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, Fatigue, Increased appetite, unexpected and unplanned weight loss
Longstanding weight gain or obesity but possible recent weight loss
History of diabetes
Vital signs: normotensive/ hypertensive.
General: Overweight or obese
Skin: acanthosis nigricans
• 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 referred to a pediatric diabetes center or a pediatric endocrinologist.
If child is:
-has ketones in urine
-has mental status changes,
They should be referred to
emergency department for
management and possible
- 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 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.
- Undetectable Pancreatic autoantibodies: islet cell antibodies (ICA), GAD-65, insulin antibodies, IA2A and ZnT8.
o Most commercial laboratories may have the assays to test for some/ most of the autoantibodies accurately.
o Should be done after discussion with the endocrinology provider
- Electrolyte abnormalities: pseudo-hyponatremia (secondary to blood glucose elevation), metabolic acidosis, elevated blood urea nitrogen and creatinine (secondary to dehydration), liver function abnormality (secondary to Non-alcoholic steato-hepatitis (NASH)).
- Children with Type 2 diabetes can present in DKA, and are also more likely to present with Hyperglycemic hyperosmolar state (HHS), both of which are medical emergencies.
Diabetes care involves close supervision, intensive education and frequent monitoring. It involves:
- Oral medications: o Biguanides (Metformin) – only oral diabetic medication approved for use in children 10 years and older.
- Injectable medications
o Insulin: rapid acting analogs (Lispro, Aspart, Glulisine), long acting insulin (Human NPH), and basal insulin analogues (Glargine, Detemir)
o Liraglutide and exenatide (glucagon-like peptide 1 receptor agonists). Approved in children 10 years and older if there is no past medical or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2.
Glycemic control is monitored with self-monitoring of blood glucose (SMBG) and quarterly hemoglobin A1c.
- Patients and their care-givers should receive diabetes self-management education which includes medical nutrition therapy, SMBG, medication administration, life style changes to encourage weight loss, need for monitoring of chronic complications, management of lipid abnormalities, and hypertension.
Treatment for comorbidities if present
- Hyperlipidemia: Lifestyle modification, statins as needed based on LDL level and level of risk factors.
- NASH: Life style modification, metformin and thiazolidinediones
- Sleep apnea: Tonsillectomy and adenoidectomy and use of CPAP device
- Hypertension: Lifestyle modifications, DASH diet and antihypertensive medication as needed.
- Menstrual irregularity/polycystic ovarian syndrome: Metformin, Oral contraceptive pills.
- 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.