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.
Polyuria, nocturia, enuresis, increased thirst, increased appetite, weight loss, fatigue.
*Vomiting, Rapid/deep breathing, Abdominal pain, lethargy may suggest DKA
Other autoimmune diseases like hypothyroidism
History of diabetes (not as likely as Type 2) and other autoimmune disorders
Vital signs: tachypnea, tachycardia, hemodynamic instability (in DKA)
General appearance: variable degrees of dehydration
Respiration: Fruity breath smell, Kussmaul breathing (in DKA)
Skin: acanthosis nigricans can be seen in obese children with Type 1 or Type 2 DM
• Random blood glucose
• Urine glucose and ketones
Other tests to consider after consultation with Pediatric Endocrinologist:
• Fasting blood glucose
• Hemoglobin A1c
• Complete blood count
• Oral glucose tolerance test
• Diabetes antibodies: islet cell, IA-2, insulin, GAD-65, ZnT8
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 immediately referred to a multidisciplinary diabetes center or to pediatric endocrinologist.
If child is:
-has ketones in urine or
-Suspected to have diabetic ketoacidosis,
They should be referred emergently to the nearest emergency department for stabilization, initiation of treatment and transportation to nearest hospital with a diabetes center/pediatric endocrinologist.
- 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)
- Diabetes is defined as fasting blood glucose > 126 mg/dl, 2 hours 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 inappropriately low.
- Presence of pancreatic auto-antibodies : islet cell antibodies (ICA), GAD-65, insulin antibodies, IA2A and ZnT8.
- Most commercial laboratories may have the assays to test for some/most of the autoantibodies accurately.
- Should be done after discussion with the endocrinology provider
- Electrolyte abnormalities are common and may include pseudo-hyponatremia (secondary to blood glucose elevation), metabolic acidosis, elevated blood urea nitrogen and creatinine (secondary to dehydration), and hypokalemia or hypophosphatemia (total body depletion)
- Other tests to screen for simultaneous autoimmune disorders: Serum TSH, free T4, T3, and anti-thyroid antibodies (thyroid peroxidase antibody, thyroglobulin antibodies), tissue transglutaminase IgA antibodies, total IgA concentration
Diabetes care involves close supervision, intensive education and frequent monitoring. It involves:
- Insulin administration by multiple daily subcutaneous injection or insulin pump. o Rapid acting analogs (Lispro, Aspart, Glulisine)
- o Long acting insulin (NPH),
- o Basal insulin analogues (Glargine, Detemir)
- Sulfonylurea, gliptins, gliflozins, and Metformin are not indicated for individuals with T1DM
- Glycemic control is monitored with multiple daily self-monitoring of blood glucose (SMBG), continuous subcutaneous glucose monitoring system and quarterly hemoglobin A1c.
- All patients with DKA should be admitted to in-patient or ICU set up and treated with IV fluids, IV insulin infusion, frequent blood glucose, and electrolyte monitoring.
- Patients and their care givers should receive diabetes self-management education including medical nutrition therapy, self-monitoring of blood glucose, insulin administration, need for monitoring of chronic complication, management of lipid abnormality, and hypertension.
- American Diabetes Association. Standards of medical care in diabetes-2021 abridged for primary care providers. Clinical Diabetes: a publication of the American Diabetes Association. 2021;39(1):14-43.
- American Diabetes Association. Children and adolescents: Standards of medical care in diabetes-2021. Diabetes Care 2021;44(suppl 1):S180-S199.
Authors: Indrajit Majumdar and Teresa Quattrin
June 23, 2021