Mr and Mrs Smyth ask for some advice about their son Tom. They have noticed that Tom has been napping frequently during the day and has no energy to play football. He has also been constantly thirsty and subsequently going to the toilet a lot, even waking through the night. What do you advise?
What is Type 1 diabetes?
According to Diabetes UK, diabetes affects 4.7 million people in the UK.(1) Approximately 8% of people with diabetes have type 1 diabetes, a chronic, metabolic disorder that results from autoimmune destruction of insulin-producing betacells in the pancreas.(1,2) This results in an absolute insulin deficiency, where the body cannot adequately store and use glucose, leading to hyperglycaemia. Patients with this condition require treatment with insulin in order to survive.(2)
What is the prevalence of Type 1 diabetes?
Type 1 diabetes is normally diagnosed before the age of 40, but is most commonly identified in children and adolescents, with the peak age of diagnosis between 10 and 14 years old and it is slightly more common in boys and men.(1,2) There are approximately 36,000 children under the age of 19 with type 1 diabetes in the UK.(1)
What are the symptoms?
The onset of type 1 diabetes occurs quickly, with signs and symptoms developing over a matter of weeks. Symptoms are often non-specific and can be confused with general flu-like illnesses.
Diabetes UK developed the “4Ts” campaign, which raises awareness of the most common symptoms of type 1 diabetes, which includes:(1)
- Toilet – urinating frequently, bed wetting or heavy nappies in babies
- Thirst – drinking large volumes of water but being unable to quench the thirst
- Tired – feeling more tired than usual
- Thinner – losing weight for no apparent reason.
Other symptoms include recurrent infections such as thrush or urinary tract infections, slow wound healing and blurred vision.(3) It is vital that children displaying any of these symptoms are referred immediately to their GP for further investigation.
How is it diagnosed?
Children with suspected type 1 diabetes should be referred on the same day to a multidisciplinary paediatric diabetes team in order to confirm diagnosis and provide care, as patients will need to start treatment immediately.(4)
Diagnosis should be confirmed using the following blood glucose criteria:(5)
- Random plasma glucose more than 11mmol/L
- Fasting plasma glucose 7mmol/L or greater
- 2-hour blood glucose concentration 11mmol/L or greater after 75g glucose in an oral glucose tolerance test
What is diabetic ketoacidosis?
Diabetic ketoacidosis (DKA) is a severe complication of diabetes that can be life-threatening and therefore must be treated as a medical emergency.(6) DKA results from a severe deficiency of insulin in the body, which means the body resorts to using fat for energy, releasing ketones into the bloodstream and making the blood acidic.(6,7) It can present as a result of undiagnosed diabetes, or in a known diabetic due to infection, non-adherence to insulin, binge drinking or pregnancy. In some instances, there is no obvious cause.(3)
DKA should be suspected in a known diabetic or those with severe hyperglycaemia (blood glucose greater than 11mmol/L) along with the following clinical features:(6)
- frequent urination
- weight loss
- persistent vomiting and/or diarrhoea
- unable to tolerate fluids
- visual disturbances
- abdominal pain
- tiredness or confusion
- sweet-smelling breath (like pear drops or nail varnish remover)
- dehydration (classified as mild, moderate, severe)
- shock due to severe dehydration
DKA is treated through a combination of fluids and insulin administered in hospital.(6) Left untreated, DKA is fatal, most commonly due to cerebral oedema.(7) It is vital that patients and caregivers are counselled on ways to prevent the recurrence of DKA, including emphasising the importance of adherence to insulin and appropriately managing concurrent illness.(4,6)
What impact has the COVID-19 pandemic had on diagnosis?
The COVID-19 pandemic has been cited as a major reason in delayed diagnosis of type 1 diabetes. Between March and June 2020, more than half of diagnoses in children and young people were only made after presenting with DKA. The main reasons given by parents and caregivers for delayed diagnosis during this time period included fear of COVID-19, lack of access to GPs and misdiagnosis of symptoms.(8)
Community pharmacists and their teams can play an important role in reassuring the public that despite the COVID-19 pandemic, NHS services remain in place and the seriousness of other medical conditions should not be negated because of the current COVID-19 situation. It is vital that parents and caregivers seek advice immediately if they suspect their child may have symptoms of type 1 diabetes because early intervention is key to preventing long-term effects. These effects can be macrovascular (eg coronary heart disease) or microvascular (eg neuropathy) and are discussed in more detail in the Update Plus Module “Chronic complications of diabetes”.
Management of Type 1 diabetes
All patients with type 1 diabetes will require insulin therapy. The overall aim of treatment is to achieve an optimal blood glucose level while achieving a balance between avoiding hypoglycaemic episodes and minimising the risk of long-term effects.(9)
There are three basic insulin regimens:(9)
Multiple daily injection basal-bolus insulin regimen
- One or more separate daily injection of intermediate or long-acting insulin (basal insulin)
- Multiple (bolus) injections of short-acting insulin before meals (which can provide flexibility to tailor insulin therapy with the carbohydrate load of each meal)
Mixed biphasic regimen
- One, two or three daily injections of a mix of short and intermediate-acting insulin
- Continuous infusion of insulin delivered through a programmable pump
All children diagnosed with type 1 diabetes should be offered a multiple daily injection of basal-bolus insulin as the first-line treatment regimen. If multiple daily injections are not appropriate, an insulin pump can be considered.(4) Diet and exercise are also critical in the management of type 1 diabetes. Children, alongside carers, parents and healthare professionals, should discuss how to manage physical activity and achieve a healthy diet alongside type 1 diabetes.(10)
Where can patients and caregivers be signposted for further information?
A diagnosis of type 1 diabetes is lifechanging for children and their families. Therefore, it is vital that patients and their caregivers are provided with appropriate support to manage their condition effectively. There are a number of useful resources that patients and caregivers can access online including:
- Diabetes UK (2019) Us, diabetes and a lot of facts and stats
- Atkinson, M, Eisenbarth G, Michels A. (2014) Type 1 diabetes. The Lancet; 383(991): 69-82
- NHS Conditions (2019) Diabetes
- National Institute for Health and Care Excellence Guideline (2015) Diabetes (type 1 and type 2) in children and young people: diagnosis and management
- World Health Organisation (2006) Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia
- National Institute for health and Care Excellence (2020) Clinical Knowledge Summaries: When should I suspect diabetic ketoacidosis in a person with type 1 diabetes?
- Wolfsdorf J, Craig, ME, Daneman D et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10(Suppl 12): 118-133.
- Ng SM, Woodger K, Regan F, et al. (2020) Presentation of newly diagnosed type 1 diabetes in children and young people during COVID-19: a national UK survey. BMJ Paediatrics Open 2020 4(1): p.e000884
- British National Formulary for Children (2020) Treatment summary: Type 1 diabetes
- Digibete.org (2021) Resources