Type 1 diabetes: diagnosis and initial management — formative SAQs

SAQ 1 — The alert child with new hyperglycaemia (10 marks)

A 6-year-old presents with a two-week history of excessive thirst, frequent urination and a 2 kg weight loss. He is alert, well perfused and tolerating oral fluids. The finger-prick glucose is 22 mmol/L. He has no vomiting, no abdominal pain and normal breathing. This is the classic presentation of new-onset type 1 diabetes without ketoacidosis. [1]

Answer the following

1. State the criteria by which you can confirm the diagnosis of diabetes in this child. [2]
2. Describe the single most important assessment you must make before deciding on the treatment pathway, and how you make it. [1]
3. Outline the initial insulin regimen you would start once ketoacidosis is excluded, including the approximate dose. [3]
4. List four components of the structured education the family needs before discharge. [3]

Model marking guide

1. Diabetes is confirmed on glucose: a random plasma glucose of 11.1 mmol/L or higher with classic symptoms (met here at 22 mmol/L), or a fasting plasma glucose of 7.0 mmol/L or higher, or an HbA1c of 48 mmol/mol (6.5 percent) or higher. In a symptomatic child a single high reading is sufficient to diagnose and act. [2]
2. The critical assessment is to exclude diabetic ketoacidosis, because acidosis diverts the child to a different pathway. Measure capillary or blood ketones together with venous pH and bicarbonate, and assess hydration, conscious level and respiratory pattern. An alert, non-acidotic child with only mildly raised ketones is suitable for the uncomplicated subcutaneous pathway. [1]
3. Start a subcutaneous basal-bolus regimen: a total daily dose of about 0.5 to 1.0 units per kilogram per day, split roughly half basal (a once or twice daily long-acting analogue) and half bolus (a rapid analogue with each meal), titrated to the glucose pattern. [3]
4. Any four of: blood glucose monitoring; carbohydrate counting and meal-time dosing; recognition and treatment of hypoglycaemia with fast-acting carbohydrate; sick-day rules built on never stopping insulin; insulin injection technique and site rotation; when and who to contact. [3]