. Insert the needle into the cartridge of short-acting insulin eg. Actrapid®, Humulin R®. Pull back the plunger of the syringe to draw up the dose required plus an extra 2 units which allows you room to get rid of any air bubbles. The rubber stopper in the cartridge will gradually move down as you draw out the insulin and equalise the pressure. 5. Remove the syringe from the bottle, hold it vertically and push the plunger gently to get rid of any air bubbles and any extra insulin to obtain the correct dose. It may help to tap the side of the syringe to remove all air bubbles. 6. Check that you have mixed the long-acting insulin eg. Protaphane®, Humulin NPH®, insert the needles into the cartridge and turn it upside down. Pull back the plunger to obtain the correct dose. If you draw back too much, you will have to discard the whole syringe and start again. Do not push any insulin into the cartridge. 7. Now you are ready to inject the insulin. If you still need to draw up insulin from vials (bottles), the procedure is similar, except air has to be injected into the bottles to avoid problems with suction and airlocks in the bottles: 1. Wash hands. 2. Check the insulin vials – name, appearance, expiry date. 3. Mix the long-acting insulin if it is a “cloudy” type (eg. Protaphane®, Humulin NPH®) thoroughly by rolling the bottle in the hands ten to 20 times until it is uniformly mixed. Mixing is very important because if the insulin is not well mixed you may draw out very dilute or very concentrated insulin and get the wrong dose. Do not shake the bottle as this damages the insulin. 4. Open a new syringe. Inject air into the bottle of long-acting insulin equal to the dose of insulin required (without the needle touching the insulin). Remove the needle. 5. Inject air into the bottle of clear insulin equal to the dose of shot-acting insulin plus two units. Leave the needle in the bottle and turn it upside down. 6. Pull back the plunger of the syringe to draw up the dose of short-acting insulin required plus the extra two units which allows you the room to get rid of any air bubbles. 7. Remove the syringe and push the plunger up to push out any air bubbles and any extra insulin to obtain the correct dose. It may help to tap the side of the syringe to remove all air bubbles 8. Check that you have mixed the long-acting insulin, then insert the needle and pull back the plunger to obtain the correct dose. If you draw back too much insulin here, you must discard the syringe and start over again. You cannot just push it out, as the ratio of long and short-acting insulin will be affected. 9. The insulin is now ready to inject.

Injection Sites

Your educator will demonstrate the best way to give insulin injections. The preferred place to give insulin is in the tummy because insulin is absorbed more evenly and the tummy is less affected by exercise than other sites. You can also give insulin into the upper thigh to obtain a slow absorption rate if given at night. It’s important not to give insulin into an area that is going to be exercising a lot eg the arm if your child is going to play tennis or the leg if your child is going to play football, as the insulin will be absorbed quicker. Insulin absorption is quickest from the tummy then arms, buttocks and thighs. Discuss with your educator what is best for your child. The following illustrates the best places to give insulin.

It’s important not to inject into the same spot all the time – it’s easy to do, as it doesn’t hurt so much! However, your child will then have unsightly fatty lumps (lipohypertrophy) if they do this, and insulin absorption will be reduced. It’s best to encourage your child to rotate their injection sites.

Insulin injections should be given into the fatty layer under the skin not into muscle, as this tends to speed up the insulin absorption. You should take a pinch of skin and give the injection at a 90 degree angle, as shown below. A short (8mm) needle is best, particularly for children with little fat. There are 5mm and 6mm pen needles also available for particularly lean children.

Giving an injection with a syringe

1. Draw up insulin as described above.
2. Take a pinch of skin at the chosen site with the index finger and thumb. The pinch needs to be at least to the depth of the needle.
3. Insert the needle straight into the pinched-up skin (ie. At 90 degrees) to its full depth and push the syringe plunger slowly all the way down to push in the insulin. In very lean individuals, injecting at a 45 degree angle to the skin may be necessary to avoid the injection going too deep.
4. Let go of the skin and leave the needle in for 5 to 10 seconds, then gradually pull out the needle.

Giving an injection with a pen

Wash hands.
2. Check that you have the correct insulin pen (have your long-acting and short-acting pens clearly marked) and that there is enough insulin remaining in the cartridge for the current injection. It is preferable to use a new needle for each injection.
3. If giving long-acting insulin that is a “cloudy” type (eg. Protaphane® or Humulin NPH®) be sure to mix the insulin well by inverting the pen 10 to 20 times. The cartridge contains a glass ball, which mixes the insulin. Do not shake the pen as this will damage the insulin.
4. Prime the pen (get rid of any air bubbles). Dial up a 2 to 4 unit dose and, holding the pen vertically, inject into the air to expel air bubbles (air shot) and to prime the pen. The pen is primed if drops of insulin without bubbles are coming from the needle. If not, repeat this procedure.
5. Dial up the required dose.
6. Select the injection site.
7. Take a pinch of skin with the index finger and thumb at the chosen site. The pinch needs to be at least to the depth of the needle.
8. Insert the needle straight into the pinched-up skin (ie. at 90 degrees) to its full depth and push the pen button slowly all the way down to push in the insulin. In very lean individuals, injecting at a 45 degree angle to the skin may be necessary to avoid the injection going too deep.
9. Let go of the skin and leave the needle in for 5 to 10 seconds, then gradually pull out the needle.
10. Remove the needle from the pen after injection.

