CYP suspected to have type1 diabetes (age 0-17)

Definition/Description

Paediatric diabetes refers to chronic metabolic disorders characterized by high blood glucose levels (hyperglycaemia) due to insufficient insulin, most commonly type 1 (autoimmune destruction of pancreas cells), and type 2 where insulin is insufficient or ineffective in glucose metabolism. Type 2 diabetes in children and young adults is known to be a more aggressive form of the condition.

There are approximately 31,500 children with type 1 diabetes in the UK

16-25% of children are not diagnosed until they are in Diabetes Ketoacidosis (DKA)

500 children every year become seriously ill with DKA because early signs of type 1 diabetes are missed

DKA is a life-threatening illness requiring intensive medical intervention and is extremely traumatic for the child and family

Children under 2 years can present with less specific symptoms

A Diabetes Referral Pathway for GPs has been developed by the service at Hull University Teaching Hospitals NHS Trust. Practices should access this referral pathway whenever they suspect that a child or young person aged 0 – 17 years may have type 1 or type 2 Diabetes.

Symptoms including those that are less common are detailed in the Guidance on Management section.

Red Flag Symptoms

If child is symptomatic, suffering from nausea/vomiting and confused/unresponsive – dial 999

It is important to remember that children as young as 6 months can develop diabetes.

Guidelines on Management

Consider the 4 Ts –

Thirsty (drinking excessive fluids),
Tired,
Thinner (weight loss),
Toilet (frequent urination).

In addition, other symptoms in children which may point towards a new diagnosis of diabetes are new onset bedwetting or rapid breathing, abdominal pain/vomiting (ketosis).

For type 2, which can develop more slowly, children may have intermittent episodes of the 4Ts and also have symptoms such as

Genital itching or thrush

Cuts and wounds taking longer to heal
Blurred vision

Symptoms specified in NICE NG18 (Diabetes (type 1 and 2) in children and young people: diagnosis and management):

Signs of type 1 diabetes in children and young people include:

Hyperglycaemia (random plasma glucose more than 11 mmol/ litre
Polyuria
Polydipsia
Weight loss
Excessive tiredness
Refer children and young people with suspected type 1 diabetes immediately (on the same day) to the paediatric registrar on call
When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of type 2 diabetes, monogenic or mitochondrial diabetes.

Consider type 2 diabetes in children and young people with suspected diabetes. Who:

Have a strong family history of type 2 diabetes
Are obese
Are from a Black or Asian family background
Show evidence of insulin resistance (for example, acanthosis nigricans)

Think about the possibility of other types of diabetes (not types 1 or 2), such as other insulin-resistance syndromes, or monogenic or mitochondrial diabetes, in children and young people with suspected diabetes who have any of the following:

Diabetes in the first 6 months of life
Rarely or never develop ketones in the blood (ketonaemia) during episodes of hyperglycaemia
Associated features, such as optic atrophy, retinitis pigmentosa, deafness or another systemic illness or syndrome
Do not measure C-peptide or diabetes-specific autoantibody titres at initial presentation to distinguish type 1 diabetes from type 2 diabetes.
Consider measuring C-peptide after initial presentation if needed to distinguish between type 1 diabetes and other types of diabetes. Be aware that C-peptide concentrations have better discriminative value the longer the interval between initial presentation and the test.
Perform genetic testing if atypical disease behaviour, clinical characteristics or family history suggest monogenic diabetes.

Where symptoms are identified, primary care should undertake Random Capillary Blood Glucose (CBG), Capillary Blood Ketones (CBK) and/or urine dipstick. If results: CBG > 11 mmol/l and/CBK (if available) is above 3mmol/l or Urine dip +ve for glucose this will require an urgent referral to Paediatric registrar via hospital switchboard 01482 875875.

Referral should be immediate as detailed in NICE NG18 and the NICE Clinical Knowledge Summary for diabetes diagnosis in children (see Additional Resources)

Referral Criteria/Information

Do Not Refer

Young person aged 17 years and over to be referred to the Adult Diabetes Services

Referral Criteria

Polyuria, Polydipsia, Excessive tiredness, Weight loss, Heavier nappies, new onset bedwetting, Abdominal pain/vomiting, Rapid breathing (acidotic)

Suspecting type 1 diabetes (Immediate Referral Needed)

Symptoms: Polyuria (frequent urination), polydipsia (excessive thirst), unexplained weight loss, excessive tiredness, blurred vision, new onset bedwetting.
Blood Glucose: Random plasma glucose >11.1 mmol/L (or whole blood >10.0 mmol/L).
Action: Immediately refer to a paediatric on-call registrar for same-day confirmation and care plan, assuming type 1 unless other signs point to different types (like monogenic/neonatal).

Suspecting type 2 diabetes (Urgent Referral Needed)

Symptoms: As with type 1, but possibly over a longer timescale and stop start. Other symptoms can include Genital itching or thrush, Cuts and wounds taking longer to heal and/or blurred vision
Features: Often includes obesity, strong family history (Black/Asian origin), acanthosis nigricans (skin darkening), persistent hyperglycaemia, recurrent infections.
Action: Urgent referral to or discussion with specialist paediatric diabetes team.

Referral Methods

Telephone referrals will be accepted into this service, as referrals are urgent – please call the Hospital switchboard on 01482 875875 requesting discussion with a paediatric registrar.

Mandatory Information

Child/ young person’s details; relevant clinical/ medical information including symptoms and outcome of CBG, CBK and/ or urine dipstick; parent/ carer details and contact information.