Worst outcomes if missed
Diabetic ketoacidosis - diabetic ketoacidosis is the leading cause of mortality and morbidity in children with type 1 diabetes. A recent national survey has shown that around 25% of children with diabetes present in diabetic ketoacidosis.
Death - children can die from unrecognised type 1 diabetes. The risk of death is small, but 10 UK children a year die from diabetic ketoacidosis, some at the first presentation of diabetes. Most of these deaths are because of cerebral oedema, which is more common when diabetic ketoacidosis occurs at onset of diabetes.
Epidemiology
- There are about 29,000 children with diabetes in the UK. Of these, 97% have type 1 diabetes.
- Around 2,000 children are diagnosed with type 1 diabetes each year.
- The peak age for diagnosis is 10 to 14 years, but the under-five age group has seen the steepest rise in diagnoses in recent years.
- A large UK general practice can expect to see a child with newly diagnosed type 1 diabetes around every two years.
- Some 25% of children are not diagnosed until they are in diabetic ketoacidosis because the early symptoms of diabetes are unrecognised by parents or medical staff. This rises to 35% in children under five years.
- Despite the rising incidence of type 1 diabetes in children, the percentage of children not diagnosed until they are in diabetic ketoacidosis has remained unchanged over the past 20 years.
Symptoms and signs
The classic symptoms of type 1 diabetes in children are:
- polyuria/nocturnal enuresis in a previously dry child. Parents may notice that nappies are heavier
- polydipsia
- lethargy
- weight loss - often not recognised by parents.
Less common symptoms are:
- constipation - secondary to chronic dehydration, a particularly important symptom in children under five years)
- oral or vulval thrush.
Children under the age of two may display less-specific symptoms and a high index of suspicion is warranted in these children.
Children do not necessarily display all symptoms at the same time, and symptoms may vary depending on the age of the child. There is usually no family history of diabetes.
Differential diagnosis
The symptoms may suggest respiratory infection, simple candidiasis, gastroenteritis or urinary tract infection. The symptoms of diabetic ketoacidosis include vomiting, deep sighing respiration, abdominal pain and reduced consciousness level. These symptoms may be misinterpreted as an acute abdomen, gastroenteritis, acute asthma or pneumonia.
Investigations
Any child with suspected type 1 diabetes should have a capillary blood glucose level performed in the GP surgery immediately.
It is important that the correct technique is followed to ensure an accurate result:
- hands should be washed and dried thoroughly
- alcohol based gels or wipes should not be used for skin cleansing
- blood testing strips should be in-date
- the blood glucose monitor should be calibrated if required.
The diagnostic criteria for diabetes are the same in children as in adults - a random blood glucose level of higher than 11mmol/l is diagnostic.
Do not wait for a urine test or a fasting blood glucose level. Any delay in diagnosis may result in the child progressing into diabetic ketoacidosis. HbA1c testing should also not be used to diagnose a child with suspected type 1 diabetes.
Any child with a raised blood glucose level should be referred the same day to a local paediatric diabetes service for confirmation of the diagnosis by laboratory blood glucose and further management.
Five key questions to ask
- Has your child recently been drinking more and passing urine more frequently?
- Has your child been wetting the bed? This is strongly suggestive if the child was previously dry at night. This can be the result of stress or emotional upset, but it is the most common feature of diabetes, so still needs a blood glucose test. Even if the test is negative, it is better than the child being hospitalised with diabetic ketoacidosis – parents won’t mind if it is explained.
- Has your child been getting thinner?
- In infants, have they been particularly unsettled and had heavier nappies than usual?
- Has your child had recurrent oral thrush or persistent nappy rash? If this is the case, please check blood glucose levels.
Five red herrings
- Children cannot be too young to have diabetes – children can develop diabetes even within the first few months of life.
- Children can not be ‘too well’ to have diabetes – it is best to diagnose while they are still well.
- Parents often don’t realise their children are losing weight – they think they are growing. Ask if they are getting thinner instead.
- Asthma and pneumonia do not cause deep sighing respiration – this is diabetic ketoacidosis until proven otherwise.
- Symptoms may be misinterpreted as an acute abdomen – parents of children with an acute abdomen should be asked about polyuria and polydipsia and should have a blood glucose level check if there is any suspicion.
Dr Julie Edge is a consultant in paediatric diabetes at Oxford Children’s Hospital, and is an honorary senior lecturer at the University of Oxford.
This article was produced in collaboration with Diabetes UK - the leading UK charity that cares for, connects with and campaigns on behalf of all people affected by and at risk of diabetes. For more information on all aspects of diabetes and access to Diabetes UK activities and services, visit www.diabetes.org.uk. For further information about Diabetes UK’s 4Ts campaign to ensure more children are diagnosed with Type 1 diabetes before they end up in diabetic ketoacidosis go to www.diabetes.org/The4Ts
Further reading
Ali K, Harnden A and Edge JA. Easily missed? Type 1 diabetes in children. BMJ, 2011:342:d294.
