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Type 1 Diabetes in Children (0-16 years) Care Pathway Overview

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Presentation

If diagnosis of any of these symptoms is missed Diabetic Ketoacidosis (DKA) can develop very quickly.

  • increased urination
  • increased thirst
  • increased fatigue
  • decreased weight

Further information on the Four T's initiative can be found by clicking on the resource link below.
 

GPs need to also be aware that some children and adolescents present with less common symptoms such as:

  • Recent onset of enuresis in previously toilet trained child, may be misdiagnosed as UTI
  • Vaginal candidiasis in pre-pubertal child
  • Chronic weight loss or failure to gain weight in growing child
  • Irritability and decreasing school performance
  • Recurrent skin infections
  • Hyperventilation of ketoacidosis misdiagnosed as pneumonia or asthma
  • Polyuria and enuresis may be misdiagnosed as UTI
  • Polydipsia may be thought of as habitual water drinking
  • Vomiting misdiagnosed as gastroenteritis or sepsis

       International Society Paed & Adol Diabetes (ISPAD) guideline 2014

Red Flags
Diabetic Ketacidosis (DKA)
Commonly presents with symptoms of:
  • polydipsia, polyuria, nausea, vomiting, weakness and lethargy
  • dehydration, Kussmaul respirations (deep respirations), fruity odour on breath, and mental status changes
Initial Primary Care Assessment

Finger prick blood tests to be carried out by GP.

Diagnosis confirmed if: random blood glucose is more than 11.1mmol/l

Refer immediately to Paediatric Assessment Unit (PAU) ON THE SAME DAY

Type 1 Diabetes Suspected

In the event that a child is suspected with diabetes the GP must:

Check blood glucose and refer

  • Immediately refer patient to on call Paediatric Consultant at the hospital via bleep no 113
  • Inform the parents to take the child immediately to the Paediatric Assessment Unit at Gloucester Royal Hospital (GRH).
Primary Care Management

Contraception to be provided routinely by GP.

Contraception should be considered for all females with diabetes in order to decrease risk of accidental pregnancy. Please consider contraception and type of contraception with your patient. 

Under the specialist diabetes team in secondary care, carbohydrate counting is the foundation of the patient’s insulin dose adjustment during the day.  Healthy Eating principles with Diabetes is therefore the mainstay of the dietary advice while ensuring the children are meeting their nutritional needs for optimal growth and development.  The patient therefore has access to a Dietitian at each clinic appointment in addition to being offered an annual dietary review appointment with a Dietitian should they wish.

Under the specialist diabetes team the patient and their family will have access to general psychological support from the paediatric diabetes team and specialist psychological support from the Paediatric Health Psychology Service. The aim of this support is to help the young person and their family come to terms with the challenges of adjusting to, and managing, the young person’s health condition.  However, if the young person is actively self-harming / having suicidal thoughts, or has a mental health condition that is not as a result of their health condition, the GP should refer to Children and Young People Services (CYPS) please see the GHC website for information https://ghc.nhs.uk/other-areas/cyp/

This service can also advise GP’s about sources of support  / counselling for young people for other non-diabetes related issues such as relationship difficulties via their practitioner advice line (01452 894272).

Other support is available as follows:

Gloucestershire Mental Health - https://www.onyourmindglos.nhs.uk/

Gloucestershire Self-harm helpline - https://www.gloucestershireselfharm.org/

Teens in Crisis - http://www.ticplus.org.uk/

For children over the age of 12 annual screening should be arranged by the GP.  Screening for diabetic retinopathy should occur annually to allow early detection and management of any problems.  For more information click here.

Secondary Care Management

Age appropriate patient education is managed by the secondary care team as well as carer support.

On initial diagnosis the secondary care team will provide the patient with education on the following:

  • What is Diabetes?
  • Insulin
  • Blood Glucose Monitoring (meters, frequency of testing, technique, glucose diary, care/cleaning/batteries)
  • Injections (pen devices, needles, sites)
  • Techniques (parent/carer, child)
  • Care and Storage (Insulin, Sharps)
  • Hypoglycaemia (causes/symptoms/treatment)
  • Hyperglycaemia (causes/symptoms/treatment)
  • Dose Adjustment (principles of dose adjustment)
  • Illness Management
  • Blood Ketones Testing (how/when/why)
  • Dietician
  • Exercise Management
  • Identification

Patients and Families are invited to education sessions held throughout the year.

These include:  

  • Primary and secondary school education sessions .Parents, children, school and school nurses are invited also so that they can receive an update in Diabetes management in school and meet the children starting in reception or year 7
  • Pump refresher sessions.
  • Annual structured Education sessions

Yearly refresher Education for parents of children under 8 years as too young for annual review education.