Insulin delivery devices

The following chart provides information of the variety of insulin delivery devices. To find the best one for you, discuss the options with your Diabetes Team.

Device	Description	Advantages	Disadvantages	Picture
Syringes	30, 50 & 100 unit sizes.	Can be used with all available insulins	Requires adequate vision and dexterity. Need to be able to see different dose increments on different sized syringes.
Insulin Pens - Not suitable for those who need to mix insulins
Novo Nordisk ® Devices (only used with Novo Nordisk insulins)
NovoPen ® 3	Dose range 2-70 units. Small fine needles available. Pen reusable	Accurate dosing. Accuracy of dose can be checked	Replacing insulin cartridge can be difficult
NovoPen ® 3 Demi	Similar to NovoPen 3, but ½ unit doses possible from 1-35 units	Useful for those requiring small doses (eg Children)	Not suitable for large doses
NovoLet ®	Disposable prefilled devices. Holds 3ml insulin. Only available in Protaphane ®. Dose up to 78 units	Useful for travel	Can be confusing to use. Errors can occur especially with large doses.
InnoLet ®	Dose range 1-50 units. Accurate, disposable. 3ml insulin device.	Clear easy to see numbers. Useful for vision impaired. Easy to use for those with decreased manual dexterity.	Only Protaphane & Mixtard 30/70 insulin available. Larger device and requires more storage space.
Pen Mate ®	Automatic needle insertion device, used with NovoPen 3. Hides needle and injects needle automatically	Useful for people with needle phobia	Device must be purchased
Flex Pen ®	Prefilled with 3ml insulin. Dose range 0-60 units	Simple dose setting mechanism	Only NovoRapid & NovoMix 30 available
Levemir® Flexpen®	Pre-filled disposable pen up to 80 units in one unit increments. Holds 3ml of insulin	Useful for travel	Whole device must be disposed of, pen cannot be re-used and re-filled.
Eli Lilly® Devices
HumaPen ®	Dose range 0-60 units. Pen reuseable with 3ml cartridges. Cartridge easy to change.	New pens not available. Previous users can have pens replaced when required.	Can only be used with Lilly ® brand insulins
Owen Mumford® Devices (Device only used with Lantus insulin)
Autopen 24 ®	Available from Aventis and selected diabetes centres free of charge for those using Lantus. Australian distributor: General Diabetes Supplies: cost $70 Holds 3ml Lantus cartridge 2 pens: Green: dose range 1-21 units in 1 unit increments. Blue: dose range 2-42 units in 2 unit increments	Easy to use with two extra attachments –to help those with manual dexterity problems.	It is not possible to dial back if you make a mistake with your dose. You must dial up carefully otherwise there is wastage. It is very important that people are taught how to use this pen as it is quite different from other pens on the market.
Sanofi Aventis
SoloSTAR ®	Pre-filled disposable pen up to 80 units in one unit increments. Holds 3ml of insulin	Pre-filled	Whole device must be disposed of, pen cannot be re-used and re-filled.
Lantus SoloStar®		Useful for travel
Apidra SoloStar®	Pre-filled disposable pen up to 80 units in one unit increments. Holds 3ml of insulin	Useful for travel	Whole device must be disposed of, pen cannot be re-used and re-filled.
Other Devices
B-D Automatic Injector (Inject-Ease ®)	Inserts syringe needle into skin.	Can be used with any size B-D ® insulin syringe. Useful for those with needle phobias.	Requires practice to use. Some small plastic parts. Device must be purchased.
Insulin Pumps Continuous subcutaneous insulin infusion (CSII)	Uses basal and bolus dosing. Uses only short acting insulin.	Can achieve close to normal insulin profile	Expensive. Requires extensive education and blood glucose monitoring to be used effectively. Ongoing cost for supplies.
Needle-less delivery Systems (Jet injectors)	No needle required. Not widely used. Insulin forced through skin under pressure.	May benefit people with needle phobia	Bruising common. Not painless. Costly-must be ordered from overseas. Most require cleaning and maintenance.