Referral Guidelines are peer reviewed guidelines developed to assist referring providers in their approach to a patient presenting with common signs or symptoms suggestive of an endocrine condition, and when to refer to Pediatric Endocrinology.
Symptoms/Signs:
Polyuria, nocturia, enuresis, increased thirst, increased appetite, unexpected weight loss, fatigue, and menstrual irregularity. May be asymptomatic and present with hyperglycemia during inter current illness or with the use of medications like glucocorticoids.
Family history:
Diabetes
Pertinent Physical signs:
Lean, Overweight or obese
Acanthosis nigricans
Blood tests:
• Random blood glucose
Urine tests:
• Urine glucose and ketones
Other tests to consider after consultation with Pediatric Endocrinologist:
• Fasting blood glucose
• CMP
• Hemoglobin A1c
• Complete blood count
• Oral glucose tolerance test
• c-peptide
• Diabetes antibodies:
islet cell, IA-2, insulin,
GAD-65, ZnT8
Prompt:
all cases of prediabetes
Urgent:
All cases of diabetes defined as fasting blood glucose > 126 mg/dl, random blood glucose > 200 mg/dl or 2 hour post prandial glucose > 200 mg/dl after glucose load of 1 gm/kg, or HbA1c > 6.5% should be referred to a pediatric diabetes center or a pediatric endocrinologist.
Emergent:
-Ill appearing child
-Ketones in urine: should be referred to emergency department for management and possible admission
- Previous growth data/growth charts
- Pertinent medical records
- Recent laboratory and radiologic studies
- Type 1 diabetes ( T1DM),
- Type 2 diabetes (T2DM)
- Chemical/medication induced diabetes
- Stress induced hyperglycemia
- Monogenic Onset Diabetes of Young/Maturity onset diabetes of Young ( MODY)
- Pre-diabetes is defined as fasting blood glucose: 100-125 mg/ dl, 2 hour post prandial glucose: 140-200 mg/dl after glucose load of 1 gm/kg (maximum dose: 75 gm) or HbA1c: 5.7-6.4%.
- Diabetes is defined as fasting blood glucose > 126 mg/dl, 2 hour post prandial glucose > 200 mg/dl after glucose load of 1 gm/ kg (maximum dose: 75 gm),
HbA1c > 6.5% or random blood glucose > 200 mg/dl in patient with classic symptoms of hyperglycemia. o In the absence of unequivocal hyperglycemia, result should be repeated.
- Simultaneous c-peptide level is elevated in stress induced hyperglycemia and T2DM, variable in chemical/medication induced diabetes and inappropriately normal or low in MODY and T1DM.
- Pancreatic autoantibodies: islet cell antibodies (ICA), GAD-65, insulin antibodies, IA2A and ZnT8 are detected only in T1DM.
o Most commercial laboratories may have the assays to test for some/ most of the autoantibodies accurately.
o Should be done after discussion with endocrinologist.
- Electrolyte abnormalities: pseudo-hyponatremia (secondary to blood glucose elevation), elevated blood urea nitrogen and creatinine (secondary to dehydration), abnormal liver function tests.
- MODY 2: have mildly elevated blood glucose, do not progress overtime and do not need treatment with sulfonylurea or exogenous insulin in the pediatric ages.
- Oral medication (sulfonylurea): MODY type 1 (hepatocyte nuclear factor (HNF) 1a) and type 3 (HNF 4a) are exquisitely sensitive to sulfonylurea.
- Insulin treatment: Needed as disease progresses and in other forms of MODY.
- American Diabetes A. Standards of medical care in diabetes-2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association. 2015;33(2):97-111. Epub 2015/04/22. doi: 10.2337/diaclin.33.2.97. PubMed PMID: 25897193; PubMed Central PMCID: PMC4398006. http://clinical.diabetesjournals.org/content/33/2/97.full.pdf+html
- Monogenic diabetes in children- ISPAD guideline. http://www.ceed3.org/en/node/158.
Indrajit Majumdar and Teresa Quattrin
May 1, 2020