The following tests will be carried out by Secondary Care Team as part of the patient’s annual review

  • HbA1c – For good health patients with diabetes should aim for an HbA1c  of 48mmols.  BP
  • BMI –Tissue Transglutaminase (TTG) – a test for coeliac disease.
  • Thyroid Function test ACR 1, 2 & 3 – urine albumin to creatinine ration to check kidneys functioning properly.
  • Retinal Screening – over 12 years of age supported by primary care
  • Footcheck
  • Annual Structured Education

Retinal screening by the Primary care team over the age of 12

 

The Unwell Diabetic Child

If an unwell child with diabetes presents to the GP then the GP should contact the specialist team at the hospital for advice and guidance

  • Immediately refer patient to on call Paediatric Consultant at the hospital via bleep no 1133

All children have open access.

Contact: Paediatric Diabetes Nurses 8am-5pm  0300 422 8473

               E-mail; pdn@glos.nhs.uk (changing to nhs.net soon)

               On call Paediatric Consultant in PAU  via hospital bleep no 1133 out of hours

All children Blood ketone test as this is more accurate than urine test

Signs and Symptoms of Ketones:

  • Nausea and/or vomiting –High blood glucose levels –
  • Fruity smelling breath –Difficulty breathing – almost certainly ketoacidotic – emergency help required immediately

Advice given to parents explaining what to look out for and what to do in the event of blood ketones and high blood glucose is as follows:

 

Blood Ketone Level

Risk of developing ketoacidosis

Action

0.5mmol/l or under

 

None

No action – this is a natural level of blood ketones

0.6 – 1.0 mmol/l

 

Slight

Give usual correction dose and test ketones and glucose again in 2 hours

 

1.1 – 1.9 mmol/l

 

Moderate

Give usual correction dose +25% extra and test ketones and glucose again in 2 hours.  If blood ketone level has dropped repeat correction dose using new blood ketone and blood glucose readings.  Contact diabetes nurses or on-call registrar for further assistance if blood ketone level not dropping

2.0 – 2.9 mmol/l

 

Moderate - High

Give usual correction dose + 50% extra and test ketones and glucose again in 2 hours.  If blood ketone level has dropped repeat correction dose using new blood ketone and blood glucose readings.  Contact diabetes nurses or on-call registrar for further assistance if blood ketone level not dropping

3.0 mmol/l

High

Give double the usual correction dose.  Seek medical advice from diabetes nurses or on-call registrar immediately.  Prepare for admission to hospital

NEVER GIVE A CORRECTION DOSE WITHIN 2 HOURS OF GIVING A PREVIOUS CORRECTION DOSE

Emergency Contact Number:  Diabetes Nurses (8am – 5pm Mon – Fri) : 0300 422 8473

                                           On-Call Registrar (out of hours):   0300 422 2222

If the GP is concerned about an unwell patient with diabetes they should contact the specialist team during the hours of 8am-5pm (0300 422 8473) or the Oncall Paediatric Consultant at the hospital via bleep no 1133 out of hours

Families are sent a quarterly newsletter from the hospital team and activities are arranged throughout the year including an annual parents evening.

Secondary care will encourage patient on self-management such as weight management, exercise on referral, dietary advice - carb counting, medication, educational support, social activities.

Prescribing and Medication

All prescriptions will be sent to the GP on patient’s discharge.  If the GP does not receive any information or has any questions or concerns they can contact the Paediatric Diabetes Nurses on their direct line:  03004 228473 or e-mail pdn@glos.nhs. uk

If considering amending the patient’s prescription please liaise with the secondary care team.

Transfer to Adult Services (Transition)

Transition starts from the age of 11 years and the secondary care team start the child on the “Ready, Steady, Go” Programme when the child is in year 7 at school.  http://www.uhs.nhs.uk/Ourservices/Childhealth/TransitiontoadultcareReadySteadyGo/Transitiontoadultcare.aspx

It is important that the transition process works well, so that patients continue to get the care they need. The Adult and Paediatric diabetes services should work together to make sure the Transition goes as smoothly as possible for the child, at an age that is right for them –. Children generally transfer to the Adult Service between the age of 16 – 18 years dependent on their individual need.

In January 2017, Diabetes UK published A Guide for Young People Moving into Adult Care

Details of adult secondary care specialist team contact:

Paediatric Diabetes Nurses;

GRH 0300 422 8473  8AM-5PM ( we do not work weekends or bank holidays)

e-mail: pdn@glos.nhs.uk (soon to change to nhs.net)

The adult diabetes phone numbers are:
CGH 03004224266
GRH 03004228613

E-mail: Ghn-tr.diabetesnurses@nhs.net

Any other considerations of change to the management of the patient please liaise with secondary care team.

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