T1D and COVID-19: what have we seen so far and what do we expect?

In the current global situation concerning coronavirus, we understand many families have questions regarding the risks to children living with diabetes.   Dr Craig Taplin (pictured right), a consultant paediatric endocrinologist at Perth Children's Hospital, shares practical experiences from the Diabetes Clinic so far.

Hopefully you have received our written correspondence in the past week or so regarding the novel coronavirus and the associated disease it causes called COVID-19. In that letter, we summarised some common-sense advice regarding the current pandemic, how to stay safe and to have a specific diabetes plan while we all wait this out. Some practical tips were included for making the most of your video or teleconference clinic visits with us such as ensuring your CGM and/or pump is linked with our clinic so we can share data.

We are now into our second week of doing diabetes clinic visits by telehealth at PCH. We believe we can keep our patients and families safe through this period of physical isolation to “flatten the curve”. With much of the data relevant to your daily glucose control and insulin dosing available online, we can still glean a lot of information and provide practical advice around insulin dose adjustment, maintain our educational goal to help you interpret glucose data, perform nutritional assessments and provide advice around meal composition, planning and carbohydrate counting, and address the important psychosocial and emotional issues around daily management of a chronic disease like type 1 diabetes with our social work and psychology teams. We do understand, though, that the fundamental humanistic element of face-to-face contact and empathy is not the same when talking on the phone or over a video-link.

Based on this past (first) week of experience with T1D during the pandemic, and applying some principles we see at other times such as outside school terms, travelling, or at times of illness, here is what you might expect to see and some practical strategies:

1.  With reduced physical activity and exercise, insulin requirements rise. We know how powerful exercise is in daily life with type 1 diabetes. Exercise lowers overall insulin requirements, reduces how high glucose levels rise after meals, and improves overall sense of wellbeing. For most families isolating at home, and minimising contact with almost everyone else, it will be difficult to maintain the same level of general physical activity. Examples of this include a reduction in the natural playtime at recess and lunch that younger primary school-aged children participate in, less spontaneous play and activity in the community such as the playground, walking and bike riding, and the shutdown of your child’s organised sports including footy, soccer, swimming, dance etc. So, what to do?

- Expect your child to need more insulin. The science suggests a more sedentary lifestyle is associated with at least 20 per cent more insulin than if we are active, and sometimes substantially more. You may need to work with us when we talk to you during these visits to adjust insulin safely, but you will likely find the long -acting insulin dose (e.g. Glargine), or the basal rates if your child is on a pump, will need to be increased by 20 per cent or more if physical activity falls. We would generally make these adjustments in increments of no larger than 10 per cent at a time, though, and then wait 72 hours to see the overall effect before making another dose change. If your child has attended diabetes camp in the past, you might reflect on how much more insulin they needed before camp compared to during camp – this will give you an idea of the magnitude of the difference you’ll see.

- Can you get out for a morning walk together? Based on current information, outside exercise is still OK as long as the recommended physical distancing is observed. Even a 30 minute walk together in the morning (around the back yard if you have to!) can provide much of the benefits of the more typical daily activity your child is used to. For example, is there a pet who needs to be walked each morning? While we are not 100 per cent sure, exercise early in the day may give your child much of the benefits of lower blood glucose levels during the day, but with a lower risk of overnight lows compared with after school (i.e.. afternoon) activity.

- You may need to change the amount of insulin to cover meals. Just as we see with the likely adjustments needed for the long acting (or basal rates) dose, the “carb ratio” may also need to be adjusted to give more insulin for the same amount of food.Remember, also, the key role insulin dose timing makes in reducing the post-meal glucose spike- this is arguably even more important when we are not as active. Dosing 10-20 minutes before a meal (and sometimes up to 30 minutes before) will assist in the peak action of an insulin bolus matching the peak glucose rise, which may be more rapid without exercise in the system.

- You might consider adjusting meal composition and volume. When sedentary we generally don’t need as much to eat as we do when very active. Our dietitians can help you with practical advice on this.

2.  Find a new daily schedule and routine that works for you and your child, and incorporate glucose checking and insulin dosing into that schedule. In general, children thrive on structure, predictability and repeatability in their daily routines. Many parents will have noticed, for example, that when on school holidays glucose control seems harder to achieve because the predictability and routine of the school year is not there. If you and your child are at home, try and find a new schedule that balances the plan for education, play, relaxation and meals, and that they can settle on. This will help to keep each day consistent, and provide you with appropriate meal times to reduce grazing, random snacking, boredom eating and the challenges around when to give insulin and potential insulin stacking. To some degree, mimicking their usual school structure may be a starting point as they will already be well accustomed to it, trust it, and help them to know what’s coming next.

3.  With acute illness (whether it’s coronavirus or something else) blood glucose levels may run much higher, and ketones can occur more quickly. This happens because of transient “insulin resistance” which is a side effect from the body’s response to fighting infection. If blood glucose is high, do a correction as you would normally, then recheck the blood glucose 2-3 hours later. If it is still very high, check for ketones. Our clinic may see more DKA (ketoacidosis) during this time - although youth with type 1 diabetes are no more likely to get coronavirus (or any virus) than their peers, glucose levels are harder to manage when sick and the risk of ketones is higher. There are excellent resources in chapter 7 of our diabetes education folder. You can find that, along with other excellent resources, on the Children’s Diabetes Centre website.

4.  Find time to play and relax. It is easy for the current coronavirus pandemic to feel scary and anxiety-provoking for parents and children together. Maintaining sleep schedules, some regular down time to relax, and other strategies that have worked for you and your children in the past might pay dividends in lowering the stress of everything, and potentially help to control high blood glucose levels due to elevated stress hormones.