DIABETES IN CHILDHOOD
Diagnosis
Diabetes in children is almost always type 1, and the onset is fairly acute. The first symptoms are polydipsia and polyuria, which may in turn result in enuresis. Weight loss and lack of energy are often present as well. The duration of symptoms at initial presentation is typically between 1 and 6 weeks.
In the context of the above symptoms, the finding of glycosuria justifies a presumptive diagnosis of diabetes, whereas the absence of glycosuria makes the diagnosis very unlikely. If a blood sugar is checked, a random sample is more useful than a fasting one (children have limited glycogen stores, and a child who is hyperglycaemic during the day may have a near-normal blood sugar first thing in the morning). If checking the blood sugar, use a blood sugar meter so that you have an instant result. An apparently well child can decompensate quickly into ketoacidosis, and a delay in referral of even one day while awaiting laboratory results is unacceptable. Prompt referral is particularly important if ketonuria is found.
Initial Management
Management is initiated in Children's ward at Raigmore - either as an in-patient, or, where circumstances permit, on an ambulatory basis. On making a presumptive diagnosis, the GP should telephone the consultant paediatrician. Dr Farmer and Dr Franklin both take a particular interest in diabetes - but if they are unavailable telephone the consultant on call.
Education
Clear and consistent guidance is essential if families are to effectively develop the skills to manage their child's diabetes. An information pack is given to the family at diagnosis, and can be accessed via the following links
(note the above links will only work if you have access to the NHS Highland intranet)
The ketonuria flow chart is also available in a wallet-sized card format (the Ketocard), available from the diabetes centre at Raigmore.
Outpatient Management
Notwithstanding the high incidence of childhood diabetes in Highland, individual GPs are unlikely to have more than two or three children with diabetes on their list. All children are followed up by the specialist team (doctor, dietician, and specialist nurse) at clinic visits which take place every 3 to 4 months. Haemoglobin A1c is measured on a capillary blood specimen at clinic, and the results are available for discussion during the consultation. The outpatient letter to the GP is copied to the family and relevant professionals. An updated cumulative clinic record is sent out with each GP letter.
We support the wishes of those families who choose to attend both the GP and the hospital team for diabetes care. Good communication and consistent advice are essential in these circumstances.
Targets for Blood Sugar Control
Children are volatile in their eating habits and activity levels, so it is unlikely that the blood sugar results will achieve the level of consistency which might be expected in adults with diabetes. We aim to get the great majority of pre-prandial results between 5 and 8 mmol/l: however, the level of variability is sometimes such that the most realistic guidance is to 'get the blood sugar results as low as they can be without causing unduly frequent or unduly severe hypoglycaemia'.
Severe hypoglycaemia (involving unconsciousness or convulsions) is extremely distressing and disruptive to families, and fear of a recurrence will often result in a subsequent deterioration in diabetes control. It should particularly be avoided in children less than 7 years old, who may be more susceptible to long-lasting adverse effects.
Management of hypoglycaemia
Our advice on the management of hypoglycaemia is given in the patient advice literature. In most instances, oral sugar (either as glucose tablets or a sugary drink) is the most appropriate initial management. If the child is confused and uncooperative during hypoglycaemia, buccal administration of Glucogel (previously known as Hypostop Gel) can be extremely useful. The whole tube should be used to ensure an adequate doseage. Treatment with oral glucose should be repeated after 10 minutes if the child remains hypoglycaemic.
More detailed advice, taking into account the weight of the child is available on the NHS Highland intranet. If you have access to the intranet please click here for a direct link.
In the event of unconsciousness or convulsions, the appropriate management is with intramuscular glucagon. The family should ask for a further prescription of hypostop or glucagon when they have used their own supply, or when the expiry date is imminent.
Management of ketonuria and prevention of ketoacidosis
The risks associated with ketoacidosis are frequently underestimated. Although much less common than hypoglycaemia, it is responsible for around 10 times more deaths in young people with diabetes. It usually results from intercurrent illness or omission of insulin doses. The patient advice literature includes 'Sick day rules' and guidance on the detection and management of ketonuria,(see Ketonuria flowchart). Each family requires a supply of ketostix for diagnosis, and rapid acting insulin for treatment. The cannister of ketostix should be replaced at the expiry date, or six months after it was first opened (whichever comes first).
For ketone testing in very young children, or where there is a particular aversion to urine collection, β – ketone blood testing strips (for use with Medisense meters) may be recommended.
See also Shared clinical guideline for the management of ketoacidosis in children
Long term complications of diabetes
Long term complications are not seen in early childhood, but may become evident after puberty. Screening is organised from the diabetes clinic, and starts at the age of 12 with annual retinal photography, measurement of blood pressure and estimation of urinary microalbumin.
