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Recognising diabetes in children: a vital skill

Elizabeth Bragg
MB ChB
Staff Grade Paediatrician
University Hospital of Wales
Cardiff

Diabetes mellitus affects about one child in every 500.(1) In the UK 2-4% of the population are diagnosed as having this condition (and it's estimated that there's an equal number of people undiagnosed), and the numbers appear to be rising.(2,3)
The Audit Commission's Testing Times report highlighted some serious inadequacies in national services with regard to diagnosis, treatment and support of patients with diabetes.(4) 
Early diagnosis, not just of the condition but also of its complications, is essential to ensure healthy, happy and continuing lives for people with diabetes. 
How good are you at recognising diabetes?

Anticipating diabetes
Part of diagnosis relies on having an index of suspicion that is tuned to the condition. This is a clinical inkling based on prior knowledge of likelihoods. Did you know that diabetes:

  • Is three to four times more common in children from Afro-Caribbean and Asian backgrounds.(4)
  • Is seen more in cooler climates than tropical ones - this holds true for the UK, where it is more common in Scotland than southern England.
  • Runs in families, whether it's type 1 or type 2. For comparison of the two types, see Table 1.
  • Is more likely in a child whose father has diabetes than whose mother has it.(6)
  • Is an autoimmune disease and as such can develop more commonly in children suffering from other autoimmune conditions (eg, thyroid disease).
  • Can develop secondary to other diseases such as cystic fibrosis, haemochromatosis and pancreatitis.
  • Type 2 might be more likely to develop in older children who overeat, don't exercise enough and have a family history of diabetes.(5)
  • Looks like it might be more common in bottlefed babies than breastfed ones.(7)
  • Can be caused by some pharmaceutical agents (pentamidine, L-asparaginase, cyclosporine(6) and steroids).

[[NIP05_table1_35]]

Recognising presentations
As a practice nurse you could come across an undiagnosed case of diabetes in a variety of clinical circumstances. These may include during a new patient assessment, in an acutely unwell child, or during diabetic clinic. 
Mostly we've come to expect that children who are new diabetics will present with the classic signs of diabetes - that is, very thirsty and urinating a lot. Although this is common, it is not always the case.
Table 2 shows other common signs and symptoms found at initial presentation. A new patient assessment would be the ideal time to question parents (or older children) about some of the more general symptoms. This is especially true if any first-degree relatives suffer from either type 1 or type 2 diabetes (see Table 3).

[[NIP05_table2_36]]

[[NIP05_table3_38]]

Sometimes patients who are being followed up for a different condition will attend the surgery for routine blood tests or repeat observations. These include patients with cystic fibrosis or autoimmune thyroid disease, or who are taking medication such as those listed above. Just because we already have one diagnosis, we must be careful not to ignore new symptoms or pass them off as part of the diagnosed condition. Only by having an awareness of the presentations and a willingness to think laterally do we stand a chance of picking up a developing additional condition. 
A child who presents with diabetic ketoacidosis (see Table 2) is more likely to be seeing the doctor urgently for persistent vomiting or severe abdominal pain. Many parents will be concerned enough to make a 999 call and get an ambulance ride direct to the hospital. If they do present to the surgery, it's generally worthwhile performing a BM heel or finger prick. This is true of any child who comes in severely unwell. Both hypoglycaemia and hyperglycaemia can manifest in many various ways.

Recognising symptoms
Once a child has been diagnosed as having diabetes, the story doesn't stop there. There will definitely be times when they are suffering from either over- or undertreatment. Both hypo- and hyperglycaemia may be fatal, so they will continue to need your vigilance. Diabetic ketoacidosis is mentioned in the previous section, since it may also be a first presentation. This section concentrates on hypoglycaemia, the symptoms of which are a lot easier to understand if the mechanism is known.
Hypoglycaemia is the most common complication of treatment in a diabetic patient. It happens because there has been a mismatch between when or how much insulin has been given and the amount of food (carbohydrate) and exercise that has been taken.
In the body there is usually a careful balance of hormones keeping blood glucose within normal limits. In a nondiabetic person, the effects of insulin are opposed by the glucose counterregulatory hormones. These include:

  • Glucagon. This is the primary hormone responsible for maintaining normal blood glucose during exercise and fasting.
  • Catecholamines, such as adrenaline. This is not essential to the regulation but can compensate for glucagon and becomes essential when there's no glucagon around.
  • Cortisol and growth hormone. These have small regulatory effects but don't work fast or well enough to replace glucagon or adrenaline.

