Diabetes

Scope

This guideline is for children and young people below 18 years of age. For young people aged 16-18 years: the use of this pathway may depend on your local paediatric service provision for new referrals within this age-group.

Background
  • There are approximately 25,000 children with diabetes in the England and Wales, of which the vast majority have type 1 diabetes.
  • Approximately 25% of cases are not diagnosed until the child is in diabetic ketoacidosis (DKA), although this rate is higher (approx. 35%) in the under 5s.
  • DKA requires intensive medical intervention, is traumatising for the child, and may have a long-term adverse effect on their diabetes control.

History

Signs and Symptoms

Symptoms of type 1 diabetes
  • Classic symptoms:
    • polyuria
    • polydipsia
    • weight loss
    • lethargy
  • Less classic symptoms:
    • enuresis / nocturia in a previously toilet-trained child
    • unusually heavy nappies
    • vaginal candidiasis (esp. in pre-pubertal girls)
    • failure to gain weight in a growing child
    • poor school performance
    • recurrent infections
  • Emergency symptoms (suggestive of DKA): Dehydration, vomiting, acetone breath, abdominal pain, hyperventilation, confusion, shock
  • Be aware:
    • symptoms can progress within days or weeks. Have a high index of suspicion. Think of the Diabetes UK campaign of 4Ts:
      • toilet
      • thirsty
      • tired
      • thinner
  • Diagnosis of diabetes can be missed in younger / preschool children due to a more rapid progression of symptoms, failure to consider the diagnosis, and more non-specific symptoms
Symptoms suggesting type 2 diabetes

Assessment and referral

If diabetes is suspected
  • Perform capillary blood glucose (BG) testing immediately
  • If BG testing is not available then perform urinary dipstick testing
  • If BG or urinalysis not available then refer immediately
  • Do not perform fasting BG measurement, HbA1C, or oral glucose tolerance test
  • Do not refer as an outpatient

Red Flags

If BG more than 11mmol/l or glycosuria (+/- ketonuria):

  • Refer immediately (same day) to the acute paediatrics on-call team
  • Inform child and family of the suspected diagnosis of diabetes

Management

Management in secondary care

For type 1 diabetes
  • Local paediatric team to confirm diagnosis
  • Admit to hospital
  • Manage DKA according to South West regional DKA guideline and local guideline for well children with diabetes
  • Stabilise blood glucose levels prior to discharge
  • Provide structured education for the child and family (to include a paediatrician with an expertise in diabetes, a paediatric diabetes specialist nurse and dietician)
  • Provide initial prescriptions for insulin and equipment for the diabetes management (further prescriptions to be dispensed in primary care)
For other forms of diabetes, including type 2 diabetes
  • Manage according to local expertise with involvement of tertiary specialists as appropriate to case

On-going care for children with diabetes

  • Care will be provided by a specialist multidisciplinary team (MDT) including a paediatrician with expertise in diabetes, paediatric diabetes specialist nursing, dietetics and clinical psychology
  • Although the MDT will be based in secondary care, support for the child and their family will also be provided in the community both at home and at school
  • High quality care in line with the criteria set out in the Paediatric Diabetes, Best Practice Tariff (introduced in 2012)
  • A minimum of 4 outpatient appointments per year including one annual review appointment, and an additional appointment with a dietitian
  • Regular contact with the diabetes team, which might include telephone support/advice, home or school visits, and on-going education
  • A minimum of 4 HbA1C measurements per year
  • 24 hour access to advice on diabetes management
  • Transition to adult services at a stage appropriate to the young person in accordance with locally agreed pathways
  • Annual retinal screening from 12 years of age to be arranged according to local pathway

Paediatric Diabetes Teams in Devon

North Devon Healthcare NHS Trust
  • Referrals: Paediatric diabetes team: 07884266159 / 07920235237
  • Email: ndht.cypdiabetes@nhs.net
  • Out of hours advice: Paediatric Registrar via switchboard - 01271 322577
  • Lead Paediatrician – Dr John-Paul Smith
  • Lead PDSN – Richard Todd
Plymouth Hospitals NHS Trust
  • All referrals to the paediatric diabetes service for newly diagnosed patients should be made through the on-call paediatric registrar through Derriford Hospital Switchboard on 0845 1558155
  • Lead Paediatrician: Dr Becky Smith
Royal Devon and Exeter Hospitals NHS Foundation Trust
  • Referrals: Contact PDSN team daily from 8am to 6pm on their pager via switchboard on 01392 411611 for urgent advice
  • Out of hours advice: Between 6pm and 8am contact switchboard on 01392 411611 and ask for on-call Paediatric Registrar. Advice is available 24 hours a day.
  • Lead Paediatrician: Dr Chris Moudiotis
  • Lead PDSN: Julie Kitchen
South Devon Healthcare NHS Foundation Trust
  • Referrals: Tel: 07788416019 between 8am to 6pm Monday to Friday
  • Out of hours advice: Contact Louisa Cary Ward on 01803 655526 or 01803 655531 and ask for the Paediatric Registrar
  • Lead Paediatrician: Dr Phil Reilly

​Supporting Information

Patient Information

Diabetes UK

Evidence

National Paediatric Diabetes Audit Report 2012-13

Diabetes UK

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: September 2016

Review date: August 2018

 

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