Over the last few years in my local area of Wakefield, we’ve experienced a couple of incidents of diabetic ketoacidosis (DKA) due to delays by GPs in diagnosing children with Type 1 diabetes. We know we’re not alone; every year some 500 children with Type 1 diabetes develop DKA in the UK before they are diagnosed. Frankly, if it is happening in my area then it’s a safe bet that it’s happening in yours.
You might never get a child in your whole career presenting with Type 1 diabetes but could you diagnose swiftly if you did? Between January and August 2011, 300 local GPs practising in the Sandwell and West Birmingham area were given the following scenario: A 14 year old girl presents to them with short history of polyuria, polydypsia, lethargy and weight loss. The management options included variations on the following – immediate referral, arranging a fasting blood glucose or oral glucose tolerance test and organising a further appointment to discuss results with parents prior to referral to the PDT or refer child ‘choose and book’ to the paediatric diabetes out patients clinic.
Some 37% (111/300) replied to the scenario, and of these 34.5% would have ‘taken an action that would have led to delay in both referral to the paediatric diabetes team and delay in initiation of appropriate therapy’.
That should worry all of us.
Type 1 diabetes is on the increase in Northern Europe. But as diabetes occurs in only about less than one in 700 children, most practices will have very few children with this condition and treatment and follow up is largely hospital based. The general practitioner however, is the key figure in the initial recognition of the condition and may be called upon for advice about complications or incurrent illness. The family doctor is also responsible for much of the ongoing prescribing for this lifelong condition.
Following a diagnosis same day referral is required so that insulin treatment can be started immediately. At times, a delay of a few hours can mean the difference between life and death. It’s crucial to always suspect the condition until it is ruled out.
Type 1 diabetes mellitus can occur at any age, although it’s much more common in children. The peak age for diagnosis is between 10 and 14 but a steep rise has also been observed in the under fives. It usually has a fairly acute presentation. The classic symptoms are clearly outlined above in the Sandwell scenario. But there are also other symptoms to be aware of, including new onset of bed-wetting and thrush. In addition, ketosis often causes abdominal pain. This is why diabetes is often ignored in favour of a diagnosis of gastroenteritis, pneumonia, appendicitis, and meningitis.
In infants and toddlers the diagnosis may not be obvious in the early stages and these children therefore often present in diabetic ketoacidosis. With any query in diagnosis, I’d advise you check blood glucose level.
When it comes to DKA, drowsiness and dehydration are both potential symptoms. Typically, the urine output may be maintained or increased by the osmotic diuresis. Other possible signs may be the smell of ketones, pale skin, lethargy, dry mucosa, decreased skin turgor and tachycardia. Let’s also consider the room for misdiagnosis for DKA. Rapid or laboured breathing can be easily confused with a primary respiratory problem or with psychogenic hyperventilation. A presentation of abdominal pain and vomiting can be confused with gastroenteritis.
Of course, you might be lucky. Sometimes parents make the diagnosis by testing themselves when another family member has diabetes Sometimes the diagnosis occurs when blood or urine is tested for another reason. But you don’t have to leave it to chance. If you spot any of the symptoms of diabetes or DKA then I’d advise do a capillary blood glucose level test straight away.
At the risk of sounding like a scratched record, I can’t emphasise enough how important it is to provide same-day referral to the paediatric diabetes team – or the on-call team if out of hours. However ‘well’ the child might appear in your surgery, children can and do decompensate rapidly. Urgent referral will enable them to be seen within 24 hours of presentation and minimise hospital stay. You can refer your team to the HCP pathway located at www.diabetes.org.uk/The4Ts if they want to know more.
Dr Johnson D’souza is a GP and diabetes lead in South Elmsall, near Wakefield, and acting medical director of NHS Wakefield