After four or five years of having diabetes, the body gives up producing glucagon - this means that adrenaline becomes the primary hormone to counter insulin action. In some patients the adrenaline response also becomes blunted or fails - this is when problems begin.
The main symptoms of mild hypoglycaemia (ie, you can recognise and treat it yourself) are those detailed as neurogenic in Table 2. An excess of catecholamines in the blood is responsible for the presence of these symptoms. 
If a person has a blunted or absent adrenaline response to too much insulin, they won't suffer these symptoms. This is known as hypoglycaemic unawareness.(6)
Moderate hypoglycaemia (ie, severe enough to interrupt your activities) gives the patient severe neurogenic symptoms and mild neuroglycopenic symptoms. The latter are caused by the actual lack of glucose available to the brain. 
Severe hypoglycaemia (ie, too bad to recognise or treat yourself) usually presents with neuroglycopenic symptoms.
The practical upshot of hypoglycaemic unawareness, or deficient adrenaline response, is that a patient will be quite ill and have quite low glucose levels (probably less than 3.0mmol/l) before they get any symptoms. 
There is some evidence that this is a vicious circle, with each bout of hypoglycaemia blunting the adrenaline response, leading to further hypoglycaemia unawareness.
Clearly there is a need for the primary healthcare provider to ensure that the patient is educated about the condition, not only so they can recognise the symptoms themselves, but also so they can actively avoid the problems. 
Primary care teams provide 75% of routine care for diabetics, and one-third of this is done by practice nurses alone.(4)

Conclusion
Diabetes is a very common condition, which is becoming commoner, and it can be fatal. It is essential that everyone who is involved in primary care should have a heightened awareness of the condition. This includes:

  • Clinical vigilance for those who may be susceptible (including screening).
  • Early recognition and implementation of treatment for the "barn-door" cases.
  • Knowledge and awareness to suspect and act on your suspicions for patients presenting with out-of-the-ordinary symptoms.

We all need to be good at recognising diabetes. There are a large number of undiagnosed people in the population, and early diagnosis is vital for their health.

References

  1. Royal College of General Practitioners. RCGP information sheet.http: //www.rcgp.org.uk /rcgp/ information/publications/information/rcf0003a/RCF0003ad.asp. October 1999.
  2. Gardner SG, Bingley PJ, Sawtell PA Weeks S, Gale EA. Rising incidence of insulin dependent diabetes in children aged under 5 years in the Oxford region: time trend analysis. BMJ 1997;315:713-7.
  3. Bingley PJ, Douek IF, Rogers CA, Gale EAM. Influence of maternal age at delivery and birth order on risk of type 1 diabetes in childhood: prospective population based family study. BMJ 2000;321:420-4.
  4. The Audit Commission. Testing times: a review of diabetes services in England and Wales. London: The Audit Commission; 2000.
  5. American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics 2000;105:671-80.
  6. Rudolph AM, Hoffman JIE, Rudolph CD. Rudolph's Pediatrics, 20th ed; 22.11, McGraw-Hill; 1995. p. 1803-27.
  7. Saukkonen, Virtanen SM, Karppinen M, et al. Significance of cow's milk protein antibodies as risk factor for childhood IDDM: interactions with dietary cow's milk intake and HLA-DQB1 genotype. Childhood Diabetes in Finland Study Group. Diabetologia 1998;41:72-8.

Resources
Diabetes UK
W:www.diabetes.org.uk
Juvenile Diabetes Research Foundation
W:www.jdrf.org.uk
Diabetes NSF
updates
W:www.doh.gov.uk/nsf/diabetes/index.htm